Professional Documents
Culture Documents
A CME-Certified Newsletter
Target Audience
This activity is intended for practicing
allergists/immunologists; fellows in allergy/
immunology, primary care physicians and
allied health professionals in the field of
allergy, asthma and immunology.
Learning Objectives
Upon completion of this activity, participants
should be able to:
Describe the close relationship of allergic
conjunctivitis to allergic rhinitis in affecting
quality of life
Explain quality of life measures used in
allergic eye disorders
Discuss how allergic eye disorders can
add to the direct and indirect cost burden
of disease
Explain the role that cells play in the inflammatory reaction characteristic of allergic
conjunctivitis
Describe the role the cytokines play in the
inflammatory reaction characteristic of
allergic conjunctivitis
Explain the differences in the inflammatory
response seen in allergic conjunctivitis and
that seen in other allergic eye disorders
Discuss the various treatment topical
ophthalmic agents, e.g. antihistamines,
multiple action agents, NSAIDs,
cyclosporine and steroids
Educational Needs
For many Americans, allergic conjunctivitis
is a major health issue, associated with vast
healthcare costs and significant morbidity.
Through a comprehensive and up-to-date
educational program regarding the etiology,
diagnosis, and treatment of both allergic and
nonallergic conjunctivitis, healthcare professionals can be kept abreast of the latest
improvements in patient care, thereby helping to reduce the overall burden. This educational activity can provide a unique set of
perspectives that underline the importance
of innovative treatments for these allergic
and nonallergic eye symptoms. We examine
the impact of various treatments on inflammation, including the class of ocular antihistamine mast cell stabilizers. In addition, there
Pathophysiology of Conjunctival
Inflammation
Phillip L. Lieberman, MD
Accreditation
The American College of Allergy, Asthma &
Immunology (ACAAI) is accredited by the
Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians.
Designation
The American College of Allergy, Asthma &
Immunology (ACAAI) designates this enduring material for a maximum of 1.0 AMA PRA
Category 1 Credit TM. Physicians should
claim only the credit commensurate with the
extent of their participation in the activity.
Phillip L. Lieberman, MD
Clinical Professor of Medicine and
Pediatrics, Departments of Internal
Medicine and Pediatrics, University of
Tennessee College of Medicine, Memphis
Speaker/Consultant/Advisory Board:
AstraZeneca, GlaxoSmithKline, Intelliject,
Pfizer, Novartis, Genentech, Schering, Dey,
MEDA
Speaker/Research Grant/Consultant/
Advisory Board: Alcon, Ipsen
Michael S. Blaiss, MD
Clinical Professor of Pediatrics and
Medicine, University of Tennessee Health
Science Center, Memphis
Speaker/Honorarium/Consultant/Advisory
Board: Novartis, Genentech, AstraZeneca,
Sunovion, Alcon, Sanofi
Speaker/Research Grant/Honorarium:
GlaxoSmithKline
Speaker/Research Grant/Honorarium/
Consultant/Advisory Board: Merck
Honorarium/Consultant/Advisory Board:
Proctor and Gamble
Leonard Bielory, MD
Director, STARx Allergy and Asthma Center,
LLC, Medicine, Pediatrics, Ophthalmology
and Visual Sciences, Rutgers University,
Center for Environmental Prediction,
Springfield, New Jersey
Consultant/Advisor: Allergan, Genentech,
ISTA, SARCode, GlaxoSmithKline
Stock/Consultant/Advisory Board:
Ocusense
Research/Consultant/Advisory Board:
Schering-Plough
Research Grant: ViroPharma, Dyax, and
Jerini
Education Staff has no relevant financial
relationships to disclose.
Allergic conjunctivitis is
more common in males under
age 15 and in females
over age 15.
In Juniper's Rhinoconjunctivitis
Quality-of-Life Questionnaire
(RQLQ), one of the major
domains measured is eye
symptoms, specifically itchy,
watery, swollen, and sore eyes.
On the VFQ-25, patients with seasonal allergic conjunctivitis scored statistically significantly worse than controls on
distance vision, ocular pain, mental health,
dependency on others, role limitations, and
overall vision.
On the RQLQ patients with seasonal
allergic conjunctivitis scored statistically
significantly worse in all domains (e.g.,
activity, sleep, nose and eye symptoms,
practical problems, nasal symptoms, eye
symptoms, and emotional symptoms).
