Consensus document on allergic conjunctivitis (DECA)

Allergic conjunctivitis (AC) is an inflammatory disease of the conjunctiva caused mainly by an IgE-mediated mechanism. It is the most common type of ocular allergy. Despite being the most benign form of conjunctivitis, AC has a considerable effect on patient quality of life, reduces work productivity, and increases health care costs. No consensus has been reached on its classification, diagnosis, or treatment. Consequently, the literature provides little information on its natural history, epidemiological data are scarce, and it is often difficult to ascertain its true morbidity. The main objective of the Consensus Document on Allergic Conjunctivitis (Documento dE Consenso sobre Conjuntivitis Alérgica [DECA]), which was drafted by an expert panel from the Spanish Society of Allergology and Spanish Society of Ophthalmology, was to reach agreement on basic criteria that could prove useful for both specialists and primary care physicians and facilitate the diagnosis, classification, and treatment of AC. This document is the first of its kind to describe and analyze aspects of AC that could make it possible to control symptoms.

Clinical grading of atopic keratoconjunctivitis

PURPOSE OF REVIEW

Atopic keratoconjunctivitis (AKC), the most severe and chronic form of ocular surface allergy-related disorder, is the ocular surface complication that some atopic dermatitis patients can suffer. Its wide range of severity, from mild and occasional problems to persistent and intense inflammation, makes it difficult to appropriately select uniform patients for clinical studies. This article proposes a new classification system for AKC based on clinical severity.

RECENT FINDINGS

Recent reports on AKC have contributed to a better understanding of the pathogenesis and clinical manifestations, and are offering new therapeutic candidates for AKC. No reports, however, have been found that address a classification of this disease.

SUMMARY

A new definition and classification for AKC is presented by this review, based on clinical severity, grading the main symptoms and signs. It intends to serve as a first forum of discussion among clinicians and other scientists working in the field of ocular surface inflammation. The final intention is to have a common language helping develop efficient clinical trials leading to successful approval of new therapeutic compounds for this blinding ocular surface condition.

[Different clinical forms of conjunctival allergy]

Allergic conjunctivitis is a frequent disorder, benign in most cases and often associated with other manifestations of atopy such as rhinitis or asthma. This disorder is increasing steadily because of the influence of environmental factors such as pollution, smoking, etc. Allergic conjunctivitis can be broken down into five clinical forms: (1) seasonal and intra-annual conjunctivitis, (2) vernal keratoconjunctivitis, (3) atopic keratoconjunctivitis, (4) gigantopapillary conjunctivitis, and (5) contact allergies (palpebral conjunctival form). Analysis of the patterns and signs of the disorder as well as the circumstances surrounding its manifestation and an allergy workup generally facilitate eliminating the allergen responsible once it has been identified.

[Childhood allergic conjunctivitis: the allergist's point of view]

Allergic conjunctivitis is one of the most frequent reasons for a child's consultation with an ophthalmologist. Once the diagnosis of conjunctivitis is made and the clinical form is clearly established, the search for a cause is the most complicated step. Consultation with an allergist is necessary, in particular when questioning the patient points toward an allergic cause or brings up conditions suggestive of atopic disease. Ocular allergy can follow a type I hypersensitivity, i.e., mediated by IgE: most frequently this is acute and chronic allergic conjunctivitis. Demonstrating the allergen requires prick tests, which are easy to carry out and painless; their sensitivity is currently satisfactory. In vitro tests can complete the workup. In case of doubt on the allergen responsability for allergy, an allergenic provocation test can confirm or refute the allergen's involvement. Ocular allergy can also stem from a type IV mechanism, i.e., a cell-mediated mechanism such as in contact allergy involving different topical substances. In these cases, the clinical aspect and the patient's history may require consultation with a dermatologist-allergist for patch tests. To adapt practices when encountering conjunctivitis in a child, the ophthalmologist should be familiar with the allergens that may set off a conjunctivitis episode. Knowledge of the mechanisms at play also helps direct the examination toward allergy or another cause. In all these steps, collaboration between the ophthalmologist and the allergist is indispensable.

