Ocular Allergy

Allergy

• Allos ergiae (Greek)

• Alter reaction’s ability
• Allergy- is a reaction mediated by immune
system
PATHOPHYSIOLOGY OF OCULAR ALLERGY

What is allergy?
• May result from a combination of Allergen
recognition
• Amplifies specific response
• Increase IgE production
• Up regulation of inflammatory cells, mast cell and
eosinophils
• Hyperesponsiveness of ocular tissue
Potential Risk Factors for Allergic Diseases

• Genetic • HLA antigens

• Age • Environment
• Gender • Allergen exposure
• Race Limbal VKC in • Endocrine influence
African • Neural factor
• Family history
Environment Factors

• Environment influence is more important than

genetic (Allergen exposure)
- Quality
- Intensity
- Route
- Duration
Mechanism of Allergic Reaction
Defense of The Eye
• Non specific :
- Eyelids
- Lashes
- Tears
• Lubricate, clean and rinse
• Secretory IgA
• Lactoferrin, lysozyme, betalysin
• Specific defense (immune response of conjunctiva
and cornea)
Immune Response of Conjunctiva

• Antigen-presenting cell(APC)
- Langerhan cell and macrophage
- Carry Ag to lymph node
- Stimulated T cellsT, B cells proliferation
- T, B cells homing
• CALT (conjunctival associated lymphoid tissue)
- Antigen uptake lymphocyte sensitized in CALT
travel to local Lymph Node
• Cytokines
Immune Response of Conjunctiva
Normal Conjunctiva
• Epithelium and Allergic Conjunctiva
• Increased mast cells
substantia propia :
and eosinophilsIgE,
- Neutrophils and
TNF
lymphocytes
• Increased levels of
• Substantia propia :
adhesion molecule
- Mast cells and Plasma
cells
• Not normally found in
the epithelium :
- Eosinophils and
basophils
Mast Cells Histamine Eosinophils
• Type I hypersensitivity • 4 types of histamine • Essential in chronic
reaction receptors allergic inflammation
• Vesicles containing • But only H1 and H2 in • Activated by :
inflammatory mediators the eyes -Inflammatory cells
• Mediators : -H1: type-c nerves -Histamine
- Preformed : endingitching -PAF
Histamine -H1 and H2: -Leukotrienes
Proteasetryptase, endothelial vascular -Cytokine
chymase smooth muscles -IgE
- Newly formed : vasodilation Release :
Pgs, leukotriene, • Release 30 sec after - Major basic protein
platelet- activating factor mast cell degranulation (MBP)
Cytokine 􀃆 IL-4, IL-5 • Peak at 3 min - Cationic protein
• Rapidly metabolized at - Leukotrienes
5 min - PG
- Cytokines
chemokines
 Immune Response of Cornea
• Antigen precenting Cells
- Peripheral central
• Antibodies
- Limbal vessels reside in stroma
- IgM
• Compliment system
- Restricted to the periphery
4 types of hypersensitivity responses

• Type I – Immediate/ Anaphylactic reaction

ex: Allergic conjunctivitis
• Type II – Cytotoxic Reaction
ex: Corneal graft rejection, drug reactions
• Type III – Immune-Complex Reaction
ex: Autoimmune disorders
• Type IV – Cell-Mediated Immunity
ex : Granuloma formation
Type I Hypersensitivity

Devided into three phases :

– Sensitization phase
– Activation phase (early allergic response)
– Late allergic response
Type II Hypersensitivity
Type II Hypersensitivity
Type IV Hypersensitivity
CLINICAL FEATURES OF
OCULAR ALLERGY

Allergic Conjunctivitis Symptomps :

• Most prevalent (95%) of allergic -Itching
conjunctivitis - Irriattion
• Hypersensitivity type I - Photophobia
Two forms : -Mucous Discharge
1. Seasonal Allergic Conjunctivitis
(SAC) “Hay Fever”
-Spring & Fall
2. Perennial Allergic Conjunctivitis Signs :
(PAC) -Bilateral
- Year round -Mild Lid Swelling
- Seasonal exacerbation is possible - Conjunctival Chemosis and
hyperemia
- Mucous discharge and some mucous
in tear film
Vernal Keratoconjunctivitis (VKC)

• Bilateral recurrent inflammation of

conjunctiva and cornea Symptoms :
• Seasonal exacerbation in summer -Intense Itching
• Chronic but limited - Intense rubbing the eyes
• Young male (3:1) in dry, hot - Redness
climate - Mucous discharge
• Onset before age 10, last 2-10 yr
• Serious vision threatening

2 Types :
- Tarsal form Signs :
- Limbal form : African, tropical -Lid swelling
area - conjunctival injection
• Horner Trantas dots - giant papillary reaction
- Horner trantas dots
-Shield Ulcer
Atopic Keratoconjunctivitis (AKC)
• Most severe form of ocular allergy
• Sight threatening inflammation of
lid and conjunctiva related to atopic
dermatitis
• Combined type I and IV
hypersensitivity
• Bilateral, symmetry, Chronic
• Genetic related
• Onset 20-50 yr with peak
incidence from 30-50 yr
• Perennial disorder exacerbate in
winter due to dryness
Symptoms :
-Intense itching
- Intense rubbing the eyes
- Redness
- Mucous discharge
Signs :
• Small or medium sized papillae,
predominantly on the lower
palpebral conjunctiva
• Hyperemia, pale white edema
• Scarring, papillary hypertrophy,
keratinization, symblepharon
VKC vs AKC
Giant Papillary Conjunctivitis (GPC)
• Chronic inflammatory process
leads to the production of giant
papillae on the tarsal conjunctiva
of upper lid
• Combined Type IV and I
hypersensitivity
• Not true allergic disease
• Results from mechanical trauma
on background of allergic diathesis
Typically associated with :
• Contact Lens (CL) wear (soft
CL and overnight retaining)
• Ocular prosthesis
• Exposed suture
• Extruded scleral buckle
• Elevated bleb
• 2 Forms
– 1. Generalized :
conventional CL user
– 2. Localized : confined
to 1 or 2 areas of tarsal
conjunctiva
Diagnosis of Allergic Conjunctivitis

• History and symptoms

• History of atopic disease
• Isolate causative agents
• Determine when allergen exposure most likely
occurs
Ophthalmic Examination

• Horner -Trantas dots

• Pseudogerontoxon
• Keratoconus
• Ocular surface evaluation
• Tear film evaluation
Diagnostic Assays in Ocular Allergy

• Skin prick test (SPT)

• Conjunctival provocation test (CPT)
• Cytology
• In vitro tests for allergen specific IgE
• Serum analysis
• Tear analysis
 Differential diagnoses

• Atopic blepharitis
• Bacterial conjunctivitis
• Chlamydial conjunctivitis
• Corneal abrasion or ulceration
• Viral conjunctivitis or keratitis
• Dry eye
• Staphylococcal marginal keratitis
MANAGEMENT
• Non-medical treatment :
1.Allergen avoidance
– Pet control
– Sheets and beddings hygeine
– Use air conditioning
– Avoid outdoor activities
during high pollen periods
2.Cold compresses
3.Avoid eye rubbing
4.Immunotherapy
• Medical treatment :
1.Antihistamines
2.Vasocontrictors
3. Steroids
4.Mast cell stabilizers
5.T cell modulators
6.Lubricants
MANAGEMENT

• Surgical Interventions :
- Corneal plaque Mechanical removal
- Shield ulcerAmnion Membrane
Transplantation
- Giant papillae Excision,Steroid injection,
Cryotherapyscarring
THANK YOU