ICON: Diagnosis and management of allergic conjunctivitis

Evaluation on the clinical findings and allergological factors of local allergic conjunctivitis and non-local allergic conjunctivitis

We previously reported that 16.9% of allergic conjunctival disease cases were local allergic conjunctivitis (LAC). We therefore retrospectively investigated the pathological and clinical changes of LAC. Tear, conjunctival, and blood tests were performed on 313 patients with allergic conjunctival disease. A total of 313 patients with allergic conjunctival disease were surveyed using tear, conjunctival, and blood tests and QOL Questionnaire. In addition, we retrospectively examined the clinical test results of patients who agreed to re-examination more than one year after being diagnosed with LAC. Of the 313 cases, 44 were diagnosed as LAC (age ranged in 11-85 years (mean 67.8 years)) and 269 were diagnosed as non-LAC (7-92 years (mean 58.2 years)). There were 6 males (13.6%) and 38 females (86.4%), with more females even after age adjustment (p = 0.043). A QOL survey showed that LAC was characterized by less interference with daily life than non-LAC. After re-examination, 6 of 12 patients (50.0%) remained with LAC, while the remaining half changed to non-LAC. LAC was more common in older women than non-LAC. Considering the clinical change from LAC to non-LAC, it is speculated that the pathology of LAC may change over time.

Current perspectives on topical antiallergics

Allergy is one of the most common diagnoses in an ocular surface clinic, and its treatment can range from a simple lubricant to the most complex combinations of medications belonging to several diverse classes. Antiallergics are the most commonly used medication overall in all forms of allergy. Several options are available, and it is important to understand how to start, select, and continue their use. Understanding the nature and severity of allergy is key to understand the effectiveness and limitations of this class of drugs in each patient. The article provides a brief overview of antiallergics in the for the busy practitioner.

Global Ragweed Allergy: Molecular Allergens and Integrated Control Strategies

Originally native to North America, ragweed has become a pervasive invasive species worldwide over the past century, posing a substantial public health risk as a potent allergen. This review explores the key allergens found in common ragweed, assesses global trends in ragweed sensitization, particularly in China, and examines various therapeutic and biological control methods. There are currently 11 identified ragweed allergens, with Amb a 1 and 11 recognized as the primary triggers. Epidemiological data indicate higher rates of sensitization in North America and Europe, with a growing trend observed in China. Ragweed-induced type I hypersensitivity typically presents as seasonal allergic rhinitis, conjunctivitis, and asthma symptoms. Strategies for managing ragweed allergy include allergen avoidance, pharmacotherapy, and allergen immunotherapy (AIT). Biological control using Ophraella communa and Epiblema strenuana effectively limits ragweed proliferation. Accurate allergen identification and personalized treatment can significantly reduce the health burden associated with ragweed. An in-depth understanding of ragweed sensitization patterns and biological control measures is essential for the long-term prevention of ragweed allergies.

Knowledge attitude and practice of patients with allergic conjunctivitis towards their disease

Allergic conjunctivitis is a common ocular allergic condition. This study aimed to assess the knowledge, attitude, and practice (KAP) regarding allergic conjunctivitis among patients. A cross-sectional study was conducted at the outpatient clinic of the Eye Hospital of China Academy of Chinese Medical Sciences from March to June 2024. Patients completed an online self-designed questionnaire to gather demographic data and KAP scores, which were compared across demographics. Correlations among KAP scores were analyzed, and factors influencing practices were explored using multivariate logistic regression. Structural equation modeling (SEM) was utilized to validate the KAP hypothesis. A total of 482 valid questionnaires were collected, yielding a validity rate of 93.77%. Among the respondents, 329 (68.26%) were female. The mean scores were 11.48 ± 6.90 (knowledge), 29.70 ± 4.33 (attitude), and 31.09 ± 8.71 (practice). Significant positive correlations were found between knowledge and attitude (r = 0.214, P < 0.001), knowledge and practice (r = 0.352, P < 0.001), and attitude and practice (r = 0.303, P < 0.001). SEM indicated that knowledge directly influenced attitude and, in turn, influenced practice. The study highlights a knowledge gap about allergic conjunctivitis, indicating a need for targeted educational interventions to improve attitudes and practices.

Ophthalmic Formulations for the Treatment of Allergic Conjunctivitis and Their Effect on the Ocular Surface: A Review of Safety and Tolerability Assessments in Clinical Trials

Allergic conjunctivitis (AC) is the most common allergic eye disorder. Antiallergic eyedrops are the first line of pharmacological treatment. However, the application of antiallergic eyedrops can potentially alter tear homeostasis and affect the ocular surface, which may result in iatrogenic diseases such as dye eye disease (DED). Long-term treatment of AC with eyedrops containing preservatives and other components may increase the risk of DED and ocular surface damage. Here, we examined 20 clinical trials published during the past ten years with antihistamine ophthalmic formulations in the treatment of AC, to evaluate the extent of evidence about their safety and tolerability. Remarkably, we find that most trials lack an evaluation of the critical ocular surface parameters, such as tear film break-up time, tear volume, corneal and conjunctival damage, and inflammation, to properly assess the state of the ocular surface state after prolonged treatment. There is a need to increase awareness of the use of specific formulations that do not increase the risk of iatrogenic DED.

Safety and efficacy of a novel 0.5% epinastine topical eyelid cream in allergic conjunctivitis: a phase 3 trial

PURPOSE

The high prevalence of allergic conjunctivitis in Japan necessitates novel, easy-to-use treatment options for prophylactic use. We evaluated the safety and efficacy of a newly-developed 0.5% epinastine topical eyelid cream to prevent the development of allergic conjunctivitis.

STUDY DESIGN

This was a phase 3, single-centre, double-masked, intra-patient randomised trial in asymptomatic adults (aged 20-65 years) with seasonal allergic conjunctivitis in Japan.

METHODS

The left and right eyes of eligible patients were randomised to receive a topical application of either 0.5% epinastine cream (~ 30 mg per dose) to one eye or placebo cream to the other (on the outer skin of the upper and lower eyelids) after a conjunctival antigen challenge (CAC) test. Symptom severity was assessed up to 24 h post-treatment. Primary efficacy endpoints were mean ocular itching and conjunctival hyperaemia severity scores in each eye; safety endpoints included adverse events (AEs) and adverse drug reaction (ADRs).

RESULTS

In total, 30 patients (60 eyes) were included in the study. The 0.5% epinastine topical eyelid cream reduced mean ocular itching scores (difference in least squares means ± standard error, - 1.12 ± 0.214; p < 0.0001) and mean conjunctival hyperaemia scores (- 0.54 ± 0.197; p = 0.0097) 24 h after treatment versus placebo. The 0.5% epinastine topical eyelid cream was well tolerated, with no AEs or ADRs reported.

CONCLUSION

With its novel route of administration, 0.5% epinastine topical eyelid cream may be considered a unique, easy-to-use, once-daily treatment option to prevent the onset of seasonal allergic conjunctivitis.

Novel therapeutic receptor agonists and antagonists in allergic conjunctivitis

PURPOSE OF REVIEW

Allergic conjunctivitis is characterized by the development of pathophysiological changes to the ocular surface, which occurs when pro-allergic and pro-inflammatory mediators interact with their cognate receptors expressed on immune and nonimmune cells. Traditional treatments with antihistamines and corticosteroids provide relief, but there is a need for more efficacious and tolerable long-term therapy with a better safety profile. This article aims to provide an overview of the mode of action and clinical application of agonist therapies targeting glucocorticoid, melanocortin, and toll-like receptors, as well as antagonist therapies targeting cytokine, chemokine, integrin, and histamine receptors.

RECENT FINDINGS

There has been considerable advancement in immunology and pharmacology, as well as a greater understanding of the cellular and molecular mechanisms of allergic conjunctivitis. Recent research advancing therapy for allergic conjunctivitis has focused on developing synthetic molecules and biologics that can interfere with the process of the allergic immune reaction.

