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Allergic eye diseases

Allergic eye diseases are widespread. About 10% of visits to ophthalmologists, 25% of visits to allergists-immunologists and 5% of visits to pediatricians and therapists are associated with them. Diagnosis and treatment of these diseases in most cases is difficult, due to the lack of clear diagnostic criteria and common approaches to treatment.

A. Differential diagnosis. Allergic eye diseases are differentiated with molluscum contagiosum, bacterial conjunctivitis, Parino conjunctivitis, dry keratoconjunctivitis, conjunctivitis with rosacea, scarring pemphigoid.

B. To examine the conjunctiva of the upper eyelid, the patient is asked to look down, then grab the upper eyelid and, pressing on its base with a cotton swab, turn it out. During the examination, the patient should continue to look down, because when you look up, the eyelid returns to its normal position. In contrast to inflammatory diseases of the anterior part of the eye with conjunctivitis, hyperemia extends to the posterior surface of the eyelids.

B. Allergic conjunctivitis. Allergic conjunctivitis is the most common allergic eye disease. Allocate seasonal and year-round forms. Seasonal allergic conjunctivitis is more common. In most cases, grass pollen is the cause.

1. Pathogenesis. The disease is caused by allergic reactions of the immediate type, which are usually caused by airborne allergens. Allergic conjunctivitis can also occur with systemic allergic reactions, for example, with Quincke's edema.

2. Anamnesis, physical and laboratory studies, differential diagnosis. Itching and burning in the eyes, lacrimation are characteristic, and with concomitant keratitis - photophobia and blurred vision. On examination, the conjunctiva is milky or pale pink, swollen, its vessels are dilated. During an exacerbation, the mucous membrane that is discharged from the eyes, with a prolonged course, is viscous. Histamine and a small number of eosinophils are sometimes detected in the lacrimal fluid.

3. Treatment

a. First of all, eliminate contact with the allergen.

b. Cold compresses reduce itching and burning in the eyes.

in. Prescribe artificial tears, 2-4 times a day, more often if necessary.

vasoconstrictor drugs for local use. Oxymetazoline is preferred. It has a faster, stronger and longer lasting effect than naphazoline and tetrisoline. Vasoconstrictors are used 2–4 times a day.

e. H1 blockers for topical application. These drugs are very often used for allergic conjunctivitis. However, the appointment of H1 blockers alone is ineffective. To reduce itching, they are best used in combination with vasoconstrictors for topical application. Among the new H1 blockers for topical use, levocabastine, a derivative of methylpiperidine, a selective H1 blocker, should be noted. The action of the drug develops quickly and lasts a long time. Eye drops with levocabastine reduces itching and flushing. The drug is used 1-2 drops 3-4 times a day. It is effective both for prevention and for the treatment of allergic conjunctivitis. According to the classification of drugs used during pregnancy (FDA), levocabastine belongs to category C.

e. Cromoline is prescribed in the form of a 4% solution, 4-6 times a day, with improvement - 2 times a day. The drug is used for prevention, and in mild cases, and for the treatment of allergic and spring conjunctivitis. Sometimes when using cromolyn there is a transient feeling of burning and tingling in the eyes. Cromolyn eye drops are available in Canada and Europe, in the USA they are not approved for use, although other dosage forms of the drug are widely available. According to the classification of drugs used during pregnancy (FDA), cromolyn belongs to category B.

g. Lodoxamide refers to mast cell degranulation inhibitors. In animal experiments, it was shown that this drug inhibits the release of histamine 2500 times more active than cromoline. In addition, lodoxamide suppresses antigen-dependent release of leukotrienes, as well as chemotaxis of eosinophils. According to clinical trials, this drug is faster and more effective than cromolyn. Lodoxamide is used to prevent allergic and spring conjunctivitis. The drug is used in the form of a 0.1% solution, prescribed for children over 2 years of age and for adults 1-2 drops in each eye 4 times a day. The maximum duration of treatment is 3 months. The most common side effect is transient itching and burning in the eyes. According to the classification of drugs used during pregnancy (FDA), lodoxamide belongs to category B.

