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AllergyAllergyAllergyAllergy
Reaction of the body tissues to an allergenReaction of the body tissues to an allergenReaction of the body tissues to an allergen Reaction of the body tissues to an allergen
which leads to production of antibodies which leads to production of antibodies
finally culminating in an antigenfinally culminating in an antigen--antibody antibody
reactionreactionreaction.reaction.
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Normal IndividualNormal IndividualNormal IndividualNormal Individual
Entry of allergenEntry of allergen AllergenAllergen--AntibodyAntibodyEntry of allergenEntry of allergen AllergenAllergen AntibodyAntibodyreactionreaction
Production ofProduction ofantibodiesantibodies
DestructionDestructionofof
AllAll
ImmuneImmunesystemsystem
AllergenAllergen
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Allergic ProcessAllergic ProcessAntigenAntigen IgE antibodyIgE antibody
Attachment of IgE to mast cellAttachment of IgE to mast cell
DegranulationDegranulation
Chenotactic FactorsChenotactic FactorsChenotactic FactorsChenotactic Factors
Migration & ActivationMigration & Activation
EosinophilsEosinophils NeutrophilsNeutrophilsBasophilsBasophilsHistamineHistamineLate PhaseLate Phase
HistamineHistamine
Chemotactic MediatorsChemotactic MediatorsH1- ReceptorReleaseRelease
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Inflammation & Tisse DamageInflammation & Tisse Damage
LATE PHASELATE PHASE
Irritation of Nose Eye Skin BronchiIrritation of Nose Eye Skin Bronchi
EARLY PHASEEARLY PHASE
Removal of the causeRemoval of the causeRemoval of the causeRemoval of the cause
Symptom control is aided by reducingSymptom control is aided by reducingSymptom control is aided by reducing Symptom control is aided by reducing exposure to the precipitating factor, which exposure to the precipitating factor, which could be eithercould be eithercould be eithercould be either
PollenPollenH d t itH d t itHouse dust miteHouse dust miteContact lensContact lensArtificial eyeArtificial eye
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Secondary Allergic ReactionSecondary Allergic ReactionSecondary Allergic ReactionSecondary Allergic Reaction
Inflammatory cells (eosinophils) are activated andInflammatory cells (eosinophils) are activated andInflammatory cells (eosinophils) are activated and Inflammatory cells (eosinophils) are activated and attracted to the site of the allergic reactionattracted to the site of the allergic reactionActivated inflammatory cells (eosinophils) release Activated inflammatory cells (eosinophils) release secondary mediatorssecondary mediatorsInflammation + hyperactivity + tissue damageInflammation + hyperactivity + tissue damageSecondary activation of mast cells causes late Secondary activation of mast cells causes late histamine releasehistamine release
Second wave of allergic symptomsSecond wave of allergic symptomsSecond wave of allergic symptomsSecond wave of allergic symptoms(sneezing, itching, nasal congestion, watery (sneezing, itching, nasal congestion, watery eyes, runny nose etc.)eyes, runny nose etc.)
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y , y )y , y )
ALLERGIC CONJUNCTIVITIS : TYPESALLERGIC CONJUNCTIVITIS : TYPESALLERGIC CONJUNCTIVITIS : TYPESALLERGIC CONJUNCTIVITIS : TYPES
Allergic conjunctivitis may be divided into 5 major Allergic conjunctivitis may be divided into 5 major subcategories:subcategories:
S l ll i j ti iti (SAC)S l ll i j ti iti (SAC)Seasonal allergic conjunctivitis (SAC) Seasonal allergic conjunctivitis (SAC) perennial allergic conjunctivitis (PAC). perennial allergic conjunctivitis (PAC). Vernal keratoconjunctivitis (VKC)Vernal keratoconjunctivitis (VKC)Vernal keratoconjunctivitis (VKC), Vernal keratoconjunctivitis (VKC), Atopic keratoconjunctivitis (AKC), and Atopic keratoconjunctivitis (AKC), and
Giant papillary conjunctivitis (GPC) Giant papillary conjunctivitis (GPC) p p y j ( )p p y j ( )
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GIANT PAPILLARY CONJUNCTIVITISGIANT PAPILLARY CONJUNCTIVITISGIANT PAPILLARY CONJUNCTIVITISGIANT PAPILLARY CONJUNCTIVITIS
GPC is an immuneGPC is an immune--mediated inflammatory disorder of mediated inflammatory disorder of yysuperior tarsal conjunctivasuperior tarsal conjunctiva..The primary finding is the presence of "giant" papillae, The primary finding is the presence of "giant" papillae, which are typically greater than 0.3 mm in diameter. which are typically greater than 0.3 mm in diameter. GPC represents an immunologic reaction to a variety of GPC represents an immunologic reaction to a variety of foreign bodies which may cause prolonged mechanicalforeign bodies which may cause prolonged mechanicalforeign bodies, which may cause prolonged mechanical foreign bodies, which may cause prolonged mechanical irritation to the superior tarsal conjunctivairritation to the superior tarsal conjunctiva. .
