Differentiating conjunctivitis of diverse origins

Development and validation of a health practitioner survey on ocular allergy

Survey studies have played a significant role in understanding the gaps in the knowledge and practices of health practitioners. However, there have been no such survey studies on Ocular Allergy (OA). Thus, the purpose of this study was to develop and validate a survey on OA to better understand the gaps in the diagnostic, treatment, and collaborative care approaches of health practitioners in OA. The survey is titled "Survey on Ocular Allergy for Health Practitioners (SOAHP)". SOAHP was developed in a five-stage process. First, item extraction via the use of a literature review, second, face and content validity, third, a pilot study, fourth, test-retest reliability, and fifth, finalisation of the survey. 65 items under 6 domains were initially generated in the item extraction phase. Content validity was conducted on 15 experts in the field. This was conducted twice to reach consensus whereby items and domains were added, edited, kept, or removed, resulting in 50 items under 7 domains. The pilot study was conducted on 15 participants from the five relevant health practitioner fields (Allergists/Immunologists, General Practitioners (GPs), Ophthalmologists, Optometrists and Pharmacists). This altered the survey further to 40 items under 7 domains. Test-retest reliability was conducted on 25 participants from the five health practitioner fields. Reliability was moderate to almost perfect for most (97%) investigated items. The finalised survey was 40 items under 7 domains. SOAHP is the first survey created to assess diagnostic, treatment and collaborative care approaches of Allergists/Immunologists, GPs, Ophthalmologists, Optometrists and Pharmacists on OA. SOAHP will be a useful tool in clinical research on OA.

Ocular Surface Disease and Anti-Glaucoma Medications: Various features, Diagnosis, and Management Guidelines

PURPOSE

Assessment of ocular surface in patients using anti-glaucoma medications (AGM) is rarely a priority for clinicians since glaucoma management targets intraocular pressure and preserves vision. This review summarizes the various adverse effects of topical AGM on the ocular surface and highlights the importance of ocular surface assessment in these patients.

METHODS

A literature search of articles (English only) on the subject matter was conducted focusing on recent articles published in the past 5 years.

RESULTS

The use of multiple anti-glaucoma medications in glaucoma patients increases patients' exposure to the drug and the preservatives present in these medications. Long-term use of these medications has deleterious effects on the conjunctiva, cornea, eyelids, and periocular tissues like trichiasis, entropion, symblepharon, forniceal shortening, punctate keratopathy, non-healing epithelial defects, and pannus. Treatment requires drug withdrawal or substitution by oral or topical non-preserved and less toxic preparations of AGMs. The ocular surface and symptoms can improve if the condition is diagnosed early and after drug withdrawal in over 90% of eyes. However, stopping or changing AGMs can often present with its own unique set of challenges in intra-ocular pressure control which may often need glaucoma surgery in close to 20% of eyes for IOP control.

CONCLUSION

Topical antiglaucoma medications (with their preservatives) can induce severe ocular surface and periorbital changes. Early identification and withdrawal of the offending drug/preservative can help to reverse the changes except in eyes with extensive cicatrization.

Demographic and Clinical Factors associated with Brimonidine-Induced Ocular Allergy

Purpose.

Ocular allergy induced by brimonidine tartrate 0.2% is a common adverse event that is associated with poor compliance and therefore treatment failure. The authors investigated the demographic and clinical characteristics associated with development of this allergy.

Methods.

In total, 133 patients with ocular hypertension or open angle glaucoma and treated with brimonidine tartrate 0.2% were retrospectively divided into two groups: allergic and nonallergic to brimonidine tartrate 0.2%. Demographic, local, and systemic ocular variables were compared in the two groups.

Results.

Altogether, 13.5% of patients (18 of 133) developed brimonidine ocular allergy, generally within 2 weeks of beginning treatment (mean time 14.8±17.9 days). Compared with the nonallergic group, the allergic group was significantly more likely to have a history of ocular allergy to eyedrops (p=0.048) and to topical beta blockers (p=0.019). Moreover, the allergic group showed decreased tear film production (p=0.044).

Conclusions.

Patients with a history of eyedrop allergy or with reduced tear film production are more likely to develop brimonidine-associated allergy. Brimonidine may therefore not be suitable for patients with a history of allergy.