[A systemic approach to the diagnosis and treatment of allergic conjunctivitis]

The diagnosis of allergic conjunctivis begins by a meticulous questioning emphasizing the existence of ocular itching, the way of evolution of the signs and allergic preceeding. The examination searchs after follicles and papillae of the conjunctiva who usually go with serous discharges, blepharitis and keratitis. So four clinical forms may be described the chronic conjunctivitis, the vernal kerato-conjunctivitis, the atopic conjunctivitis and the giganto-papillar conjunctivitis. For the treatment, all non specific signs of allergy must be eliminated, the focal infections also and allergic substance isolated. If evolution is worse, an antiallergic eye drop is given until the disappearance of all the physical signs. In the same time, steroids and anti H1 drugs must be avoided. In case of failure, the specialist in allergy will be helpful to exam the patient.

Resection and cryotherapy combined with amniotic membrane transplantation for the treatment of vernal keratoconjunctivitis with giant papillae

To evaluate the efficacy and safety of resection and cryotherapy combined with amniotic membrane transplantation (AMT) for the treatment of vernal keratoconjunctivitis (VKC) with giant papillae (GP). Eight patients (16 eyes involved) with VKC, characterized by GP on the upper tarsal conjunctiva, underwent resection and cryotherapy in combination with AMT. The follow-up lasted for 3-22 months. The results showed that corneal shield ulcers and superficial punctuate keratitis healed during the first week after surgery and did not recur. Fourteen eyes (87.5 %) were symptom-free 1 month after surgery, and no GP, ectropion, trichiasis and other complications were noted, but the blood vessels of upper tarsal conjunctiva could not be clearly seen and a little conjunctival scar was observed. Recurrence of GP was observed in 2 eyes (12.5 %), with the area being less and irritation milder as compared with those before the operation. Among the two eyes, one eye was treated by cyclosporine eyedrops with improvement, but the other eye showed no improvement after the treatment, and underwent a second surgery with a cotton patch soaked in fluorouracil applied onto the supratarsal area after resection and cryotherapy. Four months after the treatment the patient presented no symptoms and GP did not recur. It is concluded that the resection and cryotherapy combined with AMT is an effective and safe treatment for VKC with GP.

Allergic conjunctivitis: the forgotten disease

The eye is largely exposed to foreign substances, and ocular tissues have a complete array of immune cells to interact with offending antigens. In particular, the external eye represents an ideal site for immediate hypersensitivity reactions because of the high number of mast cells in the eyelids and bulbar conjunctiva, as well as for the potential local synthesis of IgE. In fact, the involvement of the eye was part of the original description of hay fever by Charles Blackley in 1873. In a large epidemiological survey of allergic patients we reported since 1987, 40% had symptoms possibly related to allergic conjunctival disease. However, the participation of the conjunctiva to the multiorgan picture of allergy is largely underestimated. Allergic eye diseases have long been referred to the classical Type I hypersensitivity mechanism according to Coombs and Gell. Recently, however, the tremendous progress in understanding allergic mechanisms and inflammation has brought new insights into the pathophysiology of several allergic diseases, including those of the eye. Accordingly, several systematic descriptions of allergic eye diseases should be revisited. In particular, the classification of the various forms of a 'red eye' of allergic origin appears inadequate to answer the progress achieved in their multifactorial pathogenesis.

Two Presentations of Contact Lens-Induced Papillary Conjunctivitis (CLPC) in Hydrogel Lens Wear: Local and General

PURPOSE

The purpose of this study was to confirm that two distinct clinical presentations of contact lens-induced papillary conjunctivitis (CLPC), local and general, occur in hydrogel lens wear.

