Treatment of seasonal allergic conjunctivitis with ophthalmic corticosteroids: in search of the perfect ocular corticosteroids in the treatment of allergic conjunctivitis

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.

Management of vernal keratoconjunctivitis: Navigating a changing treatment landscape

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

Efficacy of 2% Rebamipide Suspension for Vernal Keratoconjunctivitis: A Clinical Comparison with Topical Immune Modulators Cyclosporine and Tacrolimus

Purpose: To compare the efficacy of 2% rebamipide suspension with topical cyclosporine and tacrolimus for managing vernal keratoconjunctivitis (VKC)Methods: In this prospective, interventional study, 38 patients with moderate to severe VKC were allocated to receive either 2% rebamipide in one eye and 0.03% tacrolimus ointment in the contralateral eye (n = 19) or 2% rebamipide in one eye and 0.05% cyclosporine in the contralateral eye (n = 19) for 12 weeks. Ten ocular signs and 7 symptoms were graded on a scale of 0-3 each for each eye at every visit.Results: Total sign and symptom scores reduced significantly in all 4 subgroups (all p's <0.05) at 12 weeks. Reduction of mean sign scores between rebamipide and tacrolimus (- 4.67 ± 4.63 and - 2.80 ± 3.18 respectively) and between rebamipide and cyclosporine (-6.00 ± 3.74 and -5.42 ± 3.68 respectively) was comparable. Reduction in symptom scores was also comparable between subgroups.Conclusion: Our findings suggest that efficacy of topical rebamipide is comparable to topical cyclosporine and tacrolimus for managing moderate to severe VKC and it merits further evaluation as a novel steroid sparing alternative for this disorder.

The spectrum of allergic ocular diseases

OBJECTIVE

The purpose of this article is to review the pathophysiologic mechanisms, differential diagnosis, evaluation, and treatment of the various manifestations of ocular allergy, with an especial focus on immunoglobulin E (IgE)-mediated disease.

DATA SOURCES

A PubMed search was performed to include articles, using the search terms ocular allergy and allergic conjunctivitis.

STUDY SELECTIONS

Recent and relevant human studies in the English language pertaining to our topic of study were selected. Animal studies pertaining to pathophysiology of ocular allergy were also reviewed. We focused on clinical trials, practice guidelines, reviews, and systematic reviews. In addition, case reports were reviewed if they described rare clinical presentations, disease mechanisms, or novel therapies.

RESULTS

Ocular allergy encompasses both IgE- and non-IgE-mediated disease, and the clinical severity may range from mild to sight-threatening inflammation. A comprehensive treatment regimen including education, lifestyle measures, topical therapies, and even systemic interventions may be necessary for the effective management of ocular allergies, tailored according to symptom severity.

CONCLUSION

Ocular allergy is frequently encountered by allergists and eye-care specialists, and despite progressively increasing incidence, it often remains underdiagnosed and, hence, untreated.

Dexamethasone 0.4mg Sustained-Release Intracanalicular Insert in the Management of Ocular Inflammation and Pain Following Ophthalmic Surgery: Design, Development and Place in Therapy

Inflammation and pain are two prevalent findings after ocular surgery. Corticosteroids are widely administrated as a core treatment to control post-surgical inflammation and pain. Improper patient adherence to post-operative eye drop regimens, limited bioavailability of topical eye drops, and the negative impact of preservatives used in many of these eye drops, has made a strong case for novel therapies in the treatment of post-operative pain and inflammation. This review of the literature will focus on the role of intracanalicular sustained-release dexamethasone (Dextenza, Ocular Therapeutix, Bedford, MA, USA) for the management of ocular inflammation and pain.