SUMMARY

This review discusses novel therapeutic receptors being explored agonistically or antagonistically to develop alternative treatment options for allergic conjunctivitis. These novel approaches hold promise for improving the management of allergic eye diseases, offering patients hope for more effective and safer treatment options in the future.

Ocular surface disorders: office procedures for the allergist/clinical immunologist

PURPOSE OF REVIEW

Ocular surface disorders (OSDs) are a prevalent and often debilitating condition encountered in clinical practice, particularly by allergists and clinical immunologists.

RECENT FINDINGS

A comprehensive guide to office procedures for evaluating and managing OSDs, with a specific focus on ocular allergies, would assist in the evaluation process that begins with an initial patient assessment utilizing standardized forms to systematically gather detailed medical history, symptomatology, and environmental exposure data. This structured approach ensures a thorough understanding of the patient's condition and facilitates targeted interventions. In addition to allergy testing, the assessment of the tear film is essential for a comprehensive evaluation of OSDs. The Schirmer test is employed to quantify tear production, providing objective data on tear film adequacy and guiding interventions for tear film deficiencies.

SUMMARY

This multifaceted diagnostic approach ensures that all contributing factors to OSDs are identified and appropriately managed. By integrating these office procedures, allergists and clinical immunologists can enhance their diagnostic accuracy and therapeutic efficacy, ultimately improving patient outcomes. This manuscript provides a practical resource, outlining some of the methodologies and clinical applications of each procedure, and highlighting their role in the holistic management of OSDs in allergic patients.

The NLRP3 inflammasome in allergic diseases: mechanisms and therapeutic implications

In recent years, there has been a global increase in the prevalence of allergic diseases, including allergic rhinitis, chronic rhinosinusitis, allergic asthma, atopic dermatitis, allergic conjunctivitis, and food allergies. Since the pathogenic mechanisms of these allergic diseases are not yet fully understood, targeted and effective therapies are lacking. The NLRP3 inflammasome, a multiprotein complex implicated in various inflammatory diseases, can be activated by diverse stimuli. It assembles into NLRP3 inflammasome complexes through conformational changes, initiating the proteolytic cleavage of dormant procaspase-1 into active caspase-1 and promoting the maturation of inflammatory cytokines, including IL-1β and IL-18. Dysfunction of the NLRP3 inflammasome may serve as a key driver of inflammatory diseases, leading to pyroptosis and amplifying the local inflammatory response. As preliminarily demonstrated, specific NLRP3 inflammatory vesicle inhibitors play refectory roles in animal models of allergic diseases, and it is believed that specific NLRP3 inflammasome inhibitors may be potential therapeutic agents for allergic diseases. This review highlights the progress of research on the NLRP3 inflammasome in allergic diseases, explores its contribution to different types of allergic diseases, and identifies promising clinical targets for intervention.

A Randomized, Multicenter Phase 3 Clinical Trial Evaluating Intracanalicular Dexamethasone Insert for the Treatment of Allergic Conjunctivitis

Purpose

To evaluate the efficacy and safety of a dexamethasone intracanalicular insert (DEX) for treatment of allergic conjunctivitis (AC).

Patients and Methods

In this multicenter, randomized, double-masked, placebo-controlled phase 3 study, adults (≥18 years) with AC were randomized 1:1 to DEX or placebo insert (PBO) placed bilaterally. Subjects underwent repetitive conjunctival allergen challenges (CAC) across 30 days and were assessed for changes in AC signs and symptoms. The primary endpoint was ocular itching score at 3, 5, and 7 minutes post-CAC at Day 8 (7 days post-insertion). This trial is registered on ClinicalTrials.gov (NCT04050865).

Results

Ninety-six subjects were randomized (n=48 DEX, n=48 PBO). Compared to PBO, there were statistically significant treatment differences favoring DEX for the primary endpoint of mean ocular itching score at Day 8 (-0.86, -0.98, -0.96 at 3, 5, and 7 minutes post-CAC respectively; P<0.0001 for all). Treatment differences favored DEX for all 24 time points across 6 visits and were statistically significant (P<0.05) except for the first post-insertion (Day 7, 3 minutes). For the 18 time points at which conjunctival redness was assessed, DEX had lower scores than PBO (P<0.05 for all). The most common ocular adverse events (AEs) in DEX subjects were eye discharge and irritation. No serious AEs, elevated intraocular pressure, dacryocanaliculitis, or use of rescue medications were reported.

Conclusion

Results of this study support the potential use of dexamethasone insert as a physician-administered, preservative-free treatment for AC, with significant improvements in ocular itching and conjunctival redness compared with placebo. The dexamethasone insert was generally safe with a favorable safety profile.

Ocular effects of eye cosmetic formulations

OBJECTIVE

To study the ocular effects seen among eye cosmetic wearers in the Indian Population.

METHODS

This cross-sectional study was conducted on female participants who had fulfilled the inclusion and exclusion criteria. A detailed history was obtained and thorough ophthalmic evaluation was done. Mann Whitney U test was used. Statistical analysis was done using IBM SPSS. p < .05 was taken as the level of statistical significance.

RESULTS

Among a total of 225 participants in our study, the mean age was 24.23 ± 1.8, which comprised of young student females. Majority of the females used one eye cosmetic with Kajal (n = 156) being the most predominant. Most frequently encountered symptom upon using eye cosmetics was watering from eyes and ocular pain was the least encountered symptom. Anterior segment examination showed- allergic conjunctivitis and meibomian gland dysfunction being the most and least predominant, respectively. Our study highlights that Kajal predisposes the eyes to significant ocular morbidity with p = .039 for dry eye disease, p = .041 for allergic conjunctivitis, p = .036 for conjunctival pigmentation. Prolonged use of such formulations for more than 4 times a week (p = .046) or even daily (p = .031) for a duration of either 1-5 years (p = .033) or greater than 5 years (p = .027) was found to be statistically significant in causing ocular signs. Non removal of eye cosmetics at the end of the day was significant in causing allergic conjunctivitis (p = .035) and conjunctival pigmentation (p = .021). Plain tap water has been found to be the least effective technique in the removal of such ocular cosmetics with a statistical significance of p = .031 in causing ocular signs.

CONCLUSIONS

Eye cosmetics are a significant contributor to the development of ocular surface diseases. Removal of products along with decreased usage seems to be a significant contributor in dampening unwanted adverse effects.

Polymeric Mixed Micelle-Loaded Hydrogel for the Ocular Delivery of Fexofenadine for Treating Allergic Conjunctivitis

This study was designed to formulate a polymeric mixed micelle (PMM) formulation to sustainably release fexofenadine (FEX) to treat allergic conjunctivitis effectively. A 32 factorial design was employed where the studied factors were PL90G amount (X1) and Pluronic (F127 and P123) mixture ratio (X2), and the dependent variables were entrapment efficacy (EE, Y1, %), particle size (PS, Y2, nm), zeta potential (ZP, Y3, mV), and the percent of drug released after 6 h (Q6h, Y4, %). The optimized formula was blended with a hydrogel base to develop an FEX-PMM hydrogel, where the safety and efficiency of this hydrogel were evaluated using in vivo studies. The EE% of FEX-PMM ranged from 62.15 ± 2.75 to 90.25 ± 1.48%, the PS from 291.35 ± 6.43 to 467.95 ± 3.60 nm, the ZP from -5.41 ± 0.12 to -9.23 ± 0.23 mV, and the Q6h from 50.27 ± 1.11 to 95.38 ± 0.92%. The Draize test results confirmed the safety of the FEX-PMM hydrogel. Furthermore, the FEX-PMM hydrogel showed rapid recovery in animals with induced allergic conjunctivitis compared to the free drug hydrogel. These results assure PMM's capability to deliver FEX to the conjunctival surface in a sustained pattern, consequently achieving better therapeutic outcomes.