h. NSAIDs. In spring conjunctivitis, drugs are prescribed both for oral administration, for example aspirin, and for topical use, for example, 1% suprofen solution or 0.03% flurbiprofen solution. In allergic conjunctivitis, NSAIDs primarily reduce itching. Flurbiprofen, Ketorolac, and Diclofenac are FDA approved for use as eye drops. Clinical trials of flurbiprofen and ketorolac for the treatment of allergic conjunctivitis are currently ongoing. Unlike corticosteroids, topical NSAIDs do not mask a secondary infection, do not disrupt healing processes, do not increase intraocular pressure, and do not cause cataracts. In case of allergic eye diseases, the following NSAIDs are topically applied: indole derivatives - indomethacin, sulindac, tolmetin, pyrazolone derivatives - phenylbutazone, oxyphenbutazone, azapropazone, ketorolac, propionic acid derivatives - ibuprofen, flurbiprofen, ketoprofen, anfenofenamic acid, naprocenofenamic acid, naphrocenofenamicenamecenfenamic acid, . All of these drugs usually cause mild or moderate burning and tingling sensations in the eyes.

and. Corticosteroids for topical use, for example, 0.12% suspension of prednisolone or 1% solution of medrisone, are prescribed for the ineffectiveness of H1-blockers, NSAIDs and vasoconstrictors for local use. Treatment with corticosteroids is carried out according to the following scheme: 1 drop every 1-2 hours for 1-2 days (except for bedtime), then 1 drop 2-4 times a day until the symptoms are completely eliminated. Before prescribing corticosteroids, viral keratitis is excluded (with this disease, corticosteroids are contraindicated). To do this, conduct research using a slit lamp. Among all corticosteroids for topical use, fluorometholone has the least pronounced side effects. Corticosteroids are prescribed only after consulting an ophthalmologist.

K. Desensitization is indicated in those cases when the allergen is determined and it is impossible to avoid contact with it. With allergic conjunctivitis, this treatment is less effective than with allergic rhinitis.


l Ophthalmologist consultation is necessary in the following cases.

1) Administration of corticosteroids for topical or systemic use.

2) Long-term use of corticosteroids (more than 2 weeks) - to exclude cataracts and glaucoma.

3) Inefficiency of treatment.

m. The possibility of using new drugs for the treatment of allergic eye diseases is being investigated.

1) Nedocromil by the mechanism of action is similar to cromolyn. With seasonal allergic conjunctivitis, it reduces burning sensation and itching.

2) Pentigetide, a synthetic peptide, is a sequence of five amino acids that is identical to the IgE Fc fragment site. In addition, four of the five amino acids in its composition are identical to the first four amino acids of substance P. Pentigetide has been shown to be effective in allergic conjunctivitis.

3) Cyclosporin is a cyclic peptide that inhibits the activation of T-lymphocytes under the action of interleukin-2. The effectiveness of a 2% cyclosporin solution in spring conjunctivitis is shown.

G. Spring conjunctivitis

1. Pathogenesis. In spring conjunctivitis, conjunctival infiltration with eosinophils, degranulated mast cells, basophils, plasma cells, lymphocytes and macrophages is observed. The morphological picture indicates that in the pathogenesis of this form of conjunctivitis, allergic reactions of immediate and delayed types play a role. As the disease progresses, connective tissue overgrows, leading to conjunctival papilla hypertrophy. On the periphery of corneal ulcers and in the conjunctiva, degranulated eosinophils and mediators secreted by them are found, for example, the main basic protein.

