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- Conjunctivitis -
11/23/04 re: Difference between two conjunctival challenge tests I was hoping you could clarify the difference between the seasonalallergic conjunctivitis SAC ocular allergen testing models? Specifically the difference between the Conjunctival Allergen Challenge(CAC) and the Allergen-specific conjunctival challenge (ASCC)? The only definitions I found online were:
(1) Allergen-specific conjunctival challenge (ASCC) is a safe andreproducible experimental model of allergic conjunctivitis and a usefultool in the evaluation of effectiveness and possible mechanisms ofaction of drugs commonly used in the treatment of allergic diseases.
(2) Conjunctival allergen challenge (CAC) model has allowed precisecontrol of confounding factors that are present in the typicalenvironmental study and has helped to evaluate and bring to market effective medications for ocular allergy. The model has also been very useful in elucidating the allergic and inflammatory mechanisms of the ocular surface, in identifying the cells and mediators that are involved, and in identifying targets for novel therapies.
To respond to your question, I obtained input from Dr. Leonard Bielory of the UMDNJ, Asthma and Allergy Research Center , New Jersey Medical School, Newark, New Jersey. Dr. Bielory is an expert in ocular allergy (see enclosed abstract for a representative publication by him). Dr. Bielory's comments are enclosed below.
Dr. Bielory's comments:
There are no differences between the two studies mentioned. The FDA recognizes a conjunctival provocation study and an environmental chamber study.
Curr Opin Allergy Clin Immunol. 2002 Oct;2(5):435-45.
Topical immunopharmacology of ocular allergies.
Bielory L, Kempuraj D, Theoharides T.
Department of Medicine, UMDNJ, Asthma and Allergy Research Center, New Jersey Medical School, Newark, New Jersey, USA. bielory@umdnj.eduPURPOSE OF REVIEW: To review the histamine-1 receptor antagonists, mast cell blockers and natural agents with such actions that can be used for the topical treatment of ocular allergies.
RECENT FINDINGS: Increasing evidence indicates that some histamine-1 receptor antagonists have additional actions to inhibit secretion of inflammatory mediators, especially cytokines, from ocular mast cells and other cell types. Emerging information suggests that such actions may be through regulation of intracellular calcium ion levels of NF-kappaB activation.
SUMMARY: A number of available drugs and natural non-prescription agents may have anti-histaminic and anti-inflammatory actions.6/11/02 re: Conjunctivitis in a 3 year old child 3 yr. old boy with itchy red eyes since April, responds only to oral steroids, Pricks positive to Ragweed, dust mites and molds. No nasal symptoms, at age 1 had some wheezing, cleared with Albuterol neb. Has no other symptoms. Anti histamines, eye drops are not helpful. What are your thoughts? I have not participated in the care of very young children for many years, Therefore, I consulted Dr. Susan Schuval, a very experienced Pediatric Allergist/Immunologist and a member of our AADMC Medical Advisory Committee , about your message. Dr. Schuval's response is enclosed below. I would strongly agree with her suggestion to obtain consultation with an opthalmologist. very experienced in the eye problems of young children.
I would wonder if this is truly allergic conjunctivitis. The absence of associated rhinitis symptoms, lack of response to the usual measures (antihistamines, ophthalmic preparations), and need for oral corticosteroids call the diagnosis into question. Are the parents practicing pollen and mite avoidance measures? Are they compliant with the prescribed medications? Is there a strong family history of atopy?
I think that you have to consider other ophthalmic disorders in your differential diagnosis. I would consider other allergic diseases such as vernal conjunctivitis, atopic keratoconjunctivitis or ocular contact dermatitis, chronic infection, and rheumatologic disorders.
Vernal conjunctivitis commonly begins in the spring and is characterized by severe ocular pruritus. Cobblestoning of the lids is often seen with conjunctival hyperemia. This is usually seen in prepubertal males (usually > 6 years old). Treatment usually consists of topical cromolyn but topical steroids may be required. Atopic keratoconjunctivitis is seen in patients with underlying atopic dermatitis. Eye itching and rubbing are the predominant symptoms. Complications such as cataracts and corneal scarring may occur if the condition goes untreated.
Rheumatologic disorders such as Juvenile Rheumatoid Arthritis, sarcoidosis, systemic lupus erythematosus, and Reiter's Syndrome may present with ocular findings. Does the child have any other systemic symptoms such as fever, arthralgias, dermatitis, or urethritis? If so, laboratory testing including ESR,ANA, antibodies to double stranded DNA, and rheumatoid factor may be warranted. A slit lamp examination may also be needed to exclude chronic eye disease.
Chronic eye infections such as Toxocara and tuberculosis may also cause chronic ocular symptoms.
Again, examination by an ophthalmologist may be needed to exclude these diagnoses.
4/8/02 re: Medications for ocular allergies in a young child With a 14 month old child with chronic ocular allergies, what medication is recommended? I am an optometrist. All the literature I have (dated early 2001) indicates no ocular medication is approved for under the age of 2 years. Is there anything more current than the information I have? Alomide (Alcon) is approved for 2 years and older. Alamast and Alocril as chronic care products are approved for 3 years and older. Among the acute care products, Emadine, Patanol and Zatidor are approved for 3 years and older. What should I recommend? I referred your question to Dr. Leonard Bielory, Chief of Asthma and Allergy Center in the New Jersey Medical School in Newark, New Jersey. Dr. Bielory has been a long-time investigator of allergic problems in the eyes. His reply is enclosed below. I would suggest that you obtain written consent from the parents of the patient before using any of the medications you listed, since such medications are not FDA-approved for children less than 2 years old. I would also suggest evaluation of the patient by an experienced Pediatric Allergist to document underlying allergies playing a causal role in the eye problems. Recommendations by this allergist for avoidance and other measures may be indicated. There are no "approved" medications for children under age 2 years. Falling with in FDA approved therapeutic interventions, the first line treatment would be to use ocular lubricants such as Genteal, Hypotears and others which can provide a form of environmental control by decreasing environmental contact with specific allergens.
However, I have personally used many of the above medication in children under age 2 without complications. However, I clearly evaluate whether the infant has allergies before I start on the medication. It is unusual for a 14 month old to have "ocular allergies" alone. If there is epiphora without conjunctival injection, I would include the possibility of occluded puncta.
12/6/99 re: Causes of red eye in children Looking for info related to Pediatric Red Dye Allergies, please forward any links you can provide. Adenovirus-induced conjunctivitis is the most common cause of bilateral "red eye". Allergic conjunctivitis and blepharitis are other common, more benign causes of "red eye" in children. Sudden onset of pain, visual loss or a "ciliary flush" on exam of the eye should raise the possibility of a more severe problem. At your request I am enclosing references to 2 publications available through Medline, that deal with this subject. I purposely picked one from a Nursing publication in view of your background.
