Ocular Allergic Disease: Mechanisms, Disease Sub-types, Treatment

Historical Profiling of Dry Eye Patients - Potential Trigger Factors and Comorbidities

PURPOSE

Dry eye syndrome (DES) is one of the most common diseases of the ocular surface. Affected persons suffer from different subjective complaints, with sometimes severe impairment in the quality of life. The aetiology and pathogenesis are multifactorial, multifaceted, and not yet fully understood. The present study is intended to provide deeper insights into possible triggering factors and correlating comorbidities.

MATERIALS AND METHODS

In German ophthalmological practices, 306 persons (174 women, 132 men, age: 18 - 87 years) were interviewed by questionnaire on concomitant diseases and possible further triggering factors. DES was diagnosed by an ophthalmologist in 170 cases. The statistical comparative analysis between persons with and without DES was carried out using the chi-squared test (SPSS statistical software).

RESULTS

DES occurred with significantly (p < 0.05) increased frequency in women over 40 years of age, as well as in persons exposed to screen work, air conditioning, persons with chronic ocular inflammation, myomas (hysterectomy), dry skin, arterial hypertonicity in need of medication, cardiac arrhythmias, fatty liver, gastric ulcer, appendicitis, cholecystectomy, depression, hyperlipidaemia, hyperuricaemia, osteoporosis, and nephrolithiasis.

CONCLUSION

Some of the known comorbidities and DES risk factors, e.g., computer work or depression, were confirmed. In contrast, the higher prevalence of hyperlipidaemia, hyperuricaemia, osteoporosis, nephrolithiasis, and fibroids among DES patients has not previously been reported. Additional studies should be performed on causal connections between DES and specific comorbidities.

[From ocular itching to eye rubbing: a review of the literature]

Ocular itching and eye rubbing are frequent complaints in an ophthalmology practice. Numerous studies address the consequences of eye rubbing, such as keratoconus. However, there are few studies concerning the pathophysiology of itching, its transmission pathways, or its interactions with eye rubbing. Through this literature review, we will address the various clinical, physiological and therapeutic aspects of this pair of symptoms with a variety of ocular consequences. We will then describe the state of the art in itching and scratching in dermatology, in order to draw a parallel between these two vicious cycles. A better understanding of the pathophysiology of ocular itching and eye rubbing, as well as new studies based on dermatological data, might allow more appropriate clinical management of our patients and their symptoms.

Combination of Two Rapid Ophthalmic Test Kits for Improved Diagnosis in Cases of Severe Binocular Conjunctivitis

Introduction: Diagnosis of conjunctivitis can be sometimes difficult, especially in cases of severe conjunctivitis and those involving both eyes. In this study, we performed commercial tests for adenovirus (Capilia Adeno Eye^®) and total tear IgE (Allerwatch^®) in a single visit in patients with bilateral conjunctivitis to examine if, and by how much, the combination of these two tests would improve the diagnostic accuracy of conjunctivitis. Methods: The study included sixty patients with relatively severe conjunctivitis in both eyes within a week of consulting our clinic and who had no previous treatment. Capilia Adeno Eye^® and Allerwatch^® tests were performed. Results: A significantly higher number of cases (55/60) were diagnosed when both tests were evaluated than with either test (Capilia Adeno Eye^® (12/60; p < 0.001) or Allerwatch^® (44/60; p < 0.005)) alone. The positivity rate of Allerwatch^® was significantly higher than that of Capilia Adeno Eye^® (p < 0.001). The diagnosis rate of atopic keratoconjunctivitis was 100% in patients with allergic conjunctivitis, but there was no significant difference in positivity compared with other types of allergic conjunctivitis. Conclusions: Testing patients with both Capilia Adeno Eye^® and Allerwatch^® improves the diagnostic accuracy for conjunctivitis and can diagnose more than 90% of cases. Detection of adenovirus antigen and IgE in tears, using these simple and rapid methods, will be useful for early diagnosis and prevention of adenoviral conjunctivitis.

Anatomical and functional dichotomy of ocular itch and pain

Itch and pain are refractory symptoms of many ocular conditions. Ocular itch is generated mainly in the conjunctiva, and is absent from the cornea. In contrast, most ocular pain arises from the cornea. However, the underlying mechanisms remain unknown. Using genetic axonal tracing approaches, we discovered distinct sensory innervation patterns between the conjunctiva and cornea. Further genetic and functional analyses in rodent models demonstrate that a subset of conjunctival-selective sensory fibers marked by MrgprA3 expression, rather than corneal sensory fibers, mediates ocular itch. Importantly, the actions of both histamine and non-histamine pruritogens converge onto this unique subset of conjunctiva sensory fibers, and enable them to play a key role in mediating itch associated with allergic conjunctivitis. This is distinct from skin itch in which discrete populations of sensory neurons co-operate to carry itch. Finally, we provide a proof-of-concept that selective silencing of conjunctiva itch-sensing fibers by pruritogen-mediated entry of sodium channel blocker QX-314 is a feasible therapeutic strategy to treat ocular itch in mice. Itch-sensing fibers also innervate the human conjunctiva,and allow pharmacological silence using QX-314.Our results cast new light on the neural mechanisms of ocular itch and open a new avenue for developing therapeutic strategies.

The prevalence and characteristics of chronic ocular itch: a cross-sectional survey

Introduction

In this cross-sectional study, we aimed to determine the prevalence and characteristics of chronic ocular itch in an outpatient ophthalmology and optometry clinic.

Methods

Four hundred patients from an outpatient ophthalmology and optometry clinic were enrolled. The presence and characteristics of chronic ocular itch were assessed by a questionnaire. Data regarding ophthalmologic, dermatologic, and systemic conditions as well as current medications were extracted from medical records.

Results

Chronic ocular itch was present in 118 (29.5%) of 400 participants. Chronic ocular pruritus was significantly more prevalent in females [P=0.015; odds ratio (OR)=1.8; 95% confidence interval (CI), 1.1-2.8] and was significantly associated with the presence of allergic conjunctivitis [51.8% (n=45); P<0.001; OR=5.0; 95% CI, 3.0-8.3], dry eye syndrome [40.1% (75); P<0.001; OR=2.6; 95% CI, 1.7-4.1], blepharitis [43.8% (n=21); P=0.021; OR=2.0; 95% CI, 1.1-3.8], and atopic dermatitis [50.0% (n=10); P=0.023; OR=2.6; 95% CI, 1.1-5.8]. Chronic ocular itch was not significantly associated with systemic conditions, or the use of prescribed ophthalmologic medications.

