Module 2: Allergic Conjunctivitis an educational program of: Updated: June 2011 Sponsored by an unrestricted educational grant from.
Download ReportTranscript Module 2: Allergic Conjunctivitis an educational program of: Updated: June 2011 Sponsored by an unrestricted educational grant from.
Module 2: Allergic Conjunctivitis an educational program of: Updated: June 2011 Sponsored by an unrestricted educational grant from Global Resources in Allergy (GLORIA™) Global Resources In Allergy (GLORIA™) is the flagship program of the World Allergy Organization (WAO). Its curriculum educates medical professionals worldwide through regional and national presentations. GLORIA modules are created from established guidelines and recommendations to address different aspects of allergy-related patient care. World Allergy Organization (WAO) The World Allergy Organization is an international coalition of 89 regional and national allergy and clinical immunology societies. WAO’s Mission WAO’s mission is to be a global resource and advocate in the field of allergy, advancing excellence in clinical care, education, research and training through a world-wide alliance of allergy and clinical immunology societies Allergic Conjunctivitis Revised February 2007 an educational program of: Lecture Objectives • To understand the clinical science relating to allergic conjunctivitis • To discern the various clinical signs and symptoms of allergic conjunctivitis • To appreciate the advances in various treatment options for allergic conjunctivitis Nomenclature of Allergic Disease • The ARIA document (2001) proposed replacing the terms Seasonal with Intermittent for occasional symptoms lasting < 4 days / week for ≤ 4 weeks and Perennial with Persistent - for constant symptoms lasting > 4 days per week or > 4 weeks • These classifications have not been shown to be interchangeable1 and Seasonal and Perennial continue to be the preferred nomenclature for allergic conjunctivitis 1. Bauchau V and Durham SR, Allergy, 2005; 260; 350-353 Anatomy: The normal eyelid and conjunctiva • The surface of the eye is the most obviously exposed mucous membrane of the body. • The conjunctiva and periorbital area is one of the most densely mast cell populations of human tissues. • The conjunctival surface is accessible to allergens and is the site of allergic reactions. Classification and epidemiology of allergic conjunctivitis Allergic conjunctivitis • A broad group of allergic conditions involving inflammation of the conjunctiva • IgE-Mediated: • Acute Allergic Conjunctivitis (AAC) • Seasonal Allergic Conjunctivitis (SAC) • Perennial Allergic Conjunctivitis (PAC) IgE Mediated: acute allergic conjunctivitis • Acute Allergic Conjunctivitis (AAC) occurs at any age, especially childhood • Large quantity of allergen inoculated into eye causes: • Intense pruritus • Chemosis conjunctival swelling • Periorbital edema: may lead to eye closure • Self-limiting, usually within 24 hours IgE mediated: seasonal/perennial allergic conjunctivitis Related to perennial or seasonal allergens, association with genetic predisposition to allergic rhinitis Seasonal: Affects up to 30% of the general population • 80% of patients with allergic rhinitis • 10% without allergic rhinitis Bonini S and Bonini S. Ann Allergy 1993; 71: 296 Perennial Allergic conjunctivitis • IgE Mediated/Complex: • Giant Papillary Conjunctivitis (GPC) • Vernal Keratoconjunctivitis (VKC) • Atopic Keratoconjunctivitis (AKC) • Non-IgE-Mediated • Dermatoconjunctivitis/Allergic Contact Conjunctivitis Giant papillary conjunctivitis • • • • • • • 1. Abelson,M, Allergic Diseases of the Eye. W. B. Saunders, Philadelphia, 2000 Trauma due to foreign body intolerance eg, contact lens (CL), ocular prosthesis, sutures Extended wear SCL > Hard CL > Soft CL Aggravated by concomitant allergy Blurred vision, Mucus production, Conjunctival injection Tarsal papillary reactions (>0.3 mm) Affects 1 - 5% of rigid gas permeable contact lens wearers, and 10-15% of hydrogel (soft) contact lens wearers, USA1 IgE Mediated/Complex: Vernal