METHODS

Retrospective analyses of 124 CLPC events were identified. The classification of CLPC was based on location and extent of papillae. CLPC was classified as local if papillae were present in one to two areas of the tarsal conjunctiva and general if papillae occurred in three or more areas. The CLPC events were compared with an asymptomatic control group in prospective clinical trials conducted from 1993 until 2003 at two clinical sites, Australia and India. Two hundred sixteen subjects from Australia and 914 subjects from India wore either high Dk silicone hydrogel or low Dk hydrogel lenses on a 6-night (6N) or 30-night extended-wear (EW) schedule. The physiological responses of the ocular surface, including tarsal conjunctiva redness and roughness, number of papillae present, lens fit and performance, and subjective patient symptoms, were measured during each visit at each site. These variables listed were compared between local CLPC groups and asymptomatic controls and general CLPC groups and asymptomatic controls.

RESULTS

Two types of CLPC in hydrogel lens wearers have been confirmed. Of the 124 CLPC events, there were 61 local and 63 general events. Local and general CLPC cases reported significantly greater frequency of symptoms compared with the asymptomatic controls, in particular itching, lens awareness, secretion, and blurred vision (p < 0.1).

CONCLUSIONS

The classification of CLPC into two types, local and general, in hydrogel lens wear was confirmed based on presentations at both sites. This distribution of papillae between local and general CLPC may indicate separate etiologies involved in the pathogenesis of the condition.

Increased eotaxin in tears of patients wearing contact lenses

PURPOSE

Giant papillary conjunctivitis in patients wearing contact lenses occurs after intolerance and/or allergy to contact lenses. Eotaxin is a CC chemokine with a potent and specific chemotactic effect for eosinophils, which are involved in allergies. The purpose of this study is to measure the eotaxin levels in tears of patients wearing contact lenses and in normal subjects. Eotaxin levels were also correlated with the grade of giant papillary conjunctivitis.

METHODS

Around 10 microL of tears were collected with glass capillaries in 16 patients wearing contact lenses and in 10 normal volunteers. Giant papillary conjunctivitis was graded from 0 to 4 by reference to standard slit-lamp photographs of the superior tarsal conjunctiva. Eotaxin concentration in tears was measured by ELISA using mouse anti-human eotaxin monoclonal antibodies. For the statistical analysis of the results, the paired Wilcoxon/Kruskal-Wallis test was used.

RESULTS

The mean concentration of eotaxin was 2698+/-233 (SEM) pg/mL in patients wearing contact lenses and 1498+/-139 pg/mL in normal subjects. The difference was statistically significant (P=0.0004). The mean score of papilla grade was 1.75+/-0.19 in patients wearing contact lenses and 0.2+/-0.13 in normal subjects (P<0.0001). Papilla grade could be correlated to the eotaxin level in tears (R2=0.6562 and P<0.0001).

CONCLUSION

An increase of eotaxin levels in tears was measured in patients wearing contact lenses. Eotaxin levels correlated with the severity of giant papillary conjunctivitis. These data suggest that eotaxin could play a role in papilla formation.

Atopic keratoconjunctivitis

Atopic keratoconjunctivitis (AKC) represents a disease usually classified under the term of allergic conjunctivitis together with seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC) and vernal keratoconjunctivitis (VKC). However, AKC and VKC have clinical and pathophysiological features quite different from SAC and PAC, in spite of some common markers of allergy. This article aims to review personal studies suggesting that allergic conjunctivitis (similarly to asthma, rhinitis and atopic dermatitis) is a heterogeneous disease entity with different preferential pathogenetic mechanisms and a spectrum of clinical expression which varies according to individual cases. AKC and VKC may thus represent a model of atopy quite distinct from the classical type-1 hypersensitivity mechanism.

Prevalence and severity of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema in 6- to 7-year-old Nigerian primary school children: the international study of asthma and allergies in childhood

OBJECTIVE

To determine the prevalence and severity of symptoms of asthma, allergic rhinoconjunctivitis and eczema in Nigerian children aged 6-7 years.