2. Anamnesis, physical and laboratory studies, differential diagnosis. The disease usually begins in the spring. A characteristic manifestation is itching in the eyes, which intensifies with prolonged contact with the allergen, in windy and hot weather, under the influence of dust, sweat, bright light. When cornea is affected, photophobia, a foreign body sensation in the eye, and lacrimation appear. Other manifestations include conjunctival hyperemia, hypertrophy of the papillae of the upper eyelid conjunctiva, which increase to 7-8 mm in diameter, giving it the appearance of a cobblestone bridge, copious mucous discharge with a large number of eosinophils, epithelial cells and Charcot-Leiden crystals, yellowish-white dots on the conjunctiva and in the limbus (Trantas point), corneal ulcers infiltrated with Charcot – Leiden crystals, the Denny line, the appearance of fibrinous plaque on the conjunctiva of the upper eyelid under the influence of heat. Although both eyes suffer from spring conjunctivitis, one of them may be more affected. The most common complication of the disease is corneal clouding, reminiscent of the senile arch of the cornea, the most severe is a corneal ulcer. The lacrimal fluid in spring conjunctivitis contains histamine, the main main protein, Charcot – Leiden crystals, basophils, eosinophils and specific IgG and IgE. The level of IgE in the tear does not depend on the results of skin tests.

3. The course. Spring conjunctivitis usually occurs in childhood or adolescence. Boys get sick more often than girls, men and women get sick with the same frequency. The disease lasts 4-10 years, by 20 years it usually goes away.

4. Treatment. As symptomatic treatment, cold compresses are used on the eyes. With a pronounced seasonality, desensitization and cromolyn are prescribed. Lodoxamide has a faster and more pronounced effect than cromolin. Eye drops with lodoxamide (0.1% solution) are available. Lodoxamide is prescribed 4 times a day. The maximum duration of treatment is 3 months. In severe cases, corticosteroids are prescribed for topical use in a short course. Since topical use of corticosteroids is accompanied by a number of serious side effects, these drugs are prescribed only after consulting an ophthalmologist (see chap. 6, paragraph III.B.3.i). In severe cases, cyclosporin is applied topically.

D. Atopic keratoconjunctivitis

1. Pathogenesis. The disease is based on allergic reactions of an immediate type, as evidenced by conjunctival infiltration with mast cells, basophils and eosinophils. In addition, plasma cells and lymphocytes are found in the conjunctiva during morphological examination.

2. Anamnesis, physical and laboratory studies, differential diagnosis. A family history of atopic disease is usually noted, especially often diffuse neurodermatitis. The most common complaints are itching, burning in the eyes, lacrimation. On examination, the pallor of the conjunctiva, yellowish-white points in the limb area (points of Trantas) are determined. IgE, eosinophils, lymphocytes are detected in the lacrimal fluid. There are few basophils and mast cells. Other laboratory parameters are eosinophilia, an increase in the total serum IgE level.

3. Complications - ulcers and clouding of the cornea, retinal detachment, keratoconus, in 8% of cases of cataracts. A feature of cataracts in allergic conjunctivitis is a predominant lesion of the anterior part of the lens and rapid (within 6 months) progression to the stage of mature cataract. Staphylococcal blepharitis often joins.

4. Treatment. Cold compresses bring some improvement. The basis for the treatment of atopic conjunctivitis is corticosteroids for topical and systemic use. Occasionally, cromolyn and lodoxamide are additionally prescribed. Desensitization is ineffective. In severe cases, cyclosporin is applied topically.

E. Conjunctivitis with papillary hyperplasia

1. Pathogenesis. In the pathogenesis of the disease, basophils, mast cells, eosinophils, plasma cells and lymphocytes play a role. The disease is often observed with constant contact lens wear.

2. Anamnesis, physical and laboratory studies, differential diagnosis. Typical spring exacerbations during flowering plants. The main complaint is itching in the eyes. During sleep, transparent or white discharge accumulates on the eyelids and eyelashes, which eventually becomes dense. Sometimes yellowish-white dots (Transas points) are found on the conjunctiva and the limbus, limb infiltration, hyperemia and edema of the conjunctiva of the eyeball. It was shown that hypertrophy of the papilla of the upper eyelid is detected in 5-10% of patients wearing soft contact lenses and 3-4% of patients wearing hard contact lenses. Although the causes of the disease have not been conclusively established, it is believed that the polymeric material of contact lenses, antiseptics, such as thiomersal, and protein deposits on the surface of the lens cause it.

3. Treatment. The patient is advised to stop wearing contact lenses. If this is not effective, cromolyn and corticosteroids are prescribed for topical use.
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