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ALLERGIC CONJUNCTIVITIS
Inflammation of conjunctiva due to allergic or
hypersensitivity reactions
May be immediate(humoral) or delayed(cellular)
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
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
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
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
Recommended