Allergic diseases of the eye

Investigation of possible risk factors in the development of seasonal allergic conjunctivitis

AIM

To analyze the possible risk factors in the development of seasonal allergic conjunctivitis (SAC) through an evaluation of skin allergy tests and data obtained from questionnaires.

METHODS

The study included a total of 75 SAC patients and 71 control subjects without SAC diagnosis who were admitted to the Abant Izzet Baysal University Medical Faculty Ophthalmology Clinic between March 2016 and December 2016. Skin prick tests were performed for all participants. Serum levels of total IgE and 25-OH vitamin D were also measured. In the tear, total IgE levels were measured. Moreover, possible risk factors for the onset of SAC (smoking, paracetamol exposure, vitamin D supplementation and environmental factors etc.) were examined for all patients by both prenatal and postnatal aspects.

RESULTS

The patients with SAC were found to have a history of maternal paracetamol exposure during the prenatal period. Likewise, in the same patient group, the duration of postnatal vitamin D supplementation was shorter (P<0.001). However, no significant correlation was found between SAC and maternal antibiotic exposure, maternal smoking, the mode of delivery and birth weight, as well as presence of pets. Moreover, patients with SAC were more likely to have asthma, allergic rhinitis and oral allergy syndrome. We have also found that SAC patients' mothers and siblings were more likely to have allergic conjunctivitis. Likewise, their fathers were more likely to have allergic rhinitis.

CONCLUSION

Prenatal maternal paracetamol exposure and shorter duration of vitamin D supplementation in the postnatal period may play a role in development of SAC. Therefore prevention of unnecessary gestational paracetamol intake and vitamin D supplementation during infancy could potentially reduce the onset and development of SAC.

Topical Olopatadine Hydrochloride versus Ketotifen Fumarate for Allergic Conjunctivitis

Purpose:

Allergic conjunctivitis (AC) is associated with itching, redness, tearing, pain, and burning sensation in the eyes. The inflammatory process is caused by the mechanism of immediate hypersensitivity due to direct contact with the allergen. This process triggers mast cells in the conjunctiva to activate and release mediators. The purpose of this study was to compare topical olopatadine and ketotifen in terms of effectiveness and safety for the management of AC.

Methods:

Patients clinically diagnosed with AC were randomized into two groups of 60 patients each and received either topical olopatadine HCl 0.1% or ketotifen fumarate 0.025%. They were followed up on the 4^th, 15^th, and 30^th days to evaluate symptoms, signs, and quality of life (QOL) scoring.

Results:

There were a total of 120 patients (67 men and 53 women) with a mean age of 36.35 ± 11 years. Compared to baseline, scores of itching, tearing, redness, eyelid swelling, chemosis and papillae addition of all the individual scores mentioned above and QOL scores reduced significantly (P = 0.001) by the 4^th and 15^th days of olopatadine and ketotifen application. Compared with ketotifen, olopatadine significantly reduced itching, tearing, hyperemia, and total AC scores by the 4^th day (P = 0.001) and conjunctival papillae by the 15^th day (P = 0.001). Adverse reactions were reported in 10% and 18% of patients treated with olopatadine and ketotifen, respectively.

Conclusion:

Compared to ketotifen, olopatadine provided quicker relief of symptoms, and improved symptoms of AC and QOL, with fewer side effects.

Plasma vitamin D and serum total immunoglobulin E levels in patients with seasonal allergic conjunctivitis

PURPOSE

To evaluate plasma 25-hydroxyvitamin D and serum total immunoglobulin E (IgE) levels in patients with seasonal allergic conjunctivitis (SAC).

METHODS

This observational case-control study involved 49 patients with SAC without any other ocular and systemic diseases, and 44 consecutive, age- and sex-matched healthy subjects. Plasma 25-hydroxyvitamin D and serum total IgE levels of all subjects were quantified with electrochemiluminescence technique. Results were compared between the groups, and p values of <0.05 were considered as statistically significant.