Diagnosis and Management of Conjunctivitis for the Dermatologist

Atopic dermatitis is a chronic, sometimes relapsing inflammatory skin condition that presents with pruritus and characteristic skin manifestations. Conjunctivitis is a common ocular comorbidity affecting almost half of patients with the risk increasing with atopic dermatitis severity. Recent targeted biologic therapies that successfully treat atopic skin disease, including dupilumab, which blocks interleukin (IL)-4 and IL-13, as well as agents that block IL-13 alone, have been associated with an increased rate of conjunctivitis in clinical trials. Because conjunctivitis commonly occurs in patients with atopic dermatitis and as the treatment with targeted biologic agents may increase the risk or severity of conjunctivitis, it is important that dermatologists recognize symptoms, appreciate treatment options, and know when referral to an ophthalmologist is appropriate.

Lid wiper epitheliopathy

Some recent research has resulted in a hypothesis that there is a common 'lid wiper' region that is apposite to the ocular surface or anterior lens surface (where contact lenses are worn), responsible for spreading tears during blinking. In the upper eyelid, it extends about 0.6 mm from the crest of the sharp posterior (inner) lid border (i.e. the mucocutaneous junction, or line of Marx) to the subtarsal fold superiorly and from the medial upper punctum to the lateral canthus horizontally. Histologically, it is seen as an epithelial elevation comprising of stratified epithelium with a transitional conjunctival structure of (moving posteriorly) squamous cells then cuboidal cells, with some parakeratinised cells and goblet cells. Lid wiper epitheliopathy (LWE) denotes staining of the lid wiper observed after instillation of dyes such as fluorescein, rose bengal or lissamine green. There have been some reports of higher rates of LWE in dry eye patients and contact lens wearers, but others have failed to find such associations. The primary cause of LWE is thought to be increased friction between the lid wiper and ocular or anterior contact lens surface due to inadequate lubrication, which could be caused by dry eye and may be exacerbated by factors such as abnormal blinking patterns, poor contact lens surface lubricity and adverse environmental influences. Recent evidence suggests that LWE is associated with sub-clinical inflammation. LWE has the potential to provide the missing mechanistic link between clinical observation and symptoms associated with dry eye and contact lens wear. Clinical and fundamental research into LWE is still in its infancy and in many instances equivocal; however, it is an idea that provides a potentially important new avenue for further investigation of anterior eye discomfort associated with ocular dryness and contact lens wear.

Diagnosis of acute follicular conjunctivitis: A 5-year retrospective analysis in a referral center

OBJECTIVE AND METHODS

A retrospective analysis was performed using the medical records in a referral center in Mexico over a period of 5 years, in order to determine the frequency of acute follicular conjunctivitis.

RESULTS AND CONCLUSIONS

A total of 859,986 ophthalmology consultations were given, from which 8,930 were diagnosed with acute follicular conjunctivitis (1.03% of the total). The number of patients diagnosed range between 100 and 200 in the majority of months. In August 2012 an increase was observed with 308 cases, and then decreasing after two months. This study did not demonstrate a highest frequency by month, with exception of year 2012 that showed a peak incidence in the third trimester.

Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis

BACKGROUND

Acute infective conjunctivitis is a common problem in primary care, traditionally managed with topical antibiotics. A number of clinical trials have questioned the benefit of topical antibiotics for patients with acute infective conjunctivitis.

AIM

To determine the benefit of antibiotics for the treatment of acute infective conjunctivitis in primary care and which subgroups benefit most.

DESIGN

An individual patient data meta-analysis.

METHOD

Relevant trials were identified and individual patient data gathered for meta-analysis and subgroup analysis.

RESULTS

Three eligible trials were identified. Individual patient data were available from all primary care trials and data were available for analysis in 622 patients. Eighty per cent (246/308) of patients who received antibiotics and 74% (233/314) of controls were cured at day 7. There was a significant benefit of antibiotics versus control for cure at seven days in all cases combined (risk difference 0.08, 95% confidence interval (CI) = 0.01 to 0.14). Subgroups that showed a significant benefit from antibiotics were patients with purulent discharge (risk difference 0.09, 95% CI = 0.01 to 0.17) and patients with mild severity of red eye (risk difference 0.10, 95% CI = 0.02 to 0.18), while the type of control used (placebo drops versus nothing) showed a statistically significant interaction (P=0.03).

