Management of seasonal allergic conjunctivitis: guide to therapy

Reproxalap in patients with seasonal allergic conjunctivitis: a systematic review and meta-analysis

INTRODUCTION

Seasonal allergic conjunctivitis (SAC) is a hypersensitivity condition characterized by itching, tearing, and redness. It affects over 20% of the general population with limited therapeutic options. Reproxalap, a novel small-molecule aldehyde trap, has emerged as a potential treatment option for SAC by targeting reactive aldehydes involved in inflammation. In this systematic review and meta-analysis, we assessed the efficacy and safety of Reproxalap in treating SAC.

METHODS

Multiple databases were searched including PubMed, Cochrane Library, Scopus, and Google Scholar, to identify relevant studies. Clinical trials involving patients diagnosed with SAC and treated with Reproxalap (0.25% or 0.5%) were included. The primary outcomes were symptom relief (efficacy) and side effects (safety). Data extraction and risk of bias assessment were performed independently by two reviewers. Meta-analysis was conducted using RevMan 5.4 software.

RESULTS

Five RCTs involving 625 participants were included. Reproxalap significantly reduced ocular itching compared to control groups for both 0.25% (SMD: -0.31, 95% CI: -0.50 to -0.13, P = .001) and 0.5% concentrations (SMD: -0.31, 95% CI: -0.51 to -0.10, P = 0.004). No significant difference was observed between the two doses (SMD: -0.02, 95% CI: -0.23 to 0.19, P = 0.83). Side effects were more frequent in both Reproxalap groups compared to controls, with odds ratios of 35.31 (95% CI: 17.83 to 69.90, P < 0.00001) for 0.25% and 45.64 (95% CI: 18.49 to 112.66, P < 0.00001) for 0.5%. The 0.5% dose had significantly higher odds of side effects compared to the 0.25% dose (OR: 1.66, 95% CI: 1.10 to 2.51, P = 0.02). Heterogeneity was low for all outcomes (I2 = 0%).

CONCLUSION

Reproxalap reduces ocular itching associated with SAC. While both 0.25% and 0.5% concentrations are effective, safe and tolerable. Further research should focus on the long-term benefits and applicability of Reproxalap on diverse populations.

The therapeutic effect of IPL on children with refractory seasonal allergic conjunctivitis

OBJECTIVE

To observe the effectiveness of intense pulsed light(IPL) treatment as an adjuvant treatment of refractory seasonal allergic conjunctivitis in children.

METHODS

A total of 31 patients with refractory seasonal allergic conjunctivitis who did not respond well to anti-allergic drug treatment were randomly selected to receive drug therapy combined with IPL treatment (17 patients) and drug treatment alone (14 patients) for 1 week, and the ocular surface symptom questionnaire and ocular surface sign score were performed before and after treatment, respectively.

RESULT

After treatment, the IPL group had significantly lower scores in eye rubbing, blinking, eye itching, discharge, tearing, and total scores than before treatment (P < 0.05), while there was no significant difference in foreign body sense scores before and after treatment (P > 0.05). There were no significant differences in eye rubbing, blinking, eye itching, discharge, foreign body sensation, tearing, and total score between the control group after treatment (P > 0.05). After treatment, the scores of ocular signs in the IPL group and the control group were lower than those before treatment, and the difference was statistically significant (P < 0.01).

CONCLUSION

IPL therapy is effective in improving ocular surface symptoms in children with refractory seasonal allergic conjunctivitis, especially in suppressing eye itching, with good results.

High body mass index with the risk of allergic conjunctivitis in children: a case-control study in Southwest China

PURPOSE

To assess the correlation of body mass index (BMI), diet and lifestyle with allergic conjunctivitis (AC) in children.

METHODS

This prospective case-control study included 105 children with AC and 105 age- and sex-matched children with no AC. Clinical data were collected, including BMI, dietary habits, physical activity, and sleep time. Multivariate regression analysis was used to analyze the risk factors for AC.

RESULTS

Dietary habits including vitamin A supplement use (χ2 = 0.00; P = 1.00), the consumption of sweet food (χ2 = 6.70; P = 0.08), fast food (χ2 = 3.74; P = 0.29), beverages (χ2 = 1.17; P = 0.76), and seafood and fish (χ2 = 6.15; P = 0.10) and snacking before sleep (χ2 = 2.23; P = 0.53), were not associated with AC. There were significant differences in physical activity (χ2 = 12.64; P < 0.01) between the children with AC and healthy children. Physical activity of less than 1 h per day is more found among AC and more than 2 h of exercise per day is more found in healthy children. There were no differences in sleep duration (χ2 = 5.39; P = 0.07). Multivariate regression analysis revealed that a high BMI (overweight and obesity) (OR = 3.05; 95% CI: 1.30-7.20; P = 0.01) was a significant risk factor for AC. The consumption of fish oil supplements (OR = 0.38; 95% CI: 0.17-0.81; P = 0.01) and having been breastfed (OR = 0.34; 95% CI: 0.16-0.72; p = 0.005) were protective factors against AC.

CONCLUSION

A high BMI (overweight and obesity) can increase the incidence of AC. Breastfeeding and dietary supplementation with fish oil are recommended for children susceptible to AC.

Observational Clinical Investigation Evaluating an Ophthalmic Solution Containing Xanthan Gum and Low Concentration Desonide Phosphate in Dry Eye Disease Treatment

INTRODUCTION

Patients with dry eye disease (DED) complain of a multitude of symptoms that affect their visual function and quality of life (QoL). This clinical investigation assessed the performance, tolerance, and safety of a novel preservative-free ophthalmic solution containing xanthan gum 0.2% and desonide sodium phosphate 0.025%.

METHODS

This was an observational, prospective, multicentric, and post-market clinical investigation to assess the effect of three times a day instillation of the study formulation in patients suffering from DED. The primary objective was to achieve a 50% reduction in conjunctival hyperemia index as assessed with the OCULUS Keratograph after 1 month of treatment compared to baseline values. The secondary objectives included patient-reported outcomes, clinical performance, and safety.

RESULTS

Thirty patients were enrolled (21 women, 9 men) with a mean age of 61.10 ± 14.53 years. The instillation of the study formulation was associated with a significant reduction in redness scores after 1 month of treatment compared to baseline (mean - 0.51 ± 0.51; p ≤ 0.0001). Although the primary endpoint was not completely met, a 50% reduction in the conjunctival hyperemia index was achieved in 23% of the participants, and 77% showed a reduction of 26% of the same index. In addition, the ophthalmic solution significantly increased tear film break-up time, and a significant reduction of corneal and conjunctival staining with fluorescein was achieved. It also reduced DED symptoms and had a very good safety profile.

CONCLUSIONS

the study formulation produced a significant improvement in the signs, symptoms, and QoL of patients with mild to moderate DED with a good safety profile after 1 month of treatment.

Integrative therapeutics for ocular surface disorders

PURPOSE OF REVIEW

Integrative medicine techniques are increasingly accepted into the treatment paradigm for many chronic disorders including eye disease. Over 71% of patients, including 67% of those with eye disorders, use some form of Integrative therapy. Physicians should be well versed in evidence-based therapies to know how to refer patients for the best complimentary care. We highlight the most effective integrative therapeutics from different complementary treatment paradigms to offer a framework for approaching therapy in patients with ocular surface disorders (OSDs).