RESULTS

No significant differences were found between the groups with respect to age (p = 0.41) and sex (p = 0.98). Plasma vitamin D levels of the subjects with SAC (median 8.03 ng/ml, range 3.00-17.97 ng/ml) were significantly lower than the control group (median 10.52 ng/ml, range 3.30-25.92 ng/ml) (p = 0.007). Serum total IgE levels of patients with SAC (median 48.65 IU/ml, range 1.77-812.00 IU/ml) were significantly higher when compared to the control group (median 32.49 IU/ml, range 0.14-104.60 IU/ml) (p = 0.003).

CONCLUSIONS

We found lower plasma vitamin D levels and higher serum total IgE levels in patients with SAC.

Effectiveness of nonpharmacologic treatments for acute seasonal allergic conjunctivitis

OBJECTIVE

To investigate whether artificial tears and cold compress alone or in combination provide a treatment benefit and whether they were as effective as or could enhance topical antiallergic medication.

DESIGN

Randomized, masked clinical trial.

PARTICIPANTS

Eighteen subjects (mean age, 29.5±11.0 years) allergic to grass pollen.

INTERVENTION

Controlled exposure to grass pollen using an environmental chamber to stimulate an ocular allergic reaction followed by application of artificial tears (ATs), 5 minutes of cold compress (CC), ATs combined with CC, or no treatment applied at each separate visit in random order. A subset of 11 subjects also had epinastine hydrochloride (EH) applied alone and combined with CC in random order or instillation of a volume-matched saline control.

MAIN OUTCOME MEASURES

Bulbar conjunctival hyperemia, ocular surface temperature, and ocular symptoms repeated before and every 10 minutes after treatment for 1 hour.

RESULTS

Bulbar conjunctival hyperemia and ocular symptoms decreased and temperature recovered to baseline faster with nonpharmaceutical treatments compared with no treatment (P <0.05). Artificial tears combined with CC reduced hyperemia more than other treatments (P <0.05). The treatment effect of EH was enhanced by combining it with a CC (P <0.001). Cold compress combined with ATs or EH lowered the antigen-raised ocular surface temperature to less than the pre-exposure baseline. Artificial tear instillation alone or CC combined with ATs or EH significantly reduced the temperature (P <0.05). Cold compress combined with ATs or EH had a similar cooling effect (P >0.05). At all measurement intervals, symptoms were reduced for both EH and EH combined with CC than CC or ATs alone or in combination (P <0.014).

CONCLUSIONS

After controlled exposure to grass pollen, CC and AT treatment showed a therapeutic effect on the signs and symptoms of allergic conjunctivitis. A CC enhanced the use of EH alone and was the only treatment to reduce symptoms to baseline within 1 hour of antigenic challenge. Signs of allergic conjunctivitis generally were reduced most by a combination of a CC in combination with ATs or EH.

Comparative study of the ocular efficacy and safety of diclofenac sodium (0.1%) ophthalmic solution with that of ketorolac tromethamine (0.5%) ophthalmic solution in patients with acute seasonal allergic conjunctivitis

Background:

Seasonal allergic conjunctivitis (SAC) is the most common and most prevalent of allergic disorders which afflict the ocular surface. Of the several treatments available, ophthalmic non-steroidal anti-inflammatory drugs, are generally very safe and tolerable.

Aim:

The aim of this study is to compare the ocular efficacy and safety of diclofenac sodium (0.1%) ophthalmic solution with that of ketorolac tromethamine (0.5%) ophthalmic solution in patients with acute SAC.

Materials and Methods:

Sixty patients with signs and symptoms of SAC were evaluated in an open, randomized, parallel group study. The principle symptoms (ocular itching, burning, discharge, photophobia) and signs (ocular inflammation, lid edema, chemosis, conjunctival mucous, keratitis) were evaluated.