CONCLUSION

Acute conjunctivitis seen in primary care can be thought of as a self-limiting condition, with most patients getting better regardless of antibiotic therapy. Patients with purulent discharge or a mild severity of red eye may have a small benefit from antibiotics. Prescribing practices need to be updated, taking into account these results.

Sublingual immunotherapy for treating allergic conjunctivitis

BACKGROUND

Allergic ocular symptoms, although frequently trivialised, are common and represent an important comorbidity of allergic rhinitis. Sublingual Immunotherapy (SLIT) is an effective and well-tolerated treatment for allergic rhinitis, but its effects on symptoms of ocular allergy have not been well established.

OBJECTIVES

To evaluate the efficacy of SLIT compared with placebo for reductions in ocular symptoms, topical ocular medication requirements and conjunctival immediate allergen sensitivity.

SEARCH STRATEGY

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 1), MEDLINE (January 1950 to January 2011), EMBASE (January 1980 to January 2011), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to January 2011), Web of Science (January 1970 to January 2011), Biosis Previews, (January 1979 to January 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (January 2011), ClinicalTrials.gov (www.clinicaltrials.gov) (January 2011), the Australian New Zealand Clinical Trials Registry (ANZCTR) (www.actr.org.au) (July 2010), SCOPUS (November 2008) and the UK Clinical Trials Gateway (January 2010). There were no language or date restrictions in the search for trials. All electronic databases except for SCOPUS, the UK Clinical Trials Gateway and ANZCTR were last searched on 19 January 2011.

SELECTION CRITERIA

Randomised controlled trials (RCTs), double-masked and placebo controlled, which evaluated the efficacy of SLIT in patients with symptoms of allergic rhinoconjunctivitis (ARC) or allergic conjunctivitis (AC).

DATA COLLECTION AND ANALYSIS

The primary outcome was the total ocular symptom scores. Secondary endpoints included individual ocular symptom scores (such as itchy eyes, red eyes, watery eyes, swollen eyes), ocular medication scores (eye drops) and conjunctival immediate allergen sensitivity (CIAS). Data were analysed and reported as standardised mean differences (SMDs) using Review Manager software.

MAIN RESULTS

Forty-two trials (n = 3958 total participants; n= 2011 SLIT and n = 1947 placebo) had available data to evaluate the efficacy of SLIT on AC and were included in the meta-analyses. Heterogeneity among studies (I(2) statistic) was around 50% or below for all endpoints. Sublingual immunotherapy induced a significant reduction in both total ocular symptom scores (SMD -0.41; 95% confidence interval (CI) -0.53 to -0.28; P < 0.00001; I(2) = 59%) and individual ocular symptom scores for red eyes (SMD -0.33; 95% CI -0.45 to -0.22; P < 0.00001; I(2) = 27%), itchy eyes (SMD -0.31; 95% CI -0.42 to -0.20; P < 0.00001; I(2) = 46%) and watery eyes (SMD -0.23; 95% CI -0.34 to -0.11; P < 0.0001; I(2) = 42%) compared to placebo. Those participants having active treatment showed an increase in the threshold dose for the conjunctival allergen provocation test (SMD 0.35; 95% CI 0.00 to 0.69; P = 0.05; I(2) = 43%). No significant reduction was observed in ocular eye drops use (SMD -0.10; 95% CI -0.22 to 0.03; P = 0.13; I(2) = 34%).

AUTHORS' CONCLUSIONS

Overall, SLIT is moderately effective in reducing total and individual ocular symptom scores in participants with ARC and AC. There were however some concerns about the overall quality of the evidence-base, this relating to inadequate descriptions of allocation concealment in some studies, statistical heterogeneity and the possibility of publication bias. There is a need for further large rigorously designed studies that study long-term effectiveness after discontinuation of treatment and establish the cost-effectiveness of SLIT.