The updated role of budesonide in managing children and adolescents with allergic rhinitis

Allergic rhinitis (AR) is a prevalent disease in childhood and adolescence. A type 2 inflammation characterizes AR and, mainly, sustains nasal obstruction. Budesonide aqueous nasal spray (BANS) is an intranasal corticosteroid (INCS) available since the early 1980s. BANS is indicated for treating allergic rhinitis. There is evidence about its efficacy in treating children and adolescents with seasonal and perennial AR. In addition, BANS is safe with negligible local and systemic side effects. Recent guidelines for patients with AR recommend the use of INCS as first line in many situations. In particular, AR patients (and their parents) may assess the perception of symptoms' severity using the Visual Analog Scale (VAS). A score ≥5/10 means uncontrolled symptoms and requires adequate treatment. BANS could appropriately be used in patients with uncontrolled symptoms and/or moderate/severe nasal obstruction. In conclusion, BANS represents a valuable option in managing children and adolescents with AR.

Multidisciplinary management of type 2 inflammation diseases using a screening tool

Dysregulation of type 2 (T2) immune response leads to an aberrant inflammatory reaction that constitutes the pathophysiological basis of diseases involving various organs. For this reason, several disorders can coexist in a single patient; however, as different specialists often treat these pathologies, T2 dysregulation, particularly when mild, is not always the first diagnostic suspicion. A breakdown in interdisciplinary communication or the lack of adequate tools to detect these entities can delay diagnosis, and this, together with a lack of coordination, can lead to suboptimal care. In this context, a multidisciplinary group of specialists in pneumology, immunology, allergology, dermatology and otorhinolaryngology compiled a list of the cardinal symptoms reported by patients presenting with T2 inflammation-related diseases: asthma, chronic rhinosinusitis, allergic rhinitis, allergic conjunctivitis, IgE-mediated food allergy, atopic dermatitis, eosinophilic oesophagitis, and NSAID-exacerbated respiratory disease (NERD). Using this information, we propose a simple, patient-friendly questionnaire that can be administered at any level of care to initially screen patients for suspected coexisting T2 diseases and referral to the appropriate specialist.

Diagnosis and Treatment of Vernal Keratoconjunctivitis: A Qualitative Study of Caregiver, Patient, and Clinician Experience in the United States

PURPOSE

To better understand the patient journey and challenges in the diagnosis and treatment of patients with vernal keratoconjunctivitis (VKC).

METHODS

This qualitative study assessed the experience of caregivers of children with VKC (n = 7) and of clinicians who treat VKC (n = 16) in the United States. The structured interviews were conducted to identify key "pain points", obstacles, and trends on the path to diagnosis.

RESULTS

Like an earlier study conducted in the United Kingdom, this study found low awareness of the nature and severity of VKC among U.S. caregivers and non-specialist providers, and a tendency among young patients and their caregivers to downplay initial symptoms. Medical intervention was delayed as caregivers treated symptoms with over-the-counter medications; 88% (14 of 16) of specialists reported frequent misdiagnosis and mistreatment by pediatricians and primary care providers who were initial points of care. Time to appropriate referral ranged from 1 to 2 weeks to 3 months, in part due to convoluted referral pathways that were universal points of frustration for caregivers and specialists.

CONCLUSIONS

Limited awareness of VKC remains a barrier to timely identification and management of this rare but disruptive ocular surface disease. Caregivers underestimate symptom severity, pediatricians and primary care providers often misdiagnose VKC as allergy or infection, and referrals to appropriate specialists are delayed until symptoms are severe. Early identification is essential to improving the diagnostic journey and treatment of VKC. [J Pediatr Ophthalmol Strabismus. 2024;61(4):252-256.].

Evaluation methods using tear volume in a conjunctivitis mice model

Allergic conjunctival disease is an immune-mediated inflammatory disease of the conjunctiva. To develop clinically useful drugs, it is necessary to develop quantitative evaluation methods that reflect the clinical symptoms in experimental animal models. Allergic conjunctivitis model mice were systemically sensitised with ovalbumin (OVA) administered intraperitoneally and locally sensitised with OVA eye drops between day 14-28. Next, conjunctivitis induced by ocular administration of OVA solution to sensitised mice was evaluated based on tear volume. Additionally, we evaluated increase in tear volume induced by direct ocular instillation of histamine, compound 48/80, and carrageenan. An increase in antigen-induced tear volume was observed in the mice model. Additionally, direct instillation of histamine, compound 48/80, and carrageenan increased tear volume. Furthermore, levocabastine inhibited the increase in tear volume in antigen-induced allergic conjunctivitis and histamine- and compound 48/80-induced conjunctivitis models. In contrast, betamethasone suppressed carrageenan-induced tear volume but not histamine- or compound 48/80-induced tear volume. Histamine may be involved in increased tear volume in allergic conjunctivitis. Betamethasone is not directly involved in the action of histamine and is thought to suppress increase in tear volume. Evaluation of tear volume in a conjunctivitis mice model is highly quantitative; therefore, it is possible to evaluate drug efficacy. This is considered a useful index compared with conventional methods.

Allergic Conjunctivitis Management: Update on Ophthalmic Solutions

PURPOSE OF REVIEW

The aim of this review, is to present an updated revision of topical management of SAC and PAC, based on the available scientific evidence and focused on the impact of ophthalmic solution formulations on eye surface.

RECENT FINDINGS

Physicians treating ocular allergy should be aware of tear film and tear film disruption in SAC and PAC, and how eye drop composition and additives affect the physiology of the allergic eye. Seasonal and perennial allergic conjunctivitis (SAC and PAC) are the most frequent causes of ocular allergy (OA), and both conditions are underdiagnosed and undertreated. SAC and PAC are immunoglobulin E (IgE)-mediated hypersensitivity reactions. The additional tear film disruption caused by the release of inflammatory mediators increases and exacerbates the impact of signs and symptoms and may trigger damage of the ocular surface. Comorbidities are frequent, and dry eye disease in particular must be considered. Clinical guidelines for the management of SAC and PAC recommend topical therapy with antihistamines, mast cells stabilizers or dualaction agents as first-line treatment, but care should be taken, as many medications contain other compounds that may contribute to ocular surface damage.

Treatment of Vernal Keratoconjunctivitis Using Upadacitinib

This case report presents a case of improvement of vernal keratoconjunctivitis associated with initiation of an oral Janus kinase inhibitor upadacitinib.

Allergic Conjunctivitis: Review of Current Types, Treatments, and Trends

Allergic conjunctivitis is an allergen-induced immune response secondary to the binding of immunoglobulin-E (IgE) to sensitized mast cells. Approximately 40% of North Americans and 20% of the world's population are impacted by some form of allergy and it continues to increase in prevalence, especially among children. Specified IgE antibodies can be found in almost all cases of exposure to seasonal or perennial allergens. Activation and degranulation of mast cells lead to increased tear levels of histamine, tryptase, leukotrienes, cytokines, and prostaglandins. The release of these factors initiates the recruitment of inflammatory cells in the conjunctival mucosa, which causes the late-phase reaction. Signs and symptoms of ocular allergies include itching, tearing, chemosis, and hyperemia, which can lead to decreased productivity and poor quality of life. Many treatment options are available to improve symptoms, including, mast cell stabilizers, antihistamines, dual-acting agents, steroids, nonsteroidal anti-inflammatory drugs (NSAIDS), and other off-label treatment modalities. This review article provides an overview of different types of allergic conjunctivitis, its pathology and immunology, and recommended methods of treatment.

TPX2 upregulates MMP13 to promote the progression of lipopolysaccharide-induced osteoarthritis

Purpose

This study seeks to identify potential clinical biomarkers for osteoarthritis (OA) using bioinformatics and investigate OA mechanisms through cellular assays.

Methods

Differentially Expressed Genes (DEGs) from GSE52042 (four OA samples, four control samples) were screened and analyzed with protein-protein interaction (PPI) analysis. Overlapping genes in GSE52042 and GSE206848 (seven OA samples, and seven control samples) were identified and evaluated using Gene Set Enrichment Analysis (GSEA) and clinical diagnostic value analysis to determine the hub gene. Finally, whether and how the hub gene impacts LPS-induced OA progression was explored by in vitro experiments, including Western blotting (WB), co-immunoprecipitation (Co-IP), flow cytometry, etc.