Ocular penetration of fluorometholone-loaded PEG-PLGA nanoparticles functionalized with cell-penetrating peptides

Aim: Development of fluorometholone-loaded PEG-PLGA nanoparticles (NPs) functionalized with cell-penetrating peptides (CPPs) for the treatment of ocular inflammatory disorders. Materials & methods: Synthesized polymers and peptides were used for elaboration of functionalized NPs, which were characterized physicochemically. Cytotoxicity and ability to modulate the expression of proinflammatory cytokines were evaluated in vitro using human corneal epithelial cells (HCE-2). NPs uptake was assayed in both in vitro and in vivo models. Results: NPs showed physicochemical characteristics suitable for ocular administration without evidence of cytotoxicity. TAT-NPs and G2-NPs were internalized and displayed anti-inflammatory activity in both HCE-2 cells and mouse eye. Conclusion: TAT-NPs and G2-NPs could be considered a novel strategy for the treatment of ocular inflammatory diseases of the anterior and posterior segment.

Steroid-induced glaucoma and blindness in vernal keratoconjunctivitis

PURPOSE

To report the clinical features, treatment outcomes and blindness associated with steroid-induced glaucoma in vernal keratoconjunctivitis (VKC).

MATERIALS AND METHODS

Records of patients with VKC, who visited our tertiary centre from 1992 and 2009, were reviewed and those with steroid-induced glaucoma were included in the study. Glaucoma was diagnosed based on intraocular pressure (IOP) ≥22 mm Hg on two consecutive visits (ocular hypertension) and/or glaucomatous optic disc damage. Blindness was defined as best corrected visual acuity of ≤20/400 or visual field <10°.

RESULTS

Of the 4062 VKC subjects, 91 (157 eyes) had steroid-induced glaucoma (SIG), showing a prevalence of 2.24%. Of these 87% were men. The median (IQR) age at onset of VKC was 12 years (7-17). At presentation, the median duration of VKC was 48 months (24-72) and the median duration of steroid usage was 24 months (12-36). The median cup-to-disc ratio (CDR) was 0.9 (0.7-0.9) and median mean deviation was -21.9 dB (-30.0 to -10.2). IOP was medically controlled in 66% eyes (104/157) and 34% eyes (53/157) needed glaucoma surgery. High presenting IOP (OR: 1.04; p=0.05) and increased duration of steroid usage (OR: 1.07; p=0.02) were significantly associated with need for glaucoma surgery. At presentation, 29/91 subjects (31.8%) were bilaterally blind due to SIG. Higher CDR at presentation was significantly associated with blindness in this cohort (p=0.02).

CONCLUSION

In this cohort of VKC with SIG, the disease predominantly affected adolescent males. Glaucoma was severe with one-third needing surgery and one-third blind due to SIG.

Treatment of adenoviral keratoconjunctivitis with a combination of povidone-iodine 1.0% and dexamethasone 0.1% drops: a clinical prospective controlled randomized study

PURPOSE

To determine the efficacy of combination povidone-iodine (PVP-I) 1.0% eyedrops and dexamethasone 0.1% eyedrops in the treatment of adenoviral keratoconjunctivitis.

MATERIALS AND METHODS

In a prospective, randomized, controlled, double-blinded clinical trial patients with recent adenoviral keratoconjunctivitis (diagnosed clinically and confirmed by PCR), we randomly divided into three treatment groups: study group - received PVP-I 1.0% and dexamethasone 0.1%, control 1 group - received dexamethasone 0.1% and control 2 group - received lubricating eyedrops (hypromellose 0.3%). The treatment was administered four times a day in each group. All patients were examined and filled a questionnaire before treatment and on the 3rd, 5th and 7th days of treatment.

RESULTS

We included in the study 78 eyes (26 in each group). Adenovirus type 8 was the most common pathogen (83% of cases). The fastest improvement in patients red eyes, discharge, superficial punctate keratitis and pseudomembranes was observed in the study group (p < 0.001). Those patients reached a near complete recovery in 5-7 days, which was also confirmed by reduction in Adenovirus titres by PCR. The slowest improvement was in the control 2 group. Subepithelial infiltrates (SEI) were observed in 44% of the control 1 group, 20% of the control 2 group and in 0% of the study group. The rate of reduction in Adenovirus titres was the slowest in the control 1 group.