Study Design:

Patients were randomized into two groups of 30 each. Patients in group A received one drop of diclofenac sodium 0.1% and patients in group B received ketorolac tromethamine 0.5% in both the eyes four times a day for fourteen days. Evaluations were performed at day 0, 3, 7 and 14 of the therapy. At each visit, the signs and symptoms were rated using a scale from 0-3 (mild-1, moderate-2 and severe-3).

Results:

Significant clinical and statistical reductions in signs and symptoms from baseline were observed in both groups. Diclofenac sodium 0.1% was superior to ketorolac tromethamine 0.5% in reducing ocular itching (P < 0.05) and ocular inflammation (P < 0.05), at the final examination.

Conclusion:

Diclofenac sodium showed statistically significant better results at day 3 and 7 compared to ketorolac.

First annual register of allergenic pollen in Talca, Chile

BACKGROUND

There are no data on atmospheric pollen in Talca. In the present work, our aim is to describe the amount of pollen grain in the atmosphere of the city of Talca likely to cause pollinosis of its inhabitants.

METHODS

A volumetric Hirst sampler (Burkard seven-day recording device) was used to study pollen levels. It was placed in the centre of Talca from May 2007 to April 2008.

RESULTS

The highest airborne presence of pollen, as measured in weekly averages, was Platanus acerifolia with a maximum weekly daily average of 203 grains/m³ registered during September and October. The second highest was Acer pseudoplatanus with a maximum weekly daily average of 116 grains/m³. Populus spp. had a maximum weekly daily average 103 grains/m³. Olea europaea reached 19 grains/m³ in November. Grasses presented high levels of pollen counts with a maximum weekly daily average of 27 grains/m³ from the end of August until the end of January. Pollens of Plantago spp. Rumex acetosella and Chenopodium spp. had a similar distribution and were present from October to April with maximum weekly daily average of 7 grains/m³, 7 grains/m³ and 3 grains/m³ respectively. Significant concentrations of Ambrosia artemisiifolia were detected from February until April.

CONCLUSION

The population of Talca was exposed to high concentrations of allergenic pollen, such as P. acerifolia, A. pseudoplatanus, and grasses in the months of August through November. The detection of O. europaea and A. artemisiifolia is important as these are emergent pollens in the city of Talca. Aerobiological monitoring will provide the community with reliable information about the level of allergenic pollens, improving treatment and quality of life of patients with respiratory allergy.

Management of seasonal allergic conjunctivitis: guide to therapy

Seasonal allergic conjunctivitis (SAC) is an inflammatory response of the conjunctiva triggered by exposure to seasonal allergens. Treatment options for SAC include artificial tears, antihistamines, decongestants, mast cell stabilizers, nonsteroidal anti-inflammatory drugs, dual antihistamine/mast cell stabilizers, immunotherapy and corticosteroids. Topical, intranasal and systemic formulations of corticosteroids have traditionally provided the most effective relief of the inflammation and signs and symptoms associated with severe, acute exacerbations of SAC. However, steroid-induced ocular and systemic side-effects have limited the prescribing of these agents. This limitation of traditional corticosteroids led to the development of modified corticosteroids that retain the anti-inflammatory mechanism of action of traditional corticosteroids with a much-improved safety profile because of their rapid breakdown to inactive metabolites after exerting their activity. The development of one such novel corticosteroid, loteprednol etabonate (LE), led to the insertion of an ester (instead of a ketone) group at the carbon-20 (C-20) position of the basic corticosteroid structure. Clinical trials assessing this C-20 ester corticosteroid have demonstrated similar efficacy to C-20 ketone corticosteroids in the prevention or treatment of the signs and symptoms of SAC but with a greatly improved safety profile, as the C-20 ester corticosteroid is less likely to elevate intraocular pressure. In addition, the ketone at the C-20 position has been implicated in the formation of cataract, while nonketolic corticosteroids do not form Schiff base intermediates with lens proteins, which is a common first step in cataractogenesis. The clinical relevance of the C-20 ester corticosteroid class, as modelled by LE, is that they provide both effective and safe treatment of the inflammation associated with SAC and relief of its signs and symptoms. Loteprednol etabonate offers a well-tolerated treatment option for patients with debilitating acute exacerbations as well as chronic forms of the disease.