AllergensAllergens :: contact lenses (hard and soft) are the mostcontact lenses (hard and soft) are the mostAllergensAllergens : : contact lenses (hard and soft) are the most contact lenses (hard and soft) are the most common irritant, ocular prostheses, extruded scleral common irritant, ocular prostheses, extruded scleral buckles, and exposed sutures following previous buckles, and exposed sutures following previous surgical intervention may precipitate GPCsurgical intervention may precipitate GPC
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surgical intervention may precipitate GPC.surgical intervention may precipitate GPC.
Giant Papillary ConjunctivitisGiant Papillary ConjunctivitisGiant Papillary ConjunctivitisGiant Papillary Conjunctivitis
Spring (1974) was the first to describe this disease.Spring (1974) was the first to describe this disease.p g ( )p g ( )Commonly develops after lens useCommonly develops after lens use
Also associated with ocular prostheses, exposed Also associated with ocular prostheses, exposed sutures after cataract surgery, corneal transplants and sutures after cataract surgery, corneal transplants and extruded scleral bucklesextruded scleral bucklesextruded scleral buckles.extruded scleral buckles.Estimated 1Estimated 1--3% of the 30 million lens wearers in USA 3% of the 30 million lens wearers in USA develop the conditiondevelop the conditionSoft lens wearers Soft lens wearers -- 1010--15%15%Hard lens wearers Hard lens wearers -- 11--5%5%Drugs 1991; 42(4): 606Drugs 1991; 42(4): 606--615 Acta Ophthalmalogica Scandinavica 1999; 77: 17615 Acta Ophthalmalogica Scandinavica 1999; 77: 17--2020
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Drugs, 1991; 42(4): 606Drugs, 1991; 42(4): 606 615, Acta Ophthalmalogica Scandinavica 1999; 77: 17615, Acta Ophthalmalogica Scandinavica 1999; 77: 17 20.20.
Giant Papillary Giant Papillary j i i ij i i iConjunctivitisConjunctivitis
SymptomsSymptomsy py p
Lens intoleranceLens intolerance
Excessive mucus secretionExcessive mucus secretion
Blurred vision due to coating on the surface of the contact Blurred vision due to coating on the surface of the contact lenslens
SignsSignsSignsSigns
Large papillae on the upper conjunctivaLarge papillae on the upper conjunctiva
HyperaemiaHyperaemiaHyperaemiaHyperaemia
Mucus discharge covering areas of giant papillae (> 1 mm in Mucus discharge covering areas of giant papillae (> 1 mm in diameter which has a cobble stone appearance due to its diameter which has a cobble stone appearance due to its polygonal flat topped manifestation)polygonal flat topped manifestation)
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polygonal, flat topped manifestation)polygonal, flat topped manifestation)
Giant Papillary Giant Papillary j i i ij i i iConjunctivitisConjunctivitis
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Seasonal Allergic Seasonal Allergic j i i ij i i iConjunctivitisConjunctivitis
SAC is the most common form of the disease andSAC is the most common form of the disease andSAC is the most common form of the disease and SAC is the most common form of the disease and represents about half the cases of allergic represents about half the cases of allergic conjunctivitis.conjunctivitis.co ju ct t sco ju ct t s
Perennial allergic conjunctivitis (PAC) is a variant Perennial allergic conjunctivitis (PAC) is a variant of SAC which is chronic with year aroundof SAC which is chronic with year aroundof SAC which is chronic with year around of SAC which is chronic with year around symptoms. The prevalence is 0.035%symptoms. The prevalence is 0.035%
Most common allergen is pollen or sporeMost common allergen is pollen or sporeMost common allergen is pollen or sporeMost common allergen is pollen or sporehttp:/secure.pharmacytimes.comhttp:/secure.pharmacytimes.com
http:/www.optometry.co.ukhttp:/www.optometry.co.uk
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SAC AND PACSAC AND PAC : PATHOPHYSIOLOGY: PATHOPHYSIOLOGYSAC AND PACSAC AND PAC : PATHOPHYSIOLOGY: PATHOPHYSIOLOGY
Since conjunctiva is a mucosal surface similar to the nasal mucosa, the Since conjunctiva is a mucosal surface similar to the nasal mucosa, the same allergens that trigger allergic rhinitis may be involved in the same allergens that trigger allergic rhinitis may be involved in the pathogenesis of allergic conjunctivitis. pathogenesis of allergic conjunctivitis.