CONCLUSION

The combination of PVP-I 1.0% and dexamethasone 0.1% four times a day can reduce symptoms and expedite recovery in epidemic keratoconjunctivitis patients.

An update on ocular allergy

PURPOSE OF REVIEW

The update reviews prevalence, classification, cause, and treatment options for allergic eye disease.

RECENT FINDINGS

The incidence of allergic eye disease is underreported but may affect almost all patients with allergic rhinitis. Increased rates of oculonasal symptoms have been reported in the United States resulting in significant economic expenditures. The spectrum of allergic conjunctivitis and its differential considerations include seasonal and perennial conjunctivitis, vernal and atopic keratoconjunctivitis, and giant papillary conjunctivitis. Patients with allergic conjunctivitis have classic immunoglobulin E-mediated pathophysiology and treatments directed at allergen avoidance, traditional pharmacotherapy with oral antihistamines, topical dual-acting antihistamine/mast cell stabilizer agents, and treatment of tear film dysfunction are first-line management strategies. Immunotherapy is an effective treatment option and refractory cases may require ophthalmology comanagement for consideration of topical ester-based corticosteroid therapy and consideration of topical immunomodulators.

SUMMARY

Ocular allergy involving specific modifiable and treatable environmental sensitizations is common and often underrecognized. It can impair quality of life to varying degrees. Some cases are quite refractory to management and may require multidisciplinary coordination of care between allergy and ophthalmology specialists. Understanding classification, triggers, and treatment options is important in designing the most appropriate patient-tailored management plans.

Emerging therapeutics for ocular surface disease

PURPOSE OF REVIEW

The present review provides an overview on the potential of different systemic and topical treatments in chronic forms of ocular allergy and dry eye disorder (DED). The impact on anterior surface of ocular inflammatory disorder encompasses an array of conditions, which are frequently underreported. This can contribute to underdiagnoses and ineffective management from healthcare providers such as an allergist and/or ophthalmologist who routinely provide care for these common disorders. Owing to the current limited therapeutic options, healthcare providers are routinely seeking alternative treatments that could facilitate effective management of the conditions.

RECENT FINDINGS

Recent advances in immunopathophysiology of ocular surface disorders has provided new potential targets and therapeutic strategies for the treatment of DED and ocular allergy that may include various immunobiological modulators. These modulators have focused on regulating the Th1 and Th2 immune-mediated inflammatory pathways that inhibit various cytokines (e.g. IL-1, IL-4, IL-5, IL-9, IL-13) antibodies (e.g. IgE), and other surface markers of various cell lines (e.g. activated T-lymphocytes, lymphocyte function-associated antigen-1).

SUMMARY

Recent findings about the pathophysiology of DED and ocular allergy have led to the greater understanding of the molecular and cellular mechanisms of ocular surface diseases leading to the potential novel targets for immunomodulation of anterior surface ocular disorders. New topical glucocorticoids, leukotriene receptor antagonists, IL-1 antagonists, IL-5, IL-4/IL-13 antagonists, integrin antagonists, and quinolone derivatives appear to be encouraging.

Vernal keratoconjunctivitis: culmination of management using immunosuppression, surgical and prosthetic therapy over quarter century

A 22-year-old male patient presented in 1988 with active vernal keratoconjunctivitis. He was treated with topical mast cell stabilisers and corticosteroids. Chronic inflammation despite topical treatment necessitated oral immunosuppressants. Active disease came under control with this; however, the patient gradually developed limbal stem cell deficiency. He underwent bilateral pannus resection with amniotic membrane transplantation that resulted in improved ocular surface. In 2007, patient was found to have significant bilateral posterior subcapsular cataracts and underwent bilateral cataract surgery with intraocular lens implantation with good visual outcome. In 2016, he was provided with scleral lens prosthetic device, which further improved vision. At last follow-up, more than 25 years after his initial visit, his visual acuity was 20/25 in both eyes with a stable surface. With a comprehensive approach using immunosuppression, surgical therapy and scleral lens prosthetic device, chronic vernal keratoconjunctivitis can be well managed as illustrated in this case.