Result

Bioinformatics analysis of DEGs (142 up-regulated and 171 down-regulated) in GSE52042 identified two overlapping genes (U2AF2, TPX2) that exhibit significant clinical diagnostic value. These genes are up-regulated in OA samples from both GSE52042 and GSE206848 datasets. Notably, TPX2, which AUC = 0.873 was identified as the hub gene. In vitro experiments have demonstrated that silencing TPX2 can alleviate damage to chondrocytes induced by lipopolysaccharide (LPS). Furthermore, there is a protein interaction between TPX2 and MMP13 in OA. Excessive MMP13 can attenuate the effects of TPX2 knockdown on LPS-induced changes in OA protein expression, cell growth, and apoptosis.

Conclusion

In conclusion, our findings shed light on the molecular mechanisms of OA and suggested TPX2 as a potential therapeutic target. TPX2 could promote the progression of LPS-induced OA by up-regulating the expression of MMP13, which provides some implications for clinical research.

The new preservative-free ophthalmic formulation of bilastine 0.6% preserves the ocular surface epithelial integrity in a comparative in vitro study

Allergic conjunctivitis (AC) is the most common form of allergic eye disease and an increasingly prevalent condition. Topical eye drop treatments are the usual approach for managing AC, although their impact on the ocular surface is not frequently investigated. The aim of this study was to perform a comparative physicochemical characterization, and in vitro biological evaluations in primary conjunctival and corneal epithelial cells of the new multidose preservative-free bilastine 0.6% and main commercially available eye drops. MTT assay was used to measure cell viability; oxidative stress was analyzed with a ROS-sensitive probe; and apoptosis was evaluated monitoring caspase 3/7 activation. Differences in pH value, osmolarity, viscosity and phosphate levels were identified. Among all formulations, bilastine exhibited pH, osmolarity and viscosity values closer to tear film (7.4, 300 mOsm/l and ~ 1.5-10 mPa·s, respectively), and was the only phosphates-free solution. Single-dose ketotifen did not induce ROS production, and single-dose azelastine and bilastine only induced a mild increase. Bilastine and single-dose ketotifen and azelastine showed high survival rates attributable to the absence of preservative in its formulation, not inducing caspase-3/7-mediated apoptosis after 24 h. Our findings support the use of the new bilastine 0.6% for treating patients with AC to preserve and maintain the integrity of the ocular surface.

Budenoside aqueous nasal spray: an updated reappraisal in rhinitis management

Allergic rhinitis (AR) and nonallergic rhinitis are prevalent diseases. In western countries, type 2 inflammation usually characterizes these medical conditions and mainly sustains nasal obstruction. Budesonide aqueous nasal spray (BANS) is an intranasal corticosteroid (INCS) that has been available since the early 1980s. BANS is indicated for treating allergic rhinitis, nonallergic rhinitis, and nasal polyps (both as treatment and prevention after surgery). Consolidated evidence confirms its efficacy in treating seasonal and perennial AR, and nonallergic rhinitis. In addition, BANS is safe with negligible local and systemic side effects. Recent guidelines for patients with AR recommend using INCS as the first line in many situations. In particular, patients may assess the perception of symptoms' severity using the Visual Analog Scale. A score ≥5/10 means uncontrolled symptoms and requires adequate treatment. BANS could appropriately be used in patients with uncontrolled symptoms and/or moderate/severe nasal obstruction. In conclusion, BANS represents a valuable option in managing patients with type 2 inflammation of the nose.

Evaluation of Allergic Conjunctivitis Prevalence and Attitude Toward Prevention and Control in Saudi Arabia

BACKGROUND

Allergic conjunctivitis (AC) is a prevalent ocular condition with a substantial impact on individuals' quality of life. This study aimed to explore the demographic patterns, prevalence, symptoms, awareness, and attitudes associated with AC, while also examining potential associations with gender, age, and region of residence in Saudi Arabia.

METHODS

A cross-sectional study was conducted involving 487 participants. Data was collected through a self-administered questionnaire that included demographic information about AC prevalence, symptoms, attitudes, and awareness levels. Statistical analyses, including chi-square tests, were employed to examine associations between variables.

RESULTS

The study revealed a prevalence of AC (89, 18.3%) with common symptoms being eye redness (73, 82%) and itching (73, 82%). Participants displayed diverse awareness levels, with (376, 77.2%) correctly defining AC. The majority demonstrated either a good (230, 47.2%) or insufficient (196, 40.2%) attitude, while 54 (11.1%) had a sufficient attitude, and 7 (1.4%) exhibited an excellent attitude and awareness. Significant regional disparities were observed, impacting both prevalence and attitudes. While no gender differences were noted, the age group of 31-40 displayed a higher prevalence.

CONCLUSION

In this study, among 487 participants, the prevalence of AC was found to be 89 (18.3%). Meanwhile, attitude levels varied, with the majority demonstrating either a good or insufficient attitude. This provides valuable insights into the prevalence, symptoms, and awareness of AC in our population. The regional disparities underscore the need for tailored interventions addressing specific geographical contexts. The findings contribute to the broader understanding of AC, emphasizing the importance of targeted education and regional considerations in managing and preventing this condition.

[New and future treatment approaches for allergic conjunctivitis]

BACKGROUND

In severe and recurrent ocular allergies conventional ophthalmic drugs can reach their limits, especially in chronic forms. The first novel immunomodulators and biologicals are already in clinical use and could provide relief.

OBJECTIVE

Based on the immunopathophysiological mechanisms of ocular allergies, possible targets for innovative treatment approaches are presented. An overview of promising new and future immunomodulators and biologicals and their modes of action is also given.

MATERIAL AND METHODS

Current reviews on ocular allergies and the treatment of systemic allergic diseases were screened. Case reports on the treatment of ocular allergy using immunomodulators and biologicals were analyzed. The clinical relevance and possible applications are presented.

RESULTS

In chronic forms of ocular allergies, complex ocular surface inflammatory responses mediated via immunoglobulin E (IgE), mast cells, CD4-positive type 2 T‑helper cells and eosinophilic granulocytes are predominant. Cyclosporine A 0.1% eyedrops have been approved in Europe since 2018 for children aged 4 years and older with severe vernal keratoconjunctivitis (VKC). In addition, case reports present promising data on the systemic off-label use of biologicals, such as dupilumab or omalizumab, in refractory VKC or atopic keratoconjunctivitis (AKC).

CONCLUSION

A profound understanding of the immunopathophysiology of ocular allergies is necessary to detect further targets for future immunomodulators and biologicals. Currently, immunomodulatory therapy remains limited to cyclosporine A eyedrops. Other immunomodulatory agents, such as tacrolimus and biologicals can only be used off-label. Further studies on the controlled clinical use of these substances in the treatment of VKC or AKC are underway.

Management of vernal keratoconjunctivitis: Navigating a changing treatment landscape

Vernal keratoconjunctivitis (VKC) is a chronic, progressive, and potentially sight-threatening form of ocular inflammatory disease that primarily affects children and young adults. Prevalence varies by region, ranging from <2 per 10,000 in the United States to as high as 1,100 per 10,000 in parts of Africa. The rarity of VKC in developed countries can make differential diagnosis challenging, and treatment is often delayed until the disease is advanced, and symptoms are significantly impacting patients' quality of life. Although once viewed primarily as an immunoglobulin E-mediated condition, approximately 50% of patients with VKC do not exhibit allergic sensitization. It is now recognized that the immunopathology of VKC involves multiple inflammatory pathways that lead to the signs, symptoms, and conjunctival eosinophilic and fibroproliferative lesions that are a hallmark of the disease. We examine the evolution of our understanding of the immunopathology of VKC, the expanding VKC treatment armamentarium, the clinical implications of emerging treatment approaches, and future directions for VKC research and practice.

