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How To Deal With ALLERGIC CONJUNCTIVITIS Along with clinical

ALLERGIC CONJUNCTIVITIS
ALLERGIC CONJUNCTIVITIS

DEFINITION

  • It is the inflammation of conjunctiva due to allergic or hypersensitivity reactions which may be immediate (humoral) or delayed (cellular).

ETIOLOGY

  • Allergic conjunctivitis, is a type-I immediate hypersensitivity reaction mediated by IgE and subsequent mast cell activation, following exposure of ocular surface to airborne allergens. Family history of atopy might be present.
  • Simple allergic conjunctivitis is known to occur in two forms:
  1. SEASONAL ALLERGIC CONJUNCTIVITIS (SAC)
  2. SAC is a response to seasonal allergens such as tree and grass pollens.
  • PERENNIAL ALLERGIC CONJUNCTIVITIS (PAC)
  • PACis a response to perennial allergens such as house dust, animal dander and mite. It is not so common.

PATHOLOGY

  1. Vascular Response
  2. Characterised by sudden and extreme vasodilation and increased permeability of vessels leading to exudation.
  • Cellular Response
  • In the form of conjunctival infiltration and exudation in the discharge of eosinophils, plasma cells and mast cells producing histamine and histamine-like substances.
  • Conjunctival Response
  • In the form of boggy swelling of conjunctiva followed by increased connective tissue formation and mild papillary hyperplasia.

CLINICAL FEATURES

SYMPTOMSSIGNS
Intense itching and burning sensation in the eyesWatery mucus, stringy dischargeMild photophobia  Hyperaemia & chemosis which give a swollen juicy appearance to the conjunctivaMild papillary reaction may be seen on palpebral conjunctiva.Oedema of lids is often present.

TREATMENT

  1. Elimination of allergens if possible.
  2. Topical vasoconstrictors
  3. Naphazoline
  4. Antizoline
  5. Tetrahydrozoline.
  6. Artificial tears like carboxymethyl cellulose provide soothing effect.
  7. Mast cell stabilizers
  8. Sodium Cromoglycate
  9. Nedocromil Sodium
  10. Dual action antihistamines and mast cell stabilizers
  11. Azilastine
  12. Olopatidine
  13. Ketotifen
  14. Steroid eyedrops should be avoided.
  15. Systemic antihistaminic drugs are useful in acute cases with marked itching.
  16. Desensitization has been tried without much rewarding results.

PHLYCTENULAR KERATOCONJUNCTIVITIS

DEFINITION

  • Phlyctenular keratoconjunctivitis is a characteristic nodular affection occurring as an allergic response of the conjunctival and corneal epithelium to some endogenous allergens to which they have become sensitized.

ETIOLOGY

  • It is believed to be a delayed hypersensitivity (Type IV-cell mediated) response to endogenous microbial proteins so called as microbial allergic conjunctivitis.

CAUSATIVE ALLERGENS

  1. Tuberculous proteins
  2. Staphylococcus proteins

PREDISPOSING FACTORS

  1. Age   :   Peak age group is 3–15 years.
  2. Sex     : Incidence is higher in girls than boys.
  3. Undernourishment
  4. Living Conditions:  Overcrowded and unhygienic.
  5. Season. It occurs in all climates but incidence is high in spring and summer seasons.

 PATHOLOGY

  1. STAGE OF NODULE FORMATION.
  2. In this stage, there occurs exudation and infiltration of leucocytes into the deeper layers of conjunctiva leading to a nodule formation.
  3. The neighbouring blood vessels dilate and their endothelium proliferates.
  • STAGE OF ULCERATION
  • Later on necrosis occurs at the apex of the nodule and an ulcer is formed.
  • Leucocytic infiltration increases with plasma cells and mast cells.
  • STAGE OF GRANULATION
  • Eventually, floor of the ulcer becomes covered by granulation tissue.
  • STAGE OF HEALING
  • Healing occurs usually with minimal scarring.

CLINICAL FEATURES

SYMPTOMS

  1. Mild discomfort in the eye
  2. Irritation
  3. Reflex watering.

SIGNS

  • The phlyctenular conjunctivitis can present in three forms: Simple, Necrotizing & Miliary.
  1. SIMPLE PHYLCTENULAR CONJUNCTIVITIS
  2. It is the most commonly seen variety.
  3.  It is characterised by the presence of a typical pinkish white nodule surrounded by hyperaemia on the bulbar conjunctiva, usually near the limbus.
  4. Most of the times there is solitary nodule but at times there may be two nodules .
  5.  In a few days the nodule ulcerates at apex which later on gets epithelised. Rest of the conjunctiva is normal.
  • NECROTIZING PHLYCTENULAR CONJUNCTIVITIS
  • It is characterised by the presence of a very large phlycten with necrosis and ulceration leading to a severe pustular conjunctivitis.
  • MILIARY PHLYCTENULAR CONJUNCTIVITIS
  • It is characterised by the presence of multiple phlyctens which may be arranged haphazardly or in the form of a ring around the limbus and may even form a ring ulcer.

CLINICAL COURSE

  • It is usually self-limiting and phlycten disappears in 8–10 days leaving no trace. However, recurrences are very common.

DIFFERENTIAL DIAGNOSIS

  1. Episcleritis
  2. Scleritis
  3. Conjunctival foreign body granuloma.
  4. Presence of one or more whitish raised nodules on the bulbar conjunctiva near the limbus, with hyperaemia usually of the surrounding conjunctiva, in a child living in bad hygienic conditions (most of the times) are the diagnostic features of the phlyctenular conjunctivitis.

 MANAGEMENT

  1. LOCAL THERAPY
  2. Topical steroids, in the form of eye drops or ointment (dexamethasone or betamethasone)
  3. Antibiotic drops and ointment should be added to take care of the associated secondary infection.  
  4. Atropine (1%) eye ointment should be applied once daily when cornea is involved.
  • SPECIFIC THERAPY
  • Attempts must be made to search and eradicate the following causative conditions:
  • Tuberculous infection should be excluded by X-rays chest, Mantoux test, TLC, DLC and ESR. In case, a tubercular focus is discovered, antitubercular treatment should be started to combat the infection.
  • Septic focus, in the form of tonsillitis, adenoiditis, or caries teeth, when present should be adequately treated by systemic antibiotics and necessary surgical measures.
  • Parasitic infestation should be ruled out by repeated stool examination and when discovered should be adequately treated for complete eradication.
  • GENERAL MEASURES
  • Aimed to improve the health of child are equally important.
  • Attempts should be made to provide high protein diet supplemented with vitamins A, C and D.

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Written by DD

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