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.

Retrospective review on the use of topical cyclosporin a 0.05% for paediatric allergic conjunctivitis in Hong Kong Chinese.

PURPOSE: To evaluate the efficacy of using topical cyclosporin A 0.05% (Restasis) for the treatment of paediatric allergic conjunctivitis. METHODS: This retrospective study included consecutive cases of paediatric allergic conjunctivitis treated with Restasis between 2010 and 2013. Subjects with follow-up time less than 3 months after using Restasis were excluded. Itch severity score, symptom score, and sign score were compared before (baseline) and 3 months after using Restasis. RESULTS: In 27 eyes of 14 patients (mean age 10.8 ± 3.2 years), 44.4% had allergic conjunctivitis, 33.3% had vernal keratoconjunctivitis, and 22.2% had atopic keratoconjunctivitis. The mean duration of ocular symptoms was 20.4 ± 13.2 months. 92.6% of subjects were using steroid eye drop before Restasis. After 3 months of topical Restasis, there were statistically significant reductions in the symptom, sign, and itch severity scores compared with baseline (all P ≤ 0.001) and 78.6% of subjects were able to be tapered off steroid eye drops. CONCLUSION: Topical Restasis was effective and safe in significantly reducing ocular itchiness, sign, and symptom scores at 3 months after use in paediatric allergic ocular conditions.

Ocular allergy: recognizing and diagnosing hypersensitivity disorders of the ocular surface.

Ocular allergy includes several clinically different conditions that can be considered as hypersensitivity disorders of the ocular surface. The classification of these conditions is complex, and their epidemiology has not been adequately studied because of the lack of unequivocal nomenclature. Ocular allergy symptoms are often, but not always, associated with other allergic manifestations, mostly rhinitis. However, specific ocular allergic diseases need to be recognized and managed by a team that includes both an ophthalmologist and an allergist. The diagnosis of ocular allergy is usually based on clinical history and signs and symptoms, with the support of in vivo and in vitro tests when the identification of the specific allergic sensitization is required for patient management. The aims of this Task Force Report are (i) to unify the nomenclature and classification of ocular allergy, by combining the ophthalmology and allergy Allergic Rhinitis and its Impact on Asthma criteria; (ii) to describe current methods of diagnosis; (iii) to summarize the therapeutic options for the management of ocular allergic inflammation.

Tailored approach to the treatment of vernal keratoconjunctivitis.

PURPOSE: To develop a standardized clinical grading system for the management of patients with vernal keratoconjunctivitis (VKC) and to identify the risk factors associated with a worsened outcome of the disease, including decrease of visual acuity and ocular complications development. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 207 consecutive patients with VKC, referred to our Cornea and External Diseases Center from 1997 to 2007, were included in the study. A total of 110 of those patients were included in the follow-up study (range 1-10 years). METHODS: Classification and regression tree (CART) analysis was performed to separate the patients into 5 subgroups by therapeutic approach. Regression tree and multivariate logistic regression analyses were performed during follow-up to identify predictors of worse visual outcome. MAIN OUTCOME MEASURES: Age, gender, duration and course of disease, signs, symptoms, overall symptoms score, history of atopy, markers of allergy, best-corrected visual acuity, and therapy were collected at baseline and during follow-up. The number of relapses and number of patients with decreased visual acuity were also evaluated in the follow-up. RESULTS: A decision tree for VKC treatment was developed by CART analysis, and a new clinical grading system was proposed accordingly. Sixteen patients were classified as grade 0 (absence of symptoms and no therapy); 59 patients were classified as grade 1 (presence of symptoms without photophobia, occasional use of anti-allergic eye drop); 74 patients were classified as grade 2 (presence of symptoms including photophobia, daily anti-allergic treatment); 22 patients with superficial punctuate keratopathy (SPK) were classified as grade 3 (daily anti-allergic treatment associated with occasional topical steroid); and 36 patients were classified as grade 4 (diffuse SPK or corneal ulcer; pulsed high-dose topical steroid). A higher number of relapses and a higher baseline grade of VKC were the main predictor factors for worse visual outcome. CONCLUSIONS: This grading system allows for identifying the more severe forms of VKC that are at higher risk of recurrences, corneal ulceration, and worse final visual outcome. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Clinical Age-Specific Seasonal Conjunctivitis Patterns and Their Online Detection in Twitter, Blog, Forum, and Comment Social Media Posts.