Discussion

Chronic ocular itch is common and may be related to ophthalmologic or dermatologic pathologies. The present findings highlight the importance of identifying and managing this uncomfortable symptom that may negatively impact the quality of life and sleep of affected patients.

The effect of allergic rhinitis with positive skin prick test on choroidal thickness

Allergic rhinitis is an inflammatory disease that develops through immunoglobulin E in the rhino-ocular mucosa due to allergy. The main symptoms are runny nose, nasal congestion, sneezing and itchy nose. This study was designed to investigate the effect of allergic rhinitis on choroidal thickness. This study was planned as a case-control study. This study performed in a tertiary referral center. The study included 61 patients with allergic rhinitis and 35 healthy subjects. Patients in both groups underwent skin prick test. In allergic rhinitis patients and healthy persons; subfoveal, temporal and nasal choroidal thickness measurement was performed. The choroidal thicknesses were measured without pupil dilation using the Spectralis Optical Coherence Tomography. In the subfoveal and temporal region, choroidal tissue was followed up significantly thicker in allergic rhinitis patients statistically compared to healthy persons (p = 0.031, p = 0.049). However, no significant difference was followed up between the nasal choroidal thickness measurements statistically (p = 0.54). Runny nose (67.2%), sneeze (65.5%), stuffiness (62.2%), itching of the nose (40.9%), and nasal discharge (21.3%) complaints were observed significantly higher in the group having allergic rhinitis. The effect of allergic rhinitis on choroidal thickness were assessed and compared with the control group. Our study revealed that there was significant association between increased choroidal thickness and allergic rhinitis. Allergic sensitivity may play an important role in increased choroidal thickness.

Prevalence of allergic rhinitis symptoms and positive skin-prick test results in patients with dry eye

BACKGROUND

Dry eye is characterized by decreased tear production and/or increased evaporation rates of the tear film barrier. Allergic rhinitis is an inflammatory disease that develops through immunoglobulin E in the rhino-ocular mucosa due to allergens. To investigate the prevalence of allergic rhinitis symptoms and positive skin-prick test results in patients with dry eye.

METHODS

This is a case-control study. The study included 57 patients with dry eye and 48 healthy subjects. The prevalence of allergic symptoms and skin-prick test results were assessed and compared with the control group.

RESULTS

With regard to positive reactions to allergens in skin-prick tests, Dermatophagoides pteronyssinus allergy (p = 0.0003), Dermatophagoides farinae allergy (p = 0.0003), grass-mix allergy (p = 0.049), Salicaces allergy (p = 0.006), and Compositae allergy (p = 0.019) were significantly observed to be higher in the group with dry eye. Nasal obstruction (p = 0.027), discharge (p = 0.0001), sneeze (p = 0.0003), itching (p = 0.0001), and postnasal drainage (p = 0.001) symptoms were observed to be significantly higher in the group with dry eye.

CONCLUSIONS

Our study revealed that there was a significant association between dry eye and allergic rhinitis with positive skin-prick test results. There may be a possible link between dry eye and allergy.

Ocular diseases: immunological and molecular mechanisms

Many factors, such as environmental, microbial and endogenous stress, antigen localization, can trigger the immunological events that affect the ending of the diverse spectrum of ocular disorders. Significant advances in understanding of immunological and molecular mechanisms have been researched to improve the diagnosis and therapy for patients with ocular inflammatory diseases. Some kinds of ocular diseases are inadequately responsive to current medications; therefore, immunotherapy may be a potential choice as an alternative or adjunctive treatment, even in the prophylactic setting. This article first provides an overview of the immunological and molecular mechanisms concerning several typical and common ocular diseases; second, the functions of immunological roles in some of systemic autoimmunity will be discussed; third, we will provide a summary of the mechanisms that dictate immune cell trafficking to ocular local microenvironment in response to inflammation.

Ocular itch associated with allergic conjunctivitis: latest evidence and clinical management

Allergic conjunctivitis is one of the most common allergic conditions worldwide. Its incidence is increasing due to changing climate, pollution, increased pollen loads, and the subject's heightened immunological sensitivity in response to these environmental changes. The pathophysiology predominantly involves immunoglobulin E-related mast-cell activation, with release of histamine and other mediators contributing to the propagation of the response by calling in other immune cells and further inflammation. This article presents the evolution of ocular allergy treatments, from vasoconstrictors, to antihistamines and mast-cell stabilizers, to the dual-acting agents, as well as corticosteroid and immunomodulatory options. Future targets for allergy treatment are also discussed.

Update and clinical utility of alcaftadine ophthalmic solution 0.25% in the treatment of allergic conjunctivitis

Allergic disorders of the ocular surface are primarily characterized as IgE- and/or T-lymphocyte-mediated disorders that affect the cornea, conjunctiva, and eyelid. Approximately 40% of individuals in the developed countries have allergic conjunctivitis, and as such, it is the most common form of ocular allergy. Seasonal allergic conjunctivitis is the most prevalent type of allergic conjunctivitis that impacts the quality of life of patients. This article reviews the pharmacology, pharmacodynamics, pharmacokinetics, clinical trials, clinical efficacy, and safety of alcaftadine. Histamine and the pathological mechanism of ocular allergy will be briefly reviewed with the intent of providing a background for the detailed discussion on the clinical utility of alcaftadine in allergic conjunctivitis. The Medline PubMed, Elsevier Science Direct, and Google Scholar databases were used to search for evidence-based literature on histamine and immunopathological mechanism of allergic conjunctivitis, as well as on pharmacology, pharmacodynamics, pharmacokinetics, clinical trials, and clinical efficacy of alcaftadine. The treatment and management goals of allergic conjunctivitis are to prevent or minimize the inflammatory cascade associated with allergic response in the early stages of the pathological mechanism. It is of note that activation of histamine receptors on immune and nonimmune cells are associated with allergen-induced inflammation of the conjunctiva and its associated ocular allergic manifestations, including itching, edema, hyperemia, and tearing. Alcaftadine is an efficacious multiple action antiallergic therapeutic agent with inverse agonist activity on H1, H2, and H4 receptors, as well as anti-inflammatory and mast cell stabilizing effects that could provide therapeutic benefits to patients with allergic conjunctivitis.

Effect of alcaftadine 0.25% on ocular itch associated with seasonal or perennial allergic conjunctivitis: a pooled analysis of two multicenter randomized clinical trials

PURPOSE

Seasonal and perennial allergic conjunctivitis represent the majority of cases of ocular allergy. This analysis was designed to evaluate the efficacy and safety of once-daily alcaftadine 0.25% in preventing ocular itching associated with seasonal or perennial allergic conjunctivitis.