SUBJECTS AND METHODS

A cross-sectional study of selected children in primary schools in Ibadan, Nigeria was conducted using phase I of the International Study of Asthma and Allergies in Childhood (ISAAC) format. Standardized questionnaires were distributed to parents and guardians of 2,325 children aged 6-7 years in 31 primary schools randomly selected among 272 in Ibadan.

RESULTS

Data was collected from 1,704 children (797 boys and 907 girls; M:F ratio 1:1.14), giving a participation rate of 73.3%. Both recent rhinoconjunctivitis and wheeze were reported by 5.1%, and itchy flexural rash in the past 12 months was reported by 8.5%. The cumulative prevalences of reported symptoms of wheezing, rhinitis and eczema were 7.2, 11.3 and 10.1%, respectively. These symptoms were basically the same among the boys and girls (rhinitis 11.4 vs. 11.2%; eczema 10.7 vs. 9.5%), except for wheezing, which was higher in boys (9.0%) than girls (5.6%), p = 0.015. Current symptoms of rhinitis and atopic eczema were associated with current wheeze and severe wheezing, whereas current symptoms of allergic rhinoconjunctivitis were only associated with severe wheezing attacks. One or more current symptoms occurred in 13.2% of the children, and all three symptoms were reported by 0.5%.

CONCLUSION

The study demonstrates a high prevalence of atopic conditions among children 6-7 years old in Ibadan, Nigeria, with more than three fifths of the children who had current wheezing also showing symptoms of other atopic diseases. Children with allergic rhinoconjunctivitis were more likely to have severe wheezing attacks if they had developed atopic eczema before 2 years of age.

Animal models of allergic and inflammatory conjunctivitis

Allergic eye diseases are complex inflammatory conditions of the conjunctiva with an increasing prevalence and incidence. The diseases are often concomitant with other allergic diseases such as allergic rhinitis, atopic dermatitis and allergic asthma. Despite the disabling and prominent symptoms of ocular allergies, they are less well studied and further insights into the molecular basics are still required. To establish new therapeutic approaches and assess immunological mechanisms, animal models of ocular allergies have been developed in the past years. The major forms of allergic ocular diseases, seasonal and perennial allergic conjunctivitis, vernal and atopic keratoconjunctivitis and giant papillary conjunctivitis, each have different pathophysiological and immunological components. In contrast to these distinct entities, the current animal models are based on the sensitization against a small number of allergens such as ovalbumin, ragweed pollen or major cat allergens and consecutive challenge. Different animal species have been used so far. Starting with guinea-pig models of allergic conjunctivitis to assess pharmacological aspects, new models including rats and mice have been developed which mimic major features of ocular allergy. The presently preferred species for the investigation of the immunological basis of the disease is represented by murine models of allergic conjunctivitis. In the future, combined ocular, nasal and aerosolic challenges with allergens may provide a model of allergy that encompasses simultaneously the target organs eye, nose and airways with conjunctivitis, rhinitis and asthma.