Food-specific IgG4-guided diet elimination improves allergy symptoms in children

Allergic diseases in children are major public health concerns due to their widespread and rising prevalence. Food-specific immunoglobulin G4(FS-IgG4) has been detected in patients with allergic diseases, but its clinical significance is still debated. In the present study, 407 children with allergic diseases were recruited and categorized into three groups according to the different systems involved: the respiratory system group, the skin system group, and a multiple system group, with the collection of clinical symptoms and serum antibodies, including total immunoglobulin E (IgE), house dust mite (HDM) IgE, food-specific IgE (FS-IgE), and FS-IgG4. Part of these patients were followed up with the intervention of FS-IgG4-guided diet elimination with or without add-on probiotics supplement. The analysis at baseline revealed distinct serum levels of different antibodies. The positive rate of FS-IgG4 in all groups was more than 80%, and the proportion of total IgE and FS-IgG4 both positive in the multi-system group was the highest (p=0.039). Egg and milk were the foods with the highest positive rate of FS-IgG4 in all groups. After diet elimination for more than 3 months, serum FS-IgG4 in children significantly decreased (P<0.05) along with the improvement of clinical symptoms, regardless of the add-on of probiotics. However, the intervention did not impact the serum levels of total IgE, FS-IgE, and HDM IgE. There was no further decrease of serum FS-IgG4 level in children followed up for more than 1 year, which may be related to noncompliance with diet elimination. Multivariate regression analysis revealed that the decline of serum FS-IgG4 was an independent predictable factor for the improvement of clinical symptoms (adjusted OR:1.412,95%CI 1.017-1.96, p=0.039). The add-on of probiotics showed less efficiency in reducing the FS-IgG4 level in more patients with relief of clinical symptoms. Our results confirmed the correlation between FS-IgG4 and allergic diseases, and the decreased FS-IgG4 could be a useful predictor for the improvement of allergic symptoms. FS-IgG4-guided diet elimination is an efficient treatment for allergic diseases. Our study adds solid data to the clinical significance of FS-IgG4 in allergic diseases.

NLRP3 inflammasome-a likely target for the treatment of immunologic conjunctivitis: A protocol for systematic review and meta-analysis

BACKGROUND

Immune-mediated conjunctivitis is a prevalent ocular ailment characterized by inflammation and immune reactions in the conjunctiva. However, the precise causes and therapeutic approaches for this condition remain the main focus for numerous ophthalmological specialists. Recently, accumulating evidence from human and mouse experiments has demonstrated the critical involvement of the NLRP3 inflammasome, IL-1β, and IL-18 in the development of allergic diseases. Targeting specific NLRP3 inflammasome and its related inhibitors may hold potential as therapeutic agents for immunologic conjunctivitis. Despite this, there has been no systematic review specifically addressing the treatment of immunologic conjunctivitis related to NLRP3. Therefore, this study aims to conduct a systematic review and meta-analysis of currently published randomized controlled trials (RCTs) on NLRP3-related treatments for immunologic conjunctivitis patients, with the goal of evaluating their efficacy and safety.

METHODS

We will conduct a comprehensive search for relevant studies on NLRP3 inflammasome inhibitors or NLRP3-related treatments for immunologic conjunctivitis in various databases including PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang. The search will encompass studies from their respective inception dates to July 2023. A meta-analysis will be performed using data extracted from eligible randomized controlled trials (RCTs), focusing on the clinical manifestations of immunologic conjunctivitis, levels of NLRP3-related factors in serum or tear samples, quality of life outcomes, and adverse events. Review Manager 5.4.1 software will be employed for the meta-analysis, and the results will be analyzed using either random-effects or fixed-effects models, depending on the presence of heterogeneity. The reliability and quality of evidence will be evaluated using the Grading of Recommendations, Development, and Evaluation (GRADE) system.

RESULTS

The findings of this study will yield robust and high-quality evidence regarding the efficacy and safety of NLRP3-related treatments for immunologic conjunctivitis. This evidence will contribute significantly to our understanding of the potential benefits and risks associated with such treatments and will assist healthcare professionals in making informed decisions regarding the management of immunologic conjunctivitis.

CONCLUSION

This study represents the first comprehensive meta-analysis aiming to evaluate the efficacy and safety of NLRP3-related treatments for immunologic conjunctivitis. The findings from this study will provide valuable evidence to guide clinical management strategies for this disease. The results are anticipated to significantly contribute to the understanding of the therapeutic potential and safety profile of NLRP3-related treatments, offering valuable insights for healthcare professionals involved in the care of patients with immunologic conjunctivitis.

TRIAL REGISTRATION

Systematic review registration: PROSPERO with registration number CRD42023437076.

Allergen-specific IgE in the tear fluid of Chinese patients with common allergic conjunctivitis in autumn and winter

PURPOSE

In this study, we determined the positive rates of allergen-specific immunoglobulin E (IgE) in the tear fluid of Chinese patients with common allergic conjunctivitis (AC) in autumn and winter, compared systemic and ocular allergen tests, and explored the correlation between the numbers and categories of allergens and clinical AC features.

METHODS

This cross-sectional study recruited 44 patients with AC (86 eyes). Specific IgEs for allergens common in China (house dust mite, cat/dog dander, mugwort/ragweed pollen, cottonwood/willow/elm pollen, milk, egg whites, soybeans) were measured in collected tears using kits for allergen-specific IgE antibodies. AC signs and symptoms were graded according to severity.

RESULTS

Specific IgE in tears was positive in 87.2% of eyes. House dust mite was the most common allergen (86.0%), followed by cat (24.4%) and dog (7.0%) dander; tree and grass pollen accounted for only 4.7% and 2.3%, respectively. Food allergens were not detected. The positive rates of the systemic allergen tests were lower than in tear fluid tests in both eyes, especially for house dust mites (P = 0.000). In patients with more allergens, itching was more severe (P = 0.035), while conjunctival hyperemia was milder (P = 0.002).

CONCLUSION

In autumn and winter, the most common AC allergen in Chinese patients was house dust mites. Compared with systemic allergen tests, measuring specific IgE in tears may be a non-invasive method to diagnose and evaluate AC severity, which may be more suitable to reflect the local conditions of ocular surface inflammation due to its high positive rate and convenience.

Efficacy and Toxicity Evaluation of Bepotastine Besilate 1.5% Preservative-Free Eye Drops Vs Olopatadine Hydrochloride 0.2% Bak-Preserved Eye Drops in Patients with Allergic Conjunctivitis

Purpose

To study the efficacy and toxic effects of bepotastine besilate 1.5% preservative-free (BB-PF) and olopatadine 0.2% BAK-preserved (OL-BAK) drops on the ocular surface of patients with allergic conjunctivitis.

Patients and Methods

Ninety-seven patients with allergic conjunctivitis diagnosis participated in a prospective, multicenter, randomized, double-blind, controlled, parallel-group clinical trial. Patients received either BB-PF (n=48) or OL-BAK (n=49), both administered once daily in the morning. The patients were followed for 60 days. Ocular itching was the primary outcome measure. Secondary outcomes included ocular symptoms, signs, and non-ocular symptoms associated with rhinoconjunctivitis. Conjunctival impression cytology (CIC) was performed to evaluate histopathological changes related to the toxic effects of preservatives.

Results

BB-PF treatment was associated with a 1.30 more probability of diminished ocular itching than OL-BAK (odds ratio (OR)=1.30; 95% CI=(0.96-1.7); p=0.086). No statistically significant differences were found between treatments in the resolution of other ocular symptoms or signs, except for tearing, which was superior in the BB-PF (OR=1.37; 95% (1.26-1.47); p<0.0001). BB-PF was superior in terms of the resolution of rhinorrhea (p=0.040) and nasal itching (p=0.037). After 60 days of treatment, the BB-PF group exhibited 2.0 times higher probability of having a lower Nelson scale score compared to the OL-BAK group (OR=2.00; 95% CI=(1.19-3.34); p=0.010).

Conclusion

Both medications presented a similar efficacy in terms of the resolution of ocular signs and symptoms associated with ocular conjunctivitis. BB-PF is superior in the resolution of non-ocular symptoms and safer for the ocular surface than OL-BAK.

