Lecture on Allergic Conjunctivitis for 4th year MBBS Undergraduate Students by Prof. Dr. Hussain Ahmad Khaqan

1. Allergic Conjunctivitis
Prof. Dr. Hussain Ahmad Khaqan
 MD
 FRCS(Glasgow)
 FCPS(Ophth.)
 FCPS(Vitreo Retina)
 MHPE (KMU)
 CICO(UK)
 CMT(UOL)
 Fellowship in Medical Retina (LMU, Munich)
 Fellowship in Vitreo Retinal Surgery (LMU, Munich)
 Consultant Ophthalmologist & Retinal Surgeon
Professor of Ophthalmology
Lahore General Hospital, Lahore
Ameer Ud Din Medical College, Lahore
Post Graduate Medical Institute, Lahore
Shaukat Khanum Memorial Cancer Hospital & Research Centre ,Lahore

2. DEFINITION
• Allergic conjunctivitis is a type I immediate
hypersensitivity reaction mediated by
immunoglobulin E (IgE) and subsequent mast-cell
activation, stimulated by direct exposure to
environmental allergens.

3. TYPES
• Seasonal (grass, tree, weed pollens, ragweed)
• Perennial (animal dander, house dust mite)
• Vernal keratoconjunctivitis (VKC)
• Atopic keratoconjunctivitis (AKC)

4. Vernal keratoconjunctivitis (VKC)

5. DEFINITION
• There is both type I hypersensitivity and a cell-
mediated role with a predominantly Th2 cell
type.

6. TYPES
• Tarsal/palpebral form
• Limbal form
• Mixed

7. SYMPTOMS
• Itching
• Thick mucus discharge

8. SIGNS CONITUNE..
• Tarsal signs: flat-topped giant (‘cobblestone’)
papillae on superior tarsus.
• Limbal signs: limbal papillae, white trantas dots
(eosinophil aggregates).
• Keratitis: superior punctate epithelial erosions,
vernal ulcer with adherent mucus plaque (may result
in subepithelial scar), pseudogerontoxon.

9. Figure: Cobblestone appearance of
giant papillae
Figure: Horner trantas dots
Figure: Vernal shield ulcer Figure: Pseudogerontoxon

10. TREATMENT continue..
• Topical: Mast cell stabilizer (e.g. sodium
cromoglicate 2% g 4×/d) ± topical steroid ±
ciclosporin (either 2% g or 0.2% 3–4×/d);
consider mucolytic (e.g. acetylcysteine 5%
4×/d).
• Acute exacerbations: Topical steroids (e.g.
dexamethasone 0.1% Preservative Free (PF)
hourly), fluorometholone 0.1% 1–2×/d). 2%
ciclosporin drops and 0.2% ciclosporin
ointment.

11. • Systemic: immunosuppression, in conjunction
with dermatologist/clinical immunologist; if
using immunosuppressant’s, consider antiviral
(e.g. aciclovir 200mg 5×/d or 400mg 2×/d), as
these patients are vulnerable to herpes
simplex keratitis.
• Surgical: debridement or superficial lamellar
keratectomy to remove plaques/shield ulcers.

12. Atopic keratoconjunctivitis (AKC)

13. DEFINITION
• This is a mixed types I and IV hypersensitivity
response, but with a higher Th1 cell type component
than in vernal disease.

14. SYMPTOMS
• Itching
• Redness
• Photophobia
• Blurred vision (if keratitis)

15. SIGNS CONTINUE..
Lid eczema (often severe)
1. Staphylococcal lid disease (anterior blepharitis)
2. Small tightly packed papillae
3. Featureless tarsal conjunctiva (due to
inflammation); chemosis + limbal hyperaemia
(acute exacerbations); may develop slowly
progressive conjunctival scarring (chronic) with
forniceal shortening.

16. Keratitis:
1. Inferior punctate epithelial erosions
2. Shield ulcers
3. Pannus
4. Corneal vascularization
5. Herpes simplex, or microbial keratitis

17. Figure: Eyelid thickening, conjunctival
congestion
Figure: Palpebral conjunctival papillae
Figure: Corneal vascularization

18. TREATMENT Continue…
1. Topical: as for vernal disease(VKC), including
preservative-free ocular lubricants + mast cell
stabilizer (usually less effective than in VKC) ± topical
steroid (e.g. initially dexamethasone 0.1% hourly) ±
ciclosporin (2% g or 0.2% 3–4 x /d).
2. Systemic: Consider oral antihistamines (may help with
itching) and for severe exacerbations
corticosteroids/immunosuppressants—calcineurin
inhibitors are particularly effective; if using
immunosuppressants, consider antiviral (e.g. aciclovir
200mg 5×/d or 400mg 2×/d), as patients are
vulnerable to herpetic (HSV) disease.

19. 3. Surgical: Consider debridement or superficial
lamellar keratectomy to remove plaques.
4. For lid disease: Consider topical (e.g.
chloramphenicol 1% 4×/d) and oral (e.g.
doxycycline 50–100mg 1×/d 3mo—note
contraindications. Doses as low as 20mg 1x/d
3mo may also be effective) antibiotics.
5. For secandary infective keratitis: topical
antivirals and antibiotics.
6. Skin disease: Liaise with dermatologist; consider
topical tacrolimus to facial skin, periocular
regions to the lid margins.