Allergic conjuncticitis

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Transcript of Allergic conjuncticitis

ALLERGIC CONJUNCTIVITIS

Inflammation of conjunctiva due to allergic or

hypersensitivity reactions

May be immediate(humoral) or delayed(cellular)

TYPES OF ALLERGIC CONJUNCTIVITIS

1. SIMPLE ALLERIC CONJUNCTIVITIS

MILD non specific allergic conjunctivitis

Characterised by

Itching

Hyperaemia

Mild papillary response

IT IS SEEN IN FOLLOWING FORMS

1.HAY FEVER CONJUNCTIVITIS

ASSOCIATED WITH HAY FEVER

COMMON ALLERGENS:POLLENS,GRASS,ANIMAL DANDRUFF

2.SEASONAL ALLERGIC

CONJUNCTIVITIS

RESPOSE TO SEASONAL ALLERGENS SUCH AS GRASS POLLENS

3.PERENNIAL ALLERIC

CONJUNCTIVITIS

RESPONSE TO PERENNIAL ALLERGENS SUCH AS HOUSE DUST AND MITES

1.VASCULAR RESPONSE

EXTREME VASODILATION AND INCRESED PERMEABILITY OF VESSELS LEADING TO

EXUDATION

2.CELLULAR RESPONSE

CONJUNCTIVAL INFILTRATION AND EXUDATION IN THE DISCHARGE OF EOSINOPHILS,PLASMA CELLS,MAST CELLS

PRODUCING HISTAMINES AND HISTAMINE LIKE SUBSTANCES

3.CONJUNCTIVAL RESPONSE

BOGGY SWELLING OF CONJUNCTIVA FOLLOWED BY INCREASED CONNECTIVE

TISSUE FORMATION AND MILD PAPILLARY HYPERPLASIA

CLINICAL PICTURE

SYMPTOMS

Intense itching

Burning sensation in the eyes associated with watery discharge and mild photophobia

SIGNS

(a)Hyperaemia and chemosis which gives a swollen juicy appearance to conjunctiva

(b)Conjunctiva may also show mild papillary reaction

(c)Oedema of lids

DIAGNOSIS AND TREATMENT

2.VERNAL KERATOCONJUNCTIVITIS OR

SPRING CATARRH

RECURRENT

BILATERAL

INTERSTITIAL

SELF LIMITING ALLERGIC INFLAMMATION

ETIOPATHOGENESIS

PATHOLOGY

Conjunctival epithelium undergoes

hyperplasia send downward projection into

the subepithelial tissue

Adenoid layer shows marked cellular

infiltration

Fibrous layer shows proliferation which later

on undergoes hyaline change

Conjunctival vessels also shows

proliferation,increased permeability and

vasodilatation

CLINICAL PICTURE

SYMPTOMS SIGNS1.PALPEBRAL FORM

Upper tarsal conjunctiva of both

eyes is involved

TYPICAL LESION:presence of

hard,flat topped,papillaearranged in’COBBLE STONE’or‘PAVEMENT STONE’fashion

Conjunctival changes associated

with white ropy discharge

2.BULBAR FORM

• Dusky red triangular

congestion of bulbar

conjunctiva in palpebral area

Palpebral form of VKC

Bulbar form of VKC

CLINICAL COURSE AND DIFFERENTIAL DIAGNOSIS

CLINICAL COURSE Self limiting

Burns out spontaneously after 5-10yrs

DIFFERENTIAL DIAGNOSIS Differentiated from trachoma with

predominant papillary hypertrophy

TREATMENT

A.Local Therapy

1. Topical steroids

2. Mast cell stabilizers:like sodium cromoglycate

3. Topical antihistaminics

4. Acetyl cysteine(0.5%)

5. Topical cyclosporine(1%)

B.Systemic therapy

1. Oral antihistaminics

2. Oral steroids

C.Treatment of large papillae

• Supratarsal injection of long acting steroids

• Cryo application

• Surgical excision is recommended for extra ordinary large papillae

D.General measures

• Dark goggles to prevent photophobia

• Cold compresses and Ice packs have soothing effects

• Change of place from hot to cold areas

E.Desensitization

3.ATOPIC

KERATOCONJUNCTIVITIS(AKC)

Adult equivalent of VKC

Associated with atopic dermatitis

Most patients:Atopic adults,male predominance

CLINICAL PICTURE

SYMPTOMS

Itching,soreness,drysensation

Mucoid discharge

Photophobia or blurred vision

SIGNS

Lid margins are chronically inflamed with round posterior borders

Tarsal conjunctiva has milky appearance.