Efficacy of olopatadine hydrochloride 0.1%, emedastine difumarate 0.05%, and loteprednol etabonate 0.5% for Chinese children with seasonal allergic conjunctivitis: a randomized vehicle-controlled study

Background

Allergic conjunctivitis (AC) is a disease of various agents that affects the physical and mental health of children. Although the most effective therapy has not been found so far, it is essential to explore the considerable therapeutic method. We compared the clinical efficacy of olopatadine, emedastine, loteprednol etabonate (LE), and vehicle for treating seasonal allergic conjunctivitis (SAC) in Chinese children.

Methods

Eighty cases of 160 eyes aged from 5 to 10 years with SAC were available and those subjects were randomly distributed into 4 groups. Both their eyes received olopatadine hydrochloride 0.1% twice a day, emedastine difumarate 0.05% twice a day, or LE 0.5% 4 times a day, respectively, whereas those of the control group received artificial tears (AT) 0.5% 3 times a day. This study was conducted successfully and the observations were collected before treatment and on day 8 (±1 day) and day 15 (±2 days) afterward. The principal measurement of efficacy was focused on the signs and symptoms of the subjects, evaluated before and after treatment, in addition to visual acuity (VA) and fundus oculi.

Results

On day 8 (±1 day) and day 15 (±2 days), all the antiallergic agents were found to be more effective than vehicle (p < 0.05) in terms of all the symptoms and signs. However, there was no statistical significance (p ≥ 0.05) shown among the treatment groups. There were no evident changes in VA and no clinically significant changes were observed in fundus oculi.

Conclusion

After the treatment, the efficacy presented a similar distribution among the trial groups.

Preliminary characterization of dexamethasone-loaded cross-linked hyaluronic acid films for topical ocular therapy

The aim of this work was to design and characterize cross-linked hyaluronic acid (HA)-itaconic acid (IT) films loaded with dexamethasone sodium phosphate salt (DEX) for topical therapy of inflammatory ocular surface diseases. Films were chemically cross-linked with polyethylene glycol diglycidyl ether (PEGDE), then physical and mechanical characterization by stress-strain, X-ray diffraction, X-ray fluorescence spectrometry and swelling assays was conducted. A sequential in vitro therapeutic efficacy model was designed to assess changes in interleukin (IL)-6 production in an inflamed human corneal epithelial (HCE) cell line after film exposure. Changes in cell proliferation after film exposure were assessed using the alamarBlue(®) proliferation assay. Experimental findings showed desirable mechanical properties and in vitro efficacy to reduce cell inflammation. A moderately decreased proliferation rate was induced in HCE cells by DEX-loaded films, compared to commercial DEX eye drops. These results suggest that DEX and HA have opposite effects. The sequential in vitro therapeutic efficacy model arises as an efficient tool to study drug release from delivery systems by indirect measurement of a biological response.

Impact of the Topical Ophthalmic Corticosteroid Loteprednol Etabonate on Intraocular Pressure

Corticosteroids are a mainstay therapeutic option for the treatment of ocular inflammation. However, safety remains a concern for clinicians, particularly with long-term use. Though highly effective at suppressing inflammatory and allergic responses, topical ophthalmic corticosteroids carry an inherent risk of side effects, including elevated intraocular pressure (IOP), a risk factor for the development of glaucoma. The corticosteroid loteprednol etabonate (LE) contains an ester rather than a ketone at the C-20 position, minimizing the potential for side effects, including IOP elevation. In early pivotal clinical trials of LE ophthalmic suspension for conjunctivitis (allergic, giant papillary), anterior uveitis, and post-operative inflammation, LE had minimal impact on IOP over short-term (<28 days) and long-term (≥28 days) use. Since then, new LE formulations—including a gel, an ointment, and a suspension of LE in combination with tobramycin—have become commercially available. Multiple studies evaluating the safety and efficacy of LE for inflammatory conditions have been reported, including those requiring longer-term treatment such as photorefractive keratectomy, corneal transplantation, and dry eye disease. We review the available published data on the effect of LE on IOP and report on the cumulative incidence of clinically significant IOP elevations (≥10 mm Hg from baseline) with short-term and long-term LE use. In all studies, LE consistently demonstrated a low propensity to elevate IOP, regardless of formulation, dosage regimen, or treatment duration, including in known steroid responders. The cumulative proportion of patients exhibiting clinically significant IOP increases was 0.8% (14/1725 subjects) in studies evaluating short-term LE treatment and 1.5% (21/1386 subjects) in long-term studies. Furthermore, use of LE was associated with significantly lower rates of IOP elevation ≥10 mm Hg as compared to prednisolone acetate or dexamethasone (when used in combination with tobramycin). The cumulative data to date substantiates a favorable IOP-safety profile for LE with both short-term and long-term use.