SUBJECTS AND METHODS

Pooled data from two double-masked, multicenter, placebo-controlled studies using the conjunctival allergen challenge (CAC) model of allergic conjunctivitis were analyzed. Subjects randomized to receive treatment with alcaftadine 0.25% or placebo were challenged with seasonal (grass, ragweed, trees) or perennial (cat dander, cat hair, dog dander, dust mites, cockroach) allergens, 16 hours after treatment instillation. The primary efficacy measure was subject-evaluated mean ocular itching at 3 minutes post-CAC. Secondary measures included ocular itching at 5 and 7 minutes post-CAC. The proportion of subjects with minimal itch (itch score <1) and zero itch (itch score =0), and safety were also assessed.

RESULTS

A total of 189 subjects enrolled in the two studies were treated with alcaftadine or placebo. Overall, 129 subjects were challenged with seasonal allergens and 60 subjects were challenged with perennial allergens. Alcaftadine 0.25% achieved a statistically significant reduction in mean itch score at 3, 5, and 7 minutes post-CAC compared with placebo in subjects challenged with seasonal allergens (P<0.0001 at all time points) and those challenged with perennial allergens (P<0.0001 at all time points). A higher percentage of subjects treated with alcaftadine compared with placebo achieved minimal itch (P≤0.001 versus placebo at all time points) and zero itch (P<0.05 at all time points except 7 minutes for perennial) when challenged with either seasonal or perennial allergens. No treatment-related or serious adverse events were reported.

CONCLUSION

Once-daily alcaftadine 0.25% ophthalmic solution was well tolerated and demonstrated effective relief of ocular itching in subjects challenged with allergens classic for triggering either seasonal or perennial allergic conjunctivitis.

Efficacy of olopatadine versus epinastine for treating allergic conjunctivitis caused by Japanese cedar pollen: a double-blind randomized controlled trial

Introduction

The objective of this study was to compare the efficacy and safety of olopatadine versus epinastine in healthy Japanese adults with a history of allergic conjunctivitis to Japanese cedar pollen.

Methods

This Phase IV double-blind randomized controlled clinical trial comprised three clinical visits over 30 days. Screening tests were performed to identify subjects with a history of allergic conjunctivitis to Japanese cedar pollen in terms of skin sensitivity and positive bilateral reactions to a conjunctival allergen challenge (CAC) with Japanese cedar pollen at Visit 1, and confirmation by a positive bilateral CAC reaction at Visit 2. At Visit 3, the subjects were randomized to receive one drop of olopatadine HCl ophthalmic solution 0.1% (olopatadine) in the left or right eye (1:1 ratio). All subjects received one drop of epinastine HCl ophthalmic solution 0.05% (epinastine) in the contralateral eye as an active control. Five min later, the subjects underwent bilateral CAC tests with one drop of the allergen solution at the concentration that elicited positive reactions at Visits 1 and 2. Efficacy outcomes included the severity of ocular itching at 5, 7, and 15 min and the severity of conjunctival hyperemia at 7, 15, and 20 min after the CAC test, as graded by the investigator by biomicroscopy.

Results

Fifty people participated in this study (25 per group). Olopatadine significantly reduced ocular itching at 7 and 15 min (both p < 0.05) and conjunctival hyperemia at 7 and 20 min (p = 0.0010 and p < 0.05, respectively) after allergen exposure compared with epinastine. There were no adverse events for either treatment.

Conclusion

The results of this single-dose study suggest that olopatadine is superior to epinastine in terms of suppressing ocular itching and hyperemia induced by Japanese cedar pollen during CAC tests. Further studies are needed to confirm these findings in real-life settings.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-014-0156-2) contains supplementary material, which is available to authorized users.

Treatment of allergic conjunctivitis with bepotastine besilate ophthalmic solution 1.5%

PURPOSE

To examine the pooled per-protocol ocular end points from two conjunctival allergen challenge (CAC) clinical trials of the dual-action antihistamine bepotastine besilate ophthalmic solution (BBOS) 1.5%.

METHODS

Two Phase III, placebo-controlled, double-masked, randomized clinical trials were conducted at a total of six separate centers using the CAC model of allergic conjunctivitis. The same study design was employed for both clinical trials, with subjects randomly assigned to either BBOS 1.5% (n=78) or placebo (n=79) treatment. Each subject received one eye drop of the test agent bilaterally at different study visits 15 minutes, 8 hours, or 16 hours prior to a CAC. Primary ocular end points included changes in ocular itching reported at 3, 5, and 7 minutes and conjunctival hyperemia assessed at 7, 15, and 20 minutes following each CAC. Secondary ocular end points included chemosis as well as episcleral and ciliary hyperemia judged by investigators, and tearing (scored as either absent or present) and eyelid swelling judged by subjects.

RESULTS

A statistically significant reduction in ocular itching was observed for BBOS 1.5% treatment compared to placebo at all time points (P<0.0001), while measures for onset and 8-hour persistence of action also reached clinical significance (ie, ≥1.0 unit difference) at a majority of time points. In addition, a significant reduction in conjunctival hyperemia was achieved at a majority of time points during the onset of action CAC test. Secondary end points were also significantly improved compared to placebo, most prominently for reduced tearing at all study visits and reduced eyelid swelling at the onset of action and 8-hour study visits. Adverse events were generally mild and transient.

CONCLUSION

BBOS 1.5% rapidly reduced CAC-induced ocular itching with duration of effectiveness of at least 8 hours after dosing. Certain secondary signs of inflammation were also significantly reduced.

Prevalence of ocular symptoms in patients with allergic rhinitis: Korean multicenter study

BACKGROUND

Allergic rhinitis (AR) is often accompanied by multiple ocular symptoms. This study aimed to evaluate the prevalence of ocular symptoms and the impact of ocular symptoms on the quality of life in patients with AR.

METHODS

One thousand one hundred seventy-four patients with AR were enrolled from 24 centers in Korea. They were classified into four groups according to the Allergic Rhinitis and Its Impact on Asthma (ARIA) guideline and also classified into perennial AR (PAR) and seasonal AR groups. All patients were asked to complete the questionnaire regarding the presence of ocular symptoms, such as eye itching, watery eyes, and red eyes. The correlation between ocular symptoms and the rest of the quality-of-life areas in the Mini-Rhinoconjunctivitis Quality of Life Questionnaire (Mini-RQLQ) was also asked.

