ALLERGIC CONJUCTIVITIS

2. DEFINITION:-
It is inflammation of conjunctiva due to allergic / hypersensitivity
reactions which may be immediate(humoral) (or) delayed (cellular)
- It is most common because conjuctiva is ten times more sensitive than
skin to allergens
• TYPES:-
a) Simple allergic conjunctivitis
b) Vernal conjunctivitis (VKC)
c) Atopic keratoconjunctivitis (AKC)
d) Gaint papillary conjunctivitis (GPC)
e) Phlyctenular keratoconjunctivitis (PKC)
f) Dermato conjunctivitis (ADC)
Seasonal allergic conjunctivitis(SAC)
Perennial allergic conjunctivitis(PAC)

3. - Mild non specific allergic conjunctivitis characterized by
itching , hyperaemia , mild papillary response
- It is an acute / sub acute urticarial reaction
ETIOLOGY:-
• Type-1hypersensitivity – meidated by IgE & mastcell activation
a) Seasonal alleric conjuctivitis –
b) Perennial allergic conjunctivitis –
Features :-
- Due to seasonal allergens(tree & grass pollen)
- assosciated with hay fever (allergic rhinitis)
- Also known as hay fever conjunctivitis
- It manifest as acute allergic conjunctivitis
Features :-
-Due to perennial allergens (dust & mite &
animal dander)
- onset is sub acute
- chronic in nature & present through out year
(SAC is common in occurrence)
(PAC is not common in occurrence)

4. PATHOLOGY:-
It is vascular , cellular , conjunctival responses
a) Vascular –
b) Cellular -
c) Conjunctival -
Sudden extreme vasodilation → ↑ permeability of vessels → exudation
It is in form of conjunctival infiltration &exudation in discharge of eosinophils ,
plasma cells ,mast cells producing histamine & histamine like substances
Boggy swelling of conjunctiva followed by ↑connective tissue
formation & mild papillary hyperplasia
Symptoms:-
-Intense itching & urning sensation of
eyes
- watery mucus , tringy discharge
- Mild photophobia
Signs:-
• conjunctiva – hyperaemia & swollen juicy appr.
• palpebral conjunctiva – mild papillary reaction
• Lids - oedema

5. Treatment :-
- Elimination of allergens
- Topical vasoconstrictors(naphazoline , antizoline,
tetrahydrozoline)
- Artificial tears (caboxymethylcellulose – soothing effect)
- Mast cell stabilizers (sodium cromoglycate,nedocromil-prevent
recurrences)
- Dual action antihistamines & mastcell stabilizers
(azilastine,ketotifen – for exacerabations)
- Systemic antihistaminics for marked itching
- Desensitization

6. - It is recurrent , bilateral , self limiting allergic inflammation
of conjunctiva having periodic seasonal incidence
Pathogenesis :-
a) due to Th2 lymphocyte alteration
b) due to type 1 mediated hypersensitiviy
Predisposing factors:-
a) Age & sex – more in boys and b/w (4-20 yrs)
b) Season – more in summer but spring catarrh is misnomer now
it is believed to be warm weather conjunctivitis
c) Climate – more in tropics than temperate regions

7. Pathology:-
a) Conjuctival epithelium – hyperplasia and downward
projections in to sub epithelial tissue
b) Adenoid layer – infiltration with lymphocytes , plasmacells,
histiocytes , eosinophills
c) Fibrous layer – proliferation & undergoes hyaline changes]
d) Conjunctival – proliferation & ↑ permeability→vasodilation
SYMPTOMS:-
- Burning & itching sensation more in warm atmosphere
- Other – photophobia , lacrimation,heavylids,stringy discharge
vessels

8. SIGNS :-
PALPEBRAL FORM BULBAR LIMBAL FORM
Upper tarsal conjunctiva of both eyes involved Bulbar conjunctiva – dusky red congestion seen
Lesion – papillae are cobble stone/pavement
stone fashion
Conjunctiva – hyperemia
Gelatinous thickening around limbus
Papillae under go hypertrophy and →cauliflower
like gaint papillae
Horner tranta’s spots – whitish raised dots
around limbus

9. 3) Mixed form – shows features of palpebral and bulbar forms
Vernal keratopathy :-
- Cornea mayinvolved in vkc may primary & secondary due to
limbal extensions and type of lesions seen are
1) Punctate epithelial keratitis
2) Ulcerative vernal keratitis
3) Vernal corneal plaques
4) Sub epithelial scarring
5) Pseudogerontoxon
Clinical course – self limiting & burns out after 5-10 yrs
DD – sholud differentiated from trachoma and papillary
hypertrophy

10. Treatment:-
a) Topical anti inflammatory theraphy
i. Topical steroids – commonly used are fluromethalone,medrysone,betamethasone,
ii. Mastcell stabilizers – sodium cromoglycate(2% drops) 5 times a day
iii. NSAIDs eye drops – ketorolac , diclofenac
iv. Topical cyclosporine – immune modulator
v. Tacrolimus – (0.03%) immune modulator ointment
b) Topical lubricating & mucolytics
- Artificial tears (carboxymethyl cellulose for soothing effect)
- Acetyl cysteine topically with mucolytic propeties for early plaque formation
c) Systemic theraphy of oral anihitaminics and steroids for relief
d) Large papillae need supratarsal inj. Of long acting steroids
/cryoapplication /surgical excision for very large papillae
e) Dark goggles for photophobia ,cold compress,change of place in to cold
areas advised
f) Desensitization is tried
g) Vernal keratopathy is treated
dexamethasone

