Ординатура / Офтальмология / Английские материалы / Clinical Ocular Pharmacology 5th edition_Bartlett, Jaanus_2008

Table 27-1

Overview of Drugs for Treatment of Allergic Disease

Disease Eye Allergic 27 CHAPTER

Table 27-1

Overview of Drugs for Treatment of Allergic Disease—cont’d

Disease Eye Allergic 27 CHAPTER 552

Disease Eye Allergic 27 CHAPTER

Table 27-1

Overview of Drugs for Treatment of Allergic Disease—cont’d

Disease Eye Allergic 27 CHAPTER 554

AKC = atopic keratoconjunctivitis; FDA = U.S. Food and Drug Administration; GI = gastrointestinal; GPC = giant papillary conjunctivitis; OTC = over the counter; VKC = vernal keratoconjunctivitis; URI = upper respiratory infection; MAOI = monoamine oxidase inhibitor

From PDR electronic library 2006, Thomson PDR; Bartlett JD, ed. Ophthalmic drug facts, ed 18. St. Louis, Wolters Kluwer Health, 2007; Rhee DJ, Rapuano CJ, Papliodis GN, Fraunfelder FW, eds. Physicians desk reference for ophthalmology 2007. Montvale, NJ:Thomas PDR, 2006.

Disease Eye Allergic 27 CHAPTER

Table 27-2

Conjunctival Allergic Disease: Etiology, Immune Findings, and Clinical Manifestations

Disease Eye Allergic 27 CHAPTER 556

AKC = atopic keratoconjunctivitis; F = female; GPC = giant papillary conjunctivitis; Ig = Immunoglobulin; M = Male; n/a = not applicable; OU = both eyes; SPK = superficial punctate keratopathy;VKC = vernal keratoconjunctivitis.

Disease Eye Allergic 27 CHAPTER

Table 27-3

Treatment for Conjunctival Allergic Disease

Material-

Low water/nonionicRigid

Refit:

Switch hydroxyethylmethacrolate to glyceryl methyl methacrylate or RGP

Discontinue

Disease Eye Allergic 27 CHAPTER 558

AKC = atopic keratoconjunctivitis; GPC = giant papillary conjunctivitis; NSAIDs = nonsteroidal anti-inflammatory drugs; OTC = over the counter;VKC = vernal keratoconjunctivitis.

Disease Eye Allergic 27 CHAPTER

560 CHAPTER 27 Allergic Eye Disease

Diagnosis

The diagnosis of allergic conjunctivitis is largely based on history and clinical presentation. The ocular signs and symptoms may be the only finding, or it may occur as rhinoconjunctivitis. Seasonal signs and symptoms are important diagnostic clues, reflecting allergies to various pollens. Perennial allergic conjunctivitis usually has a less severe clinical presentation than seasonal allergic conjunctivitis but may be exacerbated during certain times of the year.

Allergic conjunctivitis affects both eyes, with symptoms of mild to moderate itching, burning, and a stringy or watery discharge. The bulbar conjunctiva may be hyperemic and chemotic, and small palpebral papillary changes are often present. Follicles may be found in chronic cases. Lid involvement includes swelling, Dennie’s line (a horizontal fold in the lower lid), and “allergic shiners.” Allergic shiners manifest as a dark pigmentation around the eye.This results from periocular venous congestion or impaired venous return (in the skin and subcutaneous tissue) that is associated with lid swelling. In allergic conjunctivitis the cornea is rarely involved and vision is usually unaffected. Rhinitis may also be present along with the ocular manifestations.

Skin testing is a good adjunctive diagnostic test. Scratch testing may assist in determining the allergen involved.

At times a definitive diagnosis of allergic conjunctivitis may be elusive. Patients may present with symptoms but without obvious clinical signs. Perennial conjunctivitis should be considered when symptoms persist year round. Differential diagnosis is also important to consider, particularly because overlapping clinical presentations occur between allergic conjunctivitis and dry eye or blepharitis (Figure 27-1).

Figure 27-1 Allergic conjunctivitis (note papillary changes in lower lid). The patient was treated with olopatadine hydrochloride. This patient also presented with a mild blepharitis and dry eye.

Management

The best treatment for allergic conjunctivitis is avoidance of the causative allergen. Because this is often impossible, the severity of the clinical manifestations determines the management. In addition to the ocular treatment, comanagement with an allergist may be necessary to determine and manage the specific underlying allergens responsible. Educating the patient to avoid rubbing the eyes because it may aggravate clinical presentations is also an important consideration.

In mild cases of allergic conjunctivitis, the use of cold compresses, nonpreserved ocular lubricants, and vasoconstrictors provide symptomatic relief. Nonpreserved lubricants dilute and flush the precorneal tear film and wash away the allergens.

When allergic conjunctivitis is of moderate severity, topical antihistamines, either in combination with decongestants or without decongestants, are the next level of treatment. Because histamine is involved in vasodilation and itching, antihistamine–decongestant combinations, such as Vasocon-A (antazoline phosphate–naphazoline), provide relief from itching, redness and hyperemia, chemosis, lid swelling, and tearing. One or two drops are used four times a day.These drops are approved for children older than 6 years of age. Rebound hyperemia and vasodilation, angle-closure glaucoma, follicular conjunctivitis, and eczematoid blepharoconjunctivitis may occur with long-term use of decongestants and vasoconstrictors such as naphazoline and tetrahydrozoline.

Emedastine difumarate (Emadine) is an H1 antagonist, approved for treating allergic conjunctivitis in patients aged 3 years and older. It is used four times a day. Levocabastine hydrochloride (Livostin), a suspension, is also a topical H1 antihistamine that provides rapid relief of ocular symptoms. Emedastine has been found to be more effective in alleviating itching, chemosis, and lid swelling in allergic conjunctivitis than levocabastine. Levocabastine is no longer available in the United States.

In moderate to severe cases of allergic conjunctivitis, treatment considerations also include mast cell stabilizers, antihistamine–mast cell stabilizer combinations, oral antihistamines, NSAIDs, and, in severe cases, topical steroids.

Mast cell stabilizers are an effective and safe treatment modality for allergic conjunctivitis. They are useful in patients who have perennial allergic conjunctivitis and as a prophylaxis for seasonal allergic conjunctivitis. Mast cell stabilizers are effective only when used before the onset of allergic symptoms, because most drugs in this class have a typical therapeutic effect that occurs in 7 days to 14 days. Because there is a delay in noticeable clinical improvement with most mast cell stabilizers, concurrent therapy with other agents may be necessary for immediate relief. Nedocromil is an exception in this category, because it provides a more rapid relief of symptoms, usually within 15 to 30 minutes.