23. Ocular Allergies II Flashcards

1
Q

Giant Papillary Conjunctivitis (1)

Symptoms: ..., ..., ..., .... In CL wearers, also ... and ....

Signs:
* ... on palpebral conjunctiva
* ... discharge, especially when ...
* Associated with ... to CL, lens ..., ..., ..., and ...
* Less common with advent of ...
* Less common with ...

A

Giant Papillary Conjunctivitis (1)

Symptoms: redness, burning, itch, foreign body sensation. In CL wearers, also increase lens awareness and symptoms exacerbated by lens wear.

Signs:
* giant papillae on palpebral conjunctiva
* mucous discharge, especially when waking
* Associated with allergy to CL, lens deposits, solution preservatives, ocular prostheses, and protruding sutures
* Less common with advent of disposable CLs
* Less common with less-toxic solution preservatives

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2
Q

Giant Papillary Conjunctivitis grading

Grade 1/Pre-clinical: ..., ... papillae, ... symptoms
Grade 2/Mild: ... injection, ...-...mm papillae, ... symptoms
Grade 3/Moderate: ... injection, ...mm papillae, ...
Grade 4/Severe: ... injection, ...mm papillae, ...

Most CL wearers will be Grade ... and may ... over time. As it progresses, some people might just ... despite ... as ....

A

Giant Papillary Conjunctivitis grading

Grade 1/Pre-clinical: slight conjunctival redness, fine papillae, no symptoms
Grade 2/Mild: mild injection, 0.3-0.5mm papillae, mild symptoms
Grade 3/Moderate: moderate injection, 0.5+mm papillae, increasing CL awareness
Grade 4/Severe: severe injection, 0.75+mm papillae, contact lens intolerance

Most CL wearers will be Grade 1 and may progress over time. As it progresses, some people might just tolerate it despite the increase in CL awareness as CLs are the only method to get good vision.

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3
Q

Pathogenesis of Giant Papillary Conjunctivitis

Involves ... and ... mechanisms. It’s a combination of Types ... and ... hypersensitivities and is a response to .... There’s an increase in ..., ..., ..., and .... Results in ..., ..., and ....

A

Pathogenesis of Giant Papillary Conjunctivitis

Involves mechanical and immunologic mechanisms. It’s a combination of Types I and IV hypersensitivities and is a response to foreign substance. There’s an increase in mast cells, eosinophils, basophils, and lymphocytes. Results in fibroblast proliferation, collagen growth, and conjunctival papillae under eyelid.

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4
Q

Giant Papillary Conjunctivitis (2)

Differential diagnosis: ..., ..., and ...

Assessment: ..., ..., ..., ..., ..., ..., ...

Treatment:
* Less severe: ... for many months
* More severe: ... for short term
* Review ..., avoid ..., modify lens .../.../..., change ...
* Long term management is ...

A

Giant Papillary Conjunctivitis (2)

Differential diagnosis: VKC, SAC, and SLK

Assessment: history, slit lamp, fluorescein, eyelid eversion, CL inspection, sutures, prosthesis

Treatment:
* Less severe: mast cell stabilisers for many months
* More severe: topical steroid for short term
* Review CL care, avoid overnight wear, modify lens design/modality/material, change CL solution
* Long term management is often required

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5
Q

What is the effect of allergic eye disease on keratoconus?

A

Patients with allergic conjunctivitis are at increased risk of keratoconus, probably due to eye rubbing. Need intensive treatment to prevent keratoconus development.

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6
Q

Allergic conjunctivitis in children

Recommendations for treatment:
* ...
* Mild - ..., ...
* Moderate - .../...
* Severe - ... (caveat), aggressive approach if ..., refer if needs ..., consider ... and/or ...

A

Allergic conjunctivitis in children

Recommendations for treatment:
* Avoid allergen
* Mild - lubrication, cold compresses
* Moderate - antihistamine/mast cell stabilisers
* Severe - short burst steroids (acceptable in children if at risk of shield ulcers and such), aggressive approach if corneal involvement, refer if needs multiple steroid burst, consider allergy testing and/or immunotherapy

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7
Q

Allergic contact dermatitis (1)

It’s a ..., typically affecting ..., ..., and ....

Symptoms: ..., ..., ..., ..., and ....

Causes: ..., ..., ..., ..., ..., and .../...