Nonlinear effects of humidex on risk of outpatient visit for allergic conjunctivitis among children and adolescents in Shanghai, China: A time series analysis

Background

Various epidemiological studies have focused on the adverse health outcomes of meteorological factors. However, there has been little research on the impact of humidex on allergic conjunctivitis, especially in child and adolescent populations. We aimed to explore the impact of humidex, a comprehensive index of relative humidity and temperature, on child and adolescent allergic conjunctivitis admissions.

Methods

Outpatient visit data for allergic conjunctivitis, meteorological factors and air pollutants in Shanghai for the 2017-2022 period were retrieved. For the purpose of analysing the nonlinear connection and lag impact between humidex and admissions for paediatric and adolescent allergic conjunctivitis, the distributed lag nonlinear model (DLNM) was fitted.

Results

A total of 147 090 cases were included in our cohort. We found a significantly nonlinear effect on humidex and allergic conjunctivitis. In the single-day lag pattern, the relative risks (RR) of allergic conjunctivitis were significant at lag 0 (RR = 1.08, 95% confidence interval (CI) = 1.05-1.11) to lag 2 (RR = 1.01, 95% CI = 1.00-1.01), lag 5 (RR = 1.01, 95% CI = 1.00-1.01) to lag 9 (RR = 1.01, 95% CI = 1.00-1.01), and lag 14 (RR = 1.02, 95% CI: 1.01-1.03). In the cumulative-lag day pattern, the RR of allergic conjunctivitis were significant at lag 0-0 (RR = 1.08, 95% CI = 1.05-1.11) to lag 0-14 (RR = 1.21, 95% CI = 1.13-1.28). We found that boys, children aged 7-17 years, and children in the warm season were more vulnerable to humidex. In addition, the highest attributable fraction (AF) and attributable number (AN) of humidex are at lag 0-14 (AF = 0.17, AN = 25 026).

Conclusions

Humidex exposure markedly increased the risk of allergic conjunctivitis, especially in highly high humidex. Appropriate public health management is needed for disease management and early intervention.

Diagnostic criteria of chronic conjunctivitis: atopic keratoconjunctivitis and vernal keratoconjunctivitis

PURPOSE OF REVIEW

Chronic ocular allergies, vernal (VKC) and atopic keratoconjunctivitis (AKC) are relatively rare conditions that require definite diagnostic criteria to the most appropriate therapeutical approach.

RECENT FINDINGS

The diagnosis of both VKC and AKC is generally based on clinical history, signs and symptoms, and the results of allergic tests, which allow to identify the different diseases phenotypes. However, other subtypes of the two diseases and/or overlaps may occur making the diagnosis non always so clear, such as VKC and AKC overlaps or adult-like VKC disease. Each of these phenotypes may be sustained by different mechanisms which are still not well defined but not only related to a type 2 inflammation. The further challenges will be to correlate clinical or molecular biomarkers to a single subtype or disease severity.

SUMMARY

Definite criteria of chronic allergies will further guide to more specific therapeutical approaches.

Dendritiform immune cells with reduced antigen-capture capacity persist in the cornea during the asymptomatic phase of allergic conjunctivitis

BACKGROUND

Increased density and altered morphology of dendritic cells (DC) in the cornea and conjunctiva occur during active allergic conjunctivitis. This study investigated whether inflammation (characterised by altered DC density and morphology) persists during the symptom-free phase of allergic conjunctivitis.

METHODS

Twenty participants (age 43.3 ± 14.3 years, 55% female) assessed during their active (symptomatic) phase of allergic conjunctivitis were re-examined during the asymptomatic phase. Ocular allergy symptoms and signs were evaluated during both phases, and five ocular surface locations (corneal centre, inferior whorl, corneal periphery, corneal limbus, and bulbar conjunctiva) were examined using in vivo confocal microscopy (HRT III). DC were counted manually, and their morphology was assessed for cell body size, presence of dendrites, presence of long dendrites and presence of thick dendrites using a grading system. Mixed model analysis (DC density) and non-parametric tests (DC morphology) were used to examine differences between phases.

RESULTS

DC density at corneal locations did not change between the active and asymptomatic phases (p ≥ 0.22). However, corneal DC body size was smaller and fewer DC presented with long dendrites during the asymptomatic phase (p ≤ 0.02). In contrast, at the bulbar conjunctiva, DC density was reduced during the asymptomatic phase compared to the active phase (p = 0.01), but there were no changes in DC morphology.

CONCLUSIONS

Dendritiform immune cell numbers persist in the cornea during the symptom-free phase of allergic conjunctivitis, whereas conjunctival DC appear to return to a baseline state. The morphology of these persisting corneal DC suggests their antigen-capture capacity is reduced during the asymptomatic phase.

Effects of Punctal Occlusion on Ocular Itching and Conjunctival Redness Associated with Allergic Conjunctivitis

PURPOSE

Punctal occlusion using punctal plugs has been successfully used to treat the signs and symptoms of dry eye disease. However, the effects of punctal occlusion on the symptoms of allergic conjunctivitis (AC) have been less well documented. There is some concern among clinicians that punctal occlusion may make signs/symptoms of allergic conjunctivitis worse by trapping allergens on the eye. The objective of this post hoc analysis was to address this question and thus assess the effect of punctal occlusion alone on ocular itching and conjunctival redness associated with AC.

METHODS

This was a pooled post hoc analysis of three randomized, double-blind, placebo insert-controlled clinical trials in subjects with AC. Enrolled subjects were generally healthy adults with ocular allergies and a positive skin test reaction to perennial and/or seasonal allergens. The study used a modified version of the traditional conjunctival allergen challenge (CAC) model, which included multiple, repeated allergen challenges following placement of the intracanalicular insert. Subjects were rechallenged on Days 6, 7 and 8; Days 13, 14 and 15; and Days 26, 27 and 28.

RESULTS

The data set included 128 subjects that were administered placebo. Baseline mean (SD) ocular itching and conjunctival redness scores were 3.52 (0.44) and 2.97 (0.39), respectively. On post-insertion Days 7, 14 and 28, mean itching scores were 2.62, 2.26 and 1.91, respectively, representing 26%, 36% and 46% itching reductions, respectively (p < 0.001). On Days 7, 14 and 28, mean conjunctival redness scores were 1.98, 1.90, and 2.08, respectively, representing 33%, 36%, and 30% redness reductions, respectively (p < 0.001).

CONCLUSIONS

Based on this post hoc pooled analysis, punctal occlusion with a resorbable hydrogel intracanalicular insert did not worsen ocular itching or conjunctival redness in this patient population.

Vernal Keratoconjunctivitis: A Systematic Review

Vernal keratoconjunctivitis (VKC) is a chronic, bilateral corneal and conjunctival problem which typically presents in young individuals. VKC is characterized by itching, photophobia, white mucous discharge, lacrimation, foreign body sensation, and pain due to corneal involvement of shield ulcers. Vernal keratoconjunctivitis is categorized within ocular diseases. The diagnosis is clinical, as no sure biomarkers pathognomonic of the disease have yet been identified. The VKC therapy relies on different types of drugs, from antihistamines and topical steroids to cyclosporine or tacrolimus eye drops. In extremely rare cases, there is also the need for surgical treatment for the debridement of ulcers, as well as for advanced glaucoma and cataracts, caused by excessive prolonged use of steroid eye drops. We performed a systematic review of the literature, according to PRISMA guideline recommendations. We searched the PubMed database from January 2016 to June 2023. Search terms were Vernal, Vernal keratoconjunctivitis, and VKC. We initially identified 211 articles. After the screening process, 168 studies were eligible according to our criteria and were included in the review. In this study, we performed a systematic literature review to provide a comprehensive overview of currently available diagnostic methods, management of VKC, and its treatments.

Blocking Th2 Signaling Pathway Alleviates the Clinical Symptoms and Inflammation in Allergic Conjunctivitis

Purpose

To explore the role of Th2 signaling pathway in allergic conjunctivitis (AC).