11. It is adult equivalent of VKC often associated with atopic dermatitis
PATHOLOGY:-
Inflammatory changes of cornea and conjunctiva are due to both
type 1 & type 4 hypersenstivity
SYMPTOMS:-
- Itching , soreness , Dry sensation
- Mucoid discharge
- Photophobia & blurred vision
SIGNS:-
a) Eyelid signs
- lid margins inflammed with rounded posterior borders
- Extra lid folds due to rubbing of eyelids
- HERTOGHE’S sign (loss of lateral eyebrows)

12. b) Conjunctival signs
♦ Tarsal conjunctiva – Milky appearance
♦ Bulbar – chemosed & congested
♦ limbal conjunctiva – gelatinous deposits & Trantas dots are seen
c) Cornea signs
♦ puntate epithelial erosions – lower half of cornea
♦ persistent epithelial defects
♦ plaque formation & peripheral vascularisation
- May assossciated with atopic cataract & keratocon
TREATMENT :-
- similar to VKC & lid margin inflammation , facial eczema treated by
oral NSAID’S , oral antibiotics

13. GPC is inflammation of conjuctiva with very large sized papillae
ETIOLOGY:-
- Mechanically induced papillary conjuctivitis is localised allergic response
to a physically rough or deposited surface (contactlens,prothesis,exposed
nylonsutures,scleralbuckle)
CLINICALFEATURES:-
Symptoms – itching,stringy discharge
Signs – papillary hypertrophy of upper tarsal conjuctiva similar to palpebral
form of VKC with hyperemia changes
TREATMENT:-
a) Offending cause to be removed
b) Mast cell stabilizer –sodium cromoglycate for relief]
c) Combined antihistamines & mastcell stabilizers – azelastine,olopatadine
d) Steroids – reistant cases

14. It is characteristic nodular affection occuring as an allergic
response of conjunctival & corneal epithelium due to
senstivity of endogenous allergens.
ETIOLOGY:– Type4 hypersensitivity due to microbial allergens so
also called as microbial allergic conjunctivitis
Causative allergens
Predisposing factors
Tuberculous protiens
Staphylococcus protiens
others – moraxella protiens and worm infestation
Age & sex – more in girls b/w 3-15 yrs
Living conditions & seasons – over crowded &
unhygienic and more in spring & summer seasons
Under nourished children

15. PATHOLOGY:-
a) Stage of nodule -
formation
b) Stage of ulceration –
c) stage of granulation –
d) Stage of healing -
SYMPTOMS – irritation , reflex watering ,irritation ,mucopurulent
conjunctivitis due to secondary bac .infection
Features :-
- Due to exudation & infiltration of leucocytes in to deeper layers of conjunctiva
- central cells are polymorphonuclear
- peripheral cells are lymphocytes
FEATURES :-
-Ulcer is formed due to necrosis at the apex of the nodule
- leucocyte infiltration occurs with increase in plasma cells & mastcells
Floor of ulcer becomes covered by granulation tissue
Healing occurs minimal with scaring

16. SIGNS :- phlyctenular conjunctivitis (PC)
1) Simple PC –
2) Necrotizing PC –
3) Miliary PC –
Phlytcenular keratitis – If cornea is involved secondary to
conjunctival phlycten or rarely as primary disease
a) Ulcerative phlyctenular keratitis
b) Diffuse infiltrative phlyctenular keratitis
FEATURES :-
- presence of pinkish wite nodule surrounded by hyperemia on the bulbar conjunctiva near the
limbus
FEATURES :-
- Presence of very large phlytcen with necrosis & ulceration
FEATURES :-
- Presence of multiple phlyctens arranged in form of ring around limbus → ring ulcer

18. A) ULCERATIVE PK :-
i. Sacrofulous ulcer – shallow marginal ulcer formed due to
breakdown of small limbal phlycten
ii. Fascicular ulcer – contain prominent parallel leash of blood
vesels
iii. Miliar ulcer – multiple small ulcers are scattered over portion
or whole cornea
B) DIFFUSE INFILTRATIVE PK :-
Appears in form of central infiltration of cornea with more
vascularization from periphery all around the limbus

19. MANAGEMENT:-
a) Local therapy
1) Topical steroids - Dexamethasone & betamethasone
2) Antibiotic drops and ointment for 20 bac. Infections
3) Atropine ointment – when cornea involved
b) Specific therapy
1) Anti Tb drugs – if Tb is ruled out
2) Systemic antibiotics – if septic focus of adenoiditis etc..,
3) Parasitic infestation is ruled out and eradicated
c) General measures – high protien supplement with Vit A,C,D

20. - Allergic disorder involving conjunctiva & skin of lids along
with surrounding area of face
ETIOLOGY :- Delayed hypersensitivity to prolonged contact eith
drugs & chemicals
Opthalmic drugs – atropine , pencillin , neomycin , soframycin
Clinical features:-
a) Cutaneous – weeping eczematous reaction in areas where
medication comes in contact
b) Conjuctiva – hyperemia with papillary response involving
lower fornix than upper
c) Cornea – punctate epithelial keratitis & erosions
(Causing this type of conjuctivitis)

21. - Diagnosis by symptoms & conjunctiva cytology shows
lymphocytic response with masses of eosinophills
TREATMENT:-
a) Discontinuation of drug
b) Topical steroid drops for releving symptoms
c) Steroid ointment on involved skin