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RECOGNIZING, TREATING AND AVOIDING OCULAR ALLERGIES Joseph P. Shovlin, OD, FAAO Northeastern Eye Institute Scranton, PA Classification of Hypersensitivity Reactions Types of Allergic Diseases of the Eye Irritative Keratoconjunctivitis & Drug Hypersensitivities of the Eye Atopic Diseases Vernal Keratoconjunctivitis Giant Papillary Conjunctivitis Contact Allergy Microbial Allergy: Phlyctenulosis Rosacea Treatment of Allergic Diseases Goals: This presentation will provide a review of the basic mechanisms operant in allergic eye disease with an emphasis placed on early recognition and differential diagnosis. Proper treatment and management including ways to avoid allergy will be offered. Learning Objectives: 1. Explain the basic process of sensitization and understand the pathways of early and late phase responses. 2. Recognize the clinical presentations of allergic eye disease. 3. Discuss the clinical management of allergic eye disease and related systemic disease. 4. Understand the strategies necessary to avoid the various causes of allergy whenever possible. Abstract: Clinicians must be able to easily identify and manage the various presentations of ocular allergy in the primary eye care practice. Several cases of ocular allergy will be shared along with the appropriate treatment plan. Emphasis will be placed on early recognition, differentials to be considered, means to avoid allergy whenever possible and the use of appropriate pharmaceuticals. Outline I. Classification of Hypersensitivity Reactions A. Coombs & Gell (1963) B. Immediate v Delayed Responses 1. Allergic sensitization 2. Early and late phase allergic response 3. Systemic ramifications II. Ocular Allergy A. Types of Allergic Diseases of the Eye 1. Characteristics 2. Causes B. Ocular Conditions 1. Acute Allergic Conjunctivitis 2. Hay Fever Conjunctivitis 3. Atopic Keratoconjunctivitis 4. Vernal Keratoconjunctivitis 5. Giant Papillary Conjunctivitis 6. Contact Allergy and Contact Dermatitis 7. Microbial Allergy (Phlyctenulosis) C. Differential Diagnoses of Other External Diseases III. Rosacea: A New Look At An Old Condition IV. Treatment of Allergic Eye Disease A. Topical Agents 1. Vasoconstrictors 2. NSAIDs 3. Antihistamines 4. Mast cell stabilizers 5. Corticosteroids B. Oral Agents 1. Stabilizers 2. Rescue therapy 3. Immunotherapy C. Supportive Therapy and Avoidance D. Newly Approved and Experimental Therapies V. Allergy Resources On the Web Transcript Quality Course Questions Cope: 7819-AS 1. Which of the following conditions has not been associated with atopic keratoconjunctivitis: A. cataracts B. keratoconus C. retinal detachment D. posterior uveitis 2. The two most operant groups of the Coomb and Gell Classification system associated with ocular allergy are: A. I and IV B. II and III C. I and III D. II and V 3. Vernal shield ulcers are best described as: A. an indolent ulcer (sterile) that forms secondary to mechanical and chemical mediators B. an infectious ulcer that is primarily due to pseudomonas C. a sterile neurotrophic ulcer secondary to crack cocaine D. a sterile ulcer secondary to vitamin A deficiency 4. Topical decongestants should be used with caution in patients with: A. primary open angle glaucoma B. secondary pigmentary dispersion glaucoma C. a known shallow anterior chamber and narrow angle D. pseudoexfoliative conditions 5. Oral antihistamines are not contraindicated in which patients: A. nursing mothers B. pregnant women C. with a known hypersensitivity to Loratidine D. with a known hypersensitivity to aspirin 6. Which of the following statements least accurately describes a delayed hypersensitivity: A. the allergen is protein B. best treatment is with the use of anti-lymphocytic drug C. mechanism of action is primarily through humoral antibodies D. the process starts at 24 hrs. and ends by 72 hrs. 7. Irritative keratoconjunctivitis can be distinguished from true allergic disease by all of the following, except: A. no allergen present B. inciting agent causes a response only after repeated exposures C. response is not greater or different between exposures D. removing the offending agent is often all that is needed to remedy the condition 8. Atopic disease includes all of the following conditions, except: A. utricarial reactions B. asthma and emphysema C. eczema D. hayfever 9. Dust mites affect approximately_________% of the population? A. 10% B. 35% C. 70% D. 99.9% 10. Patients with atopic keratoconjunctivitis and atopic dermatitis should be protected from exposure to which of the following: A. herpes simplex and vaccinia B. herpes simplex and malaria C. herpes zoster and small pox D. herpes zoster and malaria 11. Which of the following statements as they relate to a comparison of vernal keratoconjuctivitis (VKC) and giant papillary conjunctivitis (GPC) is not accurate: A. both conditions have the potential to produce large papillae of the tarsal conjuctiva B. in VKC, more mediator, like histamine, is released than in GPC C. “phantom” mast cells are more prevalent in GPC D. a greater number of eosinophils is present in VKC 12. Future direction in new therapy would include the regulation of the following chemokines: A. ICAM-1 and ICAM-3 B. ICAM-2 and VCAM-1 C. ICAM-3 and VCAM-2 D. ICAM-2 and ICAM-3 13. Which of the following best characterizes hayfever conjunctivitis: A. PMN response with minimal IgE response B. severe discharge, often purulent C. elevated IgE response, eosinophils may be absent D. corneal signs are often present and include indolent ulcers 14. The following statements are true as they relate to the use of oral agents in allergic eye disease, except: A. should involve an allergist or physician specializing in some aspects of allergic systemic disease B. might include as an entry level treatment plan the use of immunotherapy (injections) before employing corticosteroid oral agents C. oral stabilization therapy might include antihistamines, decongestants or corticosteroids D. oral rescue therapy has minimal risks to the eye with prolonged corticosteroid use 15. Recalcitrant rosacea with advanced circumferential extension of stromal thinning is best managed by the use of the following agents: A. 1% compounded medroxyprogesterone and topical cyclosporine B. oral doxycycline and topical sulfacetamide C. Theratears Nutrition for Dry Eye and artificial tears D. topical cyclosporine and artificial tears 16. Phlyctenulosis is best described as : A. a specific response to any microbial antigen characterized by focal lesions of the conjunctiva and sometimes the cornea B. a hypersensitivity reaction to aminoglycosides C. any response to airborne allergens that produces a Horner’s point or Trantas’ dot D. an indolent ulcerative lesion of the cornea caused by staphyloccus and TB 17. Treatment of contact dermatitis includes all of the following, except: A. heat applied to the involved skin area regularly B. mild topical corticosteroids C. removing the offending agent D. oral antihistamines 18. Corneal involvement in severe contact allergy would not include the following: A. punctuate epithelial erosion B. thickening of the epithelium (plaque) C. pannus formation D. filamentary keratitis 19. Which of the following is least likely to cause giant papillary conjunctivitis? A. corneal suture material with buried knots B. corneal adhesive/ glue without the use of a bandage contact lens C. short-term wear of an ocular prosthesis that is removed and cleaned every night D. extruded scleral buckle 20. The best first-line treatment options for hayfever conjunctivitis include: A. removal of the antigen and aminoglycosides B. removal of the antigen and the use of vasoconstrictors and antihistamines C. topical steroids and sulfacetamides D. sulfacetamides and vasoconstrictors ANSWERS: 1. D 2. A 3. A 4. C 5. D 6. C 7. B 8. B 9. C 10. A 11. C 12. A 13. C 14. D 15. A 16. A 17. A 18. D 19. B 20. B