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ALLERGIC KERATOCONJUNCTIVITIS

Allergy-related eye symptoms commonly occur at the beginning of summer. Patients will frequently complain about irritation of the eyes caused by tree and grass pollens and mold spores in the air. In the fall, the irritant is usually pollen from ragweed. Theses antigens, in addition to affecting the nose and upper respiratory system, will also affect the mucous membranes of the eye. There are three types of conjunctivitis that have an allergic basis: Hay fever Conjunctivitis, Vernal Keratoconjunctivitis, and Giant Papillary Conjunctivitis. These are not the same as "pink eye" and are not contagious.

HAY FEVER CONJUNCTIVITIS

Hay fever conjunctivitis is another term used for seasonal conjunctivitis. This represents a Type I allergic reaction characterized by conjuntival hyperemia, redness and slight swelling of the conjuctiva. The cornea is typically not involved.

VERNAL KERATOCONJUNCTIVITIS

This form of keratoconjunctivitis is uncommon and usually occurs in black children. This is a recurrent bilateral inflammation of the conjunctiva with a periodic seasonal incidence. It is self-limited in character and consists of an inflammatory response on the underside of the tarsus of the eyelids. There may be some white benign, gelatinous masses near the peripheral cornea. This will give the junction of the cornea and sclera a "pearl" appearance. Commonly, there is light sensitivity, conjunctival injection, tearing, and a mucinous discharge containing eosinophils. Treatment, if severe, consists of steroid eye drops and mast cell stabilizers.

GIANT PAPILLARY CONJUNCTIVITIS

This is a form of allergy usually associated with a reaction on the underside of the eyelids to contact lenses, or more commonly, the solutions used to clean contact lenses. A giant papillary response on the everted surface of the upper eyelid occurs and will give the surface a "cobblestone" appearance. These giant bumps can sometimes scratch the surface of the eye, which can be painful. Severe forms of this reaction will preclude the patient's use of contact lenses.

SYMPTOMS OF ALLERGIC CONJUNCTIVITIS

Symptoms are most commonly experienced shortly after exposure of the eye to the inciting allergen. The most frequent symptom is itching. This may be accompanied by burning and production of a watery discharge. The symptoms may be mild and self-limited or the eye and secretions may become secondarily infected by the child rubbing the eye with a dirty hand. In this case, the symptoms may be more pronounced in the eye on the same side as the dominant hand. Children and adults will frequently rub their eyes, though this usually worsens the itching. The eyelids may be puffy and the conjuctiva may be congested. Initially, the discharge is watery, but if the exposure is chronic, the tears may become thick and mucus like. A secondary infection with bacteria may cause the discharge to become cloudy. The cornea is rarely involved in typical forms of hay fever conjunctivitis. If it is, mild light sensitivity may occur and this is usually due to the child's rubbing of his or her eye. Most cases are initially seen in children four to six years of age. The symptoms will usually return each year at a similar time.

SIGNS OF ALLERGIC CONJUNCTIVITIS

The signs and symptoms of seasonal allergies are rarely limited to the eyes. The above findings are usually accompanied by rhinitis, asthma or atopic dermatitis. The signs associated with allergic involvement of the eyes are puffiness and swelling of the skin of the upper and lower eyelids. This may be severe enough to cause closure of both eyes due to the swelling. On rare occasions, the conjunctiva will become glassy and will frequently exhibit chemosis, or a collection of fluid and protein under the conjunctival tissue. This may have a striking appearance with rapid onset lasting for a period of an hour or two with resolution of findings or it may be more chronic. Findings may be severe enough to prompt a visit to your office or to an emergency facility after hours. Conjunctival vessels will become dilated and there may be papillary response on the underside of the lids involving the tarsal conjunctiva. This can be looked for if the lids are gently everted. Patients with limbal vernal conjunctivitis may have some succulent collections of eosinophils at the periphery of the cornea. Light sensitivity or photophobia is usually severe.

EVALUATION

Since mild forms of allergic conjunctivitis are self-limited, usually no specific allergy testing is necessary. A thorough history and review of the common allergic agents may be sufficient to minimize or eliminate the child's contact with the allergen, and therefore, control the symptoms. If the discharge is purulent, eye cultures may be recommended and a conjuctiva scrapping may be performed to look for eosinophils. If the symptoms are repetitive and severe, skin testing may be considered. If the allergen suspected is ragweed, RAST testing may be requested.

TREATMENT

The first treatment efforts for allergic conjunctivitis are to minimize or eliminate exposure to the allergen. Thorough washing of the hands and cool compresses applied around the eyes will reduce the irritation. This will frequently be all that is necessary to reduce symptoms and reduce the concentration of the allergen.

Mild Symptoms.Topical over-the-counter artificial tears may be helpful in mild cases. The use of these drops four times a day combined with cool compresses will usually relieve mild symptoms.

Mild to Moderate Symptoms.The prescription of a combination of antihistamine drops, in addition to the above measures, may be sufficient to control mild to moderate cases of allergic conjunctivitis. When secondary infection accompanies the allergic response, an antibiotic drop may be added to the treatment program.

Severe Allergic Responses.For the more refractory cases, a mild topical corticosteroid preparation should be considered. For more difficult cases, steroid eye drops may be more effective.  Steroid eye drops have a risk of elevating intraocular pressure in patients who are "steroid responders". Although patients who respond to steroids are uncommon in our population, careful monitoring of the intraocular pressure should be performed when patients are on these agents for several weeks. Other side effects of these stronger preparations may occur. These include increased susceptibility to infection and reactivation of viral (herpetic) disease. After years of using a preparation, early cataractous changes may be observed.

If the patient can anticipate exposure to an allergen, prophylaxis with a Mast Cell Stabilizer eye drop may be helpful to control eye symptoms. It's use for two days prior to exposure will stabilize the cell membranes of MAST cells and decrease the severity of the Type I allergic response seen with hay fever conjunctivitis. This type of medication is also good for treating giant papillary conjunctivitis and limbal vernal keratoconjunctivitis. The response to Mast Cell Stabilizers is not immediate and medication must be continued for lasting effect.

The goal of a treatment plan is to control the signs and symptoms throughout the season and to minimize any conjunctival changes resulting from the allergic reaction. Mild allergic symptoms usually do not cause permanent changes or lasting effects on the eye and its surrounding structures.

Pediatric Ophthalmology & Strabismus, Inc.