RECENT FINDINGS

Lifestyle and behavioral modifications help a proportion of people with OSDs like dry eye disease and allergic conjunctivitis, which are interrelated disorders. Nutrition and supplementation can also play a role in addressing underlying inflammation and improving OSD symptoms. Acupuncture and traditional herbal medicine may also benefit some patients. New technologies offer innovative treatment pathways in the treatment of OSD but require referral to Ocular Surface Treatment Centers.

SUMMARY

Integrative treatment approach for OSD incorporates allopathic medicine, traditional remedies and lifestyle behavioral interventions, Ayurveda and herbal medicine, Nutritional Supplements, Homeopathy, Acupuncture and Chinese Medicine. New cutting-edge technologies offer breakthroughs in difficult to treat ocular surface cases. Collaboration between allergy or otolaryngology offices, complementary practitioners, as well as optometrists and ophthalmologists in Ocular Surface Treatment Centers can offer patients new avenues of treatment.

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Are inflammation-related diseases risk factors for primary acquired nasolacrimal duct obstruction? A large scale, national case-control study

PURPOSE

To evaluate the incidence and risk factors for inflammatory conditions among patients with primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

A retrospective case-control study was conducted among patients of Clalit Health Services (CHS) in Israel from 2001 to 2022. For each case, three controls were matched among all CHS patients according to year of birth, sex, and ethnicity. Differences in demographic characteristics, ocular surface, eyelid, upper airway, and systemic diseases were assessed between the groups, and odds ratios (OR) were calculated.

RESULTS

A total of 60,726 patients diagnosed with PANDO were included. The average age of PANDO patients was 63 ± 18 years, 63% were female. Significant associations were found between PANDO and various ocular surface and eyelid conditions, including chronic conjunctivitis (OR 2.96, 95% CI [2.73-3.20]), vernal keratoconjunctivitis (OR 2.89, 95% CI [2.45-3.29]), and blepharitis (OR 2.75, 95% CI [2.68-2.83]). There was a significant association with various upper airway conditions, including rhinitis (OR 1.62, 95% CI [1.58-1.66]), chronic sinusitis (OR 1.71, 95% CI [1.62-1.80]), and deviated nasal septum (OR 1.76, 95% CI [1.69-1.84]). Association was also observed with systemic conditions, including asthma (OR 1.34, 95% CI [1.27-1.41]) and atopic dermatitis (OR 1.36, 95% CI [1.32-1.41]).

CONCLUSION

Ocular surface, eyelid, upper airway, and systemic inflammatory-related diseases were found to be associated with PANDO, supporting the theory that inflammation has a prominent role in the pathophysiology of PANDO.

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

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

Exploring the Effect of Trataka (A Yogic Cleansing Technique) and Cold Eye Pack on Eye Strain During COVID-19 Pandemic: A Randomized Three-Arm Trial

Objective: Computer vision syndrome is a major global public health concern affecting >60 million individuals globally. Yoga and naturopathy practices can reduce visual fatigue and strain. The present study attempted to explore the effect of trataka that is, a yogic cleansing technique and cold eye pack on visual strain and fatigue. Subjects: Three hundred volunteers from an IT company were recruited following inclusion and exclusion criteria. Intervention: The subjects were randomly distributed in three groups, that is, trataka, cold eye pack, and waitlist control group with an allocation ratio of 1:1:1. Outcome measure: Visual Fatigue Scale and Visual symptoms checklist (VSC) was administered at baseline and end of 2 weeks. Repeated measures analysis of variance (RM-ANOVA) with Bonferroni corrections was used to test the difference across the groups. Results: All the variables were similar at the baseline among the groups. Significant changes in the within-group analysis occurred in both the trataka and cold eye pack groups. The RM-ANOVA revealed significant differences in the VAS and VSC (p = 0.001) and the post hoc analysis suggested that there were significant differences in both the trataka and cold eye pack group when compared with the control group (p = 0.001); however, there was no differences between the trataka and cold eye pack group in both the scales (p = 1). Conclusions: The results of the present study suggest that a trataka and cold eye pack for 14 days improves self-rated visual strain and fatigue among IT professionals with computer vision syndrome. Clinical Trial registration number: CTRI/2020/11/029003.

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

Background

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

Methods

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

Results

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

Conclusions

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

Secondhand smoke exposure and ocular health: A systematic review

The toxicology of secondhand smoke (SHS), along with the harm of its exposure to human health, has been generally acknowledged; however, specific evidence is lacking on the association between SHS exposure and ocular health. In this systematic review (PROSPERO registration number: CRD42022247992), we included 55 original articles published by 12 May 2023, which dealt with SHS exposure and ocular disorders, such as eye irritation, conjunctivitis, dry eye diseases, uveitis, myopia, astigmatism, contact lens discomfort, age-related macular degeneration, glaucoma, and thyroid eye disease that addressed the ocular neurovascular structures of the macular, retinal nerve fiber layer, choroid, and corneal biomechanical parameters. We found compelling correlational evidence for eye irritation, conjunctivitis, and dry eye symptoms-supporting that SHS exposure was positively associated with inflammatory and allergic changes in the eyes. Yet, evidence about the associations between SHS exposure and other ocular disorders, structures, and parameters is still limited or controversial. Given the limitations of existing literature, more investigations with high quality and rigorous design are warranted to elucidate the potentially harmful effects of SHS exposure on ocular health.

Ocular surface itch and pain: key differences and similarities between the two sensations

PURPOSE OF REVIEW

To review the pathophysiology and treatment of ocular itch and pain, encompassing nociceptive and neuropathic categories.

RECENT FINDINGS

Ocular itch and pain are sensations that arise from activation of ocular surface polymodal nerves. Nociceptive itch, commonly comorbid with ocular pain complaints, is mainly driven by a histamine-mediated type 1 hypersensitivity reaction. Beyond topical therapy, novel drug delivery systems are being explored to improve ocular residence time of nonsteroidal anti-inflammatory drugs (NSAIDs) and antihistamines. Nociceptive ocular pain can be driven by a variety of factors. Treatment focuses on addressing the causative sources of pain. Neuropathic ocular itch and pain are driven by nerve damage and dysfunction and as such, topical and oral neuromodulation have been explored as treatments. Oral neuromodulators include alpha 2 delta ligands, tricyclic antidepressants (TCAs), and low dose naltrexone. Novel therapies are being evaluated for both modalities such as difelikefalin (κ-opioid receptor agonist) for neuropathic itch and libvatrep (transient receptor potential vanilloid 1 antagonist) for neuropathic pain.

SUMMARY

Both ocular itch and pain can be driven by nociceptive and/or neuropathic mechanisms. Identifying contributors to abnormal ocular sensations is vital for precise medical care. Novel therapeutics for these conditions aim to improve patient outcomes and quality of life.

Impaired sleep quality in children with allergic conjunctivitis and their parents

OBJECTIVES

To investigate the sleep quality in children with allergic conjunctivitis (AC) and their parents.

METHODS

Prospective, case-controlled study. Zhongshan Ophthalmic Center, a tertiary referral centre. Participants comprised 73 children aged 4-12 years with AC and their parents, and 81 healthy, age-matched children who served as controls and their parents. General information was recorded and ocular manifestations of children with AC were scored. Sleep quality of the children and parents were assessed using Children's Sleep Habits Questionnaire (CSHQ) and Pittsburgh Sleep Quality Index (PSQI).