Keratoconjunctivitis • Ptosis of upper lid • Stringy exudate • Papillary hypertrophy • “cobblestoning” • Trantas’ dots • “Horner’s points” • collection of epithelial and eosinophilic debris • Intense pruritus • Photophobia • Severe T-cell mediated disease involving the cornea: may be sight-threatening Epidemiology of Vernal Keratoconjunctivitis • Pre-pubescent boys in warm, dry climate • Increased along the borders of the Mediterranean basin • 10% of all eye patients in East Jerusalem1 • 0.5-1.0% of all patients in eye clinics worldwide2 • Age range: 5 - 20 • Sex: >12: male to female ratio • Associated with atopic disorders (50%) 1. O’Shea, J.G. Ophthalmic Epidemiology, 2000; 7; 2, 149-157(9) 2. Beigelman, MN. Vernal Conjunctivitis. Los Angeles, University of Southern California Press, 1950 IgE/Mediated/Complex: atopic Keratoconjunctivitis with periorbital involvement • • • • • • • Persistent disease involving eyelids usually beginning in young adulthood Moderate to severe itching, burning, tearing Perennial with seasonal variation Gritty sensation Atopic cataracts - anterior Related to atopic eczema Severe T-cell mediated disease involving the cornea: may be sightthreatening Atopic Keratoconjunctivitis (AKC) Keratoconus Corneal Ulcers Trantas’ dots (Horner’s points) Epidemiology of atopic Keratoconjunctivitis • Atopic Eczema (AE)|affects 10-15% of the population1 • 15-40% of Atopic Eczema patients develop AKC2 • Males more often affected than females; • Occurs 2nd through 5th decade3 1. Wuthrich, B, Ann Allergy, Asthma and Immunol, 1999; 83:464-470 2. Braude LS, Cbandler JW, Int. Ophthalmol Clin 1984; 24: 145 3. Donshik, PC, Int. Ophthal Clin, 1988; 28: 294 Prevalence of nasal and ocular allergy Prevalence of nasal allergy 40 Prevalence (%) 30 20 10 0 Austria France Germany Greece Italy Portugal • 80-90% also have Ocular Allergy ECRHS Eur Resp J. ; 1996; 9:687-695 Spain Switzerland UK Allergic Rhinoconjunctivitis Prevalence of Patients with Allergic Rhinoconjunctivitis for More than 7 days of Nasal/Ocular Symptoms in the Previous 12 Months in the USA 13.7 / 27.9 16.4 / 31.9 11.7 / 29.5 20.2 / 36.2 13.2 / 28.9 13.8 / 30.4 12.7 / 33.8 13.7 / 30.4 15.5 / 38.2 Nathan RA, Meltzer EO, Selner JC, Storm W.; Suppl J Allergy Clin Immunol, 1997; 97 99:s808-814 Prevalence of allergic conjunctivitis • 90% of rhinitis patients taking an oral or nasal treatment still have eye symptoms • Allergic Rhinoconjunctivitis • Affects >25% of the population (as high as 40%) • Accounts for 80-90% of all allergic disorders • Nearly 8 out of 10 rhinitis patients suffer from allergic conjunctivitis • Ocular symptoms severely affect 70 - 80% seasonal allergy patients Bielory L. J Allergy Clin Immunol; 2000; 106:1019-1032 Berger W, Abelson MB, Gomes PJ et al. Ann Allergy Asthma Immunol 2005;95:361-370. Allergic Rhinoconjunctivitis affects quality of life Copyright permission for reproduction pending Juniper EF, et al. Clin Exp Allergy 1991;21:77-83 Patient reported top allergy symptoms experienced in 2005* (Among allergy medication users) 84% 77% Sneezing Runny nose 72% 71% Itchy Eyes Stuffy nose/Congestion 57% Itchy Nose Sinus Pressure Headaches Watery Eyes Sinus Pain Coughing/Wheezing *Includes 40% or more mentions only. The 2005 Gallup Study of Allergies – Phase II Report 53% 50% 50% 45% 41% Pathophysiology of allergic conjunctivitis Histology: mast cell location in the eye Cornea Lens Optic Nerve Iris Choroid Reprinted with permission from Bielory L. J Allergy Clin Immunol 2000;106:805. Conjunctiva Distribution of mast cell phenotypes Copyright permission for reproduction pending Irani A-MA, Butrus SI, Tabbara KF, et al.J Allergy Clin Immunol 1990 ;86:34-40, Irani, A-MA, ,Schwartz, LB, Clin Exp Allergy 1989; 19,143-155 Mediators and symptoms in allergic conjunctivitis Histamine Leukotrienes Prostaglandins Bradykinin, PAF Mast cell Immediate rhinitis symptoms • Itch, sneezing • Watery discharge • Nasal congestion IgE Allergen B cell Chronic rhinitis symptoms • Nasal blockage IL-4 T cell (mast cell) VCAM-1 IL-3, -5 GM-CSF