A

Allergic contact dermatitis (1)

It’s a skin reaction at site of exposure, typically affecting eyelids, periorbital skin, and ocular surface.

Symptoms: redness, itching, swelling, scaling skin, and vesicles.

Causes: metals, shellac, preservatives, topical antibiotics, fragrances, and acrylates/surfactants

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8
Q

Allergic Contact Dermatitis (2)

Pathophysiology
It’s a Type ... hypersensitivity and ... lymphocyte mediated. There’s an ... cycle.

Management
... and ... of causative agent, ...

A

Allergic Contact Dermatitis (2)

Pathophysiology
It’s a Type IV hypersensitivity and Th1 lymphocyte mediated. There’s an itch-scratch cycle.

Management
Identification and removal of causative agent, ointment topical steroids

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9
Q

What is atopic dermatitis?

Definition: ..., also known as ....

Management:
* ...
* ..., which is a ... and .... ADRs include: ..., ..., ..., and ...

A

What is atopic dermatitis?

Definition: chronic inflammation, irritation, and redness of the skin, also known as eczema.

Management:
* allergen avoidance
* Dupilumab, which is a mononucleotide antibody and subcutaneous injection. ADRs include: conjunctivitis, ocular surface disease, periorbital skin changes, and conjunctival cicatrisation

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10
Q

What are the two autoimmune conjunctivitis?

A
  • Ocular cicatricial pemphigold
  • Stevens-Johnson Syndrome
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11
Q

Cicatricial Pemphigold
Definition: ... that results in ...

Systemic features include:
* Affects ... and ... more than ...
* ... affected in 80% of cases
* ... and ...
* ... in up to ...% of cases within ...yrs

A

Cicatricial Pemphigold
Definition: rare, progessive, chronic autoimmune disease that results in recurrent sub-epithelial symptoms of the skin and mucous membranes with a tendency to scar formation

Systemic features include:
* Affects eldery and females more than males
* oral mucosa affected in 80% of cases
* submucosal blisters and scarring of mucosal membranes
* ocular signs in up to 40% of cases within 5yrs

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12
Q

Ocular cicatricial pemphigold signs and symptoms

Ocular signs:
* Commonly ...
* Asymmetric ...
* ...
* Sub-conjunctival ..., ..., and ...
* Chronic ..., ..., ..., and ...

Symptoms: ..., ..., and features of ...

A

Ocular cicatricial pemphigold signs and symptoms

Ocular signs:
* Commonly bilateral
* Asymmetric papillary conjunctivitis
* conjunctival hyperaemia
* Sub-conjunctival blisters, ulceration, and scarring
* Chronic conjunctival inflammation, subepithelial scarring, conjunctival shrinkage, and entropion

Symptoms: burning, watering, and features of surface exposure disease

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13
Q

Ocular Cicatricial Pemphigold ocular complications

  • ...
  • ... due to scarring over ... and destruction of ...
  • ... which is adhesions between the ... and ...
  • ... which is adhesions at the ... between ... and ...
  • ... which is ... due to reduced tears and ... due to entropion
A

Ocular Cicatricial Pemphigold ocular complications

  • conjunctival disease
  • dry eye due to scarring over lacrimal gland ducts and destruction of goblet cells
  • symblepharon which is adhesions between the palpebral and bulbar conjunctiva
  • ankyloblepharon which is adhesions at the outer canthus between upper and lower lids
  • keratopathy which is exposure due to reduced tears and lagophthalmos due to entropion
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14
Q

Treatment of ocular cicatricial pemphigold

  • ... as it must be treated by ... and ... specialists
  • Can give ... and ... immunosuppresive agents
  • ... cytotoxic drugs
  • ... and ... steroids
  • ..., ..., and manage ...
  • Surgical correction of ... and maybe give ...
A

Treatment of ocular cicatricial pemphigold

  • REFER as it must be treated by ophthalmological and immunological specialists
  • Can give topical and oral immunosuppresive agents
  • systemic cytotoxic drugs
  • topical and systemic steroids
  • punctal occlusion, artificial tears, and manage blepharitis
  • Surgical correction of entropion and maybe give mucous membrane grafts
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15
Q

Stevens-Johnson Syndrome (1)

Signs: ... that is ..., affects both the ... and .... Tends to affect ..., ... ..., and ... more than ....

Cause: generally a ... to ..., can be associated with .... Cause is only found in ...% of cases.