Loteprednol etabonate in the treatment of allergic conjunctivitis: a meta-analysis

OBJECTIVE

This meta-analysis was designed to assess the efficacy, as well as the safety of loteprednol etabonate (LE) ophthalmic suspension compared with placebo and other commonly used eye drops for treatment of allergic conjunctivitis.

METHODS

Comprehensive searches of randomized controlled trials were carried out in a database of Medline, Embase, and the Cochrane Library. Eight qualified studies were included. This study assessed the reduction from baseline in scores of cardinal signs and symptoms, proportion of patients with improvement of allergic signs and symptoms, and incidence of clinically significant intraocular pressure (IOP) elevation (IOP elevation ≥10 mmHg).

RESULTS

The results showed that topical LE was significantly superior to placebo in reduction from baseline in signs scores (standardized mean difference [SMD] = -0.48; 95% confidence interval [CI] = -0.65 to -0.32) and symptoms scores (weighted mean difference [WMD] = -0.51; 95% CI = -0.64 to -0.38) of allergic conjunctivitis, and as effective as olopatadine and fluorometholone acetate. Topical LE was associated with a higher improvement rate of signs (risk ratio [RR] = 1.53; 95% CI = 1.26-1.86; I (2 )= 57%) and symptoms (RR = 1.29; 95% CI = 1.15-1.46; I (2 )= 54%) than placebo and the positive control treatment. Clinically significant IOP elevation was more frequent in the group of LE than the group of control treatment (pooled odds ratio = 3.03; 95% CI = 1.04-8.80), which was affected by the response to corticosteroid of the individual patient and the wearing of contact lenses.

CONCLUSIONS

Topical LE is effective in treating allergic conjunctivitis. However, it should be used with caution due to the higher incidence of IOP elevation compared with placebo and olopatadine. A large-scale trial would be required to confirm the effect of different concentrations of LE on IOP.

Advances in pharmacotherapy for allergic conjunctivitis

INTRODUCTION

Allergy is the fifth leading group of chronic diseases, affecting as much as 40% of the first-world population. Its pathophysiology has a genetic component, and is driven by the immune system's sensitized response to antigens and environmental factors. As research continues to uncover the mediators responsible for ocular allergy, the development of novel drugs should progress.

AREAS COVERED

A literature review of allergic conjunctivitis, ocular allergy and their treatment was performed using PubMed and Medline. Additional information is also included from clinicaltrials.gov and associated web sites for drugs currently in clinical trials.

EXPERT OPINION

The initial step of therapy remains identification and avoidance of allergic triggers. The mainstay of treatment is the new generation of dual-acting antihistamines. Drugs that improve the magnitude and duration of relief, with greater subject responder rates, are gradually making their way into the clinic. Allergic conjunctivitis is a relatively easy disease to study because of the availability of models such as the conjunctival allergen challenge. New classes of drugs that target inflammatory pathways or mediators involved in the early and late-phase allergic response are being screened in these models and we are making progress in identifying the next generation of anti-allergic therapy.