RESULTS

Seven hundred nineteen (61.2%) of 1174 patients had ocular symptoms. In detail, the numbers of patients with eye itching, watery eyes, red eyes, and other ocular symptoms were 605 (51.5%), 313 (26.7%), 207 (17.6%), and 66 (5.6%), respectively. Female patients (72.5%) complained of ocular symptoms more commonly than male patients (55.1%). The patients with moderate-severe persistent AR showed the highest prevalence of ocular symptoms. The correlation coefficients between ocular symptoms and the rest of the quality-of-life areas in the Mini-RQLQ were statistically significant (p < 0.05).

CONCLUSION

Sixty-one percent of Korean AR patients experienced ocular symptoms. The patients who were women and had PAR and more severe AR showed higher prevalence of ocular symptoms. The ocular symptoms might have a significant impact on the quality of life in patients with AR.

Topical cyclosporine in the treatment of allergic conjunctivitis: a meta-analysis

PURPOSE

To assess the efficacy and safety of topical cyclosporine versus placebo in the treatment of allergic conjunctivitis.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

Seven qualified studies incorporating 306 eyes of 153 patients were analyzed.

METHODS

Searches of randomized controlled trials were conducted in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform.

MAIN OUTCOME MEASURES

We assessed the methodologic quality of individual included trials and performed meta-analyses using the random effects model if P<0.1 in the test for heterogeneity, or otherwise used the fixed effects model. We assessed scores of composite signs and symptoms, reduction in steroid eye drop use in steroid-dependent patients, and safety outcomes (i.e., stinging or burning sensation).

RESULTS

At 2 weeks of follow-up or longer, evidence suggests a statistically significant improvement in the composite signs (standardized mean difference [SMD], -1.21; 95% confidence interval [CI], -1.80 to -0.62; I(2) = 71%) and symptoms (SMD, -0.84; 95% CI, -1.51 to -0.16; I(2) = 80%) after topical cyclosporine treatment for allergic conjunctivitis regardless of the dosage of treatment. There was a significant reduction (mean difference, -61.16; 95% CI, -101.61 to -20.72; I(2) = 58%) in the use of steroid eye drops in patients with steroid-dependent allergic conjunctivitis. Stinging or burning sensation (odds ratio, 2.56; 95% CI, 0.19-35.06; I(2) = 73%) was common in both the cyclosporine and placebo groups.

CONCLUSIONS

This systematic review and meta-analysis suggests topical cyclosporine could be an effective and safe treatment method for allergic conjunctivitis. Further randomized controlled trials with larger sample sizes and standardized outcome measurements, follow-up periods, and cyclosporine concentrations are warranted to determine the short- and long-term efficacy and safety and the minimal effective dosage of topical cyclosporine for allergic conjunctivitis.

Therapeutic targeting of eosinophil adhesion and accumulation in allergic conjunctivitis

Considerable evidence indicates that eosinophils are important effectors of ocular allergy. Increased worldwide prevalence of allergic eye pathologies has stimulated the identification of novel drug targets, including eosinophils and adhesion molecules. Accumulation of eosinophils in the eye is a key event in the onset and maintenance of allergic inflammation and is mediated by different adhesion molecules. Antihistamines with multiple mechanisms of action can be effective during the early and late phases of allergic conjunctivitis by blocking the interaction between β(1) integrins and vascular cell adhesion molecule (VCAM)-1. Small molecule antagonists that target key elements in the process of eosinophil recruitment have been identified and reinforce the validity of α(4)β(1) integrin as a therapeutic target. Glucocorticoids are among the most effective drugs for ocular allergy, but their use is limited by adverse effects. Novel dissociated glucocorticoids can prevent eosinophil accumulation and induce apoptosis of eosinophils, making them promising candidates for ophthalmic drugs. This article reviews recent understanding of the role of adhesion molecules in eosinophil recruitment in the inflamed conjunctiva along with effective treatments for allergic conjunctivitis.

Alcaftadine for the Prevention of Itching Associated with Allergic Conjunctivitis

OBJECTIVE:

To evaluate the safety and efficacy of alcaftadine for the prevention of itching associated with allergic conjunctivitis.

DATA SOURCES:

A medical literature search was conducted in MEDLINE/PubMed (2006-February 2012) and EMBASE (2006-February 2012) using the search terms alcaftadine and Lastacaft. References from these publications were reviewed for additional resources. Additional information was collected from Web sites of the US government ( http://www.clinicaltrials.gov , http://www.fda.gov ) and of Allergan Inc., the manufacturer of Lastacaft ( http://www.lastacaft.com ).

STUDY SELECTION AND DATA EXTRACTION:

All identified articles and publications in English were reviewed for pharmacology, pharmacokinetics, efficacy, and safety data. Priority was placed on clinical trials.

DATA SYNTHESIS:

Two published clinical trials evaluated the efficacy of alcaftadine in the prevention of ocular itching and conjunctival redness associated with allergic conjunctivitis. One trial compared alcaftadine to placebo, and another trial compared alcaftadine to placebo and olopatadine HCl to placebo. Both studies showed superior efficacy, both clinically and statistically, in the prevention of ocular itching associated with allergic conjunctivitis compared to placebo. Although conjunctival redness was evaluated in the 2 trials, neither trial demonstrated both clinical and statistical significance. Both trials demonstrated a rapid onset of action of less than 15 minutes, as well as a duration of action greater than 16 hours, which supports the use of once-daily administration. Overall, alcaftadine was well tolerated, and common adverse effects, reported in less than 4% of patients, included ocular irritation, pruritus, erythema, and stinging or burning upon instillation. Ocular adverse effects were typically mild in severity and self-limiting.

CONCLUSIONS:

Alcaftadine is a safe and effective option for the prevention of ocular itching associated with allergic conjunctivitis, is dosed once daily, and is competitively priced among prescription medications for allergic conjunctivitis. Additional studies are needed to further evaluate the comparative efficacy among ocular antihistamine/mast cell stabilizing medications.

The safety and efficacy of alcaftadine 0.25% ophthalmic solution for the prevention of itching associated with allergic conjunctivitis

OBJECTIVE

The purpose of this study was to evaluate the safety and clinical efficacy of alcaftadine 0.25% ophthalmic solution, a new topical anti-allergic agent for the prevention of the signs and symptoms of allergic conjunctivitis induced by conjunctival allergen challenge (CAC).

STUDY DESIGN AND METHODS

This two-arm, double-masked, multi-center, placebo-controlled Phase III study (NCT00889330) enrolled healthy volunteers (N = 58) with a history of allergic conjunctivitis. Subjects ≥10 years of age with a reproducible, positive reaction to a CAC were randomized to receive either one drop of alcaftadine 0.25% ophthalmic solution bilaterally or vehicle bilaterally. After 16 hours (Visit 3) and 15 minutes (Visit 4), a CAC was performed and ocular and nasal symptoms of allergy were graded over a 20-minute period. Clinical and statistical significance were evaluated.