RESULTS

Children with AC and their parents had reduced sleep quality (Children's CSHQ: 48.3 ± 6.55 vs. 38.8 ± 4.63; Parental PSQI: 5.62 ± 2.12 vs. 3.40 ± 1.90, both p < 0.001) and significantly higher prevalence of poor sleep quality (CSHQ ≥ 41 in Children: 89.0% vs. 23.5%; PSQI > 7 in Parents: 18.5% vs. 1.23%, both p < 0.001). Children with AC scored worse on subcomponents of CSHQ including sleep onset delay, sleep duration, parasomnia, sleep-disordered breathing, and daytime sleepiness. Parents scored worse on subscores of PSQI including sleep duration, sleep disturbances, use of sleeping medication, and daytime sleepiness. Poor sleep quality in children with AC was associated with follicle formation (OR:3.95; 95% CI: 1.88-8.31, p < 0.001) and keratitis (OR:6.03; 95% CI: 1.29-28.3, p = 0.028). Parental poor sleep quality was associated with follicle formation (OR:7.14; 95% CI: 2.06-24.8, p = 0.002) and keratitis (OR:4.49; 95% CI: 1.27-15.9, p = 0.020) in children.

CONCLUSIONS

AC has a negative association with sleep quality in children and their parents, especially in those children with severe follicle formation and keratitis.

STATE THE DETAILS OF CLINICAL TRIALS

Chictr.org.cn, https://www.chictr.org.cn/showproj.aspx?proj=43511 , ChiCTR1900027486.

STATEMENT OF SIGNIFICANCE

Allergic conjunctivitis is a frequently encountered problem diagnosed and managed by ophthalmologists, paediatricians, allergists, and primary care physicians and has become a major public health issue. Sleep is crucial for learning and effective development in children. Our study discovered a strong association between these two conditions. This is the first study to evaluate the association of allergic conjunctivitis and sleep quality in children and their parents. This case-controlled study found that allergic conjunctivitis had a negative impact on sleep quality not only for children but also for their parents. The findings of this study suggest a multifaceted impact of AC with sleep quality; detailed assessment of sleep quality for improved care of paediatric patients with allergic conjunctivitis would be useful.

Discovery and Preclinical Development of Novel Intraocular Pressure-Lowering Rho Kinase Inhibitor: Corticosteroid Conjugates

Purpose: A new class of ocular steroids designed to mitigate steroid-induced intraocular pressure (IOP) elevation while maintaining anti-inflammatory activity was developed. Herein is described the discovery and preclinical characterization of ROCK'Ster compound 1. Methods: Codrugs consisting of a Rho kinase inhibitor (ROCKi) and a corticosteroid were synthesized. Compounds were initially screened in vitro for ROCKi activity and anti-inflammatory activity against the proinflammatory interleukin 23 and bacterial lipopolysaccharide (LPS) pathways. Selected compounds were then screened for solubility, chemical stability, and ex vivo corneal metabolism. Lead compound 1 was evaluated for IOP lowering in the Dutch Belted rabbit and for anti-inflammatory efficacy in both a postcataract surgery model and an allergic eye disease (AED) mouse model. Results: Several ROCK'Sters were found to be potent inhibitors of ROCK (K_is < 50 nM), have high anti-inflammatory activity in vitro (IC₅₀s < 50 nM), display sufficient stability in topical ophthalmic formulations, and have a moderate rate of corneal metabolism. Compound 1 (0.1% and 0.25%, quater in die [QID]-4 times a day) demonstrated IOP-lowering capability without inducing hyperemia in our rabbit model. When compared with the marketed steroids, Durezol^® and Pred Forte^®, compound 1 (0.1%, 0.25%) demonstrated noninferiority in clinical scoring in a rabbit model of inflammation after surgery. In addition, anti-inflammatory outcomes were observed with compound 1 (0.1%) relative to Lotemax^® or vehicle control in an AED mouse model. Conclusion: ROCK'Ster compound 1 is a novel compound suitable for topical ocular dosing that possesses IOP-lowering capability along with similar anti-inflammatory activity compared with marketed steroids.

Quantifying the associations of the air pollutant SO2 on outpatient visits for conjunctivitis in Hangzhou, China

The aim of this study is to further investigate the single and cumulative associations of SO₂ on outpatient visits for conjunctivitis. Data from outpatient visits, air pollutants, and meteorology was collected by the Eye Center of the Second Affiliated Hospital of the Zhejiang University School of Medicine, the Environmental Protection Department of Zhejiang Province, and the Meteorological Administration of Zhejiang Province from July 1, 2014, to November 30, 2019. A Poisson generalized linear regression model (PGLM), combined with a distributed lag nonlinear model (DLNM), was employed to analyze the association between SO₂ and outpatient visits for conjunctivitis using PM_2.5 and NO₂ as covariates. Of the 539,649 outpatients for conjunctivitis recruited for analysis, 58.1% were female. Obvious single associations of SO₂ were observed in outpatient visits for conjunctivitis, which is consistent with our previous results using a time-stratified case crossover design. A delay in the associations of SO₂ on outpatient visits for conjunctivitis was further confirmed, with the longest lag being 12 days. The strongest lag effect was found at lag 0-11 with RR_95th vs _25th = 1.30 (1.24, 1.37), and RR_90h vs _25th = 1.23 (1.18, 1.28). Furthermore, the results showed that old people may be more sensitive to the associations of SO₂ than adults and the younger ones. Our study provides the first evidence that outpatient visits for conjunctivitis are positively associated with both single and cumulative air pollutant SO₂ exposure, suggesting that people especially elders had better to decrease outdoor activities when the SO₂ concentration is above safe level.

Associations between conjunctivitis and ambient PM2.5 and physical activity: A nationwide prospective cohort study

BACKGROUND

Currently, there is no evidence of fine particulate matter pollution (PM_2.5) altering the relationship between physical activity (PA) and the risk of conjunctivitis.

METHODS

Based on the UK Biobank study, we included 308,507 participants aged 40-69 years at baseline (2006 to 2010) and prospectively followed up for conjunctivitis diagnosis till 2020. Annual concentrations of PM_2.5 in 2010 were estimated for each participant using Land Use Regression models. PA levels during work and leisure time were reported via the International Physical Activity Questionnaire at baseline. We used Cox proportional hazards models to examine the associations of PM_2.5 and PA with incident conjunctivitis, as well as their interaction at both multiplicative and additive scales.

RESULTS

During the 11.6 years of follow up, we identified 4002 incident conjunctivitis cases. High-PA (≥3000 metabolic equivalent of task [MET]-mins/week) was associated with lower risk of conjunctivitis (hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.73-0.86) compared to low-PA (0 to <600 MET-mins/week), while every 1 μg/m³ increment in PM_2.5 was associated with a 16% higher risk of conjunctivitis (HR = 1.16, 95% CI: 1.09-1.23). We did not observe statistically significant interactions between PM_2.5 and PA on their associations with conjunctivitis.

CONCLUSION

Habitual PA and PM_2.5 exposure were oppositely related to incident conjunctivitis. The benefits of PA remain in people irrespective of exposure to air pollution.