Mapracorat, a selective glucocorticoid receptor agonist, causes apoptosis of eosinophils infiltrating the conjunctiva in late-phase experimental ocular allergy

Background

Mapracorat, a novel nonsteroidal selective glucocorticoid receptor agonist, has been proposed for the topical treatment of inflammatory disorders as it binds with high affinity and selectivity to the human glucocorticoid receptor and displays a potent anti-inflammatory activity, but seems to be less effective in transactivation of a number of genes, resulting in a lower potential for side effects. Contrary to classical glucocorticoids, mapracorat displays a reduced ability to increase intraocular pressure and in inducing myocilin, a protein linked to intraocular pressure elevation. Allergic conjunctivitis is the most common form of ocular allergy and can be divided into an early phase, developing immediately after allergen exposure and driven primarily by mast cell degranulation, and a late phase, developing from 6–10 hours after the antigen challenge, and characterized by conjunctival infiltration of eosinophils and other immune cells as well as by the production of cytokines and chemokines.

Methods

In this study, mapracorat was administered into the conjunctival sac of ovalbumin (OVA)-sensitized guinea pigs 2 hours after the induction of allergic conjunctivitis, with the aim of investigating its activity in reducing clinical signs of the late-phase ocular reaction and to determine its mechanism of anti-allergic effects with respect to apoptosis of conjunctival eosinophils and expression of the chemokines C-C motif ligand 5 (CCL5), C-C motif ligand 11 (CCL11), and interleukin-8 (IL-8) and the proinflammatory cytokines interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α).

Results

Mapracorat, administered into the conjunctival sac of OVA-sensitized guinea pigs 2 hours after allergen exposure, was effective in reducing clinical signs, eosinophil infiltration, and eosinophil peroxidase activity in the guinea pig conjunctiva; furthermore, it reduced conjunctival mRNA levels and protein expression of both CCL5 and CCL11. Mapracorat was more effective than dexamethasone in increasing, in conjunctival sections of OVA-treated guinea pigs, apoptotic eosinophils.

Conclusion

Mapracorat displays anti-allergic properties in controlling the late phase of ocular allergic conjunctivitis and is a promising candidate for the topical treatment of allergic eye disorders.

Vernal keratoconjunctivitis: a severe allergic eye disease with remodeling changes

Vernal keratoconjunctivitis (VKC) is an unusually severe sight-threatening allergic eye disease, occurring mainly in children. Conventional therapy for allergic conjunctivitis is generally not adequate for VKC. Pediatricians and allergists are often not familiar with the severe clinical symptoms and signs of VKC. As untreated VKC can lead to permanent visual loss, pediatric allergists should be aware of the management and therapeutic options for this disease to allow patients to enter clinical remission with the least side effects and sequelae. Children with VKC present with severe ocular symptoms, that is, severe eye itching and irritation, constant tearing, red eye, eye discharge, and photophobia. On examination, giant papillae are frequently observed on the upper tarsal conjunctiva (cobblestoning appearance), with some developing gelatinous infiltrations around the limbus surrounding the cornea (Horner-Trantas dot). Conjunctival injections are mostly severe with thick mucus ropy discharge. Eosinophils are the predominant cells found in the tears and eye discharge. Common therapies include topical antihistamines and dual-acting agents, such as lodoxamide and olopatadine. These are infrequently sufficient and topical corticosteroids are often required for the treatment of flare ups. Ocular surface remodeling leads to severe suffering and complications, such as corneal ulcers/scars. Other complications include side effects from chronic topical steroids use, such as increased intraocular pressure, glaucoma, cataract and infections. Alternative therapies for VKC include immunomodulators, such as cyclosporine A and tacrolimus. Surgery is reserved for those with complications and should be handled by ophthalmologists with special expertise. Newer research on the pathogenesis of VKC is reviewed in this article. Vernal keratoconjunctivitis is a very important allergic eye disease in children. Complications and remodeling changes are unique and can lead to blindness. Understanding of pathogenesis of VKC may lead to better therapy for these unfortunate patients.

Allergic conjunctivitis in Jos-Nigeria

Background:

Allergic conjunctivitis (AC) may follow seasonal or perennial pattern. There are climatic and racial risk factors involved in some types of AC. It is more prevalent in warm climatic conditions and among Afro-Caribbeans, Arabs and Asians and less among the White populations. Clinical presentations also seem to follow climatic and genetic predisposition. The purpose of this study is to determine the prevalence of AC and its clinical presentations in a hospital setting in this region in people of all ages.