A review of non-pharmacological and pharmacological management of seasonal and perennial allergic conjunctivitis

Allergic eye disease encompasses a group of hypersensitivity disorders which primarily affect the conjunctiva and its prevalence is increasing. It is estimated to affect 8% of patients attending optometric practice but is poorly managed and rarely involves ophthalmic assessment. Seasonal allergic conjunctivitis (SAC) is the most common form of allergic eye disease (90%), followed by perennial allergic conjunctivitis (PAC; 5%). Both are type 1 IgE mediated hypersensitivity reactions where mast cells play an important role in pathophysiology. The signs and symptoms are similar but SAC occurs periodically whereas PAC occurs year round. Despite being a relatively mild condition, the effects on the quality of life can be profound and therefore they demand attention. Primary management of SAC and PAC involves avoidance strategies depending on the responsible allergen(s) to prevent the hypersensitivity reaction. Cooled tear supplements and cold compresses may help bring relief. Pharmacological agents may become necessary as it is not possible to completely avoid the allergen(s). There are a wide range of anti-allergic medications available, such as mast cell stabilisers, antihistamines and dual-action agents. Severe cases refractory to conventional treatment require anti-inflammatories, immunomodulators or immunotherapy. Additional qualifications are required to gain access to these medications, but entry-level optometrists must offer advice and supportive therapy. Based on current evidence, the efficacy of anti-allergic medications appears equivocal so prescribing should relate to patient preference, dosing and cost. More studies with standardised methodologies are necessary elicit the most effective anti-allergic medications but those with dual-actions are likely to be first line agents.

The patient with allergies

Allergic disease affects a sizeable percentage of the general population, has a significant impact on patient quality of life, and exerts a significant financial burden on society. Atopic symptoms from inhalant allergens are among the most frequent complaints in outpatient medical visits. Key history and physical examination findings help to distinguish allergic rhinitis from other forms of chronic rhinosinusitis. Diagnostic testing may not be necessary unless immunotherapy is contemplated.

Allergic conjunctivitis and the impact of allergic rhinitis

Although nasal allergy has been prominent in allergy research, ocular allergy is increasingly recognized as a distinct symptom complex that imposes its own disease burden and reduction in patients' quality of life. In the past year, knowledge of the relationships between allergic conjunctivitis and allergic rhinitis has increased. Allergic conjunctivitis is highly prevalent and has a close epidemiologic relationship with allergic rhinitis. Both conditions also exhibit similar pathophysiologic mechanisms. Pathways of communication are thought to increase the likelihood of an inflammatory reaction at both sites following allergen exposure of nasal or ocular tissue. Clinical trials of intranasal therapies have demonstrated efficacy in allergic conjunctivitis and rhinitis. Newer intranasal steroids decrease ocular symptoms, potentially achieving efficacy by suppressing the naso-ocular reflex, downregulation of inflammatory cell expression, or restoration of nasolacrimal duct patency. Proposed pathophysiologic interactions between allergic rhinitis and ocular allergy underscore the need for therapies with efficacy in both symptom sets.

Emerging drugs for conjunctivitis

BACKGROUND

Conjunctivitis is a highly prevalent ocular condition with potential complications that include visual impairment. Infectious causes include bacterial, viral, parasitic and fungal etiologies, while noninfectious conjunctivitis is typically owing to allergy, tear film dysfunction or chemical trauma. Treatment requires frequent dosing and often lacks complete efficacy.

OBJECTIVE

The goal of this review is to investigate therapies for conjunctivitis that are undergoing clinical study and development. These data are presented in light of currently available treatment options to provide an understanding of the present and future direction of conjunctivitis management.

METHODS

The Pharmaprojects database was searched for conjunctivitis therapies currently in development around the world. Current treatment guidelines for infectious and noninfectious conjunctivitis were researched through PUBMED and OVID databases.