Cornea may show punctate epithelial keratitis,moresevere in lower half

CLINICAL COURSE

AND ASSOCIATIONS CLINICAL COURSE

AKC has protracted course with exacerbation and remissions

When patient reaches his fifth decade it becomes inactive

ASSOCIATIONS

Keratoconus

Atopic cataract

4.GIANT PAPILLARY CONJUNCTIVITIS

INFLAMMATION OF CONJUNCTIVA

With FORMATION OF VERY LARGE PAPILLAE

LOCALISED ALLERGIC RESPONSE TO A PHYSICALLY ROUGH OR DEPRESSED SURFACE(CONTACT LENS)

IT IS A SENSITIVITY REACTION TO COMPONENTS OF THE PLASTIC LEACHED OUT BY THE ACTION OF TEARS

CLINICAL PICTURE

SYMPTOMS

Itching

Stringy discharge

Reduced wearing time of contact lens or prosthetic shell

SIGNS

Papillary hypertrophy of the upper tarsal conjunctiva,similar to that seen in palpebral form VKC with hyperaemia

TREATMENT

THE OFFENDING CAUSE SHOULD BE REMOVED After discontinuation of contact lens or artificial eye or removal of nylon sutures,the papillae resolve over a period of one month

DISODIUM CROMOGLYCATE relive the symptoms and enhance rate of resolution

STEROIDS are not of much use

5.PHLYCTENULAR KERATOCONJUNCTIVITIS

Nodular affection occurring as an allergic response of conjunctival and corneal epithelium to some endogenous allergens to which they become sensitized

ETIOLOGY

1.CAUSATIVE ALLERGENS

o Tuberculous proteinso Staphylococcus proteinso Other allergens:protein of Moraxella

Axenfeld bacillus and certain parasites

2.PREDISPOSING FACTORS

a) Age:Peak age group 3-15yrsb) Sex:incidence higher in girlsc) Undernourishmentd) Living condition:over crowded and

unhygienice) Season:incidence high in Spring and

Summer

PATHOLOGY

1.STAGE OF NODULE FORMATION

Exudation and infiltration of leucocytes into deeper layers of conjunctiva leading to nodule formation

Central cells are polymorphonuclear and peripheral cells are lymphocytes

Neighbouring blood vessels dilate and their endothelium proliferates

2.STAGE OF ULCERATION

Necrosis occurs at apex of nodule and an ulcer is formed

Leucocyte infiltration increases with plasma and mast cells

3.STAGE OF GRANULATION

Floor of ulcer becomes covered by granulation tissue

4.STAGE OF HEALING

Healing with minimal scarring

CLINICAL PICTURE

SYMPTOMS

Mild discomfort in the eye

Irritation

Reflex watering

Mucopurulent conjunctivitis due to secondary bacterial infection

SIGNS

1.SIMPLE PHLYCTENULAR CONJUNCTIVITIS

Characterised by:

• presence of typical pinkish white nodule surrounded by hyperaemia on the bulbar conjunctiva,near limbus

• In a few days nodules ulcerate at apex which later on gets epithelized

2.NECROTISING PHLYCTENULAR CONJUNCTIVITIS

Characterised by:

• Presence of large phlycten with necrosis and ulceration leading to a severe pustular conjunctivitis

3.MILIARY PHLYCTENULAR CONJUNCTIVITIS

Characterised by:

• Presence of multiple phlyctens arranged haphazardly or in form of a ring around limbus and may even form ring ulcer

DIFFERENTIAL DIAGNOSIS

Phlyctenullar conjunctivitis needs to be differentiated from the

episcleritis,scleritis and conjunctival foreign body

granuloma

Presence of one or more whitish raised nodules on the bulbar

conjunctiva near the limbus with hyperaemia usually of surrounding

conjunctiva,in a child living in bad hygienic conditions are

diagnostic features of phlyctenular conjunctivitis

MANAGEMENT

1.LOCAL THERAPY 2.SPECIFIC THERAPY

Attempt must be made to search and

eradicate following causative conditions:

i. TUBERCULOUS infection should be

excluded by chest X-ray,Mantoux

test,TLC,DLC,and ESR.

ii. SEPTIC FOCUS in the form of

tonsillitis,adenoiditis,or caries teeth

when present should be adequately

treated by systemic antibiotics and

necessary surgical measures

iii. PARASITIC INFESTATION should be

ruled out byrepeated stool

examination

3.GENERAL MEASURES

6.CONTACT DERMOCONJUNCTIVITIS

ALLERGIC DISORDER INVOLVING CONJUNCTIVA AND SKIN OF LIDS

ALONG WITH SURROUNDING AREAS OF FACE

o IT IS A DELAYED HYPERSENSITIVITY(TYPEIV)RESPONSE TO PROLONGED CONTACT WITH CHEMICAL AND DRUGS

o FEW TOPICAL OPHTHALMIC MEDICATIONS KNOWN TO PRODUCE CONTACT DERMOCONJUNCTIVITIS

ATROPINE

PENICILLIN

NEOMYCIN

SOFRAMYCIN

GENTAMYCIN

CLINICAL PICTURE AND DIAGNOSIS

CLINICAL PICTURE

CUTANEOUS INVOLVEMENT is in the form of weeping eczematous reaction,involving all areas with which medication comes in contact

CONJUNCTIVAL RESPONSE is in the form of hyperaemia with generalized papillary response affecting the lower fornix and lower palpebral conjunctiva more than the upper

DIAGNOSIS is made from

Typical clinical picture

Conjunctival cytology shows a lymphocytic response with masses of eosinophils

Skin test to the causative allergen is positive in most of the cases

TREATMENT

1. Discontinuation of the causative medication

2. Topical steroid eye drops to relieve symptoms

3. Application of steroid ointment on the involved skin

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