Clinical Characterization of Inpatients with Acute Conjunctivitis: A Retrospective Analysis by Natural Language Processing and Machine Learning

Background Acute bacterial conjunctivitis (ABC) is a relatively common medical condition caused by different pathogens. Although it rarely threatens vision, it is one of the most common conditions that cause red eyes and may be accompanied by discomfort and discharge. The study aimed to identify and characterize inpatients with ABC treated with topical antibiotics. Methods The EHRead® technology, based on natural language processing (NLP) and machine learning, was used to extract and analyze the clinical information in the electronic health records (EHRs) of antibiotic-treated patients with conjunctivitis and admitted to five hospitals in Spain between January 2014 and December 2018. Categorical variables were described by frequency, whereas numerical variables included the mean, standard deviation, median, and quartiles. Results From a source population of 2,071,812 adult patients who attended the participating hospitals in the study period, 11,110 patients diagnosed with acute conjunctivitis were identified. Six thousand five hundred eighty-three patients were treated with antibiotics, comprising the final study population. Microbiology was tested only on 12.1% of patients. Antibiotics, mainly tobramycin, and corticosteroids, mainly dexamethasone, were usually prescribed. NSAIDs were also used in about 50% of patients, always combined with antibiotics. Conclusions The present study provided a realistic representation of the hospital practice concerning managing patients with acute antibiotic-treated conjunctivitis. The diagnosis is usually based on the clinical ground, microbiology is rarely tested, few bacteria species are involved, and local antibiotics are frequently associated with corticosteroids and/or NSAIDs. Moreover, this study provided clinically relevant outcomes, based on new technology, that could be applied in clinical practice.

Efficacy of Topical Administration of Corticosteroids for the Management of Dry Eye Disease: Systematic Review and Meta-Analysis

The efficacy of corticosteroids (CS) for dry eye disease (DED) has been investigated in the clinical setting. The present study investigated whether topical CS application improves the clinical outcome at last follow-up compared to the baseline. The present study was conducted according to the PRISMA 2020. All the randomized clinical trials (RCTs), which investigated the efficacy of corticosteroids in the management of DED, were accessed. In September 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar, and Embase. The following data were extracted at baseline and at last follow-up: Ocular Surface Disease Index (OSDI), tear breakup time test (TBUT), Schirmer I test (SIT), and corneal staining. Data from 425 patients were retrieved. A total of 69.4% (295 of 425 patients) were women. CS were effective to improve SIT (p = 0.02) and corneal staining (p = 0.003) at the last follow-up of 10.0 ± 15.3 weeks. TBUT was greater in the CS than in the control group at the last follow-up (p = 0.002). Concluding, topical CS administration led to an increase of SIT and a reduction of corneal staining at a mean of 10 weeks follow-up in patients with DED. Compared to a control group, topical CS administration evidenced greater values of TBUT. Altogether, a good safety profile was witnessed in DED patients receiving CS. However, different safety profiles of different CS formulations were not investigated due to a lack of quantitative data. The exact dosing frequency, duration of therapy, and favorable potency of the CS are still under investigation. Future randomized, controlled trials with larger sample sizes are warranted to provide higher-quality evidence to establish the role of CS in DED.

Alleviating experimental allergic eye disease by inhibiting pro-lymphangiogenic VEGFR3 signal

PURPOSE

Ocular allergy leads to acute and chronic inflammation that may deteriorate the conjunctiva and other ocular tissue. The conjunctiva is covered with abundant lymphatic vessels but how the conjunctival lymphatic system patriciates in the development of allergic eye disease (AED) remains to be elucidated.

METHODS AND RESULTS

By using ovalbumin (OVA)+pertussis toxin (PTX) as a sensitizer followed by daily OVA challenges, we induced optimized AED manifestations in mice. We show that conjunctival lymphatics underwent significant expansion after 28 days of chronic OVA challenge, and this process can be prevented by inducible genetic ablation of lymphatic Vegfr3. Through transcriptomic profile analysis in combination with histopathological examinations, we found that pro-lymphangiogenic VEGFR3 signal promoted allergy-induced activation of T helper 2 (Th2) type immune responses, including antigen presentation, and Th2 cells, B cells and mast cell-related pathways in the conjunctiva, thereby critically contributing to the immunoglobulin E (IgE) production and AED manifestations. As a result, ocular allergy can be alleviated by genetic inhibition of lymphatic Vegfr3. Interestingly, pro-lymphangiogenic VEGFR3 signal did not appear to affect the obstruction of meibomian glands (MGs) or the activation of Th17 type and neutrophil pathways that are associated with AED.

CONCLUSIONS

These data reveal the key role of pro-lymphangiogenic VEGFR3 signaling in the development of AED and provide experimental evidence that VEGFR3 inhibition may be useful in treating ocular allergy in patients.

Ophthalmic Antimicrobial Prescribing in Australian Healthcare Facilities

The National Antimicrobial Prescribing Survey (NAPS) is a web-based, standardized tool, widely adopted in Australian healthcare facilities to assess the reasons for, the quantity of, and the quality of antimicrobial prescribing. It consists of multiple modules tailored towards the needs of a variety of healthcare facilities. Data regarding ophthalmological antimicrobial use from Hospital NAPS, Surgical NAPS, and Aged Care NAPS were analysed. In Hospital NAPS, the most common reasons for inappropriate prescribing were incorrect dose or frequency and incorrect duration. Prolonged duration was also common in Aged Care prescribing: about one quarter of all antimicrobials had been prescribed for greater than 6 months. All three modules found chloramphenicol to be the most prescribed antimicrobial with a high rate of inappropriate prescribing, usually for conjunctivitis.

Therapeutic Targets in Allergic Conjunctivitis

Allergic conjunctivitis (AC) is a common condition resulting from exposure to allergens such as pollen, animal dander, or mold. It is typically mediated by allergen-induced crosslinking of immunoglobulin E attached to receptors on primed conjunctival mast cells, which results in mast cell degranulation and histamine release, as well as the release of lipid mediators, cytokines, and chemokines. The clinical result is conjunctival hyperemia, tearing, intense itching, and chemosis. Refractory and chronic cases can result in ocular surface complications that may be vision threatening. Patients who experience even mild forms of this disease report an impact on their quality of life. Current treatment options range from non-pharmacologic therapies to ocular and systemic options. However, to adequately control AC, the use of multiple agents is often required. As such, a precise understanding of the immune mechanisms responsible for this ocular surface inflammation is needed to support ongoing research for potential therapeutic targets such as chemokine receptors, cytokine receptors, non-receptor tyrosine kinases, and integrins. This review utilized several published articles regarding the current therapeutic options to treat AC, as well as the pathological and immune mechanisms relevant to AC. This review will also focus on cellular and molecular targets in AC, with particular emphasis on potential therapeutic agents that can attenuate the pathology and immune mechanisms driven by cells, receptors, and molecules that participate in the immunopathogenesis and immunopathology of AC.

Prevalence of SARS-CoV-2 in Conjunctival Swab Samples Among Patients Presenting with Conjunctivitis During the COVID-19 Pandemic

Purpose

To investigate the prevalence of SARS-CoV-2-associated conjunctivitis among patients presenting with conjunctivitis to ophthalmology clinics in the absence of respiratory symptoms suggesting COVID-19 during the first year of the pandemic.