MAIN OUTCOME MEASURES

The primary endpoints were ocular itching and conjunctival redness. The secondary endpoints were all other signs and symptoms of allergic conjunctivitis. Visual acuity, slit lamp biomicroscopy and adverse event reporting were the predetermined safety measures.

RESULTS

Alcaftadine was effective in the prevention of ocular itching based on both clinically relevant and statistically significant differences compared with vehicle (placebo). Alcaftadine significantly reduced conjunctival redness, and almost all other allergic signs and symptoms at both 15 minutes and 16 hours after drug administration. No significant safety issues were reported. Between-group differences in ocular itching were higher 16 hours after drug administration than at 15 minutes after drug administration.

CONCLUSIONS

With an onset of action within 3 minutes and a duration of action of at least 16 hours, the statistically and clinically significant effect of alcaftadine 0.25% on itching make it an important addition to therapy for ocular allergy. Additional studies are warranted to better understand the mechanisms affording a fast onset and prolonged duration of action.

Comparison of effects of alcaftadine and olopatadine on conjunctival epithelium and eosinophil recruitment in a murine model of allergic conjunctivitis

Background:

Antihistamines constitute the first line of therapy for allergic conjunctivitis, and are safe and effective in relieving the signs and symptoms of ocular allergy. Despite this, they are less effective than some other drugs in relieving delayed symptoms of allergic conjunctivitis. Recent evidence suggests that changes in the conjunctival epithelium may underlie aspects of delayed reactions. In this study we compared two antihistamines, olopatadine and alcaftadine, for their ability to modify epithelial cell changes associated with allergic conjunctivitis at time points selected to reflect late-phase reactions.

Methods:

Studies employed a modified conjunctival allergen challenge model. Sensitized mice were challenged with topical allergen with or without drug treatments. Treatment groups were assayed for acute-phase (15 minutes) and delayed-phase (24 hours) responses. Groups were scored for allergy symptoms (redness, itch, tearing, and edema) and for conjunctival mast cell numbers. Delayed-phase groups were also examined for eosinophil numbers and for tight junctional protein expression.

Results:

Olopatadine-treated and alcaftadine-treated animals had similar efficacy profiles and mast cell numbers, suggesting both were effective at ameliorating symptoms of the acute phase. In contrast, alcaftadine-treated animals had significantly lower conjunctival eosinophil infiltration than either controls or olopatadine-treated animals. Allergen challenge caused a significant decrease in expression of the junctional protein, ZO-1, and this decrease was prevented by alcaftadine but not by olopatadine.

Conclusion:

Alcaftadine displays therapeutic properties beyond its antihistamine action. These include an ability to reduce conjunctival eosinophil recruitment, and a protective effect on epithelial tight junction protein expression.

Evaluation of alcaftadine 0.25% ophthalmic solution in acute allergic conjunctivitis at 15 minutes and 16 hours after instillation versus placebo and olopatadine 0.1%

PURPOSE

To evaluate the effectiveness of alcaftadine 0.05%, 0.1%, and 0.25% ophthalmic solutions in treating the signs and symptoms of allergic conjunctivitis when compared with olopatadine hydrochloride 0.1% and placebo using the conjunctival allergen challenge (CAC) model.

METHODS

One hundred and seventy subjects were randomized and 164 subjects completed all visits. CAC was performed to determine and confirm subjects' eligibility at visits 1 and 2, respectively. The CAC was repeated at visit 3 (day 0 ± 3), 16 hours after study medication instillation, and at visit 4 (day 14 ± 3), 15 minutes after instillation. Ocular itching and conjunctival redness were evaluated after an allergen challenge, along with several secondary endpoints.

RESULTS

Alcaftadine 0.25% and olopatadine 0.1% treatments exhibited significantly lower mean scores compared with placebo for ocular itching and conjunctival redness at visits 3 and 4. Most adverse events were self-limiting and mild in severity. No serious treatment-related adverse events occurred.

CONCLUSION

Treatment with alcaftadine 0.25% ophthalmic solution resulted in mean differences of >1 unit (ocular itching) and approximately >1 unit (conjunctival redness), which was significant (P < 0.001) compared with placebo treatment. All doses of alcaftadine were safe and well tolerated in the population studied.

Ocular surface disease: a case of vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a recurrent, chronic allergic inflammation of the ocular surface associated with remodeling of the cornea and conjunctiva, with a potential to adversely affect the patient's vision and quality of life. It affects mainly children and young adults. The purpose of this interventional case report is to present a typical case of limbal VKC, which was unresponsive to antiallergic treatment alone. A 5-year-old boy, who was previously unsuccessful with conventional anti-allergic therapy alone, presented with clinicopathological features pathognomonic of limbal VKC. The patient was successfully managed with a combination of palliative, anti-allergic and anti-inflammatory therapy. Prophylaxis with an anti-allergic pharmaceutical agent was initiated for long term use to prevent the release of allergic mediators. This case highlights the importance of prescribing the most appropriate pharmaceutical medication for VKC since conjunctival fibroproliferative lesions are often resistant to anti-allergy therapy. Allergic inflammatory mediators are responsible for the fibroproliferative changes of the conjunctiva and corneal lesions in VKC. Thus, it is crucial to prescribe the most appropriate pharmaceutical medication that will prevent the release of allergic inflammatory mediators, control the allergic inflammatory cascade and prevent ocular surface damage. The fine points of this case are presented with a review of applicable literature.

Non-clinical pharmacology, pharmacokinetics, and safety findings for the antihistamine bepotastine besilate

SCOPE

The purpose of this review is to examine published non-clinical literature on the antihistamine bepotastine besilate, including pharmacokinetic and pharmacologic properties.

METHODS

Standard literature searches using diverse databases were used to find articles on bepotastine besilate published between 1997 and 2009. Articles primarily described non-clinical data utilized for the development of an oral formulation of bepotastine besilate and were published in Japanese. No publications of non-clinical data for an ophthalmic formulation were found in the database searches.

