Allergic Conjunctivitis
By: Nor Faezah Abd Hamid
012007090047
Definition
The inflammation of conjunctiva due to
allergic or hypersensitivity reactions
Maybe immediate (humoral) or delayed
(cellular)
Types
Simple allergic conjuntivitis
◦ Seasonal allergic conjunctivitis (SAC)
◦ Perennial allergic conjunctivitis (PAC)
Vernal keratoconjunctivitis (VKC)
Atopic keratoconjunctivitis (AKC)
Giant papillary conjunctivitis (GPC)
Phlytecnular keratoconjunctivitis (PKC)
1. Simple allergic conjunctivitis
A. Pathophysiology
Seasonal allergic conjuntivitis
◦ symptoms for a defined period of time
◦ common airborne antigens, including pollen
(spring) , grass (summer), and weeds (fall).
◦ symptom-free during winter (decreased
airborne transmission)
Perennial allergic conjunctivitis
◦ symptoms that last the whole year
◦ common household allergens, such as dust
mite, cockroaches, and pet dander
Pathological features
Vascular response
◦ vasodilation increased permeability
exudation
Cellular response
◦ conjunctival infiltration & exudation
(eosinophils, plasma cells, mast cells)
Conjunctival response
◦ boggy swelling & mild papillary hyperplasia
Clinical features
Symptoms of :
◦ intense itching, burning sensation in the eyes,
watery discharge & mild photophobia.
Signs of :
◦ hyperemia & chemosis
◦ swollen-juicy appearance of conjunctiva
◦ mild papillary reaction
◦ oedema of lids
Diagnosis
Typical symptoms & signs
Normal conjunctival flora
Eosinophils in discharge
Measurement of tear levels of various
inflammatory mediators as indicators of
allergic activity
Skin testing by an allergist
Treatment
Eliminationof allergens if possible
Pharmacologic intervention to alleviate
the symptoms
◦ artificial tear substitutes
◦ topical antihistamines (epinastine, azelastine
◦ systemic antihistamines
◦ vasoconstrictors (naphazoline, phenylephrine,
oxymethazoline, tetrehydrozoline)
◦ mast cell stabilizers (cromolyn sodium)
Vernal keratoconjunctivitis
Recurrent, bilateral, interstitial, self
limiting allergic inflammation of the
conjunctiva having a periodic seasonal
incidence
Commonly associated with a personal or
family history of atopy (more than 90%
exhibit one or more atopic conditions
(asthma, eczema, seasonal allergic
rhinitis)
Epidemiology
Predominantly in areas with tropical and temperate
climates (Mediterranean, the Middle East, and
Africa)
More common in summer ( warm weather
conjunctivitis )
Significant male preponderance
Typically affect young males with onset generally
in the first decade and with duration up to one
decade
Symptoms usually peak prior to the onset of
puberty and then subside
Pathology
Large number of mast cells within
substantia propria
Mast cells releases neutral proteases,
tryptase and chymase
Enhanced fibroblast proliferation, leads to
deposition of collagen within substantia
propria resulting in conjunctival
thickening
Clinical features
Symptoms
◦ marked itching & burning sensation, mild
photophobia, foreign body sensation, tearing
and blepharospasm
◦ eyelid skin usually no involved
Signs of VKC
Palpebral form
◦ classic conjunctival sign is the presence of
giant papillae assume a flattop appearance,
“cobblestone papillae”
◦ severe cases, large papillae may cause
mechanical ptosis
◦ ropy mucous discharge
Limbal form
◦ papillae tend to occur at the limbus & have
thick gelatinous appearance
◦ multiple white spots ( Horner- Trantas dots ),
collection of degenerated epithelial cells &
eosinophils, lasting for 1 week approx.