RESULTS

Several new compounds, including antimicrobial, antihistamine, anti-inflammatory and immunomodulating drugs, along with a novel thiazolidinedione, are currently undergoing investigation for their potential use in conjunctivitis management. These ophthalmic agents show promise in improving clinical outcomes for infectious and noninfectious conjunctivitis.

Intranasal corticosteroids: do they improve ocular allergy?

Allergic rhinoconjunctivitis (ARC) is a commonallergic condition associated with high financial costs and decreased quality of life. Medical treatment options are extensive and include oral, ophthalmic, and intranasal agents. Intranasal corticosteroids (INS) have traditionally been used for chronic management of nasal symptoms, but have also demonstrated an impact on decreasing ocular symptoms of itching, tearing, and redness. Study design, including the method and timing of scoring ocular symptoms, is an important factor affecting whether changes in ocular symptoms are detected in INS clinical trials. INS are thought to exert their influence on the eye through the naso-ocular reflex, and to date their impact on ocular symptoms appears to be a class effect.

Quantitative assessment of allergic shiners in children with allergic rhinitis

BACKGROUND

The knowledge on allergic shiners is extremely limited. A conceivable tool able to quantify allergic shiners has not been established.

OBJECTIVES

We sought to determine the significance and changeability of allergic shiners through our newly developed computerized method.

METHODS

We developed a novel computerized method to measure allergic shiners and enrolled a cohort of children with or without allergic rhinitis. Children with allergic rhinitis were prospectively assessed. A standardized digital photograph was taken during each visit, and a modified Pediatric Rhinoconjunctivitis Quality of Life Questionnaire was completed. Subject global assessment for nose symptoms and subject global assessment for eye symptoms (SGAE) were self-recorded daily.

RESULTS

We included 126 children with allergic rhinitis and 123 healthy control subjects. One hundred three (82%) participants with allergic rhinitis completed at least 4 prospective assessments. Shiners were darker (P < .001) and larger (P < .001) in children with allergic rhinitis. Darkness and sizes of allergic shiners were paradoxically inversely correlated (P = .02). Darkness of allergic shiners positively correlated with the duration of allergic rhinitis, practical problem scores, and SGAE values (P = .02, P = .004, and P = .002, respectively), but sizes of allergic shiners did not. Shiners were found to be darker in children with scores of eye symptoms of greater than 6, scores of practical problems of greater than 5, and SGAE values of greater than 0 (P = .02, P < .001, and P = .003, respectively), whereas shiners were larger in children with scores of other symptoms of greater than 9 and activity limitations of greater than 4 (P = .02 and P = .002, respectively).

CONCLUSION

Computer-analyzed allergic shiners correlate with the chronicity and severity of allergic rhinitis.

[Intra-annual and seasonal allergic conjunctivitis treatment: comparison of two therapeutic protocols]

INTRODUCTION

Allergic conjunctivitis is the most common form of conjunctivitis encountered in daily ophthalmological practice. Its therapy can be problematic: it must be simple, free of complications, and adaptable to everyday life.

PATIENTS AND METHODS

We conducted a randomized prospective single-center survey on 102 patients between 4 and 80 years of age who presented moderate allergic conjunctivitis. Patients were divided into two groups, one treated in monotherapy with N-acetyl-aspartyl glutamic acid (NAAGA) over 4 weeks and the other treated with bi-therapy (NAAGA and Levocabastine during the first week and NAAGA only for the next 3 weeks), with evaluation of the sum of the scores of the cardinal signs of allergic conjunctivitis at D0, D7 and D28.

RESULTS

The two populations were homogeneous at inclusion: the majority of the patients had a history of allergies, with a nonspecific disrupted allergy workup (IgE and eosinophils) and a higher initial score for the children included in the study. The scores decreased sharply at D7 (50% reduction) and at D28 (bordering 1) with no significant difference between the two groups. Tolerance to the treatment judged by unusual sensations upon instillation was better for the NAAGA treatment (80.8% of the cases). Clinical and functional signs disappeared without recourse to corticoids.