Methods

Serum Th2 cytokines IL-4 or IL-13 of patients with AC were detected using the Meso scale discovery assay to verify the correlation of Th2 immunity and AC pathogenesis. Wistar Han rats were intraperitoneally and subcutaneously injected with ovalbumin (OVA) to establish an experimental AC model and the Th2 signaling pathway was blocked by an investigational neutralizing antibody (CM310). Serum IgE and OVA-specific IgE were detected by ELISA. Conjunctivitis inflammation, infiltration of eosinophils, and mast cell degranulation were detected by histological examination. Immortalized human conjunctival epithelial cells, a conjunctival epithelial cell line, and peripheral blood mononuclear cells of patients with AC were used as the target cells to study the impact of IL-4 or IL-13 on AC progression. Finally, a STAT6 reporter gene system was constructed using immortalized human conjunctival epithelial cells to confirm whether the downstream signaling pathway activated by IL-4 or IL-13.

Results

Serum IL-4 or IL-13 were increased in patients with AC versus healthy individuals. In an OVA-induced rat experimental AC model, blocking the Th2 signaling pathway with CM310, an investigational neutralizing antibody, alleviated the conjunctival symptoms, and decreased serum IgE, suppressed infiltration of eosinophils and mast cell degranulation. Further, an in vitro model showed CM310 suppressed the secretion of inflammatory cytokine from both immune cells and epithelial cells in both patients peripheral blood mononuclear cells and cell line.

Conclusions

Blocking Th2 signaling pathway alleviates the clinical symptoms and inflammation in AC.

How Can We Best Diagnose Severity Levels of Dry Eye Disease: Current Perspectives

Dry eye disease (DED) is a common ocular condition, but the diagnosis relative to other ocular conditions and the evaluation of severity of the condition has often been difficult. This challenge can be due to clinical signs and symptoms not always correlating with each other. An understanding of the various components which create the condition, as well as the diagnostic measures used to evaluate these components, is useful to the clinician working with DED patients. This review paper will discuss traditional diagnostic options, diagnostic imaging, and Advanced Point of Care testing capabilities to determine the severity level of dry eye disease more adequately.

Clarifying the effect of gut microbiota on allergic conjunctivitis risk is instrumental for predictive, preventive, and personalized medicine: a Mendelian randomization analysis

Background

Allergic conjunctivitis is an ocular immune disease which affects the conjunctiva, eyelids, and cornea. Growing evidence implicates the gut microbiota in balancing and modulating immunity response, and in the pathogenesis of allergic disease. As a result, gut microbial imbalance could be a useful indicator for allergic conjunctivitis. From the perspective of predictive, preventive, and personalized medicine (PPPM), clarifying the role of gut microbial imbalance in the development of allergic conjunctivitis could provide a window of opportunity for primary prediction, targeted prevention, and personalized treatment of the disease.

Working hypothesis and methodology

In our study, we hypothesized that individuals with microbial dysbiosis may be more susceptible to allergic conjunctivitis due to an increased inflammatory response. To verify the working hypothesis, our analysis selected genetic variants linked with gut microbiota features (N = 18,340) and allergic conjunctivitis (4513 cases, 649,376 controls) from genome-wide association studies. The inverse-variance weighted (IVW) estimate, Mendelian randomization (MR)-Egger, weighted median estimator, maximum likelihood estimator (MLE), and MR robust adjusted profile score (MR.RAPS) were employed to analyze the impact of gut microbiota on the risk of allergic conjunctivitis and identify allergic conjunctivitis-related gut microbes. Ultimately, these findings may enable the identification of individuals at risk of allergic conjunctivitis through screening of gut microbial imbalances, and allow for new targeted prevention and personalized treatment strategies.

Results

Genetic liability to Ruminococcaceae_UCG_002 (OR, 0.83; 95% CI, 0.70-0.99; P = 4.04×10^-2), Holdemanella (OR, 0.78; 95% CI, 0.64-0.96; P = 2.04×10^-2), Catenibacterium (OR, 0.69; 95% CI, 0.56-0.86; P = 1.09×10^-3), Senegalimassilia (OR, 0.71; 95% CI, 0.55-0.93; P = 1.23×10^-2) genus were associated with a low risk of allergic conjunctivitis with IVW. Besides, we found suggestive associations of a genetic-driven increase in the Oscillospira (OR, 1.41; 95% CI, 1.00-2.00; P = 4.63×10^-2) genus with a higher risk of allergic conjunctivitis. Moreover, MLE and MR.RAPS show consistent results with IVW after further validation and strengthened confidence in the true causal associations. No heterogeneity and pleiotropy was detected.

Conclusions

Our study suggests that gut microbiota may play a causal role in the development of allergic conjunctivitis and provides new insights into the microbiota-mediated mechanism of the disease. Gut microbiota may serve as a target for future predictive diagnostics, targeted prevention, and individualized therapy in allergic conjunctivitis, facilitating the transition from reactive medical services to PPPM in the management of the disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-023-00321-9.

Pediatric Conjunctivitis: A Review of Clinical Manifestations, Diagnosis, and Management

Conjunctivitis is a common pediatric problem and is broadly divided into infectious and non-infectious etiologies. Bacterial conjunctivitis makes up the majority of cases in children and often presents with purulent discharge and mattering of the eyelids. Treatment is supportive with an individual approach to antibiotic use in uncomplicated cases since it may shorten symptom duration, but is not without risks. Viral conjunctivitis is the other infectious cause and is primarily caused by adenovirus, with a burning, gritty feeling and watery discharge. Treatment is supportive. Allergic conjunctivitis is largely seasonal and presents with bilateral itching and watery discharge. Treatment can include topical lubricants, topical antihistamine agents, or systemic antihistamines. Other causes of conjunctivitis include foreign bodies and non-allergic environmental causes. Contact lens wearers should always be treated for bacterial conjunctivitis and referred to evaluate for corneal ulcers. Neonatal conjunctivitis requires special care with unique pathogens and considerations. This review covers essential information for the primary care pediatric provider as they assess cases of conjunctivitis.

Self-reported symptoms of ocular allergy and its comorbid factors among residents living near a landfill site in Ghana

Residents close to landfill sites may be exposed to long-term emitted toxic compounds that may have effects on their eyes. The aim of this study was to determine the prevalence of symptomatic ocular allergy and its comorbid factors among residents living near a landfill site in Ghana. An exploratory cross-sectional design involving 400 inhabitants living around a landfill site was employed. The prevalence of symptomatic ocular allergy was 59.3%. In a bivariate analysis, comorbid conditions including respiratory disease, coughing, flu, cholera, skin disease, diarrhoea, and hypertension predicted symptomatic ocular allergy. However, only cholera remained a significant predictor of symptomatic ocular allergy in the multivariate analysis. Symptomatic ocular allergy was high among inhabitants around the landfill site in Ghana. While proper design and management of landfills in Ghana is crucial, further longitudinal and clinical studies are required to clinically establish the link between landfill and ocular allergy.

Biologics for allergy: therapeutic potential for ocular allergic diseases and adverse effects on the eye

Biologics applying antibodies against IgE, IL-5, IL-5 receptor α, IL-4 receptor α, and IL-13 have dramatically improved recent treatment outcomes in allergic diseases including asthma, rhinitis, and atopic dermatitis. However, these drugs have not been approved for ocular allergic diseases such as allergic conjunctivitis, vernal keratoconjunctivitis, and atopic keratoconjunctivitis. Although the putative mechanisms suggest that these drugs should have beneficial effects in patients with ocular allergies and some studies have reported such beneficial effects, various adverse ocular symptoms have also been observed in clinical trials and off-label use studies. Since ocular allergic diseases have distinct pathogeneses, each biologic drug must be examined regarding specific effects on each ocular allergy. For example, IgE-mediated type 1 hypersensitivity plays a critical role in allergic conjunctivitis. By contrast, T cells and eosinophilic and non-IgE-mediated type 2 inflammation play important roles in vernal keratoconjunctivitis. Allergists must fully understand the effects of each drug on the eye. This review outlines both potential therapeutic and adverse effects of various biologics on allergic diseases of the eye.