Effects of common topical antiglaucoma medications on the ocular surface, eyelids and periorbital tissue

Glaucoma affects millions of people around the world. With the baby boom generation aging, the number of people affected by primary open-angle glaucoma in the US is expected to reach 3.3 million by 2020, and about half may not know they have the disease. The treatment of most forms of glaucoma includes the use of topical agents that enhance aqueous humour outflow, reduce aqueous production, or both. Topical intraocular pressure-lowering drugs must penetrate across the tissues of the eye to reach their therapeutic targets. Often, these tissues show the first signs and symptoms of drug toxicity and adverse effects. These include eyelid dermatitis, malpositions, lacrimal system scarring, ocular discomfort upon instillation, tear film instability, conjunctival inflammation, subconjunctival fibrosis, conjunctival epithelium changes, and corneal surface and endothelial impairment. For these reasons, ophthalmologists should evaluate the risks and benefits of ophthalmic medications before initiating therapy, identify the minimum dosages necessary to achieve a therapeutic benefit, and monitor patients for local and systemic adverse effects. Adverse events may be reduced by changing to a different class of topical medication, using corticosteroids, lubricating the eyes frequently, and reducing exposure to preservatives. This in turn can lead to higher levels of adherence to antiglaucoma therapy, improved outcomes and a reduction in the costs associated with long-term glaucoma complications. This article reviews the ocular adverse effects associated with the various classes of topical antiglaucoma drugs, with a particular focus on the ocular surface, eyelids and periorbital tissue.

Nonsteroidal anti-inflammatory drugs in ophthalmology

Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly employed in ophthalmology to reduce miosis and inflammation, manage scleritis, and prevent and treat cystoid macular edema associated with cataract surgery. In addition, they may decrease postoperative pain and photophobia associated with refractive surgery and may reduce the itching associated with allergic conjunctivitis. In recent years, the U.S. Food and Drug Administration has approved new topical NSAIDs, and previously approved NSAIDs have been reformulated. These additions and changes result in different pharmacokinetics and dosing intervals, which may offer therapeutic advantages. For example, therapeutic effects on diabetic retinopathy and age-related macular degeneration may now be achievable. We provide an updated review on NSAIDs and a summary of their current uses in ophthalmology with attention to potential future applications.

Management strategies for acute infective conjunctivitis in primary care: a systematic review

A systematic review of the literature on all aspects of the management of acute infective conjunctivitis is undertaken. Acute infective conjunctivitis is a common presentation in primary healthcare. It is usually a mild condition and serious complications are rare. Clinical signs are a poor discriminator of bacterial and viral causes. Studies of treatment show that there is a high rate of clinical cure without any treatment (65% within 2-5 days). Treatment with topical antibiotics improves the rate of clinical recovery and this is more marked in the first 2-5 days after presentation (number needed to treat [NNT] = 6), but less by 6-10 days (NNT = 13). Studies comparing treatment with different antibiotics do not demonstrate that any one antibiotic is superior; the choice of antibiotic should be based on consideration of cost and bacterial resistance. The present practice of prescribing antibiotics to most cases is not necessary.

Differential diagnoses of conjunctivitis for clinical allergist-immunologists

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

RESULTS

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

CONCLUSIONS

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

Mycobacterium tuberculosis presenting as chronic red eye

PURPOSE

To report a case of tuberculosis of the conjunctiva.

METHODS

Case report with pathologic correlation. A 17-year-old man who had relocated to Australia from Liberia presented with chronic unilateral conjunctivitis.

RESULTS

The diagnosis was not initially evident, despite 2 separate biopsy specimens, conjunctival cultures, and polymerase chain reaction testing. Definitive diagnosis was made after repeated histologic examination. Antituberculous treatment resulted in prompt resolution of all ocular signs.

CONCLUSION

Tuberculous conjunctivitis is now a very rare condition in the developed world. Definitive diagnosis requires the identification of Mycobacterium tuberculosis organisms in conjunctival biopsy specimens-either through microscopic detection of acid-fast bacilli or more sensitive culture techniques.

Demographic and Clinical Factors Associated with Development of Brimonidine Tartrate 0.2%-Induced Ocular Allergy

PURPOSE

To identify demographic and clinical characteristics associated with the development of brimonidine tartrate 0.2%-induced ocular allergy.

PATIENTS AND METHODS

In this retrospective study, 133 patients affected by primary open-angle, pigmentary, narrow angle, or pseudo-exfoliative glaucoma and treated with brimonidine tartrate 0.2% were divided into two groups: allergic and non allergic to brimonidine tartrate 0.2%. The distribution of demographic (age and sex), local (history of allergic conjunctivitis, previous eye-drop ocular allergy, use of other concurrent topical medications, amount of topical medications previously used, use of contact lenses, and tear film production), and systemic (history of systemic allergies and use of systemic drugs) factors was evaluated by comparing the brimonidine tartrate 0.2% allergic and the non-allergic groups.