CONCLUSION

In the moderate forms of seasonal and intra-annual allergic conjunctivitis, NAAGA treatment alone is sufficient. The association with Levocabastine is necessary only in cases of highly bothersome functional signs. The use of corticoids should be reserved for the serious forms.

Vernal conjunctivitis

Vernal conjunctivitis is a bilateral, seasonal, external ocular inflammatory disease of unknown cause. Afflicted patients experience intense itching, tearing, photophobia, and mucous discharge, and usually demonstrate large cobblestone papillae on their superior tarsal conjunctiva and limbal conjunctiva. It primarily affects children, may be related to atopy, and has environmental and racial predilections. Although usually self-limited, vernal conjunctivitis can result in potentially blinding corneal complications. Treatment of chronic forms of ocular allergies may necessitate collaborative efforts between the ophthalmologist and the allergist or immunologist.

Allergic conjunctivitis

Allergic conjunctivitis is common, especially during the allergy season. Consultation with the allergist to perform skin tests or in vitro tests may be useful and confirmatory in the diagnosis of ocular allergy. If treatment is necessary, antihistamines, mast cell stabilizers, and nonsteroidal anti-inflammatory drugs are safe and reasonably effective. Corticosteroids are an order of magnitude more potent than noncorticosteroids; however, they have attendant side effects that are best monitored by the ophthalmologist. The development of "modified" corticosteroids has been a boon to the treatment of ocular allergy because these drugs may reduce potential side effects without sacrificing potency.

Ocular symptom reduction in patients with seasonal allergic rhinitis treated with the intranasal corticosteroid mometasone furoate

BACKGROUND

Allergic rhinitis (AR) is more appropriately termed allergic rhinoconjunctivitis owing to the equally bothersome nasal and ocular symptoms. Extensive evidence supports the ability of intranasal corticosteroids to reduce nasal symptoms of AR, although less evidence is available to define clearly their impact on allergic conjunctivitis.

OBJECTIVE

To determine the effect of the intranasal corticosteroid mometasone furoate nasal spray (NS) on the ocular symptoms of seasonal AR.

METHODS

This retrospective pooled analysis of 4 placebo-controlled clinical studies randomized patients 12 years and older with symptomatic seasonal AR to receive mometasone furoate NS, 200 microg once daily (n = 491), or placebo (n = 492). Ocular symptom (eye tearing [epiphora], itching [pruritus], and redness [erythema]) severity was rated by patients twice daily on a 4-point scale (0 = none to 3 = severe) in the morning and evening, with scores averaged to obtain a daily mean score. Efficacy variables were the pooled mean change from baseline in the averaged morning and evening total ocular symptom score (TOSS) and the individual ocular symptom scores.

RESULTS

The change in mean TOSS from baseline to days 1 to 15 was -1.33 (-19.8%) with mometasone furoate NS and -0.93 (-5.6%) with placebo (P < .001). Improvements in individual symptoms were significantly better with mometasone furoate NS than with placebo on days 2 (tearing) and 4 (itching and redness). A slightly greater reduction in TOSS was seen with mometasone furoate NS treatment in the evening than in the morning.

CONCLUSIONS

This detailed analysis of an intranasal corticosteroid on individual ocular symptoms supports the positive impact of mometasone furoate NS on ocular symptoms.

Evolving paradigm in the management of allergic rhinitis-associated ocular symptoms: role of intranasal corticosteroids

BACKGROUND

Along with nasal symptoms, ocular symptoms such as itching, tearing, and redness are common, bothersome components of the allergic rhinitis (AR) profile. Treatment of the patient with ocular allergy symptoms should take into account a variety of factors, including severity of symptoms, convenience/compliance issues, and patient preferences.

OBJECTIVES

To review from the primary care perspective the epidemiology, pathophysiology, and management of ocular symptoms associated with AR, and to evaluate the emerging role of intranasal corticosteroids (INSs).