Common airborne antigens :Common airborne antigens : pollen, grass, and weeds may provoke pollen, grass, and weeds may provoke the symptoms of acute allergic conjunctivitis such as ocular the symptoms of acute allergic conjunctivitis such as ocular itching, redness, burning, and tearing. itching, redness, burning, and tearing.
SAC :symptoms during a particular seasonSAC :symptoms during a particular season
PAC t th t l t th h lPAC t th t l t th h lPAC : symptoms that lasts the whole yearPAC : symptoms that lasts the whole year
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Seasonal Allergic Seasonal Allergic j i i ij i i iConjunctivitisConjunctivitis
Signs and SymptomsSigns and Symptomsg y pg y pRed, itchy eyesRed, itchy eyes
Burning, stinging, photophobia and a watery or a ropy Burning, stinging, photophobia and a watery or a ropy dischargedischargeConjunctiva takes on a pinkish, milky appearance Conjunctiva takes on a pinkish, milky appearance Contact lens intoleranceContact lens intoleranceContact lens intoleranceContact lens intolerance
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Seasonal Allergic Seasonal Allergic j i i ij i i iConjunctivitisConjunctivitis
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Vernal KeratoconjunctivitisVernal KeratoconjunctivitisVernal KeratoconjunctivitisVernal Keratoconjunctivitis
Also known as spring catarrhAlso known as spring catarrhp gp g
Primarily seen in prepubertal children occurs more Primarily seen in prepubertal children occurs more often in boys than in girlsoften in boys than in girls
Prevalence : 0.5 Prevalence : 0.5 –– 2% of ocular allergic disease2% of ocular allergic disease
Long duration (up to 10 years)Long duration (up to 10 years)
Commonly seen in hot and dry such as Middle East, Commonly seen in hot and dry such as Middle East, Africa and the Indian subcontinentAfrica and the Indian subcontinent
Shows seasonal variations in severity, being worst Shows seasonal variations in severity, being worst over the warm spring and summer monthsover the warm spring and summer months
Ref : Drugs of Today 1998; 34(11):957Ref : Drugs of Today 1998; 34(11):957--971971
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Ref.: Drugs of Today, 1998; 34(11):957Ref.: Drugs of Today, 1998; 34(11):957 971971http://www.optometry.co.ukhttp://www.optometry.co.uk
Hay fever (seasonal allergic) Hay fever (seasonal allergic) ConjunctivitisConjunctivitisCo ju ct t sCo ju ct t s
This is very common and innocuous condition is This is very common and innocuous condition is usually managed by a nonusually managed by a non ophthalmologist It isophthalmologist It isusually managed by a nonusually managed by a non--ophthalmologist. It is ophthalmologist. It is often associated with seasonal rhinitis.often associated with seasonal rhinitis.Clinical featuresClinical featuresClinical featuresClinical features
The symptoms are transient attacks of itching,The symptoms are transient attacks of itching,lacrimation and redness during the hay feverlacrimation and redness during the hay feverlacrimation, and redness during the hay feverlacrimation, and redness during the hay feverseason.season.The conjunctiva shows mild chemosis and aThe conjunctiva shows mild chemosis and aThe conjunctiva shows mild chemosis and aThe conjunctiva shows mild chemosis and adiffuse papillary reactiondiffuse papillary reactionIn severe cases, the eyelids may be slightlyIn severe cases, the eyelids may be slightly
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In severe cases, the eyelids may be slightlyIn severe cases, the eyelids may be slightlyoedamatous but the cornea is uninvolved.oedamatous but the cornea is uninvolved.