RESULTS

In this study, 13.5% of patients (18 of 133) developed brimonidine ocular allergy generally within two weeks from the beginning of treatment (mean time 14.8 +/- 17.9 days). The brimonidine tartrate 0.2% allergic group showed a significantly higher frequency of history of ocular allergy to eye-drops (P = 0.048) and to topical beta-blockers (P = 0.019) when compared with the brimonidine tartrate 0.2% non-allergic group. Moreover, the allergic group showed a decreased tear film production (P = 0.044).

CONCLUSION

This study showed that history of eye-drop allergies and reduction of tear film production were more frequently associated with the development of brimonidine tartrate 0.2%-induced ocular allergy.

Prospective cohort trial of Euphrasia single-dose eye drops in conjunctivitis

INTRODUCTION

Eye drops made from Euphrasia rostkoviana Hayne have been used in anthroposophical medicine for more than 70 years for the structuring of the fluid organism in the eye, especially in inflammatory and catarrhal conjunctivitis. The aim of this prospective cohort trial was to describe the efficacy and tolerability of these eye drops in a community-based setting. To evaluate these questions, prospective cohort studies are the best method. This enables the investigator to attain real insights as to which treatment administered related to specific results in a specific group of patients.

DESIGN

Prospective, open label, one-armed, multicentered, multinational cohort trial.

SETTING

The trial was carried out in the clinics of 12 experienced anthroposophical general practitioners and ophthalmologists in Germany and Switzerland.

PATIENTS

Patients with inflammatory or catarrhal conjunctivitis, treated with Euphrasia single-dose eye drops were included in the trial.

INTERVENTION

One drop of Euphrasia single-dose eye drops 1-5 times a day was prescribed. The prescription was determined solely by medical therapeutic needs.

OUTCOME MEASURES

Efficacy variables were: redness, swelling, secretion, burning of the conjunctiva, and foreign body sensation. Tolerability variables were: conjunctival reddening, burning of the conjunctiva, foreign body sensation, and veiled vision. All symptoms were given for the right or left eye separately, with degree of severity in relation to baseline after approximately 7 days (+/-3 days; first follow-up examination) and after approximately 14 days (+/-3 days; second follow-up examination). If, after the first follow-up, all symptoms had disappeared, no second follow-up was done.

RESULTS

Sixty-five (65) patients fulfilled the inclusion criteria for the protocol evaluation. A complete recovery was seen in 53 patients (81.5%) and a clear improvement in 11 patients (17.0%). A slight worsening could only be determined in 1 patient in the second week of treatment (1.5%). No serious adverse events were observed during the entire trial. The efficacy and tolerability were evaluated by the patients and doctors as "good" to "very good" in more than 85%.

CONCLUSION

Euphrasia single-dose eye drops can effectively and safely be used for various conjunctival conditions by general practitioners and ophthalmologists. A dosage of one drop three times a day seems to be the general prescribed dosage.

Ocular allergy: causes and therapeutic options

Ocular allergic eye conditions are among the most common anterior eye problems encountered in optometric practice. There are six common forms of ocular allergy: seasonal allergic conjunctivitis, perennial allergic conjunctivitis, vernal keratoconjunctivitis, atopic keratoconjunctivitis, contact lens associated papillary conjunctivitis and contact ocular allergy. Here, we review the current understanding of the pathophysiology underlying ocular allergic conditions and describe the different causes and forms of allergic eye disease and different treatment options.

Conjunctivitis of allergic origin: clinical presentation and differential diagnosis

Conjunctivitis of allergic origin is associated with a diversity of clinical presentations. Common features include pronounced itching, a milky conjunctival appearance, a stringy or ropy discharge and papillary hypertrophy of the tarsal conjunctiva in severe cases, and a family history of allergy. The diagnosis should be based on thorough history-taking and careful ophthalmic examination, and, when necessary, confirmation by laboratory testing. An IgE-mediated immediate hypersensitivity mechanism is associated with most types of allergic conjunctivitis, although contact allergy is mediated by lymphocytes rather than antibody. Treatment is based on the diagnosis and severity of signs and symptoms. An array of medications is available to control symptoms, and the regimen of choice should be based on the response to milder forms of therapy and consideration of drug side effects.