FINDINGS

A search of the PubMed database identified clinical trials that assessed efficacy of agents in reducing ocular allergy symptoms. Internet searches identified further information including data on over-the-counter agents for treatment of ocular symptoms. Searches were conducted using search terms such as pathophysiology, epidemiology, ocular allergy, quality of life, drug class, and drug names. Primary care physicians are often the first point of contact for patients with seasonal AR (SAR) or perennial AR (PAR) symptoms. Ocular allergy associated with SAR and PAR (seasonal and perennial allergic conjunctivitis, respectively) is characterized by both early- and late-phase reactions, with symptoms often persisting long after allergen exposure. Non-pharmacologic measures such as allergen avoidance, use of artificial tears, and cool compresses are pertinent for all ocular allergy sufferers, but may not afford adequate symptom control. Pharmacotherapy options have traditionally included topical ophthalmic products for cases of isolated ocular symptoms, and oral antihistamines for patients with both nasal and ocular symptoms. However, this paradigm is changing with new evidence regarding the efficacy of INSs in reducing ocular symptoms. A number of meta-analyses and individual studies, most of which studied ocular symptoms as secondary variables, have demonstrated the ocular effects of INSs versus topical and oral antihistamines. Additional prospective studies on this topic are encouraged to provide further evidence for these findings.

CONCLUSIONS

In light of their well-established efficacy in reducing nasal allergy symptoms, INSs offer a comprehensive treatment option in patients with nasal and ocular symptoms. Oral antihistamines and/or topical eye drops may also be necessary depending on symptom control.

Intranasal corticosteroids reduce ocular symptoms associated with allergic rhinitis

OBJECTIVE: Clinical data and recent guidelines support the positive effects of intranasal corticosteroids on allergic rhinitis-associated ocular symptoms. This article reviews the epidemiology and pathophysiology of ocular allergy symptoms and efficacy, tolerability, and potenti mechanisms of action of intranasal corticosteroids in the treatment of this condition.

DATA SOURCES: MEDLINE database.

REVIEW METHODS: A search of pertinent literature identified in vitro, preclinical, and clinical data that involve intranasal corticosteroids in ocular-related studies. Searches that used epidemiology, pathophysiology, drug class and specific agents, and other appropriate search terms were conducted.

RESULTS: Ocular symptoms, common in patients with allergic rhinitis, are associated with reduced quality of life and substantial economic costs. In the conjunctival epithelium, an early, type-1 hypersensitivity reaction occurs after direct allergen exposure. Progression to late-phase response, with recurrence of symptoms and infiltration of inflammatory cells, may occur 4 to 8 hours later and appears to be dose-related. Alteration of nasal ocular reflex pathways may also contribute to ocular symptoms in allergic rhinitis. Clinical data indicate that intranasal corticosteroids significantly reduce total and individual ocular symptoms in subjects with allergic rhinitis. Meta-analyses have found that oral/topical antihistamines are not superior to intranasal corticosteroids in reducing ocular allergy symptoms. Ocular adverse events from intranasal corticosteroids are rare.

CONCLUSION: Intranasal corticosteroids are effective and well-tolerated in the treatment of ocular symptoms associated with allergic rhinitis. Additional studies are needed to better understand the mechanisms underlying the effects of intranasal corticosteroids on ocular symptoms.

Classification of ocular allergy

PURPOSE OF REVIEW

The purpose of this article is to summarize the clinical presentations associated with the classification of ocular allergy. This article also serves to summarize recent findings of pathophysiological mechanisms associated with ocular allergy and to highlight recently improved diagnostic methods for ocular allergic inflammation.

RECENT FINDINGS

The term allergic conjunctivitis may not sufficiently describe all forms of allergic eye disease, thus a new classification system is desirable, preferably derived from the varied pathophysiological mechanisms operating in the different forms of ocular allergy. Recent published material has further characterized the roles that inflammatory and structural cells have in ocular allergic inflammation. Improved diagnostic methods have also been developed to assess the underlying causes of ocular allergy.