Vernal KeratoconjunctivitisVernal KeratoconjunctivitisVernal KeratoconjunctivitisVernal Keratoconjunctivitis
Also known as spring catarrhAlso known as spring catarrhp gp g
Primarily seen in prepubertal children occurs more Primarily seen in prepubertal children occurs more often in boys than in girlsoften in boys than in girls
Prevalence : 0.5 Prevalence : 0.5 –– 2% of ocular allergic disease2% of ocular allergic disease
Long duration (up to 10 years)Long duration (up to 10 years)
Commonly seen in hot and dry such as Middle East, Commonly seen in hot and dry such as Middle East, Africa and the Indian subcontinentAfrica and the Indian subcontinent
Shows seasonal variations in severity, being worst Shows seasonal variations in severity, being worst over the warm spring and summer monthsover the warm spring and summer months
Ref : Drugs of Today 1998; 34(11):957Ref : Drugs of Today 1998; 34(11):957--971971
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Ref.: Drugs of Today, 1998; 34(11):957Ref.: Drugs of Today, 1998; 34(11):957 971971http://www.optometry.co.ukhttp://www.optometry.co.uk
VERNAL KERATOCONJUNCTIVITISVERNAL KERATOCONJUNCTIVITISVERNAL KERATOCONJUNCTIVITISVERNAL KERATOCONJUNCTIVITIS
VKC is a chronic bilateral inflammation of the VKC is a chronic bilateral inflammation of the conjunctiva, commonly associated with a personal conjunctiva, commonly associated with a personal and/or family history of atopy. and/or family history of atopy.
More than 90% of patients with VKC exhibit one or More than 90% of patients with VKC exhibit one or more atopic conditions such as asthma, eczema, ormore atopic conditions such as asthma, eczema, ormore atopic conditions such as asthma, eczema, or more atopic conditions such as asthma, eczema, or seasonal allergic rhinitis.seasonal allergic rhinitis.
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Vernal Keratoconjunctivitis Vernal Keratoconjunctivitis (Contd.)(Contd.)
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ATOPIC KERATOCONJUNCTIVITISATOPIC KERATOCONJUNCTIVITISATOPIC KERATOCONJUNCTIVITISATOPIC KERATOCONJUNCTIVITIS
AKC is a bilateral inflammation of conjunctiva and eyelids, which AKC is a bilateral inflammation of conjunctiva and eyelids, which has a strong association with atopic dermatitis. It is also a type has a strong association with atopic dermatitis. It is also a type I hypersensitivity disorder with many similarities to VKC, yet I hypersensitivity disorder with many similarities to VKC, yet AKC is distinct in a number of waysAKC is distinct in a number of ways. .
In 1953, Hogan first described the association between atopic In 1953, Hogan first described the association between atopic dermatitis and conjunctival inflammation. dermatitis and conjunctival inflammation.
Approximately 3% of the population is afflicted with atopic dermatitis Approximately 3% of the population is afflicted with atopic dermatitis and of these approximately 25% have ocular involvementand of these approximately 25% have ocular involvementpp ypp y
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MAJOR DIFFERENTIATING FACTORS BETWEEN VKC MAJOR DIFFERENTIATING FACTORS BETWEEN VKC AND AKCAND AKC
CharacteristicsCharacteristics VKCVKC AKCAKC
Age at onsetAge at onset Generally presents at a Generally presents at a younger ageyounger age
SexSex Males are affected Males are affected preferentiallypreferentially
No sex predilectionNo sex predilection
Seasonal variationSeasonal variation Typically a disorder that Typically a disorder that occurs during spring monthsoccurs during spring months
Generally perennialGenerally perennial
DischargeDischarge Thick mucoid dischargeThick mucoid discharge Watery and clear dischargeWatery and clear discharge
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DischargeDischarge Thick mucoid dischargeThick mucoid discharge Watery and clear dischargeWatery and clear discharge
Conjunctival scarringConjunctival scarring -- Higher incidence of Higher incidence of conjunctival scarringconjunctival scarring
HornerHorner--Trantas dotsTrantas dots HornerHorner--Trantas dots and Trantas dots and shield ulcers are commonly shield ulcers are commonly seenseen
Presence of HornerPresence of Horner--Trantas Trantas dots is raredots is rare
Corneal neovascularizationCorneal neovascularization Not presentNot present Tends to develop deep Tends to develop deep corneal neovascularizationcorneal neovascularization