Eosinophil • Loss of smell • Nasal hyperreactivity Ocular allergy Conjunctival Time Course of Cells & Mediators 120 Median Values 100 80 60 Histamine Prostaglandins Leukotrienes Tryptase Neutrophils Eosinophils Basophils Macrophages ICAM ECP 40 20 0 0 0.25 0.5 1 Time (hours) 6 24 Diagnosis and management of allergic conjunctivitis Diagnosis of allergic conjunctivitis • Detailed personal and family allergic history and physical examination • History of typical eye symptoms • Appearance of everted (flipped) eyelid • Important to look for papillary and follicular development in patients with more chronic forms of conjunctivitis. Examination of the conjunctival surface: the everted eyelid A. The eversion of the upper lid is performed by the placement of a cottontipped swab above the eyelid; B. while the patient is asked to look downward, gently grasp the upper eyelash; C. gently pull down upper eyelid while placing pressure on upper portion of eyelid with cotton swab; D. lift the eyelid over the surface of the cotton swab. Diagnosis of allergic conjunctivitis: clinical investigations • Allergy skin tests performed by an allergist and/or other well-trained physician • Measurement of allergen specific IgE antibody (Radioallergosorbent tests) • Conjunctival scrapings for eosinophils – particularly elevated in VKC, AKC and GPC • Conjunctival challenge (in specialist units) Differential diagnosis of conjunctivitis Copyright permission for reproduction pending Bielory L. In: Lieberman P, Blaiss MS, eds. Atlas of Allergic Diseases. Lippincott; Williams & Wilkins; Philadelphia, PA. :105, 2002. Differential Dx of the Red Eye Red Eye Allergic Acute Infectious Chronic Viral Immune Intraocular [Uveitis] Nonspecific Dry Eye Acne Rosacea Seasonal Perennial Vernal Keratoconjunctivitis Bacterial Extraocular e.g., Episcleritis/Scleritis Foreign Body Atopic Keratoconjunctivitis Giant Papillary Conjunctivitis Chemical Medication Other Vasomotor Ocular allergy: allergy consultation • Systemic evaluation of atopy (eczema, rhinitis, sinusitis, asthma) • Consideration for systemic immunomodulation (immunotherapy) • Systemic assessment of an autoimmune process • For persistent moderate to severe clinical allergic ocular complaints • At the patient’s request, in accordance with physician’s treatment plan Ocular Allergy: Ophthalmological Consultation • Any patient using ocular steroids for more than 2 weeks for the presence of cataracts and level of intraocular pressure • Any persistent qualities of any ocular complaint • The consideration of strong topical steroids or systemic steroids • The presence of ciliary blush suggesting uveitis • Ocular pain The ocular allergy immune response treatment targets Allergen IgE synthesis Allergen Avoidance Immunotherapy Anti-IgE Mast Cell Activation Mast Cell Stabilization Cromones Multiple Action Agents Inflammatory Mediators Mediator Antagonists Steroids Multiple Action Agents Antihistamines Leukotriene Antagonists Treatment of allergic conjunctivitis: non-pharmacological therapy • It is logical to think about allergen avoidance to airborne allergens but the evidence base for efficacy is small • Cold compresses • Preservative-free tears • Sunglasses: ameliorate photosensitivity, and may provide a degree of barrier protection against airborne allergens Pharmacotherapy of allergic conjunctivitis: vasoconstrictors and topical NSAID’s Older pharmacotherapies are commonly available over the counter but should not be abused: • vasoconstrictors - not recommended for regular use • topical NSAID’s • ketorolac Pharmacotherapy of allergic conjunctivitis: topical antihistamines • Topical antihistamines • levocabastine, emedastine, azelastine, olopatadine, ketotifen, epinastine • Topical antihistamine plus vasoconstrictor • antazoline-naphazoline, chlorpheniraminenaphazoline Pharmacotherapy of allergic conjunctivitis: oral antihistamines • May be less effective than topical therapies: May be associated with additional drying in patients with a mixed allergy and dry eye syndrome (tear film dysfunction – if oral