Materials and Methods:

This is a hospital-based retrospective study of new patients seen at Adoose Specialist Hospital, Jos the capital city of Plateau State in North Central Nigeria with clinical diagnosis of AC from 2000 to 2009.

Results:

There were 972 subjects, 474 (48.8%) males and 498 (51.2%) females with M:F ratio of 1:1.05. The most common symptom was itching followed by redness, pains, watery/mucoid discharge, sticky eyes, puffy eyes and photophobia. The presence of papillae in the upper tarsal or lower conjunctiva, a discrete or confluent gelatinous hypertrophy of the limbal conjunctiva (Trantas dots), hyperpigmentation, hyperemia/chemosis of the conjunctiva were the common signs. AC was more prevalent in those aged 1−16 years 38.4% decreasing to 4.9% in the age group above 50 years. The presentation followed perennial pattern, with a peak around July. The most prevalent ocular comorbid condition was refractive error (distant RE and presbyopia) in 15.4%, followed by pterygium/pinguecula 3.6%, bacterial conjunctivitis in 2.2%, glaucoma 2.1% and eyelid disorders 1.7%. Cataract was present in 1.3%, and keratopathy 1.1%. Other conditions such as episcleritis, dry eye, vitamin A deficiency and posterior segment disease were also present in decreasing order. Systemic association were few with generalised body atopy in 0.3%.

Conclusion:

The prevalence of AC was 32% and is similar to what pertains in some of the African hospital studies, but differs in presentation from the Caucasians.

Comparative evaluation of olopatadine 0.01% combined fluorometholone 0.1% treatment versus olopatadine 0.01% combined ketorolac 0.4% treatment in patients with acute seasonal allergic conjunctivitis

PURPOSE

To evaluate the therapeutic effects of low-effective steroid fluorometholone 0.1% and non-steroidal anti-inflammatory ketorolac 0.4% when concomitantly used with olopatadine 0.01% in relieving clinical signs and symptoms of acute seasonal allergic conjunctivitis (SAC).

METHODS

In this randomized, placebo-controlled, multi-center study, 104 eyes of 52 patients with the diagnosis of SAC were conducted. The patients were assigned into two groups to receive either olopatadine and fluorometholone one eye and placebo in the contralateral eye or olopatadine and ketorolac one eye and placebo in the contralateral. The clinical signs (chemosis, mucus secretion, eyelid edema) and symptoms (itching, redness, tearing, burning) of the patients were evaluated by summing up the scores using a 3-point scale. Results were analyzed by Mann-Whitney U test, p values less than 0.05 were defined as significant.

RESULTS

All parameters were improved less amount on the first day of the treatment in both groups, however, significant reduction in clinical signs and symptoms were seen on the 10th day compared with those receiving placebo. Fluorometholone was found superior to ketorolac in reducing redness, mucus secretion, chemosis and eyelid edema (p = 0.032 for redness, p = 0.028 for mucus secretion, p = 0.030 for chemosis, p = 0.042 for eyelid edema) and both drugs were similar in alleviating the symptoms itching, burning and tearing (p = 0.074 for itching, p = 0.064 for burning, p = 0.072 for tearing).

CONCLUSIONS

Fluorometholone was better than ketorolac in relieving redness, chemosis, mucus secretion and eyelid edema when concomitantly used with olopatadine, however, these two drugs were found equal in attenuating the symptoms itching, burning and tearing.

Intraocular pressure effects of common topical steroids for post-cataract inflammation: are they all the same?

