Contact dermatitis caused by allergy to ophthalmic drugs and contact lens solutions

Local anesthesia for cataract surgery

Various aspects of local anesthesia for cataract surgery, such as the anesthetic agents and their interaction with ocular nerve supply, anesthesia requirements, available clinical techniques and their inherent complications are reviewed. A comparative evaluation of clinical techniques in terms of efficacy, akinesia, and patient-perceived pain during both anesthesia administration and intraoperative cataract surgery is presented, along with the prevailing practice patterns of anesthesia techniques among refractive surgeons in the United Kingdom and United States. More randomized clinical trials are needed to facilitate statistical methods of metaanalysis to establish convincingly the overall benefits and efficacy of the various local anesthesia procedures in cataract surgery. The wide scope of the present review is of relevance in structuring ophthalmology and anesthesia specialist training programs for junior staff.

Allergic contact dermatitis from ophthalmics: 2007

We previously reviewed allergic contact dermatitis due to ophthalmic drugs and contact lens solutions. Since 1997, an additional 15 allergens have been reported. Here, we provide a review and discussion of these allergens.

Allergic contact dermatitis from ophthalmic products: can pre-treatment with sodium lauryl sulfate increase patch test sensitivity?

In patients suspected of allergic contact dermatitis because of topical ophthalmic medicaments, patch tests performed with patients' own products are often negative. The irritant anionic surfactant sodium lauryl sulfate (SLS) may alter the stratum corneum and increase antigen penetration. Pre-treatment of the skin with SLS 0.5% for 24 h was performed in the sites of patch tests with patients' own products in 15 selected patients. In patients previously negative to their own products tested with conventional patch tests, SLS pre-treatment showed 6 new relevant positive reactions and induced a stronger positive reaction in 1 patient. SLS pre-treatment could be proposed as an alternative promising method, which may increase sensitivity of patch tests with patients' own products.

Contact allergy from tobramycin eyedrops

We report a patient with allergic conjunctivitis and blepharitis as a result of tobramycin eyedrops.

Allergic and non-allergic periorbital dermatitis: patch test results of the Information Network of the Departments of Dermatology during a 5-year period

Periorbital dermatitis is common and can be due to the external use of ophthalmic drugs. We evaluated patch test results of the Information Network of the Departments of Dermatology. During a 5-year period (1995-99), of a total 49,256 patch-tested patients, 1053 (2.1%) were eventually diagnosed as allergic periorbital contact dermatitis (APD) and 588 (1.2%) as non-allergic periorbital dermatitis (NAPD). Patient characteristics between APD, NAPD and other cases (OCs) differed with respect to sex (19.7% male in both periorbital groups versus 36.3% in OCs), atopic dermatitis (10.4% in APD versus 60.2% in NAPD versus 16.9% in OCs) and age, APD being substantially more often (68.2%) aged 40 and above than NAPD (52.6%). Several of the top allergens in OCs [such as fragrance mix, Myroxylon pereirae resin (balsam of Peru), lanolin alcohol and potassium dichromate] caused significantly fewer positive test reactions in both periorbital groups. In contrast, thimerosal, phenylmercuric acetate, sodium disulfite, gentamicin sulfate, phenylephrine hydrochloride and benzalkonium chloride tested positively significantly more often in APD but not in NAPD, verifying them as true ophthalmic allergens. Finally, in 42 cases (4%) of APD patients, additional allergens were identified by testing of the patients' own substances (mostly beta-blockers, oxybuprocaine and dexpanthenol), supporting the necessity of testing with ophthalmic drugs as is where individual substances are not readily available.

Strong irritants masquerading as skin allergens: the case of benzalkonium chloride

Chemicals may possess a number of hazards to human health including the ability to cause skin irritation and contact allergy. Identification and characterization of these properties should fall within predictive toxicology, but information derived from human exposure, including clinical experience, is also of importance. In this context, it is of interest to review the case of benzalkonium chloride, a cationic surfactant. This chemical is a well-known skin irritant, but on occasions it has also been reported to have allergenic properties, typically on the basis of positive diagnostic patch test data. Because the accumulated knowledge concerning the properties of a chemical is employed as the basis for its regulatory classification (e.g. in Europe), as well as for informing the clinical community with respect to the diagnosis of irritant versus allergic contact dermatitis (ACD), it is important to distinguish properly which chemicals are simply irritants from those which are both irritant and allergenic on skin. A review of the information on benzalkonium chloride confirms that it is a significant skin irritant. However, both predictive test results and clinical data lead to the conclusion that benzalkonium chloride is, at most, an extremely rare allergen, except perhaps in the eye, but with many supposed cases of ACD being likely to arise from the misinterpretation of patch test data. As a consequence, this substance should not normally be regarded as, or classified as, a significant skin sensitizer.

Ocular tolerance of preservatives and alternatives

Eye drops are multiple dosage forms protected against microbial contamination by means of preservatives. However, the ocular tolerance of these chemicals can vary and this may result in adverse toxic or allergic reactions. This overview presents the pharmacopoeial requirements for the preservation of eye drops, the factors affecting ocular tolerance as well as the adverse external ocular effects induced by preservatives. The alternatives to the use of preservatives are also discussed, including the recent progress in eye drops packaging.

