Key Points

• Symptoms of eye allergy include pruritus, erythema, and lacrimation.

• Treatment includes oral antihistamines plus topical medications such as mast cell stabilizers or H, blockers.

Conjunctivitis is the usual ocular reaction to airborne allergens. As in other forms of allergic inflammation, the mast cell plays a key role. Itching is the first symptom and may be associated with lacrimation. Dilation of the conjunctival blood vessels produces a "red" eye. Transudation of fluid through vessel walls results in edema of the conjunctiva, and exuded cells with increased glandular mucus secretions result in ocular discharge. In most atopic patients, conjunctivitis and allergic rhinitis occur together, but some patients are bothered only by eye symptoms. In contrast to other forms of conjunctivitis, the secretions contain eosinophils.

Vernal conjunctivitis is so called because of its occurrence in spring and summer. It is characterized by a bilateral recurrent inflammation of the conjunctiva. Vernal conjunctivitis typically occurs between ages 5 and 20 years. It often spontaneously resolves in 10 years. More than 50% of children with vernal conjunctivitis also have an atopic disorder such as allergic rhinitis, eczema, or asthma. Signs and symptoms include acute itching, tearing, photophobia, and excess mucus production. The patient often has a sense of a foreign body in the eye.

The topical conjunctival appearance establishes the diagnosis, which is confirmed by cytologic smears showing numerous eosinophils. In the tarsal (palpebral) form, there are flat-top cobblestone papillae; in the limbal form, there may be gelatinous hypertrophy and limbal papillary hypertrophy often associated with white dots (Trantas' dots). Although vernal conjunctivitis is usually self-limiting, corneal complications can occur, and ophthalmology consultation should be obtained. Although conjunctivitis is typically seasonal and common in atopic patients, no allergens have been identified as causal or aggravating factors.

The usual therapy for allergic conjunctivitis is an oral anti-histamine with a topical medication (Table 20-3). Cromolyn (Opticrom) and lodoxamide 0.1% (Alomide) are mast cell stabilizers. Topical Hj histamine blockers are also effective for treating allergic conjunctivitis. Ophthalmic histamine blocker solutions include emedastine (Emadine) and levoca-bastine (Livostin). Azelastine (Optivar), epinastine (Elestat), ketotifen (Zaditor, Claritin Eye, Zyrtec Itchy Eye) and olopa-tadine (Patanol, Pataday) are dual-acting drugs, preventing mast cell release and exerting antihistamine activity as well. Ketorolac (Acular) is a NSAID. Regular daily use is necessary to obtain maximum positive results with all topical agents. In severe cases and in vernal conjunctivitis, a soluble steroid such as fluorometholone ophthalmic solution (0.1%) is effective. The dose should be titrated to the minimum required to control symptoms. Use should be intermittent because glucocorticoids can lead to the development of cataracts, potentiate a secondary bacterial infection or a herpes simplex keratitis, and increase intraocular pressure. Steroid eyedrops should always be used under supervision by an ophthalmologist.

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