The efficacy of topical corticosteroids as ocular anti-inflammatory agents following cataract surgery is well-documented. They also help to prevent a number of complications associated with post-operative ocular inflammation, including corneal edema and cystoid macular edema. However, topical corticosteroids are associated with side effects, such as increased intraocular pressure (IOP). Indeed, corticosteroid-induced ocular hypertension and the potential for steroid-induced glaucoma remain the leading drawbacks of topical corticosteroid therapy. Some individuals are known to experience a high degree of IOP elevation with low doses or short durations of treatment with topical corticosteroids. Careful monitoring of IOP in such individuals is essential. Few randomized, controlled studies are available on the comparative safety and efficacy of common topical corticosteroids in the treatment of post-operative ocular inflammation. Furthermore, the lack of consistent reporting criteria for clinically significant IOP increases across clinical studies makes meaningful comparisons among corticosteroids difficult. This review aims to examine data from available published studies, including studies in steroid responders, to determine whether topical corticosteroids are the same in terms of their effect on IOP. Early generation corticosteroids, such as dexamethasone and prednisolone, are more likely to result in clinically significant increases in IOP. Newer corticosteroids, such as rimexolone and the retro-metabolically designed corticosteroid, loteprednol etabonate, offer similar anti-inflammatory efficacy to older corticosteroids with less effect on IOP. However, randomized controlled trials of newer corticosteroids are needed. The proportion of patients exhibiting an increase of ≥10 mmHg IOP in clinical studies has emerged as the most clinically relevant parameter for ophthalmologists to consider when deciding on which topical corticosteroid to use.

Ocular 'Roid Rage

Corticosteroids use can cause raised intraocular pressure (IOP), leading to glaucoma. We present a case report of steroid induced glaucoma in a young male with keratoconjunctivitis (VKC). Our patient was uncompliant with instructions to stop steroid use, initially started for VKC treatment, and required aggressive medical and surgical intervention for IOP control. He eventually progressed to severe glaucomatous optic neuropathy and eventual tunnel vision. Steroid induced glaucoma is an important and frequently encountered condition in ophthalmology clinics. This report serves to remind all physicians of the dangers of steroid eye drop usage.

Ocular allergy

The eye is probably the most common site for the development of allergic inflammatory disorders, because it has no mechanical barrier to prevent the impact of allergens such as pollen on its surface. Physicians in various specialties and subspecialties who provide some form of primary care frequently encounter various forms of inflammation of the anterior surface of the eye that present as "red eye." However, the eye is rarely the only target for an immediate allergic-type response. Typically, many patients have other combinations of allergic disorders, such as rhinoconjunctivitis, rhinosinusitis, asthma, urticaria, or eczema. Even so, ocular signs and symptoms can frequently be the most prominent features of the entire allergic response for which a patient visits his or her physician. An improved differential diagnosis provides the basis for improved treatment algorithms. Over the past 20 years, we have witnessed an astonishing growth in therapeutic advances, ranging essentially from derivatives of simple aspirin to various newly developed biologic immunomodulatory agents, utilizing implantable drug-delivery devices that exceed the safety and efficacy of those available for other organ systems, and resorting to advanced surgical techniques for the correction of sight-threatening, disease-related complications. Overall, with the expanding knowledge base, the intricacy of ocular inflammation appears to be becoming ever more manageable and, with the team approach between the primary care physician, the ophthalmologist, and the clinical allergist/immunologist, the new "immuno-ophthalmology" approach improves patient outcomes.

Ocular allergy

PURPOSE OF REVIEW

Ocular allergy is often encountered by allergists, ophthalmologists, pediatricians, and primary care physicians. An understanding of the immunologic mechanisms, the differential diagnosis, the clinical features, and the treatment of ocular allergy will be useful to all physicians who encounter these patients.

RECENT FINDINGS

Basic and clinical research has provided a better understanding of the cells, mediators, and immunologic events which occur in ocular allergy. New pharmacological agents, including more potent mast cell stabilizers, and low-dose corticosteroids, have improved the efficacy and safety of ocular allergy treatment.

SUMMARY

Physicians who currently treat ocular allergy have a greater familiarity with the signs and symptoms of allergic disease, a better understanding of the mechanisms and clinical features of allergic conjunctivitis, and improved therapeutic tools to deliver satisfactory outcomes in the management of ocular allergy.

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

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