Corneal signs
Punctate epithelial keratitis
Ulcerative vernal keratitis ( shield
ulceration )
Vernal corneal plaques
Subepithelial scarring
Pseudogerontoxon
Keratoconus
Treatment
Mast cell stabilizers are the mainstay of
treatment (Sodium cromoglycate,
Lodoxamide, Olopatadine, Nedocromil &
Ketotifen), long term benefit
Topical Corticosteroids
( Fluorometholone, medrysone )
Topical cyclosporine (1%)
Topical antihistaminics
Mucolytic agent, Acetyl cycteine (0.5%)
– for early plaques
Treatment
Of large papillae
◦ supratarsal injection of long acting steroid or
◦ Cryoablation
◦ surgical excision
Of vernal keratopathy
◦ superficial keratectomy for large vernal plaque
◦ severe shield ulcer may need debridement,
superficial keratectomy, excimer laser PTK as
well as amniotic membrane transplantation
Atopic keratoconjunctivitis
Bilateral inflammation of conjunctiva &
eyelids
Strong association with atopic dermatitis
Also a type 1 hypersensitivity disorder
with many similarities to VKC
Symptoms
Perennial
There maybe a seasonal variation with
worsening symptoms during winter
months
Common symptom is bilateral itching of
the eyelids but watery discharge, redness,
photophobia and pain maybe associated
Signs
Eyelids
◦ may exhibit eczematoid dermatitis with dry,
scaly and inflamed skin.
◦ margins may show meibomian glands
dysfuntion & keratinization
◦ staphylococcal colonization of eyelid margins
may result in blepharitis
Signs
Conjunctiva
◦ Chemosis & papillary reaction prominent in
inferior tarsal conjunctiva
◦ Hyperemia
◦ Fibrosis & scarring of conjunctiva
shortened fornix symblepharon
Signs
Corneal
◦ Horner Trantas dots ( rare )
◦ Punctate epithelial keratopathy
neovascularization stromal scarring
possibly ulceration
◦ Keratoconus
Signs
Lenticular changes
◦ anterior or posterior subcapsular cataract
formation
◦ opacities usually bilateral & present in 2nd
decade of life but progress slowly
Retina
◦ Increased incidence of RD following surgical
removal of cataracts
Treatment
Similar to that of VKC
Controlling the environment and avoiding
allergens
Topical and systemis medications to provide
symptomatic relief
◦ Topical mast cell stabilizers
◦ Topical corticosteroids
◦ Systemic antihistamines
◦ Systemic cyclosporine
◦ Topical or oral antiviral agents in concomitant HSV
infection
Giant papillary conjunctivitis
Immune mediated inflammatory disorder
of superior tarsal conjunctiva
Giant papillae greater than 0.3mm in
diameter
Represents an immunologic reaction to a
variety of foreign bodies ( contact lenses,
ocular prostheses, extruded scleral
buckles and exposed sutures may
precipitate GPC )
Clinical features
Symptoms
◦ Ocular itching with a mucoid or ropy discharge
◦ Persistent foreign body sensation when using CL
resulting in an inability to wear it for the desired
length of time
Signs
◦ Large cobblestone papillae, 0.3mm or greater in
diameter on superior tarsal conjunctiva
◦ Severe cases may cause mechanical ptosis of upper lid
◦ Chronic bulbar conjunctival injection &inflammation
due to prolonged & persistent use of CL
Treatment
Goal of treatment is resolution of symptoms &
restoration of functional use of CLs or ocular prosthetics.
Changing the CLs care routine
Disinfecting solutions containing chemical preservatives
should be discontinued
Soft daily wear CLs to disposible or daily-disposible soft
CLs to prevent accumulation of proteinaceous deposits
Pharmacologic treatment
◦ Mast cell stabilizers
◦ Topical corticosteroids
◦ Antihistamines
Phlytecnular keratoconjunctivitis
Nodular reaction occurring as an allergic
response to an endogenous allergen
Worldwide distribution but higher
incidence in developing countries
Peak age between 3-15 years
Girls preponderance
Causative allergens
◦ Tuberculous proteins
◦ Stapylococcus proteins
Pathology
Stage of nodule formation
◦ Exudation & infiltration of leukocytes into deeper
layers
Stage of ulceration
◦ Necrosis at the apex of nodule and an ulcer is
formed
Stage of granulation
◦ Floor of ulcer covered by granulation tissue
Stage of healing
◦ Minimal scarring
Clinical features
Symptoms
◦ Mild discomfort and irritation, reflex watering
◦ Mucopurulent conjunctivitis due to secondary bacterial
infection
Signs
◦ Simple phlycten : pinkish white nodule surrounded by
hyperemia on bulbar conjunctiva, usually near the limbus
◦ Necrotizing phlycten : very large phlycten with necrosis
& ulceration
◦ Miliary phlycten : multiple phlyctens
◦ Phlyctenular keratitis
Treatment
Local therapy
◦ Topical steroids
◦ Antibiotic drops and ointment
◦ Atropine when cornea involved
Specific therapy
◦ Excluded tuberculous infection
◦ Ruled out parasitic infestation
THANK YOU!!!
