23. Ocular Allergies II

Question 1

Giant Papillary Conjunctivitis (1)

Symptoms: ..., ..., ..., .... In CL wearers, also ... and ....

Signs:
* ... on palpebral conjunctiva
* ... discharge, especially when ...
* Associated with ... to CL, lens ..., ..., ..., and ...
* Less common with advent of ...
* Less common with ...

Answer 1

Giant Papillary Conjunctivitis (1)

Symptoms: redness, burning, itch, foreign body sensation. In CL wearers, also increase lens awareness and symptoms exacerbated by lens wear.

Signs:
* giant papillae on palpebral conjunctiva
* mucous discharge, especially when waking
* Associated with allergy to CL, lens deposits, solution preservatives, ocular prostheses, and protruding sutures
* Less common with advent of disposable CLs
* Less common with less-toxic solution preservatives

Question 2

Giant Papillary Conjunctivitis grading

Grade 1/Pre-clinical: ..., ... papillae, ... symptoms
Grade 2/Mild: ... injection, ...-...mm papillae, ... symptoms
Grade 3/Moderate: ... injection, ...mm papillae, ...
Grade 4/Severe: ... injection, ...mm papillae, ...

Most CL wearers will be Grade ... and may ... over time. As it progresses, some people might just ... despite ... as ....

Answer 2

Giant Papillary Conjunctivitis grading

Grade 1/Pre-clinical: slight conjunctival redness, fine papillae, no symptoms
Grade 2/Mild: mild injection, 0.3-0.5mm papillae, mild symptoms
Grade 3/Moderate: moderate injection, 0.5+mm papillae, increasing CL awareness
Grade 4/Severe: severe injection, 0.75+mm papillae, contact lens intolerance

Most CL wearers will be Grade 1 and may progress over time. As it progresses, some people might just tolerate it despite the increase in CL awareness as CLs are the only method to get good vision.

Question 3

Pathogenesis of Giant Papillary Conjunctivitis

Involves ... and ... mechanisms. It’s a combination of Types ... and ... hypersensitivities and is a response to .... There’s an increase in ..., ..., ..., and .... Results in ..., ..., and ....

Answer 3

Pathogenesis of Giant Papillary Conjunctivitis

Involves mechanical and immunologic mechanisms. It’s a combination of Types I and IV hypersensitivities and is a response to foreign substance. There’s an increase in mast cells, eosinophils, basophils, and lymphocytes. Results in fibroblast proliferation, collagen growth, and conjunctival papillae under eyelid.

Question 4

Giant Papillary Conjunctivitis (2)

Differential diagnosis: ..., ..., and ...

Assessment: ..., ..., ..., ..., ..., ..., ...

Treatment:
* Less severe: ... for many months
* More severe: ... for short term
* Review ..., avoid ..., modify lens .../.../..., change ...
* Long term management is ...

Answer 4

Giant Papillary Conjunctivitis (2)

Differential diagnosis: VKC, SAC, and SLK

Assessment: history, slit lamp, fluorescein, eyelid eversion, CL inspection, sutures, prosthesis

Treatment:
* Less severe: mast cell stabilisers for many months
* More severe: topical steroid for short term
* Review CL care, avoid overnight wear, modify lens design/modality/material, change CL solution
* Long term management is often required

Question 5

What is the effect of allergic eye disease on keratoconus?

Answer 5

Patients with allergic conjunctivitis are at increased risk of keratoconus, probably due to eye rubbing. Need intensive treatment to prevent keratoconus development.

Question 6

Allergic conjunctivitis in children

Recommendations for treatment:
* ...
* Mild - ..., ...
* Moderate - .../...
* Severe - ... (caveat), aggressive approach if ..., refer if needs ..., consider ... and/or ...

Answer 6

Allergic conjunctivitis in children

Recommendations for treatment:
* Avoid allergen
* Mild - lubrication, cold compresses
* Moderate - antihistamine/mast cell stabilisers
* Severe - short burst steroids (acceptable in children if at risk of shield ulcers and such), aggressive approach if corneal involvement, refer if needs multiple steroid burst, consider allergy testing and/or immunotherapy

Question 7

Allergic contact dermatitis (1)

It’s a ..., typically affecting ..., ..., and ....

Symptoms: ..., ..., ..., ..., and ....

Causes: ..., ..., ..., ..., ..., and .../...