The HEDQ questionnaire found that
20% of patients with seasonal allergic conjunctivitis missed work due to their condition, and 45% reported that they had
decreased productivity of 35% (18.58%).
Moderate
Intermittent
Persistent
Grade 3
Very Severe
Severe
Oral steroids
Grade 5
Topical cyclosporine
Evolution
Grade 0
Quiescent
Avoidance
Daily Administration of
Disposable
Contact Lenses
No treatments
Oral
Antihistamines
NSAIDs
Treatment of Comorbidities Allergic Rhinitis
Immunotherapy, Intranasal Steroids
Bielory L, Joint Task Force Allergic Conjunctivitis Practice Parameter (2010 under review)
Epinastine
(Elestat)
Ketotifen
(Zaditor)
Olopatadine
(Patanol)
Olopatadine
(Pataday)
Bepotastine
(Bepreve)
Alcaftadine
(Lastacaft)
Rx
itch
itch
itch
itch
itch
itch
itch
Dose
1 gtt OU bid
1 gtt OU
bid >3yrs
1 gtt OU bid
8-12 hrs
1 gtt OU
6-8 hrs
1 gtt OU
every day
1 gtt OU bid
>2 yrs
1 gtt OU
every day
Adverse
effects
Transient sting,
headache,
bitter taste (<1%
discontinued
due to adverse
effects)
Burning,
infection
(URI/cold
symptoms)
10%
Headache and
conjunctival
injection
Transient sting/
burn (<5%),
headache (7%)
Transient sting/
burn (<5%),
headache (7%),
flu-like symptoms
(10%)
Taste perversion
<25%, eye
irritation,
headache,
nasopharyngitis
(<5%)
Transient sting/
burn, headache,
flu-like symptoms
(<4%)
Manufacturer
MEDA
Allergan
Novartis
Alcon
Alcon
ISTA
Allergan
Future Therapy
New treatments under investigation include
a contact lens with ketotifen. Preliminary
results show no adverse effects. A ketotifen
patch is also being studied. In addition,
NSAIDs, such as topical bromfenac, are
being studied for allergic conjunctivitis and
potentially for tear film dysfunction (a
common comorbid state with ocular
allergy).
Histamine Receptors in Ocular Tissue
Histamine is one of the most common
chemical mediators causing pruritus. In
addition to histamine (specifically H1 and
H 2), other sensory molecules on nerves
include opioids, leukotriene B4, prostaglandin E, osmolarity, neurokinins, proteases, among others.
Several histamine receptors are in
ocular tissue. Histamine binding to H 1
receptors causes ocular itch. Stimulation
of H 2 receptors in blood vessels causes
vasodilation. A study by Abelson and Udell
showed that instillation of a known H2 agonist (dimaprit) induced hyperemia.24 Onset
was at 10 minutes and peak effect was at
30 minutes. There was no itch associated
with H2 receptor stimulation. Itch occurs
References
1. Bacon AS et al. Tear and conjunctival changes during the allergen-induced early- and latephase responses. J Allergy Clin Immunol. 2000;106(5):948-954. 2. Choi SH, Bielory L. Latephase reaction in ocular allergy. Curr Opin Allergy Clin Immunol. 2008;8(5):438-444. 3. Bielory
L. Allergic and immunologic disorders of the eye. Part I: immunology of the eye. J Allergy Clin
Immunol. 2000;106(5):805-816. 4. Fukuda K et al. Critical role of IgE-dependent mast cell activation in a murine model of allergic conjunctivitis. J Allergy Clin Immunol. 2009;124(4):827833. 5. Baudouin C et al. CCR 4 and CCR 5 expression in conjunctival specimens as differential
markers of T(H)1/T(H)2 in ocular surface disorders. J Allergy Clin Immunol. 2005;116(3):614619. 6. El-Asrar AM et al. Expression of T lymphocyte chemoattractants and activation markers in vernal keratoconjunctivitis. Br J Ophthalmol. 2002;86(10):1175-1180. 7. Kumagai N
et al. Active matrix metalloproteinases in the tear fluid of individuals with vernal keratoconjunctivitis. J Allergy Clin Immunol. 2002;110(3):489-491. 8. Ueta M et al. Toll-like receptor
3 enhances late-phase reaction of experimental allergic conjunctivitis. J Allergy Clin Immunol.