Presence of eosinophils in Presence of eosinophils in conjunctival scrapingconjunctival scraping
Conjunctival scraping reveals Conjunctival scraping reveals eosinophils to a greater eosinophils to a greater degree in VKCdegree in VKC
Presence of eosinophils is Presence of eosinophils is less likelyless likely
TherapyTherapyTherapyTherapy
Removal of the causeRemoval of the causeRemoval of the causeRemoval of the cause
Artificial tearsArtificial tearsArtificial tearsArtificial tearsVasoconstrictorsVasoconstrictorsA tihi t iA tihi t iAntihistaminesAntihistaminesCycloCyclo--oxygenase inhibitors (NSAIDS)oxygenase inhibitors (NSAIDS)Mast cell inhibitorsMast cell inhibitorsSteroidsSteroids
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ARTIFICIAL TEARSARTIFICIAL TEARSARTIFICIAL TEARSARTIFICIAL TEARSArtificial tear substitutes provide a barrier function and Artificial tear substitutes provide a barrier function and pphelp to improve the firsthelp to improve the first--line defense at the level of line defense at the level of conjunctival mucosa. conjunctival mucosa.
Artificial tear substitutes help to dilute various allergens Artificial tear substitutes help to dilute various allergens and inflammatory mediatorsand inflammatory mediatorsand inflammatory mediators and inflammatory mediators
Artificial tear substitutesArtificial tear substitutes they help flush the ocular they help flush the ocular surface of these agentssurface of these agents
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VASOCONSTRICTORSVASOCONSTRICTORSVASOCONSTRICTORSVASOCONSTRICTORSVasoconstrictors are available either alone or in Vasoconstrictors are available either alone or in conjunction with antihistamines to provide shortconjunction with antihistamines to provide short--term relief of vascular injection and redness.term relief of vascular injection and redness.C i i l d h liC i i l d h liCommon vasoconstrictors include naphazoline, Common vasoconstrictors include naphazoline, phenylephrine, oxymetazoline, and phenylephrine, oxymetazoline, and tetrahydrozolinetetrahydrozolinetetrahydrozoline.. tetrahydrozoline.. These pharmacologic agents are ineffective These pharmacologic agents are ineffective against severe ocular allergies and against other against severe ocular allergies and against other more severe forms of allergic conjunctivitis, such more severe forms of allergic conjunctivitis, such as atopic and vernal disease.as atopic and vernal disease.
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ANTIHISTAMINESANTIHISTAMINESANTIHISTAMINESANTIHISTAMINESSystemic and/or topical antihistamines may be given to relieve acute Systemic and/or topical antihistamines may be given to relieve acute
d i i f hi i l H1 d H2d i i f hi i l H1 d H2symptoms due to interaction of histamine at ocular H1 and H2 symptoms due to interaction of histamine at ocular H1 and H2 receptors. receptors. systemic side affects such as drowsiness and dry mouth. systemic side affects such as drowsiness and dry mouth.
Topical antihistamines competitively and reversibly block histamine Topical antihistamines competitively and reversibly block histamine receptors and relieve itching and redness but only for a short time.receptors and relieve itching and redness but only for a short time.
. . e.g: epinastine and azelastinee.g: epinastine and azelastine
. . potent antihistamines potent antihistamines h id t d ff ti i li i th i dh id t d ff ti i li i th i dhave a rapid onset and are effective in relieving the signs and have a rapid onset and are effective in relieving the signs and
symptoms of allergic conjunctivitis.symptoms of allergic conjunctivitis.
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NSAIDSNSAIDSNSAIDSNSAIDS
Nonsteroidal antiNonsteroidal anti--inflammatory drugs (NSAIDs)inflammatory drugs (NSAIDs)Nonsteroidal antiNonsteroidal anti inflammatory drugs (NSAIDs) inflammatory drugs (NSAIDs) act on the cyclooxygenase metabolic pathway act on the cyclooxygenase metabolic pathway and inhibit production of prostaglandins and and inhibit production of prostaglandins and thromboxanes. thromboxanes. They have no role in blocking mediators formed They have no role in blocking mediators formed by the lipoxygenase pathway such as by the lipoxygenase pathway such as leukotrienes. leukotrienes. C NSAID h d f ll iC NSAID h d f ll iCommon NSAIDs that are approved for allergic Common NSAIDs that are approved for allergic indications include ketorolac tromethamine .indications include ketorolac tromethamine .