FINDINGS

Bepotastine besilate is a second-generation antihistamine drug possessing selective histamine H(1) receptor antagonist activity. Bepotastine has negligible affinity for receptors associated with undesirable adverse effects, including histamine H(3), α(1)-, α(2)-, and β-adrenergic, serotonin (5-HT(2)), muscarinic, and benzodiazepine receptors. Bepotastine possesses additional anti-allergic activity including stabilization of mast cell function, inhibition of eosinophilic infiltration, inhibition of IL-5 production, and inhibition of LTB(4) and LTD(4) activity. Bepotastine in vivo dose-dependently inhibited the acceleration of histamine-induced vascular permeability and inhibited homologous passive cutaneous anaphylaxis in guinea pig studies. In mouse models of itching, oral bepotastine inhibited the frequency and duration of scratching behavior. Multiple in vivo animal toxicology studies have demonstrated bepotastine to be safe with no significant effects on respiratory, circulatory, central nervous, digestive, or urinary systems. The concentration of bepotastine after intravenous administration of bepotastine besilate (3 mg/kg) in rats was lower in the brain than in plasma, predicting reduced sedation effects compared to older antihistamines.

CONCLUSION

Non-clinical in vitro and in vivo studies have demonstrated bepotastine is a histamine H(1) receptor antagonist with favorable pharmacokinetic, pharmacologic, safety, and antihistamine properties as well as operating on other pathways leading to allergic inflammation beyond those directly involving the histamine H(1) receptor.

Bepotastine besilate ophthalmic solution for the relief of nonocular symptoms provoked by conjunctival allergen challenge

BACKGROUND

Bepotastine besilate is a selective histamine1-receptor antagonist and mast cell stabilizer with inhibitory effects on eosinophilic activity.

OBJECTIVE

To evaluate the safety and efficacy of 1.5% bepotastine besilate ophthalmic solution in alleviating nonocular symptoms induced by a conjunctival allergen challenge (CAC), a clinical model of allergic conjunctivitis.

METHODS

This was a single-center, double-masked, randomized, placebo-controlled clinical trial performed from March 1 to April 4, 2007. Patients 10 years or older with a history of allergic conjunctivitis and a reproducible, positive, clinical response to a CAC were eligible. Patients received either placebo or 1.5% bepotastine besilate, 1 drop in each eye. After 15 minutes, 8 hours, or 16 hours after dosing, a CAC was performed and patients evaluated nonocular symptoms using standardized grading scales.

RESULTS

Seventy-one patients were enrolled in the study, and 66 comprised the per protocol population. A clinically meaningful reduction (> or = 1.0 unit) compared to placebo was achieved for rhinorrhea and nasal congestion at most time points after 1.5% bepotastine besilate instillation at 8 hours before a CAC test. Significant reductions (P < or = .05) in mean values were seen with 1.5% bepotastine besilate at 15 minutes and 8 hours after dosing for CAC-induced nasal congestion, rhinorrhea, ear or palate pruritus, nasal pruritus, and summed nonocular composite symptom (NOCS) scores and also at 16 hours after dosing for nasal congestion and rhinorrhea.

CONCLUSIONS

The 1.5% bepotastine besilate formulation produced statistically significant reductions after a CAC in individual nonocular symptoms and NOCS scores at onset of allergic response and for at least 8 hours after instillation, with the greatest reduction seen for nasal congestion and rhinorrhea.

Multicenter clinical evaluation of bepotastine besilate ophthalmic solutions 1.0% and 1.5% to treat allergic conjunctivitis

PURPOSE

To evaluate the effectiveness of bepotastine besilate ophthalmic solutions 1.0% and 1.5% compared with placebo at reducing ocular itching and conjunctival hyperemia in the conjunctival allergen challenge (CAC) model of allergic conjunctivitis.

DESIGN

Prospective, double-masked, randomized, placebo-controlled, phase 3 CAC clinical trial.

METHODS

This multicenter trial enrolled 130 subjects with a clinical history of allergic conjunctivitis who were randomized to bepotastine besilate ophthalmic solution 1.0%, 1.5%, or 0.0% (placebo). One drop of test agent was instilled bilaterally before a CAC test evaluating responses at 15 minutes, 8 hours, or 16 hours after test agent instillation. Primary efficacy outcomes were unit improvements relative to placebo in mean scores for ocular itching and conjunctival hyperemia, each graded on 0- to 4-unit scales.

RESULTS

Reductions of 1.2 units or more in mean ocular itching scores at all time points for both bepotastine besilate ophthalmic solutions 1.0% and 1.5% were observed at onset of action and 8-hour duration-of-action CAC tests (P < .0001). Statistically significant reductions in conjunctival hyperemia (P < or = .0125) were observed for bepotastine besilate ophthalmic formulations only at the onset of action CAC test.

CONCLUSIONS

Bepotastine besilate ophthalmic solutions 1.0% and 1.5% both substantially decreased CAC-induced ocular itching for at least 8 hours after dosing. Reductions in conjunctival hyperemia after a CAC, although statistically significant for bepotastine besilate ophthalmic solutions 1.0% and 1.5% compared with placebo when assessed at 15 minutes after dosing, were modest.

Bepotastine besilate, a highly selective histamine H(1) receptor antagonist, suppresses vascular hyperpermeability and eosinophil recruitment in in vitro and in vivo experimental allergic conjunctivitis models

To elucidate the ocular pharmacological properties of bepotastine besilate, a selective histamine H(1) receptor antagonist, when compared with other histamine H(1) receptor antagonists, using guinea pig allergic conjunctivitis models and in vitro models of eosinophil recruitment and mast cell membrane stabilization. Conjunctival vascular hyperpermeability was studied in guinea pigs passively sensitized with anti-ovalbumin antiserum or following subconjunctival injection of histamine. Modulation of eosinophil recruitment was evaluated for both platelet-activating factor (PAF)-induced eosinophil infiltration in guinea pigs and leukotriene B(4)-induced in vitro chemotaxis of guinea pig peritoneal eosinophils. Membrane-stabilizing effects of bepotastine also were studied with rat peritoneal mast cells stimulated with the ionophore A23187. Histamine H(1) receptor antagonists including bepotastine besilate were topically administered before ovalbumin, histamine or PAF challenges for in vivo experiments or were added directly to mast cell and eosinophil medium in vitro. Bepotastine besilate significantly inhibited conjunctival vascular hyperpermeability in a dose-dependent manner with maximal effect for bepotastine besilate 1.5%. In separate in vivo experiments, bepotastine besilate 1.0% was significantly more effective than levocabastine 0.025% in the passive sensitization model or olopatadine 0.1% in the histamine-induced hyperpermeability model. Bepotastine besilate 1.0% further suppressed PAF-induced eosinophil infiltration into conjunctival tissue more effectively than ketotifen 0.05%. Chemotaxis of guinea pig peritoneal eosinophils and histamine release from rat peritoneal mast cells in vitro were also inhibited by addition of bepotastine. Olopatadine had a weak effect as compared to that of bepotastine on eosinophil chemotaxis and no effect on mast cell histamine release in our study conditions. Bepotastine besilate was more potent than olopatadine, ketotifen, or levocabastine in reducing vascular hyperpermeability in various animal models of allergic conjunctivitis. Mast cell function and eosinophil chemotaxis were also inhibited in vitro with bepotastine, suggesting bepotastine acts as an inhibitor of allergic response through multiple mechanisms: histamine H(1) receptor antagonism, mast cell stabilization, and inhibition of eosinophil migration to ocular inflammatory sites.