SUMMARY

The underlying immune responses of ocular allergies are complex, indicating the critical need to understand the pathophysiology behind these diseases. Extensive research over the past several years has provided valuable insight into understanding the pathophysiology associated with the different forms of allergic conjunctivitis. Further clarification of the mechanisms associated with different forms of ocular allergy is essential for improved methods of classification, diagnosis, and treatment.

Systematic review and meta-analysis of randomised clinical trials on topical treatments for vernal keratoconjunctivitis

AIMS

The aim of this study was to assess the efficacy of currently available topical drugs for vernal keratoconjunctivitis (VKC) through a meta-analysis of randomised clinical trials (RCTs).

METHODS

Twenty-seven RCTs (n = 2184 eyes) that had evaluated the efficacy of topical drugs for the treatment of VKC were selected according to the set criteria; 10 of these trials were suitable for statistical analysis and were enrolled in the meta-analysis. Articles published up to December 2005 were identified from the following

DATA SOURCES

Medline, Embase, Lilacs, the Cochrane Controlled Trials Register, and references from relevant articles. Articles in any language published with an English abstract, were screened, and those selected for inclusion were written in English, French, German, Italian, Portuguese or Spanish. The quality of the trials was assessed by the Delphi list. Statistical analysis was performed using STATA software.

RESULTS

A significant improvement in all signs and symptoms, except photophobia, was observed after topical treatment for active VKC, independent of the type of treatment. Comparison of the efficacy of different drugs was not possible due to a lack of standardised criteria among studies.

CONCLUSION

The currently available topical drugs are effective in treating acute phases of VKC. However, there is a lack of evidence to support the recommendation of one specific type of medication for treating this disorder. There is a need for standard criteria to assess diagnosis and therapy based on severity. There is also a need for RCTs assessing long-term effects of single drugs to control the disease and to prevent complications.

Differential diagnoses of conjunctivitis for clinical allergist-immunologists

OBJECTIVE

To provide a clinical overview of the types of conjunctivitis that are encountered by practicing clinical allergist-immunologists.

DATA SOURCES

Published literature in peer reviewed journals found in the National Library of Medicine (PubMed) database using the keywords ocular allergy and/or allergic conjunctivitis.

STUDY SELECTION

Studies related to ocular allergy and/or allergic conjunctivitis were selected for inclusion in this review.

RESULTS

Four clinical scenarios are presented that mimic frequently encountered inflammatory disorders that present as red eyes.

CONCLUSIONS

The signs and symptoms associated with the various inflammatory conditions affecting the conjunctiva often overlap and need to be differentiated to maximize care for patients with conjunctivitis.

Vasomotor (perennial chronic) conjunctivitis

PURPOSE OF REVIEW

To increase the awareness of nonimmunoglobulin E-mediated conjunctival disorders similar to those recognized to affect other organs that are targets in immunoglobulin E-mediated disorders. Such conditions may include 'vasomotor' instability, that is vasomotor conjunctivitis, which leads to a more common perennial chronic conjunctivitis. These conditions are not commonly included in the differential diagnosis of allergic conjunctivitis.

RECENT FINDINGS

Although there have not been specific recent findings regarding the eye, it appears that evidence for such disorders in the rhinitis literature suggests that they can be involved in more than 25% of chronic conjunctivitis cases. The extrapolation of such conditions to the conjunctival surface clearly reflects these syndromes which have clearly been underappreciated and underdiagnosed.

SUMMARY

A significant amount of work remains to be performed to understand perennial chronic conjunctivitis (vasomotor conjunctivitis or nonallergic noninfectious conjunctivitis) as well as other forms of chronic conjunctivitis that can mimic or exist in a comorbid state with ocular allergy. These disorders need to be better defined, categorized and classified to determine the best treatment modalities. Management guidelines and parameters of chronic noninfectious conjunctivitis need to be set on a national and international basis that will advance clinically applicable research results, pharmaceutical development and relief for patients.