Vernal keratoconjunctivitis in Thailand

A prospective, cross-sectional and randomized cross-over study was conducted to study the clinical features and treatment outcome among Thai patients with vernal keratoconjunctivitis (VKC). History-taking and eye examinations were performed. Mild cases of VKC were given topical antihistamine four times daily. Moderate and severe cases of VKC were treated with topical lodoxamide four times a day. Severe cases of VKC were given topical corticosteroids. Moderate and severe cases of VKC, which were refractory to treatment with either corticosteroids or a mast cell stabilizer had topical cyclosporine 0.5% instilled four times daily. Five patients were exposed to two different treatment regimens in sequence. As main outcome measures, itching, foreign body sensation, photophobia, conjunctival injection, papillae and chemosis were evaluated weekly. The patients with the palpebral type of VKC had daily symptoms, which were more severe and triggered by house-dust with a significant difference among the groups. Limbal VKC was associated with allergic rhinitis more commonly than palpebral VKC. Positive results of skin prick testing to acacia, careless weed, mold, Johnson grass and cow's milk were significantly more common in patients with palpebral VKC. The most common symptoms and signs were found in the mixed type of VKC. Purulent discharge, pannus and lid erythema were found in the palpebral type. Levocabastine hydrochloride was sufficient for mild cases of limbal VKC; lodoxamide for the limbal and mixed types. Prednisolone acetate was the drug of choice in severe cases of any type but only for a short period of time. The success rate of topical cyclosporine in the palpebral type was lower than in the limbal type due to an intolerable burning sensation. Topical cyclosporine used in 4 patients with limbal and palpebral type had a success rate of 100% which was greater than in the lodoxamide group (66.7%, 0%). Compared with topical corticosteroid-treated eyes in one patient, the success rate in topical cyclosporine-treated eyes was not success. Grading the severity of each type of VKC is crucial to obtain good response of any medication and compliance. Topical cyclosporine 0.5% can be an alternative drug to relieve symptoms and signs of VKC in order to avoid steroid-induced glaucoma.

Spectrum of ocular allergy

PURPOSE OF REVIEW

To elaborate and review the immunologic spectrum of the five basic types of ocular allergy.

RECENT FINDINGS

Perennial allergic conjunctivitis (PAC) appears to be an extension of seasonal allergic conjunctivitis (SAC) based on the similarity of clinical symptoms and the immune mechanism involved. T helper type 2 (TH2)-type cytokines, increased ratio of TH1/TH2 cytokines and increased statement of adhesion molecules all appear to play an integral role in the inflammatory process of SAC and PAC. Vernal keratoconjunctivitis (VKC), which is a pediatric disease, differs from SAC and PAC by its more severe and chronic nature. Increased numbers of T cells, eosinophils (along with the products of degranulation), chemokines and their receptors may contribute to the more serious symptoms of VKC. Atopic keratoconjunctivitis (AKC) is similar to VKC by the increased concentration of cytokines involved (i.e. interleukin-4 and -5). Despite clinical similarities with VKC, the presence of atopic dermatitis, along with some differences in clinical signs, make AKC a separate entity, which is sometimes referred to as an adult variant of VKC. Giant papillary conjunctivitis has similar cell involvement as VKC and AKC. However, giant papillary conjunctivitis differs from VKC and AKC by the clinical signs present (i.e. the presence of giant papillae) and the necessary concurrent contact lens wear.

SUMMARY

The important differences and similarities observed in these five types of allergic diseases might help to better treat the patients affected with these disorders.

Current opinion of immunotherapy for ocular allergy

PURPOSE OF REVIEW

Allergic conjunctivitis is common and may be the most prominent or the only feature of allergies. Immunotherapy has been used as a primary treatment for allergies since the early 1900s. Currently the use of immunotherapy for allergic rhinoconjunctivitis is well established and has been shown to decrease the development of bronchial hyperreactivity and asthma. However, the role of immunotherapy for primary treatment of allergic conjunctivitis is unclear. We reviewed the studies where immunotherapy was used with particular attention to the affects on ocular allergies.

RECENT FINDINGS

There are many schedules and methods of delivering immunotherapy. Recent studies have started to assess ocular symptoms as one of the parameters to monitor efficacy of therapy. They follow the affects of immunotherapy on conjunctival provocation tests, ocular symptoms, or the use of eye drops. The literature suggests that using the various immunotherapy modalities at different schedules, ocular symptoms improved even when immunotherapy was used on a rush schedule.