Patients and Methods

This prospective, observational, cross-sectional study enrolled patients aged 18 years and older who presented with acute conjunctivitis between May 2020 and May 2021. After reviewing demographics, ocular and systemic symptoms, a slit lamp examination was performed. Five samples were collected (conjunctival swab from each eye, nasal swab from each nostril, and a nasopharyngeal swab) in separate tubes for a reverse transcription-polymerase chain reaction test for SARS-CoV-2. Patients were called at 1 and 2 weeks to follow up on their ocular and systemic symptoms and collect information about conjunctival adenovirus test results and COVID-19 test results if performed outside of the study.

Results

A total of 36 patients were enrolled. The most common ocular symptom was redness (35/36, 97%), and 14 patients (39%) had symptoms in both eyes at the time of the presentation. SARS-CoV-2 RNA was not detected in any samples collected during the study visit (95% confidence interval [CI] from 0 to 0.08). None of the study participants were diagnosed with COVID-19 following conjunctivitis during the 2-week follow-up period. We found that 25 patients had a conjunctival adenovirus test done on the day of their study visit, 9 of which reported positive results.

Conclusion

Our data suggest that it may not be valuable to obtain routine testing of SARS-CoV-2 in patients presenting with conjunctivitis in the absence of COVID-19.

A Systematic Review of Clinical Practice Guidelines for Infectious and Non-infectious Conjunctivitis

PURPOSE

To systematically review and critically appraise clinical practice guidelines (CPGs) and summarise the recommendations for non-infectious and infectious conjunctivitis.

METHODS

CPGs published on non-infectious and infectious conjunctivitis between 2010 and March 2020 were reviewed, evaluated, and selected using nine items from the Appraisal of Guidelines for Research and Evaluation II tool (4, 7, 8, 10, 12, 13, 15, 22 and 23). CPGs with an average score for items 4, 7, 8, 12, or 22 below 3 and/or a sum of the two researchers' average score for all nine items less than 45 were excluded. Two authors independently extracted and validated the data using standardised forms.

RESULTS

Fifteen CPGs from five sources remained for data extraction. CPGs consistently recommended non-pharmacological interventions (artificial tears, cold compress, avoidance or removal of allergens) for non-infectious conjunctivitis and pharmacological interventions (topical anti-histamine, mast-cell stabiliser and dual-acting agent) for allergy types. Observation without treatment was strongly recommended for non-herpetic viral and bacterial infections. Systemic and topical anti-viral was consistently recommended for herpetic viral conjunctivitis, while systemic and topical antibiotics were recommended for chlamydial and gonorrhoeal conjunctivitis. The methods used to assess the level of evidence and the strength of recommendation varied among CPGs.

CONCLUSIONS

There are a number of high-quality CPGs for non-infectious and infectious conjunctivitis. While there were a number of consistencies in the recommendations provided within these CPGs, several inconsistencies were also identified. Many of which related to the scope of practise of the targeted end-user of the particular guideline.

Ocular redness - II: Progress in development of therapeutics for the management of conjunctival hyperemia

Conjunctival hyperemia is one of the most common causes for visits to primary care physicians, optometrists, ophthalmologists, and emergency rooms. Despite its high incidence, the treatment options for patients with conjunctival hyperemia are restricted to over-the-counter drugs that provide symptomatic relief due to short duration of action, tachyphylaxis and rebound redness. As our understanding of the immunopathological pathways causing conjunctival hyperemia expands, newer therapeutic targets are being discovered. These insights have also contributed to the development of animal models for mimicking the pathogenic changes in microvasculature causing hyperemia. Furthermore, this progress has catalyzed the development of novel therapeutics that provide efficacious, long-term relief from conjunctival hyperemia with minimal adverse effects.

Corneal biomechanical changes in allergic conjunctivitis

Background

To explore corneal biomechanical changes, identify related factors and determine early indicators of keratoconus (KC) development risk in allergic conjunctivitis (AC) patients.

Methods

A total of 50 patients, including 20 eyes without AC and 30 eyes with AC were enrolled in this study. All patients underwent a complete ocular examination, including evaluations of clinical manifestations of AC, corneal tomography and densitometry by Pentacam, corneal biomechanics by Corvis ST, and corneal and epithelial thickness mapping by RTvue optical coherence tomography (OCT).

Results

The index of surface variance (ISV), index of vertical asymmetry (IVA), keratoconus index (KI), index of height decentration (IHD) and Belin/Ambrosio enhanced ectasia total deviation index (BAD-D) were significantly higher in the AC group than in the non-allergic conjunctivitis (NAC) group (P < 0.05). The tomography and biomechanical index (TBI) was also significantly higher in the AC group (P = 0.04). The average epithelial thickness in the 2–7 mm annulus was significantly thinner in the AC group than in the NAC group (P < 0.05). The average densitometry of the total cornea and the anterior layer were higher in the AC group than in the NAC group (P < 0.001). The ISV, IVA, KI, IHD and BAD-D were significantly correlated with the TBI and changes in corneal epithelial thickness in AC patients (P < 0.05). The changes in epithelial thickness were closely related to the eye rubbing frequency and allergic sign scores (P < 0.05).

Conclusions

AC patients should be advised to routinely undergo corneal tomographic and biomechanical measurements, and the TBI could be used as an indicator of KC development risk in AC patients.

Trial registration

Corneal Biomechanical Changes of Allergic Conjunctivitis, NCT04299399. Registered March 3, 2020 - Retrospectively registered.

Therapeutic efficacy of tacrolimus in vernal keratoconjunctivitis: a meta-analysis of randomised controlled trials

Background and objective

Tacrolimus has been widely used in recent years for treating allergic conjunctivitis, but there is currently no available meta-analysis regarding its therapeutic efficacy. This study systematically evaluated the effectiveness of tacrolimus in the treatment of allergic conjunctivitis.

Methods

Data obtained from literature searches of the PubMed, Cochrane Library, Embase, CNKI, and Wanfang databases were retrieved by combining medical subject words and free words. Literature was selected on the basis of established inclusion and exclusion criteria, and the extracted data were evaluated for risk of bias using RevMan 5.3 for meta-analysis.

Results

A total of 177 articles were retrieved, of which 5 articles were eventually selected, all of which involved tacrolimus treatment for vernal keratoconjunctivitis. A total of 203 samples were analysed. Results of the meta-analysis showed that the tacrolimus treatment group had significantly lower ocular objective sign scores (SMD −1.39, 95% CI −2.50 to −0.27; p<0.05) and had a significantly lower subjective symptom evaluation score (SMD −0.92, 95% CI −1.59 to −0.24; p<0.05) than the control group.

Conclusion

Current evidence shows that tacrolimus is effective in treating vernal keratoconjunctivitis.