Time to onset and duration of action of the antihistamine bepotastine besilate ophthalmic solutions 1.0% and 1.5% in allergic conjunctivitis: a phase III, single-center, prospective, randomized, double-masked, placebo-controlled, conjunctival allergen challenge assessment in adults and children

BACKGROUND

Bepotastine besilate is a highly selective histamine H(1)-receptor antagonist with antihistaminic, mast cell stabilizing, and anti-inflammatory activity. Based on a history of clinical effectiveness and tolerability of oral bepotastine besilate in the treatment of allergic symptoms, bepotastine besilate is being tested as a potential ophthalmic medication for allergic conjunctivitis.

OBJECTIVE

The aim of this study was to assess the effects of bepotastine besilate ophthalmic solution 1.0% and 1.5% for the treatment of ocular itching and conjunctival hyperemia in a conjunctival allergen challenge (CAC) model in adults and children.

METHODS

This Phase III, single-center, prospective, randomized, double-masked, placebo-controlled, CAC clinical trial enrolled patients >or=10 years of age with a history of allergic conjunctivitis, skin-test reaction, and CAC response. Patients received bepotastine besilate ophthalmic solution 1.0%, bepotastine besilate ophthalmic solution 1.5%, or placebo, 1 drop on each eye on days 14 +/- 3 and 28 +/- 3. The primary efficacy end points, patient-assessed ocular itching (at 3, 5, and 7 minutes) and investigator-assessed conjunctival hyperemia (at 7, 15, and 20 minutes), were determined after CAC according to standardized 5-point scales (0 = none to 4 = severe). Clinical significance was defined in the protocol as >or=1.0-U between-group difference in mean ocular itching scores at the majority of time points at a study visit and also a >or=0.5-U difference at all time points. Tolerability of the test agent was assessed by visual acuity, slit-lamp biomicroscopy, intraocular pressure, dilated funduscopy, and adverse events.

RESULTS

A total of 107 patients (male, 54%; age range, 11-73 years; white race/ethnicity, 93%) received investigational product and comprised the intent-to-treat (ITT) population (bepotastine besilate ophthalmic solution 1.0%, 36 patients; bepotastine besilate ophthalmic solution 1.5%, 35; and placebo, 36). All 107 patients received investigational product at visit 3A (day 0) and were included in the ITT population. Of the 107 patients who were enrolled, 103 completed the study without a protocol deviation or violation. The 1.0% and 1.5% solutions were associated with clinically and statistically significant reductions in mean ocular itching scores compared with placebo on the 15-minute onset-of-action and 8-hour duration-of-action CAC tests (reductions, 1.3-1.5 U and 1.0-1.7 U respectively; all, P < 0.001). Statistically significant reductions in conjunctival hyperemia were achieved with both bepotastine besilate concentrations. Overall, 13 patients experienced a treatment-emergent adverse event considered related to the study drug (bepotastine besilate ophthalmic solution 1.0%, 6 patients; bepotastine besilate ophthalmic solution 1.5%, 4; and placebo, 3).

CONCLUSIONS

In this CAC model of allergic conjunctivitis in adults and children, bepotastine besilate ophthalmic solutions 1.0% and 1.5% were associated with clinically and statistically significant reductions in ocular itching, but not conjunctival hyperemia, within 15 minutes that were maintained for at least 8 hours after administration. Both solutions were well tolerated. ClinicalTrials.gov identifier: NCT00424398.

Efficacy of once-daily olopatadine 0.2% ophthalmic solution compared to twice-daily olopatadine 0.1% ophthalmic solution for the treatment of ocular itching induced by conjunctival allergen challenge

Olopatadine 0.1% (Patanol) and olopatadine 0.2% (Pataday) ophthalmic solutions are topical ocular anti-allergic agents with antihistaminic and mast cell stabilizing properties. The efficacy of two doses of olopatadine 0.1% was compared to one dose of olopatadine 0.2% in the prevention of ocular itching associated with allergic conjunctivitis over 24 hours. This double-masked conjunctival allergen challenge (CAC) study found no significant difference in the mean itching scores between two drops of olopatadine 0.1% and one drop of olopatadine 0.2%. Both showed significant activity at the 24-hour time point and were statistically superior to placebo. No adverse events occurred while on drug therapy.

Pharmacotherapy of allergic eye disease

Allergic eye disease is a term that refers to a number of disease processes that affect about one-fifth of the world's population. Although the more advanced forms of the disease can be sight threatening, the most disabling effects are due to the clinical manifestations, and hence quality of life, with some patients having seasonal exacerbations of their symptoms, whereas others have symptoms that are present throughout the year. Recent increased understanding of the cellular and mediator mechanisms that are involved in the various disease manifestations has greatly facilitated the development of more effective treatment options. Newer topical medications are being used that have multiple actions, such as an antihistaminic effect coupled with mast-cell stabilisation, and which require reduced daily dosing due to their longer duration of action. With greater research into newer therapies and more effective modes of delivery, improved healthcare outcomes with a lower economic burden will be achieved for patients with allergic eye disease.

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.

The Definition and Classification of Dry Eye Disease: Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007)

The aim of the DEWS Definition and Classification Subcommittee was to provide a contemporary definition of dry eye disease, supported within a comprehensive classification framework. A new definition of dry eye was developed to reflect current understanding of the disease, and the committee recommended a three-part classification system. The first part is etiopathogenic and illustrates the multiple causes of dry eye. The second is mechanistic and shows how each cause of dry eye may act through a common pathway. It is stressed that any form of dry eye can interact with and exacerbate other forms of dry eye, as part of a vicious circle. Finally, a scheme is presented, based on the severity of the dry eye disease, which is expected to provide a rational basis for therapy. These guidelines are not intended to override the clinical assessment and judgment of an expert clinician in individual cases, but they should prove helpful in the conduct of clinical practice and research.