SUMMARY

The initiation of immunotherapy for allergic rhinoconjunctivitis has been shown to switch the immune response to T helper 1 and thus avoid the progression of other atopic conditions. Current literature shows that using many allergens with different forms of immunotherapy appear to have a significant improvement in ocular allergy symptoms and this can be achieved rapidly and safely in most patients. Whether using immunotherapy early in allergic conjunctivitis will alter the progression of other atopic conditions remains to be investigated.

The clinical spectrum of ocular allergy

Ocular allergy is a very common pathology, and its incidence has increased in industrial countries in combination with an increase in atopy. Many different clinical features characterize the ocular allergy, which can be seasonal, perennial, or chronic. Therefore, ocular allergy must be considered part of the allergic syndrome; perennial or seasonal keratoconjunctivitis appear to be directly related to allergic rhinitis manifestations and, less frequently, to asthma and eczema. The principal field of research in ocular allergy concerns therapeutic applications and new concepts of physiopathologic mechanisms needed to understand the most optimal treatment that can be delivered.

Epidemiological study of 134 subjects with allergic conjunctivitis

At times it is difficult to distinguish among the subtypes of chronic allergic conjunctivitis. A prospective study with 134 patients was carried out. Patients were diagnosed with vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC) or perennial allergic conjunctivitis (PAC). Demographic information was also collected including, age at symptom onset, sex, history of non-ocular allergy, and history of family allergy. Forty-six percent were diagnosed with VKC, 40% with AKC, 8% with PAC, and 6% were not specifically diagnosed. This distribution information as well as the demographic information collected demonstrates that there are patterns within each subgroup of chronic ocular allergy sufferers. These findings will be helpful in the diagnosing and proper classification of ocular allergic conditions.

Classification of ocular atopic/allergic disorders and conditions: an unsolved problem

PURPOSE

To review the different classifications of ocular allergic diseases and to define the most suitable one according to the current understanding of the pathophysiology and clinical course of these disorders.

METHODS

Review of the major published ocular allergy classifications.

RESULTS

Based on past and present classifications, the author proposes the following classification: 1. allergic conjunctivitis (acute and chronic); 2. giant papillary conjunctivitis; 3. vernal keratoconjunctivitis; and 4. atopic keratoconjunctivitis. In addition, use of the term "allergic conjunctivitis" as a synonym for all ocular allergic disease is discouraged.

CONCLUSION

The proposed classification for ocular allergic disorders intends to unify the present criteria and to serve as an initial forum of discussion. This should enhance a common understanding among and between ophthalmologists and other allergy specialists. Constructive criticism of this classification system is required for further improvement.

[Therapy of allergic conjunctivitis]

Among the several eye diseases (or diseases involving the eye) based on hypersensitivity reactions, the most frequent is allergic conjunctivitis. Recently six types of allergic conjunctivitis/keratoconjunctivitis are distinguished: 1. seasonal, 2. perennial, 3. vernal, 4. giant papillary, 5. atopic and 6. of contact origin. Their treatment is generally local. In the most frequent seasonal ("hay fever") and perennial forms the elimination of the allergen or when it is impossible antihistamines (with or without vasoconstrictors), "weak" steroids or hyposensitisation are offered. In vernal and atopic keratoconjunctivitis mast cell stabilizers are the most effective, with special effect of lodoxamide in the vernal type. In giant papillary and contact allergic inflammations the elimination of the causative agent is the first method of choice. In resistant cases "strong" steroids, in extreme forms immunosuppressive, cytostatic and systemic treatment may become necessary. The paper gives a review of currently applied medicines (mainly eyedrops) and other methods of treatment, and includes therapeutic principles applying to various forms of allergic conjunctivitis.

[The clinico-statistical aspects in allergic conjunctivitis]

Ocular allergy represents the hypersensitivity reaction of the ocular surfaces in contact with the external environment. Allergic conjunctivitis are one of the frequent disorders of the clinical practice. In this paper we present statistically the cases attended in our service for one year, a few pathogenetical factors; the positive diagnose and the therapeutic strategy.