Purpose: We sought to determine whether big data from social media might reveal seasonal trends of conjunctivitis, most forms of which are nonreportable. Methods: Social media posts (from Twitter, and from online forums and blogs) were classified by age and by conjunctivitis type (allergic or infectious) using Boolean and machine learning methods. Based on spline smoothing, we estimated the circular mean occurrence time (a measure of central tendency for occurrence) and the circular variance (a measure of uniformity of occurrence throughout the year, providing an index of seasonality). Clinical records from a large tertiary care provider were analyzed in a similar way for comparison. Results: Social media posts machine-coded as being related to infectious conjunctivitis showed similar times of occurrence and degree of seasonality to clinical infectious cases, and likewise for machine-coded allergic conjunctivitis posts compared to clinical allergic cases. Allergic conjunctivitis showed a distinctively different seasonal pattern than infectious conjunctivitis, with a mean occurrence time later in the spring. Infectious conjunctivitis for children showed markedly greater seasonality than for adults, though the occurrence times were similar; no such difference for allergic conjunctivitis was seen. Conclusions: Social media posts broadly track the seasonal occurrence of allergic and infectious conjunctivitis, and may be a useful supplement for epidemiologic monitoring.

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.

[A systemic approach to the diagnosis and treatment of allergic conjunctivitis]. / Démarche diagnostique et thérapeutique des conjonctivites allergiques.

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.

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.

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.

Systematic approach to managing vernal keratoconjunctivitis in clinical practice: Severity grading system and a treatment algorithm.

Vernal keratoconjunctivitis is an ocular allergy that is common in the pediatric age group. It is often chronic, severe, and nonresponsive to the available treatment options. Management of these children is difficult and often a dilemma for the practitioner. There is a need to simplify and standardize its management. To achieve this goal, we require a grading system to judge the severity of inflammation and an algorithm to select the appropriate medications. This article provides a simple and practically useful grading system and a stepladder algorithm for systematic treatment of these patients. Use of appropriate treatment modalities can reduce treatment and disease-related complications.

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.

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.

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.

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.

[Therapy of allergic conjunctivitis]. / Az allergiás conjunctivitisek terápiája.

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.

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.

[The clinico-statistical aspects in allergic conjunctivitis]. / Aspecte clinico-statistice în conjunctivitele alergice.

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.

Quantitative conjunctival provocation test for controlled clinical trials.

BACKGROUND: The conjunctival provocation test (CPT) is a diagnostic procedure for the assessment of allergic diseases. Photographs are taken before and after provocation increasing the redness of the conjunctiva due to hyperemia. OBJECTIVE: We propose and evaluate an automatic image processing pipeline for objective and quantitative CPT. METHOD: After scale normalization based on intrinsic image features, the conjunctiva region of interest (ROI) is segmented combining thresholding, edge detection and Hough transform. Redness of the ROI is measured from 0 to 1 by the average pixel redness, which is defined by truncated projection in HSV space. In total, 92 images from an observational diagnostic study are processed for evaluation. The database contains images from two visits for assessment of the test-retest reliability (46 images per visit). RESULT: All images were successfully processed by the algorithm. The relative redness increment correlates between the two visits with Pearson's r = 0.672 (p < .001). Linear correlation of the automatic measure is larger than the manual measure (r = 0.59). This indicates a higher reproducibility and stability of the automatic method. CONCLUSION: We presented a robust and effective way to objectify CPT. The algorithm operates on low resolution, is fast and requires no manual input. Quantitative CPT measures can now be established as surrogate endpoint in controlled clinical trials.