Two types:
* Erythema Multiforme Minor - ... involvement
* Erythema Multiforme Major - ..., ..., and ... - ...

A

Stevens-Johnson Syndrome (1)

Signs: acute inflammation that is self-limiting, affects both the skin and mucous membranes. Tends to affect healthy, young individuals, and males more than females.

Cause: generally a hypersensitivity reaction to systemic or topical drugs, can be associated with systemic infections. Cause is only found in 50% of cases.

Two types:
* Erythema Multiforme Minor - only skin involvement
* Erythema Multiforme Major - skin, two mucous membranes, typically the conj, and systemic malaise - SJS

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16
Q

Stevens-Johnson Syndrome (2)

Acute phase: .... Often misdiagnosed as acute phase can .... When the later symptoms appear, they can quickly develop into ... and require ... for treatment.

Symptoms: ..., ..., ..., ..., and .... Also ... which develop every 2-3weeks for 1-2 months.

Signs: ... and ... in oral mucosa/lips and ..., particularly in ...

A

Stevens-Johnson Syndrome (2)

Acute phase: systemic features. Often misdiagnosed as acute phase can resemble other conditions. When the later symptoms appear, they can quickly develop into scarring and require immunosuppressants for treatment.

Symptoms: fever, malaise, sore throat, cough, and headache. Also skin lesions which develop every 2-3weeks for 1-2 months.

Signs: bullae and erosion in oral mucosa/lips and skin lesions, particularly in extremities

17
Q

Stevens-Johnson Syndrome - ocular aspect

Occurs in ...% of cases

Acute phase:
* ...
* ...
* Conjunctival ..., ..., and ...
* Could have ... or ...
* Could have ...

Long term complications
* Conjunctival ... and ...
* ... and ... problems
* ...
* ...

A

Stevens-Johnson Syndrome - ocular aspect

Occurs in 60% of cases

Acute phase:
* papillary conjunctivitis
* focal red ischaemic areas
* Conjunctival redness, blisters, and ulceration
* Could have pseudomembranes or membranes
* Could have purulent conjunctivitis

Long term complications
* Conjunctival scarring and symblepharon
* dry eye and exposure-related problems
* lacrimal drainage obstructions
* epiphora

18
Q

Stevens-Johnson Syndrome - treatment of systemic aspect

  • ...
  • ...
  • ... may be required if using multiple medications

Refer!
* ... is often necessary for acute phase
* Need to treat ...
* ... or ... steroids

A

Stevens-Johnson Syndrome - treatment of systemic aspect

  • eliminate causative agent
  • advise against future use of drug class
  • allergist may be required if using multiple medications

Refer!
* hospitalisation is often necessary for acute phase
* Need to treat long term ocular complications
* topical or systemic steroids

19
Q

Stevens-Johnson Syndrome - treatment of ocular aspect

  • ... or ...
  • ... - ... of eyelash follicles
  • ... CLs to provide ... and not ...
A

Stevens-Johnson Syndrome - treatment of ocular aspect

  • artificial tears or punctal occlusion
  • surgery - cauterization of eyelash follicles
  • scleral CLs to provide physical protection and not optical correction
20
Q

Immunotherapy
* Training ... to be less sensitive to allergens
* Requires allergen exposure to be: ..., ..., and .... Treat needs ...-... years.
* Both types are highly effective for allergic eye disease; resulting in ... and less reliance on ...

A

Immunotherapy
* Training immune system to be less sensitive to allergens
* Requires allergen exposure to be: at high dose, constant, and long. Treat needs 3-5 years.
* Both types are highly effective for allergic eye disease; resulting in improved symptoms and less reliance on topical medications

21
Q

Types of immuntherapy

Subcutaneous (SCIT) is effective against ... but inconvenient as .... Risks include ... and ....

Sublingual (SLIT) is effective against ..., in particular ... or .... It’s a ... dose at home where no ... or ... are required; still an issue with .... Risks include ... and ....

A

Types of immuntherapy

Subcutaneous (SCIT) is effective against all types of allergens but inconvenient as requires 4-8weekly visits. Risks include local reaction to needle and low risk of anaphylaxis.

Sublingual (SLIT) is effective against fewer allergens, in particular grass or dust mites. It’s a daily dose at home where no needles or injections are required; still an issue with compliance. Risks include very frequent but mild local AE and very rare systemic effects.