2009;123(5):1187-1189. 9. Ueta M et al. Prostaglandin E receptor subtype EP3 in conjunctival
epithelium regulates late-phase reaction of experimental allergic conjunctivitis. J Allergy Clin
Immunol. 2009;123(2):466-471. 10. Bacsi A et al. Effect of pollen-mediated oxidative stress on
immediate hypersensitivity reactions and late-phase inflammation in allergic conjunctivitis.
J Allergy Clin Immunol. 2005;116(4):836-843. 11. Motterle L et al. Altered expression of neurotransmitter receptors and neuromediators in vernal keratoconjunctivitis. Arch Ophthalmol.
2006;124(4):462-468. 12. Sacchetti M et al. Hyperosmolar conjunctival provocation for the
evaluation of nonspecific hyperreactivity in healthy patients and patients with allergy. J Allergy
Clin Immunol. 2006;118(4):872-877. 13. Vanna AT et al. International Study of Asthma and
Allergies in Childhood: validation of the rhinitis symptoms quesionnaire and prevalence of rhinitis in schoolchildren in So Paulo, Brazil. Pediatr Allergy Immunol. 2001;12(2):95-101.
14. Hesselmar B et al. Allergic rhinoconjunctivitis, eczema, and sensitization in two areas with
differing climates. Pediatr Allergy Immunol. 2001;12(4):208-215. 15. Wthrich B et al.
Epidemiological survey in hay fever patients: symptom prevalence and severity and influence on
Please complete the Self-Assessment Test, Evaluation and Credit Claim information. Mail a copy of these documents to the American College of
Allergy, Asthma & Immunology, 85 West Algonquin Road, Suite 550, Arlington Heights, IL 60005, or FAX to (847) 427-1294, Attn: CME Administrator.
Credit should not be claimed by participants who received credit by attending this session at the 2010 Annual Scientific
Meeting in Phoenix, Arizona. A minimum score of 80% must be achieved in order to earn a certificate of credit. For credit to be awarded,
all posttests, evaluations, and claiming of credit must be submitted prior to the Expiration Date of June 1, 2012.
Alternatively, to receive credit quickly, please go directly to http://www.acaai.org/Pages/CONJUNCT2011.aspx
and complete the entire activity and post test online.
Self-Assessment Test
After reading each item carefully, please select the best response (one) and enter your choice on the reverse.
1. Which of the following allergic eye disorders can exist in a non-IgE-mediated
(nonatopic) form?
A. Seasonal allergic conjunctivitis
B. Atopic keratoconjunctivitis
C. Perennial allergic conjunctivitis
D. Vernal conjunctivitis
2. Which one of the following conditions is most
commonly associated with atopic dermatitis?
A. Seasonal allergic conjunctivitis
B. Atopic keratoconjunctivitis
C. Perennial allergic conjunctivitis
D. Vernal conjunctivitis
3. Neutrophil chemotactic factor in tear fluid is
most characteristic of:
A. Seasonal allergic conjunctivitis
B. Giant papillary conjunctivitis
C. Perennial allergic conjunctivitis
D. Vernal conjunctivitis
4. A 32-year-old man is participating in a spring
allergy clinical study. The Rhinoconjunctivitis
Quality-of-Life Questionnaire (RQLQ) is
administered during the trial. Which of the
following 4 eye symptoms are assessed in
this patient by the RQLQ?
A. Itchy, watery, swollen, sore
B. Itchy, red, swollen, watery
C. Red, swollen, watery, sticky
D. Swollen, watery, red, sore
Continued on reverse.
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Activity Evaluation
1. As a result of this activity, do you intend to do anything differently in your practice? Yes No
If Yes, what specifically?
If No, what might be barriers to making any changes?
2. Based on educational needs, please provide healthcare or professional practice gaps that should be addressed in future educational activities
and that may be applicable to your practice:
3. Was this a fair and balanced publication? Yes No
If No, please comment on the scientific rigor, fairness, and balance of the material.
4. Did this publication properly disclose relevant financial relationships of all persons in control of content? Yes No
If No, please explain:
5. Did this publication include proper disclosure of discussion of off-label (investigational/experimental) use of medications or medical devices?
Yes No
If No, please comment:
6. How well organized was the publication? (1=poor, 2=fair, 3=good, 4=excellent)
7. How would you rate the clarity of this publication? (1=poor, 2=fair, 3=good, 4=excellent)
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