Answer 7

Allergic contact dermatitis (1)

It’s a skin reaction at site of exposure, typically affecting eyelids, periorbital skin, and ocular surface.

Symptoms: redness, itching, swelling, scaling skin, and vesicles.

Causes: metals, shellac, preservatives, topical antibiotics, fragrances, and acrylates/surfactants

Question 8

Allergic Contact Dermatitis (2)

Pathophysiology
It’s a Type ... hypersensitivity and ... lymphocyte mediated. There’s an ... cycle.

Management
... and ... of causative agent, ...

Answer 8

Allergic Contact Dermatitis (2)

Pathophysiology
It’s a Type IV hypersensitivity and Th1 lymphocyte mediated. There’s an itch-scratch cycle.

Management
Identification and removal of causative agent, ointment topical steroids

Question 9

What is atopic dermatitis?

Definition: ..., also known as ....

Management:
* ...
* ..., which is a ... and .... ADRs include: ..., ..., ..., and ...

Answer 9

What is atopic dermatitis?

Definition: chronic inflammation, irritation, and redness of the skin, also known as eczema.

Management:
* allergen avoidance
* Dupilumab, which is a mononucleotide antibody and subcutaneous injection. ADRs include: conjunctivitis, ocular surface disease, periorbital skin changes, and conjunctival cicatrisation

Question 10

What are the two autoimmune conjunctivitis?

Answer 10

• Ocular cicatricial pemphigold
• Stevens-Johnson Syndrome

Question 11

Cicatricial Pemphigold
Definition: ... that results in ...

Systemic features include:
* Affects ... and ... more than ...
* ... affected in 80% of cases
* ... and ...
* ... in up to ...% of cases within ...yrs

Answer 11

Cicatricial Pemphigold
Definition: rare, progessive, chronic autoimmune disease that results in recurrent sub-epithelial symptoms of the skin and mucous membranes with a tendency to scar formation

Systemic features include:
* Affects eldery and females more than males
* oral mucosa affected in 80% of cases
* submucosal blisters and scarring of mucosal membranes
* ocular signs in up to 40% of cases within 5yrs

Question 12

Ocular cicatricial pemphigold signs and symptoms

Ocular signs:
* Commonly ...
* Asymmetric ...
* ...
* Sub-conjunctival ..., ..., and ...
* Chronic ..., ..., ..., and ...

Symptoms: ..., ..., and features of ...

Answer 12

Ocular cicatricial pemphigold signs and symptoms

Ocular signs:
* Commonly bilateral
* Asymmetric papillary conjunctivitis
* conjunctival hyperaemia
* Sub-conjunctival blisters, ulceration, and scarring
* Chronic conjunctival inflammation, subepithelial scarring, conjunctival shrinkage, and entropion

Symptoms: burning, watering, and features of surface exposure disease

Question 13

Ocular Cicatricial Pemphigold ocular complications

• ...
• ... due to scarring over ... and destruction of ...
• ... which is adhesions between the ... and ...
• ... which is adhesions at the ... between ... and ...
• ... which is ... due to reduced tears and ... due to entropion

Answer 13

Ocular Cicatricial Pemphigold ocular complications

• conjunctival disease
• dry eye due to scarring over lacrimal gland ducts and destruction of goblet cells
• symblepharon which is adhesions between the palpebral and bulbar conjunctiva
• ankyloblepharon which is adhesions at the outer canthus between upper and lower lids
• keratopathy which is exposure due to reduced tears and lagophthalmos due to entropion

Question 14

Treatment of ocular cicatricial pemphigold

• ... as it must be treated by ... and ... specialists
• Can give ... and ... immunosuppresive agents
• ... cytotoxic drugs
• ... and ... steroids
• ..., ..., and manage ...
• Surgical correction of ... and maybe give ...

Answer 14

Treatment of ocular cicatricial pemphigold

• REFER as it must be treated by ophthalmological and immunological specialists
• Can give topical and oral immunosuppresive agents
• systemic cytotoxic drugs
• topical and systemic steroids
• punctal occlusion, artificial tears, and manage blepharitis
• Surgical correction of entropion and maybe give mucous membrane grafts

Question 15

Stevens-Johnson Syndrome (1)

Signs: ... that is ..., affects both the ... and .... Tends to affect ..., ... ..., and ... more than ....

Cause: generally a ... to ..., can be associated with .... Cause is only found in ...% of cases.