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MAST CELL STABILISERSMAST CELL STABILISERSMAST CELL STABILISERSMAST CELL STABILISERSMechanism of actionMechanism of action: Decrease in degranulation of mast cells, which : Decrease in degranulation of mast cells, which
prevents release of histamine and other chemotactic factors . prevents release of histamine and other chemotactic factors .
Note that mast cell stabilizers do not relieve existing symptoms and are Note that mast cell stabilizers do not relieve existing symptoms and are g y pg y pto be used on a prophylactic basis to prevent mast cell to be used on a prophylactic basis to prevent mast cell degranulation with subsequent exposure to the allergen. degranulation with subsequent exposure to the allergen.
Therefore, they need to be used long term in conjunction with various Therefore, they need to be used long term in conjunction with various other classes of medications. other classes of medications.
Common mast cell stabilizersCommon mast cell stabilizers include include cromolyn sodium and cromolyn sodium and lodoxamide ,Olopatadine , nedocromil,and ketotifenlodoxamide ,Olopatadine , nedocromil,and ketotifen
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CORTICOSTEROIDSCORTICOSTEROIDSCORTICOSTEROIDSCORTICOSTEROIDSCorticosteroids exist in various forms and potencies. Corticosteroids exist in various forms and potencies. Relatively weak steroids such as rimexolone, medrysone, and Relatively weak steroids such as rimexolone, medrysone, and fluorometholone tend to have less potency with fewer ocular side fluorometholone tend to have less potency with fewer ocular side effects. effects. I t t t h d i l t t t tI t t t h d i l t t t tIn contrast, agents such as prednisolone acetate are more potent In contrast, agents such as prednisolone acetate are more potent and have a higher incidence of side effects.and have a higher incidence of side effects.A relatively new steroid, loteprednol etabonate , is rapidly A relatively new steroid, loteprednol etabonate , is rapidly metabolized once it enters the anterior chamber of the eyemetabolized once it enters the anterior chamber of the eyemetabolized once it enters the anterior chamber of the eye. metabolized once it enters the anterior chamber of the eye. Therefore, it is extremely useful in treating ocular surface and Therefore, it is extremely useful in treating ocular surface and superficial corneal inflammations.superficial corneal inflammations.loteprednol has a specific indication for ocular allergy and has loteprednol has a specific indication for ocular allergy and has p p gyp p gybeen shown in clinical studies to have fewer ocular side been shown in clinical studies to have fewer ocular side effectseffects. . topical steroids should be prescribed only for a short period of time topical steroids should be prescribed only for a short period of time and for se ere cases that do not respond to con entional therapand for se ere cases that do not respond to con entional therap
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and for severe cases that do not respond to conventional therapyand for severe cases that do not respond to conventional therapy
ALLERGIC CONJUNCTIVITIS : CIPLA’S ALLERGIC CONJUNCTIVITIS : CIPLA’S RANGERANGERANGERANGE
Artificial tears : Artificial tears : Add tearsAdd tears , Flow gel, Flow gel : to : to t c a tea st c a tea s dd tea sdd tea s , o ge, o ge totowash away inflammatory mediatorswash away inflammatory mediatorsMast cell stabilisers: Mast cell stabilisers: Cromal/Cromal forteCromal/Cromal forte: :
h l i f ll i j i i ih l i f ll i j i i iprophylactic agent for allergic conjunctivitisprophylactic agent for allergic conjunctivitisNSAIDS: NSAIDS: KetodropsKetodrops :USFDA approval for SAC:USFDA approval for SACSTEROIDSSTEROIDSSTEROIDS: STEROIDS: FlomexFlomex : recommended for paediatric allergic : recommended for paediatric allergic conjunctivitisconjunctivitisconjunctivitis . conjunctivitis . LoteflamLoteflam :the only steroid approved by :the only steroid approved by USFDA for all types of allergic conjunctivitisUSFDA for all types of allergic conjunctivitis
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yp g jyp g j