Current reviews of allergy and clinical immunology
Allergic and immunologic disorders of the eye. Part II: Ocular allergy,☆☆

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Abstract

Allergy affects more than 15% of the world population, and some studies have shown that up 30% of the US population has some form of allergy. Most of these patients have various target organs for their allergies, and most have ocular involvement. The ocular component may be the most prominent and sometimes disabling feature of their allergy. Some are affected for only a few weeks to months, whereas others have symptoms that last throughout the year. The seasonal forms may present to clinical allergists, whereas the more chronic forms may present to ophthalmologists. Thus, in the second of this 2-part review series (Part I: Ocular Immunology appeared in the November issue of the Journal), an overview is provided of the spectrum of ocular allergy that ranges from acute seasonal allergic conjunctivitis to chronic variants of atopic keratoconjunctivitis. With a better understanding of the immunologic mechanisms, we now can develop better treatment approaches and design further research in intervention of allergic eye diseases. (J Allergy Clin Immunol 2000;106:1019-32.)

Section snippets

Allergy

The allergic inflammatory component in allergic rhinitis has been extensively studied because of the high incidence of this condition, the significant morbidity it imposes, and the accessibility of nasal tissue. However, ocular symptoms are less well studied as an independent entity, and much of the clinical information is commonly buried within the rhinoconjunctivitis literature.1 Allergic conjunctivitis is commonly associated with allergic rhinitis and symptoms of watery (88%), itchy (88%),

Seasonal and perennial allergic conjunctivitis overview

Allergic conjunctivitis is caused by direct exposure of the ocular mucosal surfaces to the environment and is the most common hypersensitivity response of the eye.5 Seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC) are the most prevalent forms of ocular allergy and are seldom followed by permanent visual impairment. Of the two, SAC is more common. Of the aeroallergens, ragweed is the most common cause of allergic conjunctivitis accompanying allergic rhinitis.

Late-phase reactions

A conjunctival late-phase reaction has been described.16, 17, 18, 19, 20 In this model used by Leonardi et al, the late-phase reaction manifested itself in several forms including a classic biphasic response (33%), a multiphasic response (25%), and a single prolonged response (41%).21 The histologic evaluation of the conjunctiva revealed the typical influx of nonspecific cells of the inflammatory response including neutrophils, basophils, and eosinophils. Tears collected from timed periods over

Atopic keratoconjunctivitis

Atopic keratoconjunctivitis (AKC) is a chronic inflammatory process of the eye with disabling symptoms most commonly involving the lower tarsal conjunctiva. When it involves the cornea, it can lead to blindness. A family history of atopy, such as eczema and asthma, is very common, with more than 95% of AKC patients also having eczema and 87% having history of asthma. However, the inverse (ie, the reported incidence of ocular involvement in AKC patients with atopic dermatitis) reveals a range of

Vernal keratoconjunctivitis

Vernal keratoconjunctivitis (VKC) is a severe bilateral recurrent chronic ocular inflammatory process of the upper tarsal conjunctival surface. It has a marked seasonal incidence, and its frequent onset in the spring has led to the term vernal catarrh. It occurs most frequently in children and young adults who have a history of seasonal allergy, asthma, and eczema. Interestingly, a physiologic correlation of VKC with bronchial responsiveness to methacholine has been reported.59

The age of onset

Clinical features

GPC has been directly linked to chronic exposure to foreign bodies, such as the continued use of contact lenses,81 ocular prostheses,82 sutures,83 scleral buckles,84 cyanoacrylate adhesive,85 filtering blebs,86 and elevated corneal deposits.87 There is an increase of symptoms during spring pollen season. Symptoms include itching, tearing, and excessive ocular discomfort and mucus production. Signs include a white or clear exudate on awakening, which chronically becomes thick and stringy.

Ocular allergy treatment

It is apparent that the treatment of ocular allergies is based largely on the important aspect of the interference with quality of life that the patient experiences (ie, severity of symptoms).98 It has been demonstrated that such quality-of-life parameters may take up to 2.5 weeks to improve with treatment. The easiest and most direct therapeutic method is the direct placement of a “topical” agent on the affected tissue. Several topical agents are available for the treatment and, to some

Summary

Ocular allergy includes a spectrum of clinical disorders that involve different levels of activity of the TH2-directed immune response at the conjunctival interface. The spectrum can be better appreciated through immunopathologic and molecular immunologic techniques. In SAC there are minimal pathologic changes such as an increase in mast cell activation, minimal presence of migratory inflammatory cells, and early signs of cellular activation at the molecular level. In PAC, these markers are

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    Supported by a grant from Astra Pharmaceuticals, Westborough, Mass

    ☆☆

    Reprint requests: Leonard Bielory, MD, UMDNJ–Asthma and Allergy Research Center, 90 Bergen St, DOC Suite 4700, Newark, NJ 07103.

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