EAACI-2024: Allergist's Perspective on Managing Ocular Allergy
Speaker: Vibha Sharma
Red-eye cases and ocular allergy are interlinked, and while there are various etiologies, the session primarily focuses on allergic presentations of red eyes. These presentations can be acute or chronic episodes; acute exhibits are seasonal or perennial, often manifest due to sensitivities to diverse allergens beyond pollen. Chronic cases of red eye, notably vernal and atopic keratoconjunctivitis, persist over extended durations and pose management challenges. Despite their expected seasonal nature, vernal keratoconjunctivitis can occur year-round in individuals sensitized to allergens beyond pollen. Based on the research by John Look Farquhar, Ocular surface Hypersensitivity can either be IgE or non-IgE mediated pathways in their pathology. However, clinical practice proves challenging due to overlapping symptoms and immunopathology. In the allergy clinic, pediatric patients often present with red flushing on the forehead and periorbital areas, conjunctival suffusion and mild eyelid swelling. Fluorescent dye application reveals yellow-stained mucus at the eye angles. However, the speaker suggests that signs such as Hertoghe’s sign, where the lateral third of the eyebrow has been wiped out, signifying chronic rubbing due to ocular discomfort and Morgan-Dennie lines, Allergic shine and nasal symptoms such as Rhinorrhoea, itch, sneeze suggesting rhinitis. Ocular allergy, categorized as an ocular surface disorder, frequently coexists with systemic afflictions. Despite its prevalence, it is often underrecognized and undertreated. While mild cases respond well to antihistamines or over-the-counter eye drops, chronic severe cases pose challenges in treatment.
The session further highlighted a study where children with conjunctivitis were found to have concomitant allergic conditions, with 97% being diagnosed with allergic rhinitis. Only 1% of those with eczema and 2% with asthma did not exhibit conjunctivitis but had allergic rhinitis. The correlation between rhinitis and asthma was evident, with 56% of the cohort having asthma and 33% having eczema. It's crucial to differentiate between conjunctivitis and keratitis. In conjunctivitis, conjunctiva, the lining of the undersides of the lids, and the palpebral conjunctiva are prominently affected and can often be managed conservatively. However, as seen in keratitis, involvement of the cornea escalates symptomatology significantly, marked by foreign body sensation, photophobia, mucus production, and difficulty separating eyelids in the morning. Such cases warrant immediate referral to an ophthalmologist. In individuals with ocular allergy, a spectrum ranges from mild, acute cases to severe, chronic conditions. Chronic cases may experience acute exacerbations necessitating escalated treatment. Clinical presentation often includes eyelid swelling and mucus on the eyelashes, with one or both eyes affected. Atopic keratoconjunctivitis is more likely to be seen in cases associated with significant eczema. Vernal keratoconjunctivitis typically occurs in younger individuals and tends to recede with age, unlike atopic keratoconjunctivitis, which occurs in older children and persists into adulthood. When assessing a child with ocular allergy in the clinic, history-taking and correlation of findings are crucial. After reverting the eyelid, the examination may reveal papillae, larger than one millimetre in diameter, on the underside of the eyelid, indicative of chronic inflammation. These papillae may persist even after acute exacerbations resolve, accompanied by yellow mucus accumulation. Gelatinous swellings known as Horner's or Tranter's dots may also be observed in the limbal area, with increased vascularity indicating inflammation. Slit lamp examination of the cornea may reveal punctate epitheliopathy, characterized by tiny dot-like lesions. These lesions can progress to form ulcers. Early ulcers may heal, but chronic ulcers may require further management.
When comparing vernal kerato-conjuctivitis (VKC) with atopic kerato-conjunctivitis (AKC), it is often more prevalent in males and observed in hot and dry areas. While VKC affects pre-pubertal children, AKC is more prevalent in older children. Some chronic cases may present with exacerbations and pose a mild risk; however, their severity may remain sub-optimally controlled. In VKC, 57.7% sensitization is observed, which can be detected through specific IgE, skin prick tests, and conjunctival provocation tests. Complications include corneal opacity, the presence of abraded mucosa that allows sensitization and thus leads to treatment tolerance, and Iatrogenic complications, including glaucoma and cataracts, require sub-optimal monitoring follow-up and sub-optimal compliance: longer-term avoidable complications. In individuals with allergic eye disease, keratoconus was observed in about 26% of cases, characterized by an outpouching of the cornea, which hindered proper eyelid apposition and caused additional difficulties. Constant eye rubbing could also lead to laxity in the tarsal collagen, resulting in floppy eyelids. This condition made the eyelids prone to aversion with minimal trauma, such as rubbing against a pillow, exposing the eyes to irritants and therefore needs extra care.
The speaker further highlighted that the UK study revealed an approximate two-year delay in diagnosis, leading to inconsistent care. The educational impact was significant; in certain cases, individuals imposed dietary restrictions on children, thus resulting in nutritional deficiencies. They subsequently faced difficulties due to photophobia and eye irritation due to the elements, suggesting an increased risk of vitamin D deficiency. Psychological effects included disruption in play & recreation, dependence on parents for morning routines involving eye cleaning, relationship strain and potential underachievement. Treatment options included lubricants and artificial tears, which are effective for washing out eosinophil chemotaxis and allergens but are often underutilized. Mild steroids were sometimes used, though strong topical steroids were typically reserved for ophthalmologists. Instilling eye drops in children was challenging; a recommended technique involved placing the drop on the medial canthus and letting the child blink. Additional treatments included oral antihistamines, montelukast, biologics, and specific immunotherapy. The session addressed a Cochrane review indicating immunotherapy reduced total symptom scores and increased allergen provocation thresholds, with similar benefits observed in children with allergic rhinoconjunctivitis.
The speaker further highlighted Manchester’s simple escalation module for managing allergic eyes. This approach involved assessments by an ophthalmologist, a symptom score, and a medication score. An electronic application called the e-quick system was also developed, allowing families to report symptoms remotely via mobile devices. Patients received a QR code with their clinic invitation letter, which provided access to the app and enabled easy tracking of symptom progression. A simple medication score was used, and more potent and systemic treatments were assigned higher scores. The management strategy involved investigating and establishing the severity of the eye condition, determining necessary therapies, and identifying triggering allergens to advise on exposure minimization or plan specific immunotherapy. Therapeutic options included non-surgical and surgical treatments, focusing on symptom control and complication prevention. A holistic, multidisciplinary approach to managing allergic eye disease involving clinical psychologists and school interactions included recommendations, such as allowing them to wear wrap-around glasses, modifying seating arrangements, or assigning an assistant to install eye drops. Strong patient engagement through remote symptom reporting revealed that parents often underestimated their children's symptoms. An allergy management plan addressed allergic eye disease and other related disorders, facilitating better overall condition management.
The session concluded with key takeaways, such as referrals to eye specialists in presenting photophobia, foreign body sensation or grittiness, and matted eyelids due to stringy mucus. Prolonged or unsupervised topical steroid use and suboptimal symptom control also require recognition and escalation. Additionally, if other systems are involved, a multidisciplinary approach is crucial.
European Academy of Allergy and Clinical Immunology (EAACI), 2024 31st May-3rd June, Valencia