Immunomodulatory Actions of Cannabinoids: Clinical Correlates and Therapeutic Opportunities for Allergic Inflammation

Endogenously produced cannabinoids as well as phytocannabinoids broadly exhibit anti-inflammatory actions. Recent emergence of cannabis for multiple medical issues combined with reports on potent immunomodulatory actions of distinct components has underscored the therapeutic potential of cannabis. Although synthetic cannabinoids that are based on structural similarities to the existing class of cannabinoids have been on the rise, their application in therapeutics have been limited owing to toxicity concerns. Herein, we review the current literature that details the immunomodulatory actions of cannabinoids. Further, we highlight the complexities of cannabinoid biology and examine the potential inflammatory risks associated with the use of cannabis including potential for toxic interactions between distinct constituents of cannabis.

Intense Pulsed Light Attenuates Oxidative Stress in Perennial Allergic Conjunctivitis

Objective: To assess the effects of intense pulsed light (IPL) on oxidative stress (OS) in perennial allergic conjunctivitis (PAC). Background: IPL treatment has been proven effective for dry eye disease (DED). However, we have observed that, after IPL treatment, some patients with DED combined with allergic conjunctivitis (AC), an immune response condition in which excessive OS causes and exacerbates inflammatory damage, not only show an improvement in eye dryness, but also their AC-related eye itching is relieved. The mechanism by which IPL inhibits allergic reactions is not clear. Methods: Five patients with moderate-to-severe PAC were given two IPL treatments on the periorbital skin with a 2-week interval. Visual analog scale (VAS) scores and signs of AC, including eye redness and conjunctival follicles, were assessed before the first treatment (day 1) and 2 weeks after the second treatment (day 30). Tears were also collected at the same time, and lipid oxidation (LPO) metabolite analysis was performed using liquid chromatography tandem mass spectrometry (LC-MS/MS) to investigate the effects of IPL on OS response. Results: The average VAS score significantly decreased with treatment (30.2 for day 1, 10.6 for day 30; p < 0.001). The general signs of PAC showed no difference (p > 0.05). LPO metabolite analysis revealed that 17,18-diHETE, which is an oxidation product of eicosapentaenoic acid, and 13-OXoODE, which is an oxidation product of linoleic acid, are significantly downregulated after IPL treatment. Conclusions: The photothermal effect of IPL attenuates OS in PAC, and this seems to be one of the mechanisms by which IPL treatment improves PAC. Clinical Trial Registration number: ChiCTR1900022202.

Safety and Tolerability of Bilastine 0.6% Ophthalmic Solution: An 8-Weeks Phase III Study

Purpose

The objective of this study was to assess the safety and tolerability of preservative-free bilastine 0.6% ophthalmic solution after 8 weeks of once-daily administration in patients with allergic conjunctivitis (AC).

Patients and Methods

Multi-center, international, randomized, double blind, placebo-controlled, parallel-group, phase III study of adult patients with seasonal or perennial AC. The study was conducted in 26 centers of 5 European countries. Duration of daily treatment with bilastine 0.6% ophthalmic solution or placebo was 8 weeks. Safety was evaluated by analyzing incidence of ocular treatment-emergent adverse events (TEAEs); additionally, and as secondary parameters, ocular tolerability was assessed, in addition efficacy was also assessed by the average daily total eye symptoms score (TESS).

Results

A total of 333 randomized patients with AC were included (bilastine, N=218; placebo, N=115). Mean (SD) age of the patients was 39.9 (13.7) and were 63.7% female. Overall, the percentage of ocular related TEAEs was low, and the percentage of patients with ocular related TEAEs was lower in the bilastine ophthalmic solution group (2.8%) than in the placebo group (4.3%). No severe TEAEs were reported. The ocular symptoms and TESS improved during the trial in both treatment groups. Statistically significant treatment differences were observed at Week 8 for the TESS and all individual ocular symptoms, being significantly better in the bilastine ophthalmic solution group than in placebo group.

Conclusion

Bilastine 0.6% ophthalmic solution revealed no safety concerns in patients with AC after 8 weeks of once-daily administration. Bilastine was effective in reducing ocular symptoms associated with AC in response to both seasonal and perennial allergens.

Sensitization to Furry Animals in Patients with Suspected Allergic Disease in China: A Multicenter Study

PURPOSE

An objective of this study was to investigate the allergen sensitization characteristics of cat, dog and horse dander in patients with suspected allergic diseases in different geographical regions of Chinese mainland.

PATIENTS AND METHODS

We invited 2377 patients aged 0-86 years with suspected allergic diseases to participate in a cross-sectional survey in 11 provinces in China. Combined with the questionnaires and animal-specific IgE levels, we analyzed the epidemiological characteristics and risk factors of furry animal sensitization in different regions and populations of Chinese Mainland.

RESULTS

Among the 2377 patients with suspected allergic diseases, 14.9% were sensitized to cat dander, 9.3% to dog dander and 5.5% to horse dander. Animal allergens mainly cause low-level sensitization (class 1-3). There was a significant correlation between cat, dog and horse dander allergen sIgE, with correlation coefficients (rs) all greater than 0.750. The majority (46.5%) of sIgE-positive patients were sensitized to at least two animal allergens simultaneously. The prevalence of these animals all showed a trend of increasing first and then decreasing with age, and all reached the peak in young adolescence. As for the geographical factors, the sensitization rate of cats and dogs in Western was significantly higher than that in Eastern (cat: 18.4% vs 9.2%, dog: 11.6% vs 5.5%, all P < 0.001), however, no significant differences were found in horses. Aged ≤6 years, living in Western, and high animal allergen exposure elevated the risk of cat or dog sensitization. Living on a lower floor (aOR: 0.56) was a protective factor for horse sensitization.

CONCLUSION

In this representative sample of Chinese patients with suspected allergic diseases, there was an apparent geographic variation in sensitization to cats and dogs. Age factor and living in Western also had a significant impact on animal allergen sensitization rate.

PAF-induced inflammatory and immuno-allergic ophthalmic diseases and their mitigation with PAF receptor antagonists: Cell and nuclear effects

Ocular allergies are becoming more prevalent as more airborne pollutants, irritants and microbes pervade our environment. Inflammatory and allergic mediators released by dendritic and mast cells within the conjunctiva cause allergic conjunctivitis (AC), a prevalent ocular surface disorder that affects >40% of the world's human population on a seasonal or perennial basis. Even though histamine is a major culprit, platelet-activating factor (PAF) also contributes to AC, acting either directly or synergistically with histamine and other mediators. PAF receptor-meditated inflammatory reactions, via cell-membrane-bound and nuclear-membrane-bound and nuclear PAF receptors, are also implicated in the etiology of other eye diseases such as uveitis, diabetic retinopathy, corneal and choroidal neovascularization, and age-related macular degeneration which cause serious visual impairment and can lead to blindness. This review highlights the various deleterious elements implicated in the pathological aspects of ocular allergic reactions and inflammation and provides concepts and treatment options to mitigate these eye disorders with a special focus on PAF and PAF receptor antagonists.

Management of allergic rhinitis symptoms in the pharmacy Pocket guide 2022

Background

Allergic rhinitis (AR) management requires a coordinated effort from healthcare providers and patients. Pharmacists are key members of these integrated care pathways resolving medication-related problems, optimizing regimens, improving adherence and recommending therapies while establishing liaisons between patients and physicians.

Methods

Allergic Rhinitis and its Impact on Asthma (ARIA) first published a reference document on the pharmacist's role in allergic rhinitis management in 2004. Several guidelines were developed over the past 20 years improving the care of allergic rhinitis patients through an evidence-based, integrated care approach.

Results

This ARIA/EAACI/FIP Position Paper is based on the latest ARIA in the Pharmacy guidelines and provides: (a) a structured approach to pharmacists identifying people with AR and/or allergic conjunctivitis as well as those at risk of poor disease control; (b) an evidence-based clinical decision support tool for optimising the management of allergic rhinitis in the community pharmacy; and (c) a framework of referral to the physician.

Conclusion

This document is not intended to be a mandatory standard of care but is provided as a basis for pharmacists and their staff to develop relevant local standards of care for their patients, within their local practice environment. Pharmacy care varies between countries, and the guide should be adapted to the local situation.