Therapeutic options in ocular allergic disease

The term ocular allergy encompasses a group of diseases in which there is a high frequency of atopy, ocular itching, stringy discharge and a papillary conjunctival reaction. Conditions confined to the lids and conjunctiva (e.g. seasonal allergic conjunctivitis) have a good prognosis but those involving the cornea may result in visual impairment (e.g. atopic keratoconjunctivitis). Mast cell and eosinophil mechanisms are important in al the ocular allergies, but T cell inflammation is prominent only in vernal keratoconjunctivitis, atopic keratoconjunctivitis and giant papillary conjunctivitis. Therapy involves the use of antigen avoidance (where possible), nonspecific medical therapy (e.g. cold compresses, artificial tears), specific medical therapy and, in certain situations, immunotherapy and surgery. Topical antihistamines (often in combination with a vasoconstrictor) and oral antihistamines are widely used in perennial and seasonal conjunctivitis. Levocabastine is a new preparation which is more rapid and potent. Mast cell inhibitors [e.g. sodium cromoglycate (cromolyn sodium)] have a proven track record as safe and effective therapy for all ocular allergic diseases and the newer, more potent nedocromil and lodoxamide are now available. Topical steroids are only indicated in sight-threatening disease due to their serious adverse effects and other therapy should be continued to minimise the dose required. There is a lack of intermediate potency and high potency but safe topical preparations. A number of future possibilities exist, some of which have been partially explored. Cyclo-oxygenase inhibitors have proved of limited use, but inhibitors of lipoxygenase and kinin pathways are awaited. Although results with HEPP have been disappointing, other modulators of mast cell function (e.g. picumast, beta-agonists and phosphodiesterase inhibitors) may prove useful in the future. So far, results with topical cyclosporin in serious disease are very encouraging. Future developments in the manipulation of eosinophilic products, cytokines and adhesion molecules may also be relevant. However, the current situation for those with serious ocular allergy remains a disturbing dependence upon topical steroids, with all the attendant risks.

Shield ulcers and plaques of the cornea in vernal keratoconjunctivitis

BACKGROUND

Shield-shaped corneal ulcers and plaques are serious sight-threatening corneal manifestations of vernal keratoconjunctivitis. There are few reports describing the management of these patients and their outcomes.

METHODS

The clinical presentation, treatment, and outcome of 66 shield ulcers and/or plaques in 55 eyes of 41 patients with vernal keratoconjunctivitis were studied in this retrospective study of patients treated at King Khaled Eye Specialist Hospital during an 11-year period.

RESULTS

Patients with shield ulcers where the base of the ulcer was transparent usually had rapid re-epithelialization and an excellent visual outcome with medical treatment alone. Patients with shield ulcers and visible plaque formation had delayed re-epithelialization when receiving only medical treatment. Complications of delayed re-epithelialization consisted of bacterial keratitis in five eyes, amblyopia in one eye, and strabismus in one patient.

CONCLUSIONS

Patients with shield ulcers and/or plaques that do not re-epithelialize once active vernal keratoconjunctivitis has been controlled should have surgical intervention. In this series, a simple scraping of the base and margins of the ulcer with removal of the inflammatory material (i.e., the plaque) resulted in rapid re-epithelialization in 20 of 23 ulcers and plaques. An algorithm for treating shield ulcers and/or plaques is presented based on the experience at this institution.

Allergic conjunctivitis disorders

Allergic conjunctivitis is one of the most common disorders of the external eye. Hypersensitivity of the conjunctiva to foreign substances is characterized by discharge, redness, itching, irritation, swelling, light sensitivity, and tearing. The tear fluid contains a small amount of eosinophils and histamine. Allergic eye conditions can be classified into four categories. They are hay fever conjunctivitis, vernal conjunctivitis, atopic keratoconjunctivitis, and giant papillary conjunctivitis.

Conjunctival provocative tests: a model of human ocular allergy

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