Conjunctivitis: A Systematic Review

Conjunctivitis is a commonly encountered condition in ophthalmology clinics throughout the world. In the management of suspected cases of conjunctivitis, alarming signs for more serious intraocular conditions, such as severe pain, decreased vision, and painful pupillary reaction, must be considered. Additionally, a thorough medical and ophthalmic history should be obtained and a thorough physical examination should be done in patients with atypical findings and chronic course. Concurrent physical exam findings with relevant history may reveal the presence of a systemic condition with involvement of the conjunctiva. Viral conjunctivitis remains to be the most common overall cause of conjunctivitis. Bacterial conjunctivitis is encountered less frequently and it is the second most common cause of infectious conjunctivitis. Allergic conjunctivitis is encountered in nearly half of the population and the findings include itching, mucoid discharge, chemosis, and eyelid edema. Long-term usage of eye drops with preservatives in a patient with conjunctival irritation and discharge points to the toxic conjunctivitis as the underlying etiology. Effective management of conjunctivitis includes timely diagnosis, appropriate differentiation of the various etiologies, and appropriate treatment.

The effectiveness of olopatadine hydrochloride eye drops for allergic conjunctivitis: Protocol for a systematic review

BACKGROUND

Allergic conjunctivitis (AC) is a multifactorial and common type of ocular surface disease that affects many people. The quality of life for AC patients can be significantly decreased caused by symptoms of ocular itching, swelling, redness, and tearing. Topical antihistaminics, mast cell stabilizers, non-steroidal anti-inflammatory drugs (NSAIDs), and steroids have been widely used to treat AC. Many clinical trials have indicated that olopatadine hydrochloride eye drops can provide quick relief of symptoms and signs. The purpose of this review is to evaluate systematically the effectiveness of olopatadine hydrochloride eye drops for treating AC.

METHODS

A systematic review of all of the randomized controlled trials on the effectiveness and safety of olopatadine hydrochloride eye drops for AC will be conducted. We will search PubMed, Web of Science (WOS), EMBASE (OVID), the Cochrane Library, Google Scholar, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal database (VIP), Wanfang Database, and CBM, from the database inception date to October 31, 2019. There are no language or publication status restrictions. Registers of clinical trials, potential gray literature, reference lists of studies, and conference abstracts will also be searched. Two reviewers will independently read the articles, extract the data information, and assess the quality of the studies. Data will be synthesized by a heterogeneity test. The primary outcomes include the main symptom and sign scores before and after treatment, the eye redness index, the presence of eosinophils in the conjunctival scraping. Quality of life, the total treatment efficacy, and safety will be evaluated as the secondary outcomes. RevMan V.5.3 software will be used for the meta-analysis.

RESULTS

The study will provide an objective and normative systematic review to evaluate the effectiveness and safety of olopatadine hydrochloride eye drops for the treatment of AC.

CONCLUSION

Our review will provide useful information to judge whether olopatadine hydrochloride eye drops is an effective intervention for patients with AC.

ETHICS AND DISSEMINATION

It is not necessary to obtain ethical approval as participants are not involved patients. The protocol and results will be published in a peer-reviewed journal. The systematic review will also be disseminated electronically and in print to help guide health care practice and policy.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019132232.

Ocular symptoms improvement from intranasal triamcinolone compared with placebo and intranasal fluticasone propionate: A meta-analysis

BACKGROUND

Allergic rhinitis is a prevalent disease, which can be classed as seasonal (SAR) or perennial. In addition to nasal symptoms, up to 75% of sufferers experience itching, redness, and tearing of the eyes. Intranasal corticosteroids are effective in controlling the allergic nasal symptoms, and increasing evidence suggests that they also can relieve some of the allergic ocular symptoms.

OBJECTIVE

To evaluate the magnitude of efficacy of triamcinolone acetonide (TAA) compared with placebo or fluticasone propionate (FP) on ocular symptom improvement in patients with SAR.

METHODS

A meta-analysis of summary data from 8 randomized, double- or single-blind trials, assessing mean change in total or individual (tearing, redness, and itching) eye symptoms was conducted. Trials that administered a daily dose of 220 μg TAA vs placebo or 200 μg FP over at least 2 weeks' duration, in patients aged 12 years or older with SAR, were analyzed.

RESULTS

Total eye symptom reduction after 2 weeks was greater with TAA than placebo, with a mean treatment difference of -0.32 (95% CI, -0.444 to -0.203). In addition, significant reductions in tearing, but not itching or redness, were observed after TAA treatment compared with placebo. No significant treatment difference was seen between TAA and FP in total ocular symptoms at any of the time points measured (weeks 1, 2, 3, and overall). All treatments exhibited similar safety profiles and were deemed well tolerated.

CONCLUSION

The meta-analysis demonstrated the positive clinical improvements TAA has on total ocular allergy symptoms, especially tearing, in addition to its recognized nasal symptom efficacy in SAR.

Topical Low Dose Preservative-Free Hydrocortisone Reduces Signs and Symptoms in Patients with Chronic Dry Eye: A Randomized Clinical Trial

PURPOSE

Dry eye disease (DED) is a highly prevalent ocular condition with a significant burden on affected patients. Regardless of the underlying etiology, DED is associated with increased ocular surface inflammation. We investigated the safety and efficacy of a short-term treatment with topical low dose hydrocortisone in patients with chronic DED and ocular surface inflammation.

METHODS

A total of 60 patients (mean age 51 ± 14 years) with chronic DED and conjunctival hyperemia greater than grade 2 on the Efron scale were included. Patients were randomized to receive either preservative-free hydrocortisone 0.335% (Softacort, Laboratories Thea, France) for 12 days four times daily followed by 2 days twice daily instillation (intense treatment group) or 8 days three times daily followed by 3 days twice daily treatment (standard treatment group). Ocular redness was assessed at baseline, day 14, and day 28. Measurement of intraocular pressure (IOP) and clinical tests to assess signs and symptoms of DED were performed.

RESULTS

Conjunctival hyperemia and Ocular Surface Disease Index (OSDI) significantly decreased in both treatment groups (p < 0.001 each) after hydrocortisone treatment. A significant increase in tear film thickness was seen 4 weeks after treatment start (p = 0.03 and p = 0.04, respectively). IOP did not change in either of the two treatment groups (p = 0.45).

CONCLUSION

Treatment with low dose hydrocortisone 0.335% reduced ocular inflammation and decreased OSDI score. No change in IOP was observed in either of the two treatment schedules. Because of its good safety profile, low dose hydrocortisone may be an interesting alternative to standard corticosteroid treatment in DED.

FUNDING

Laboratories Thea.

TRIAL REGISTRATION

Clinicaltrials.gov registry: NCT03907865.

Resolvin D1 treatment on goblet cell mucin and immune responses in the chronic allergic eye disease (AED) model

Severe, chronic eye allergy is an understudied, vision-threatening condition. Treatments remain limited. We used a mouse model of severe allergic eye disease (AED) to determine whether topical application of the pro-resolution mediator Resolvin D1 (RvD1) terminates the response. AED was induced by injection of ovalbumin (OVA) followed by topical challenge of OVA daily. RvD1 was applied topically prior to OVA. Clinical symptoms were scored. Eye washes were assayed for MUC5AC. After 7 days, eyes were removed and the number of goblet cells, T helper cell responses and presence of immune cells in draining lymph nodes and conjunctiva determined. Topical RvD1 treatment significantly reduced symptoms of AED. RvD1 did not alter the systemic type 2 immune response in the lymph nodes. AED increased the total amount of goblet cell mucin secretion, but not the number of goblet cells. RvD1 prevented this increase, but did not alter goblet cell number. Absolute numbers of CD4 + T cells, total CD11b + myeloid cells, eosinophils, neutrophils, and monocytes, but not macrophages increased in AED versus RvD1-treated mice. We conclude that topical application of RvD1 reduced the ocular allergic response by local actions in conjunctival immune response and a decrease in goblet cell mucin secretion.