Two types:
* Erythema Multiforme Minor - ... involvement
* Erythema Multiforme Major - ..., ..., and ... - ...

Answer 15

Stevens-Johnson Syndrome (1)

Signs: acute inflammation that is self-limiting, affects both the skin and mucous membranes. Tends to affect healthy, young individuals, and males more than females.

Cause: generally a hypersensitivity reaction to systemic or topical drugs, can be associated with systemic infections. Cause is only found in 50% of cases.

Two types:
* Erythema Multiforme Minor - only skin involvement
* Erythema Multiforme Major - skin, two mucous membranes, typically the conj, and systemic malaise - SJS

Question 16

Stevens-Johnson Syndrome (2)

Acute phase: .... Often misdiagnosed as acute phase can .... When the later symptoms appear, they can quickly develop into ... and require ... for treatment.

Symptoms: ..., ..., ..., ..., and .... Also ... which develop every 2-3weeks for 1-2 months.

Signs: ... and ... in oral mucosa/lips and ..., particularly in ...

Answer 16

Stevens-Johnson Syndrome (2)

Acute phase: systemic features. Often misdiagnosed as acute phase can resemble other conditions. When the later symptoms appear, they can quickly develop into scarring and require immunosuppressants for treatment.

Symptoms: fever, malaise, sore throat, cough, and headache. Also skin lesions which develop every 2-3weeks for 1-2 months.

Signs: bullae and erosion in oral mucosa/lips and skin lesions, particularly in extremities

Question 17

Stevens-Johnson Syndrome - ocular aspect

Occurs in ...% of cases

Acute phase:
* ...
* ...
* Conjunctival ..., ..., and ...
* Could have ... or ...
* Could have ...

Long term complications
* Conjunctival ... and ...
* ... and ... problems
* ...
* ...

Answer 17

Stevens-Johnson Syndrome - ocular aspect

Occurs in 60% of cases

Acute phase:
* papillary conjunctivitis
* focal red ischaemic areas
* Conjunctival redness, blisters, and ulceration
* Could have pseudomembranes or membranes
* Could have purulent conjunctivitis

Long term complications
* Conjunctival scarring and symblepharon
* dry eye and exposure-related problems
* lacrimal drainage obstructions
* epiphora

Question 18

Stevens-Johnson Syndrome - treatment of systemic aspect

• ...
• ...
• ... may be required if using multiple medications

Refer!
* ... is often necessary for acute phase
* Need to treat ...
* ... or ... steroids

Answer 18

Stevens-Johnson Syndrome - treatment of systemic aspect

• eliminate causative agent
• advise against future use of drug class
• allergist may be required if using multiple medications

Refer!
* hospitalisation is often necessary for acute phase
* Need to treat long term ocular complications
* topical or systemic steroids

Question 19

Stevens-Johnson Syndrome - treatment of ocular aspect

• ... or ...
• ... - ... of eyelash follicles
• ... CLs to provide ... and not ...

Answer 19

Stevens-Johnson Syndrome - treatment of ocular aspect

• artificial tears or punctal occlusion
• surgery - cauterization of eyelash follicles
• scleral CLs to provide physical protection and not optical correction

Question 20

Immunotherapy
* Training ... to be less sensitive to allergens
* Requires allergen exposure to be: ..., ..., and .... Treat needs ...-... years.
* Both types are highly effective for allergic eye disease; resulting in ... and less reliance on ...

Answer 20

Immunotherapy
* Training immune system to be less sensitive to allergens
* Requires allergen exposure to be: at high dose, constant, and long. Treat needs 3-5 years.
* Both types are highly effective for allergic eye disease; resulting in improved symptoms and less reliance on topical medications

Question 21

Types of immuntherapy

Subcutaneous (SCIT) is effective against ... but inconvenient as .... Risks include ... and ....

Sublingual (SLIT) is effective against ..., in particular ... or .... It’s a ... dose at home where no ... or ... are required; still an issue with .... Risks include ... and ....

Answer 21

Types of immuntherapy

Subcutaneous (SCIT) is effective against all types of allergens but inconvenient as requires 4-8weekly visits. Risks include local reaction to needle and low risk of anaphylaxis.

Sublingual (SLIT) is effective against fewer allergens, in particular grass or dust mites. It’s a daily dose at home where no needles or injections are required; still an issue with compliance. Risks include very frequent but mild local AE and very rare systemic effects.