Efficacy and response with olopatadine versus epinastine in ocular allergic symptoms: A post hoc analysis of data from a conjunctival allergen challenge study

OBJECTIVES

This post hoc analysis used data from a previous study to more precisely evaluate the efficacy of olopatadine hydrochloride and epinastine hydrochloride in alleviating various levels of severity of ocular itching and conjunctival redness and to determine whether there were any significant differences in the number of responders to treatment.

METHODS

The original study was a randomized, double-masked allergen challenge comparison assessment. Adult patients with allergic conjunctivitis were screened (visits 1 and 2); those who exhibited positive allergic reactions at both visits were randomized to 1 of 3 groups. olopatadine/epinastine, olopatadine/placebo, or epinastine/placebo. At visit 3, each eye was treated with study medication, and then challenged with allergen. Itching, redness, and chemosis assessments were recorded. For the present post hoc analysis, each eye in the olopatadine/epinastine group was separately classified at each time point, based on the pretreatment severity of their symptom (itching) and sign (conjunctival redness) scores, as moderate, moderate/severe, or severe. Data were analyzed to determine responders (eyes with itching and/or conjunctival redness scores of 0 [none]).

RESULTS

Of 96 patients screened, 66 were randomized to treatment (36 women, 30 men; mean age, 44.38 years [range, 20-71 years]). Olopatadine-treated eyes exhibited lower mean itching scores than epinastine-treated eyes in the moderate/severe and severe groups at all 3 time points (3, 5, and 7 minutes), with significance in the moderate/severe group at 5 minutes (P = 0.05) and in the severe group at 5 and 7 minutes (P = 0.017 and P = 0.02, respectively). Olopatadine-treated eyes had mean conjunctival redness scores similar to epinastine-treated eyes in all severity groups at all time points (10, 15, and 20 minutes) except in the severe group at 10 minutes (P = 0.03). On response analysis, for itching, the proportion of responders was significantly greater in the olopatadine group versus the epinastine group 7 minutes after challenge (27 [50.9%] vs 14 [26.4%]; P = 0.016). For conjunctival redness, the proportion of responders was significantly greater with olopatadine treatment versus epinastine treatment at 15 and 20 minutes after challenge (15 minutes, 12 [22.6%] vs 1 [1.9%] [P = 0.002]; 20 minutes, 10 [18.9%] vs 1 [1.9%] [P = 0.008]).

Effects of adjuvant therapy with 0.1% olopatadine hydrochloride ophthalmic solution on quality of life in patients with allergic rhinitis using systemic or nasal therapy

BACKGROUND

Allergic rhinoconjunctivitis patients are often treated with nasal or systemic allergy therapy, forgoing therapy for ocular symptoms. This treatment regimen leaves important aspects of the allergic reaction untreated and affects quality of life (QoL). The Rhinoconjunctivitis Quality of Life Questionnaire and the Allergic Conjunctivitis Quality of Life Questionnaire quantify separate aspects of QoL.

OBJECTIVE

To determine the benefit gained in QoL, measured by these questionnaires, when antiallergy eyedrops (olopatadine) were added to patients' preexisting regimens of nasal or systemic allergic rhinitis treatment.

METHODS

This was a 4-week prospective, multicenter, open-label, crossover, environmental QoL study. Visit 1 randomized patients to treatment group A or B and included baseline examinations and questionnaires. Group A instilled olopatadine twice daily and concomitantly with previously prescribed nasal or systemic antiallergy medication for 2 weeks. Group B received no ocular therapy and used only previously prescribed antiallergy medication for 2 weeks. Treatment group crossover occurred at visit 2. Patients again completed the questionnaires at visits 2 and 3.

RESULTS

Two hundred patients completed the study, 97 in group A and 103 in group B. Groups A and B experienced ocular allergic symptoms for 3.88 and 3.96 days, respectively, during the week before baseline. At visits 2 and 3, questionnaire scores were significantly improved for each group when olopatadine was added compared with the nontreatment periods. By visit 2, olopatadine improved QoL by 49% compared with 5% in the nontreated group (P < .001).

CONCLUSIONS

In this study, 90.5% of patients with allergic rhinitis treated nasally or systemically also had ocular allergic symptoms. Adding olopatadine to these patients' medication regimens significantly improved ocular allergic symptoms and overall QoL.

A review of olopatadine for the treatment of ocular allergy

Ocular allergy affects > 20% of the general population and many therapeutic preparations are available to individuals experiencing the most common forms--seasonal and perennial allergic conjunctivitis. 0.1% Olopatadine topical ophthalmic solution is currently approved for the treatment of allergic signs and symptoms in patients > or = 3 years of age. Olopatadine is available in Europe as Opatanol) and in > 30 other countries as Patanol. It inhibits mast cell degranulation and antagonises histamine receptors to manage the itching, redness, chemosis, tearing and lid swelling of the ocular allergic reaction, and its mast cell stabilising ability has been demonstrated both in vitro (using human conjunctival mast cells) and in vivo (human clinical experience). This article reviews both the laboratory and clinical information available on olopatadine, prefaced by a discussion of the current understanding of the ocular allergic reaction and followed by the future implications for this compound. Both laboratory and clinical studies have established the efficacy, safety and comfort of olopatadine in several study design models and comparisons to other antiallergy medications. The application of olopatadine, specifically in the management of lid swelling, an allergic sign recalcitrant to therapy and nasal allergic symptoms has also been established. In the future, a new formulation containing 0.2% olopatadine exhibits a duration of action up to 24 h, supporting once-daily dosing.

The relation of conjunctival and corneal findings in severe ocular allergies

OBJECTIVE

Corneal lesions such as ulcers and erosions are major complications observed in patients with severe ocular allergic diseases. We aimed to look into the relationship between specific clinical conjunctival findings and the severity of corneal complications.

METHODS

Thirty eyes of 6 patients with vernal keratoconjunctivitis (VKC) and 13 patients with atopic keratoconjunctivitis (AKC) were evaluated in this study. Slit-lamp photographs of upper tarsal conjunctiva and cornea were used to evaluate the clinical findings objectively. The corneal findings and clinical findings of upper tarsal conjunctiva such as conjunctival injection, edema, the height of papillae, and mucous discharge were evaluated and graded. Statistical correlations between conjunctival findings and the severity of corneal damage were analyzed.

RESULTS

Conjunctival injection and edema significantly correlated with the severity of corneal complications. The height of the papillae and the amount of mucous discharge did not correlate with the severity of corneal complications.

CONCLUSION

Direct signs of inflammation such as injection and edema correlated with corneal damage. The height of papillae did not show a significant correlation with the corneal findings. Our results suggest that inflammation of the conjunctiva rather than mechanical factors may play a greater role in the formation of corneal damage in severe ocular allergies.