Preclinical Development of EBI-005: An IL-1 Receptor-1 Inhibitor for the Topical Ocular Treatment of Ocular Surface Inflammatory Diseases

OBJECTIVE

Topical interleukin (IL)-1 receptor (R)1 blockade is therapeutically active in reducing signs and symptoms of dry eye disease. Herein, we describe in vitro and in vivo nonclinical Investigational New Drug (IND)-enabling studies of EBI-005, a novel protein chimera of IL-1β and IL-1 receptor antagonist (IL-1Ra or anakinra) that potently binds IL-1R1 and blocks signaling. These studies provide an assessment of receptor affinity, drug bioavailability, immunogenic response, safety, and tolerability in mice and rabbits.

METHODS

In vitro and in silico along with Good Laboratory Practices (GLP) and non-GLP in vivo studies in mice and rabbits assessed the topical ocular and systemic immunogenicity and toxicology of EBI-005. Animals were treated with EBI-005 once daily subcutaneously or four times daily by topical ocular administration for up to 6 weeks (with 2-week recovery phase).

RESULTS

EBI-005 has 500 times higher affinity than anakinra to IL-1R1. Predictive immunogenicity testing suggested that EBI-005 is not more immunogenic. Systemic bioavailability of EBI-005 is low (1.4% in mice and 0.2% in rabbits) after topical ocular administration. EBI-005 penetrated into the anterior ocular tissues within 15 min of topical ocular administration. However, it is low or undetectable after 4 hr and does not form a depot after repeated topical ocular administration. EBI-005 was safe and well tolerated, and exposure to drug was maintained despite an antidrug antibody response after systemic administration, based on IND-enabling toxicology and safety pharmacology studies.

CONCLUSIONS

Ocular doses of EBI-005 at 50 mg/mL in mice and rabbits totaling 0.15 mg/eye in mice and 1.5 mg/eye in rabbits, administered 4 times daily, did not produce adverse effects, and demonstrated excellent bioavailability in target tissues with low systemic exposure. In addition, immunogenic response to the drug did not cause adverse effects or diminish the drug's activity in most cases. The results support drug administration of the highest anticipated human clinical study dose of a 20 mg/mL solution (40 μL 3 times daily in each eye).

Bepotastine besilate ophthalmic solution 1.5% for alleviating nasal symptoms in patients with allergic conjunctivitis

Background

Bepotastine besilate ophthalmic solution (BBOS) 1.5% is a topical antihistamine for the treatment of ocular itching associated with allergic conjunctivitis (AC). Allergic rhinitis and AC are common comorbid conditions. We explored the efficacy of BBOS 1.5% in alleviating nasal symptoms in an integrated analysis of two Phase III conjunctival allergen challenge (CAC) studies and a Phase IV environmental allergen study.

Methods

In the Phase III trials, a CAC was performed 15 minutes, 8 hours, and 16 hours following ocular instillation of BBOS 1.5% (n=78) or placebo (n=79), and subjects evaluated nasal symptoms. In the environmental study, subjects instilled BBOS 1.5% (n=123) or placebo (n=122) twice daily and nasal symptoms were evaluated over 2 weeks.

Results

In the Phase III trials, BBOS 1.5% had reduced CAC-induced nasal congestion and pruritus at 15 minutes and 8 hours postdosing and rhinorrhea and a non-ocular composite-symptom score (sum of nasal scores plus ear or palate pruritus) at all time points postdosing (all P≤0.01 vs placebo). In the Phase IV environmental study, BBOS 1.5% reduced sneezing and nasal pruritus over 2 weeks and median number of days to improvement of nasal pruritus and total nasal symptom score (sum for rhinorrhea, sneezing, nasal pruritus, and nasal congestion; P≤0.04 vs placebo). Additionally, investigator-reported improvement in overall ocular (pruritus, hyperemia, tearing) and nasal symptoms was greater with BBOS 1.5% vs placebo (P≤0.03).

Conclusion

Results of these exploratory analyses indicate that topical ocular BBOS 1.5% reduced nasal symptoms, supporting its use for alleviating rhinitis symptoms associated with AC.

Loteprednol etabonate for inflammatory conditions of the anterior segment of the eye: twenty years of clinical experience with a retrometabolically designed corticosteroid

INTRODUCTION

Topical corticosteroids are an important pharmacotherapy for the management of various inflammatory conditions affecting the anterior segment of the eye. However, medications in this class are associated with well-known risks including increased intraocular pressure (IOP) and development of cataracts. The topical corticosteroid loteprednol etabonate (LE) was developed with the specific intention of minimizing these side effects.

AREAS COVERED

The focus of this review is to examine published efficacy and safety data for LE, a drug engineered to undergo rapid metabolism to inactive metabolites with the goal of improved safety. Two decades of clinical research focused on LE formulations are reviewed, including the use of LE in combination with tobramycin. The cumulative body of experience affirms the concept that the molecular design of LE confers certain safety benefits without compromising the desired anti-inflammatory efficacy of a topical corticosteroid.

EXPERT OPINION

Loteprednol etabonate is a mainstay for topical therapy of a wide variety of commonplace and niche conditions of the ocular surface and the anterior segment, including in the healing post-operative patient. Its versatility and safety allow eye care providers to recommend both acute induction as well as chronic maintenance therapy with appropriate follow-up.

Clinical implications of mast cell involvement in allergic conjunctivitis

The conjunctiva is a common site for the allergic inflammatory response due to it being highly vascularized, having constant exposure to environmental pollutants and allergenic pollens and having a unique conjunctival associated lymphoid tissue. The primary morbidity of anterior surface conjunctival disorders that include allergic conjunctivitis and tear film disorders is associated with its high frequency of involvement rather than its severity, although the more chronic forms can involve the cornea and lead to sight-threatening conditions. Ocular allergy is associated with IgE-mediated mast cell activation in conjunctival tissue leading to the release of preformed mediators including histamine and proteases and subsequent de novo formation of lipid-derived mediators and cytokines that trigger a cascade of cellular and molecular events leading to extensive migration and infiltration of inflammatory cells to the ocular surface. The trafficking of neutrophils, eosinophils, and lymphocytes to the ocular surface is due to establishing various chemokine gradients (mainly CCL11, CCL24, CCL5, MCP-3, and MCP-4), cell surface expression of adhesion molecules (such as VCAM-1 the ligand for VLA-4), and leukocyte adhesion to vascular endothelium. The release of preformed mediators underlies the acute ocular surface response while the secondary influx of inflammatory cells leading to the recruitment and activation of eosinophils and the subsequent activation of Th2 and Th1 lymphocytes at the level of the conjunctiva reflects the late-phase reaction.

Manifestations of Inhalant Allergies Beyond the Nose

The upper and lower airways are linked epidemiologically and pathophysiologically. The upper and lower airways are considered a single, functional unit characterized by shared immunologic mechanisms, often referred to as the unified airway. Upper and lower airway inflammatory disease frequently coexist in the same patient. Allergic rhinitis and rhinosinusitis are associated with asthma. Treatment of both diseases impacts asthma outcomes. The otolaryngologist may be the first physician to suspect and diagnose asthma in patients with upper airway complaints. A thorough understanding of the relationship between allergic rhinitis, rhinosinusitis, and asthma will facilitate early identification of asthma and improve patient outcomes.