antihistamines indicated for other reasons, give a tear film substitute) • Useful for nasal, cutaneous and ocular symptoms • If indicated for multiple allergic symptomatology, nonsedating oral antihistamines are preferable: loratadine, fexofenadine, cetirizine, desloratadine Ocular allergy relief with oral antihistamines 24-hour reflective individual symptom scores (ISS) Rhinorrhea Itchy, Watery, Red Eyes Placebo (n=201) 0 – 0.2 Improvement Mean change from baseline Sneezing Itchy Nose/ Palate/ Throat – 0.4 – 0.6 – 0.8 ** – 1.0 Howarth PH, Stern MA, Roi L, et al. J Allergy Clin Immunol 1999;104:927-933 ** * * * * Fexofenadine HCl 180 mg qd (n=202) Cetirizine 10 mg qd (n=207) *P=0.0001 Pharmacotherapy of allergic conjunctivitis: topical mast cell stabilizers • Improves healing (pannus formation) of corneal defects • DSCG • First useful mast cell stabilizer, 2-5 doses/day • Nedocromil • Effective twice daily • Lodoxamide • Highly potent, rapid relief, additional anti-eosinophilic • Pemirolast • Twice or four times daily dosing, effective for itch Pharmacotherapy of allergic conjunctivitis: multiple-action antihistamine/mast cell stabilizer • Olopatadine HCl 0.2% ocular allergy drop newly available for once daily dosing • Ketotifen 345 mcg twice daily • Azelastine 0.05% twice daily • Epinastine 0.05% twice daily Pharmacotherapy of allergic conjunctivitis: topical corticosteroids • Topical corticosteroids should only be prescribed and monitored by a suitably qualified allergist or ophthalmologist: • Only appropriate for treatment of severe allergic ocular disease – not for AAC/SAC • Prolonged use can lead to secondary bacterial infection, glaucoma and cataracts • Concern for viral or fungal infections Adverse effects of corticosteroids in the Eye Pharmacotherapy of allergic conjunctivitis: specific allergen immunotherapy (allergen vaccination) • Must be supervised by someone suitably experienced in allergen immunotherapy with facilities to treat anaphylaxis • Helpful in managing persistent allergic rhinitis and SAC and PAC • Not indicated in vernal keratoconjunctivitis or atopic keratoconjunctivitis • Of value in patients with multi-organ symptoms of IgE-mediated allergic sensitization • Risk-to-benefit ratio must be considered in all cases • Highly effective in selected patients Importance of factors for allergy medication brand selection in 2005 among allergy medication users % very important Fast-acting 81% Few side effects 79% Non-habit forming 79% Long-lasting The 2005 Gallup Study of Allergies – Phase II Report 77% Ocular allergy treatment algorithm primary Acute vs Chronic Acute Chronic Primary Treatment Cool Compresses Lubrication Ocular allergy treatment algorithm secondary Acute vs Chronic Acute Chronic Secondary Treatment Topical Antihistamines Pruritus Antihistamine/Decongestants Pruritus Erythema Multiple Action Agents Evolving Perennial Rhinoconjuntivitis Mast Cell Stabilizing Agents "Corneal Involvement" Severe Seasonal Prophylactic Ocular allergy treatment algorithm tertiary treatment (1) Acute vs Chronic Acute Tertiary Treatment Oral Antihistamines Multiple Action Agents Topical Steroids Immunotherapy Alrex Vexol Ocular allergy treatment algorithm tertiary treatment (2) Acute vs Chronic Chronic Tertiary Treatment Oral Antihistamines Topical Steroids FML Dexamethasone Multiple Action Agents Immunomodulation Cyclosporine Tacrolimus anti-IgE Summary • Allergic conjunctivitis is a common condition, • It is frequently underdiagnosed and inappropriately treated • It may present to different health professionals; pharmacist, GP, allergist, ophthalmologist • Conjunctivitis is an important symptom of allergic rhinoconjunctivitis • An understanding of the underlying pathophysiology defines appropriate management World Allergy Organization (WAO) For more information on the World Allergy Organization (WAO), please visit www.worldallery.org or contact the: WAO Secretariat 555 East Wells Street, Suite 1100 Milwaukee, WI 53202 United States Tel: +1 414 276 1791 Fax: +1 414 276 3349 Email: [email protected]