Clinical trial of a patient-operated microwave care system for hydrogel contact lenses

The clinical effects of a patient-operated system of microwave disinfection for soft contact lenses were assessed in a prospective pilot trial involving 103 patients who were drawn from five optometric practices. Fifty-six subjects used the test system for 1 month, and 13 subjects continued use for a total of 3 months. Both test and control subjects were examined for clinical signs using slitlamp tests. After 1 month, the incidence of all signs reported in the microwave group was not significantly greater than in the control group (p = 0.267), and the same was true after 3 months (p = 0.214). There was a significantly greater incidence of edema in the 1-month test group and of staining in the control group. UV spectroscopic examination of worn lenses from test subjects exhibiting significant signs did not show a higher level of deposition than on lenses worn by control subjects (p = 0.397).

Fingertip dermatitis in an ophthalmologist caused by proparacaine

PURPOSE

To report the late diagnosis of allergic response to proparacaine hydrochloride in an ophthalmologist.

METHOD

Case report. In a 49-year-old practicing ophthalmologist, the history, clinical findings of fingertip dermatitis, skin pathology, and skin patch testing are described.

RESULTS

Proparacaine, as the initiating agent, took almost 3 years to identify because of the unusual pattern of allergy. We explored numerous treatment options before identifying and removing the offending agent.

CONCLUSIONS

Ophthalmologists may be exposed to proparacaine on a daily basis. This unique report heightens the awareness of this rare work-related complication.

A case of contact dermatitis due to sodium bisulfite in an ophthalmic solution

We report a case of contact dermatitis due to sodium bisulfite in Tathion eye drops. A 72-year-old woman was treated daily with two solutions including Tathion eye drops for senile cataract for two years and three months. She developed edema, swelling, erythema, and vesicles on her eyelids. Because contact dermatitis due to a topical medication was suspected, patch testing was performed after disappearance of her eruption. A positive reaction to sodium bisulfite in Tathion eye drops was confirmed. Therefore, we diagnosed her eruption as contact dermatitis due to sodium bisulfite. The reaction to sodium sulfite in the next patch testing was negative. To the best of our knowledge, this is the first report from Japan about contact dermatitis caused by this medication.

Allergic contact reactions due to phenylephrine hydrochloride in eyedrops

BACKGROUND

Dermatitis of and around the eye is common. Allergic contact reactions from phenylephrine are rare despite extensive use by ophthalmologists. Previous reports do not indicate crossreactivity between phenylephrine and other sympathomimetic drugs in patch testing.

METHODS

We report three cases of allergic contact reactions (dermato-conjunctivitis) after eyedrops. Skin prick tests, epicutaneous testing with the implicated drugs, additives, and a complete patch test battery, TRUE test (Upjohn-Pharmacia, Sweden), were performed in each patient.

RESULTS

All skin prick tests were negative. The three patients showed positive patch tests to phenylephrine and one of them also to ephedrine. Tolerance of the other eyedrops without phenylephrine was verified by challenge.

CONCLUSION

Phenylephrine was the responsible agent for the reactions in our patients as confirmed by clinical findings and positive patch tests. Our findings suggest the central structure as the sensitizing part of drug in the second patient. Patch testing is essential for diagnosis of allergic contact reactions of and around the eye.

Dermatologic diagnosis and treatment of itchy red eyelids

Distinguishing the cause of itching, red eyelids is often difficult. Pruritic, inflamed eyelids can reflect various etiologies and are a common clinical presentation to the office of a dermatologist or ophthalmologist. In this article, five of the more common causes of eyelid dermatitis (atopic dermatitis, contact dermatitis, contact urticaria, rosacea, seborrhea, and psoriasis) are reviewed in detail, with particular emphasis on the ocular and periocular features. Clinical clues, historical features, and patch testing in cases of eczematous eyelid dermatitis aid in differential diagnosis. In addition, pathogenesis and treatment are reviewed.

Occupational conjunctivitis associated with type IV allergy to methacrylates

On rare occasions, exposure to methacrylates (MAs) may induce mucosal symptoms. Three patients, two dental laboratory workers and one hearing aid laboratory worker, are presented. All three had allergic contact dermatitis from MAs which disappeared after avoidance of contact with uncured MA compounds. Two of the patients, the dental laboratory assistant and the hearing aid worker, had also developed symptoms of conjunctivitis. Both were exposed to chemically curable and light-curable MAs. The association between their conjunctivitis and type IV allergy to MAs was supported by the following observations: 1) sensitization to several MAs including methylMA, 2-hydroxyethylMA, ethyleneglycol diMA, triethyleneglycoldiMA, tetrahydrofurfuryldiMA, and 1,4-butanedioldiMA, as well as to pentaerythritol triacrylate; 2) simultaneous appearance of their eye symptoms and allergic contact dermatitis; 3) high exposure to MAs because of disturbances of ventilation; 4) disappearance of the eye symptoms during holidays; and 5) opthalmologist's findings of follicular conjunctivitis with some papillae, eosinophilia, and lymphocytosis in conjunctival scrapings corresponding to allergic contact conjunctivitis. In addition, the activation of eosinophils in the conjunctival scrapings was demonstrated with the monoclonal antibody technique, and an elevated level of eosinophilic cationic protein was found in the tear fluid. Our cases suggest that conjunctivitis may be caused by type IV allergy to MAs, although type I allergy (even though prick tests were negative), other hypersensitivity mechanisms, or irritation cannot be excluded. 4H-Gloves seem to give adequate hand protection even to allergic patients. More attention should be paid to ventilation systems if MA exposure occurs. In some cases, patients with eye symptoms need to be patch tested.