Risk of allergic conjunctivitis in patients with type 1 diabetes mellitus: a population-based retrospective cohort study

OBJECTIVE

In accordance with the dichotomy between T helper type 1(Th1) and T helper type 2 (Th2) responses, the occurrence of allergic conjunctivitis (AC) and type 1 diabetes mellitus (T1DM) is, in theory, inversely related in the individual. However, recent studies investigating the association between the two diseases are controversial.

DESIGN

Population-based cohort study.

SETTING

We used claims data of the National Health Insurance Research Database of Taiwan.

PARTICIPANTS

We identified 4160 patients aged 1-30 years with newly diagnosed T1DM and no history of AC at baseline. For each patient with T1DM, four non-T1DM controls (n=16,640) were matched by sex. The mean follow-up time was 6 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Multivariate Cox proportional hazards regression analysis was used to evaluate the risk of AC. We additionally evaluated the association between risk of AC and T1DM progression by examining Diabetes Complications Severity Index (aDCSI) changes from the date of diagnosis until the end of follow-up.

RESULTS

The overall incidence of allergic conjunctivitis (AC) was higher in the type 1 diabetes mellitus (T1DM) cohort than in the control cohort (23.0 vs 13.5 per 1000 person-years, adjusted incidence rate ratio (aIRR): 1.59, 95% CI 1.47 to 1.71). Relative to that in patients with mildly progressive T1DM, the risk of AC increased as the adapted Diabetes Complications Severity Index (aDCSI) increased (aIRR: 1.68, 3.78 and 18.8, with yearly changes in aDCSI score: 0.51 to 1.00, 1.01 to 2.00, and >2.00 vs <0.51, respectively; for trend <0.001).

CONCLUSION

Patients with T1DM are at an elevated risk of developing AC; this risk increases with T1DM progression. The T helper type 1/T helper type 2 hypothesis is an overly simplistic explanation for this association.

Clinical Evaluation of Red Eyes in Pediatric Patients

Patients with the primary symptom of a red eye are commonly seen in pediatric primary care clinics. The differential diagnoses of a red eye are broad, but with a succinct history and physical examination, the diagnosis can be readily identified in many patients. Identifying conditions that threaten vision and understanding the urgency of referral to an ophthalmologist is paramount. Some systemic diseases such as leukemia, sarcoidosis, and juvenile idiopathic arthritis can present with the chief symptom of a red eye. Finally, trauma, ranging from mild to severe, often precipitates an office visit with a red eye, and thus understanding the signs that raise concern for a ruptured globe is essential. In the primary care setting, with a focused history, a few simple examination techniques, and an appreciation of the differential diagnosis, one can feel confident in managing patients with acute red eyes.

Ambient air pollution, weather changes, and outpatient visits for allergic conjunctivitis: A retrospective registry study

Allergic conjunctivitis is a common problem that significantly impairs patients’ quality of life. Whether air pollution serves as a risk factor for the development of allergic conjunctivitis remains elusive. In this paper, we assess the relationship between air pollutants and weather conditions with outpatient visits for allergic conjunctivitis. By using a time-series analysis based on the largest dataset ever assembled to date, we found that the number of outpatient visits for allergic conjunctivitis was significantly correlated with the levels of NO₂, O₃, and temperature, while its association with humidity was statistically marginal. No associations between PM₁₀, PM_2.5, SO₂, or wind velocity and outpatient visits were seen. Subgroup analyses showed that sex seemed to modify the effects of humidity on outpatient visits for allergic conjunctivitis, but not for NO₂, O₃, or temperature. People younger than 40 were found to be susceptible to changes of all four parameters, while those older than 40 were only consistently affected by NO₂ levels. Our findings revealed that higher levels of ambient NO₂, O₃, and temperature increase the chances of outpatient visits for allergic conjunctivitis. Ambient air pollution and weather changes may contribute to the worsening of allergic conjunctivitis.

Treating allergic conjunctivitis: A once-daily medication that provides 24-hour symptom relief

BACKGROUND

Allergic conjunctivitis (AC) is a common ocular inflammatory manifestation of allergen exposure in sensitized individuals. Signs and symptoms of AC can decrease quality of life, interfere with productivity, and lead to considerable economic burden. Consistent suppression of conjunctival inflammation is necessary for managing AC, but currently available medications require frequent administration and exhibit limited duration of action.

METHODS

In this review, we summarized AC pathogenesis, diagnosis, and current treatment options as well as their limitations. Findings from the literature were discussed in the context of the unmet need for a once-daily medication with sustained 24-hour effectiveness.

RESULTS

Topical pharmacologic treatments are the most common approach for managing extant AC; however, most available medications require multiple daily instillations. Dual-acting antihistamine-mast cell stabilizing agents are currently considered first-line therapeutics for AC because they provide acute relief of signs and symptoms and block persistent inflammation to promote regression of AC. Recent studies of a newly-developed, higher-concentration formulation of a dual-acting antihistamine-mast cell stabilizer have demonstrated that this formulation provides a 24-hour duration of action with once-daily dosing.

CONCLUSIONS

Dual-acting AC medications exhibit a high degree of overall effectiveness and are well tolerated for chronic use. A newly available once-daily medication that manages signs and symptoms of AC for a full 24 hours may be considered a treatment of choice for patients experiencing seasonal or perennial AC. ClinicalTrials.gov NCT01743027 and NCT01479374.

Possible Mechanism of Action of the Antiallergic Effect of an Aqueous Extract of Heliotropium indicum L. in Ovalbumin-Induced Allergic Conjunctivitis

Heliotropium indicum is used traditionally as a remedy for conjunctivitis in Ghana. This study therefore evaluated the antiallergic potential of an aqueous whole plant extract of Heliotropium indicum (HIE) in ovalbumin-induced allergic conjunctivitis and attempted to predict its mode of action. Clinical scores for allergic conjunctivitis induced by intraperitoneal ovalbumin sensitization (100 : 10 μg OVA/Al(OH)3 in phosphate-buffered saline [PBS]) and topical conjunctival challenge (1.5 mg OVA in 10 μL PBS) in Dunkin-Hartley guinea pigs were estimated after a week's daily treatment with 30-300 mg kg(-1) HIE, 30 mg kg(-1) prednisolone, 10 mg kg(-1) chlorpheniramine, or 10 mL kg(-1) PBS. Ovalbumin-specific IgG and IgE and total IgE in serum were estimated using Enzyme-Linked Immunosorbent Assay. Histopathological assessment of the exenterated conjunctivae was also performed. The 30 and 300 mg kg(-1) HIE treatment resulted in a significantly (p ≤ 0.001) low clinical score of allergic conjunctivitis. Ovalbumin-specific IgG and IgE as well as total serum IgE also decreased significantly (p ≤ 0.01-0.001). The conjunctival tissue in HIE treated guinea pigs had mild mononuclear infiltration compared to the PBS-treated ones, which had intense conjunctival tissue inflammatory infiltration. HIE exhibited antiallergic effect possibly by immunomodulation or immunosuppression.