Case 1
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32-year-old white female complaining of itchy eyes (especially in corners; no burning). History of seasonal and ocular allergies since childhood. Had been taking Allegra-D, which took care of ocular itching, but discontinued because insurance company no longer covered the cost. |
Took Patanol bid and it worked but there is now a $50 copay she cannot afford. OTC ocular allergy meds and Claritin do not work for itching. She has punctal plugs (insurance company would pay), but do not relieve the itch.
VA 20/20 OD, OS; no conjunctival injection; grade 1 papillae on lower and upper palpebral conjunctiva; TBUT >10 secs OD, OS.
Assessment: Mild allergic conjunctivitis.
Plan: Optivar bid (because of cost); consider mast cell stabilizer (Crolom) in future plus steroid for acute problem; refer to allergist.
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Seasonal Allergic Conjunctivitis (SAC)
Significant dry eye plus allergic conjunctivitis:
Topical antihistamines or antihistamine/mast cell stabilizer may cause increase drying and exacerbate the problem. Treatment with artificial tears + steroid + mast cell stabilizer. Oral antihistamines may be drying out eye; consider having patient switched to nasal inhaler.
Palliative treatment: Artificial tears, cold compresses.
Mild to Moderate Allergic Conjunctivitis: Mast cell stabilizer/antihistamine . . . which one? Optivar because lower cost.
Significant/severe allergic conjunctivitis: Steroid plus mast cell stabilizer . . . which one? Lotemax or Alrex + Alocril. Taper steroid after 2 weeks and continue the mast cell stabilizer.
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Case 2
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28-year-old white male having difficulty wearing contact lenses (Proclear); can only wear 4-6 hours comfortably. Reports that they itch and burn (especially when removing).
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VA 20/20 OD, OS with contact lenses. Grade 3+ papillae on upper conjunctiva; palpebral lids.
Assessment: Giant papillary conjunctivitis (GPC).
Plan: Discontinue lens wear for 1 month. Rx Lotemax for 1 week (qid); then discontinue. Switch to Focus Dailies.
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Giant papillary conjunctivitis (GPC)
Traditional therapeutic strategies:
- Decrease wearing time
- Switch to disposable contact lenses
- Consider daily disposable lenses
- Consider extra strength daily cleaner or increasing enzyme use
Controversial as to best treatment with drops. Author recommends one of the following:
- a mast cell stabilizing antihistamine--OR
- a topical steroid alone (if patient discontinues lens wear)--OR
- a mast cell stabilizer (start out qid and then go to bid) plus a topical steroid drop (Alrex or Lotemax qid); discontinue steroid drop after 1-2 weeks; continue with mast cell stabilizer.
Allergy drops can be used with contact lenses (preferably disposable).
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Case 3
VA 20/80 OD, OS. Signs: 4+ SPK OU, 3+ conjunctival injection OU, ectropia OU with red scaly lids, grade 1 papillae OU.
45-year-old white female complaining of chronic ocular irritation and redness for several years. History of eczema. Has used punctal plugs, topical steroids, artificial tears, allergy medications with no improvement in symptoms.
Assessment: Atopic keratoconjunctivitis.
Post treatment with Tacrolimus |
Plan: Tacrolimus bid OU to lids. Improvement in lids, conjunctiva, and cornea; VA 20/30 OD, OS. |
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Atopic Keratoconjunctivitis (AKC)
Treatment: Avoid eye rubbing, precipitating factor, or antigen. Do palliative treatments.
- Acute management: Mast cell stabilizer (Alocril or Alamast) + steroid (Alrex or Lotemax) 2 weeks qid then taper --OR-- Mast cell stabilizing antihistamine.
- Long-term management: In future, use mast cell stabilizer before exacerbation occurs if possible.
- Skin condition: Treat with an immunosuppressant cream--either Elidel (primecrolimus cream 1%) or tacrolimus (0.03%) cream bid --OR-- a topical steroid cream.
Refer to allergist for allergy workup.
Elidel was developed as a systemic agent for the prevention of organ transplant rejection. It is an
immunosuppressant creme that works by suppressing T lymphocytes and cytokines. Elidel applied to the lids has been shown to have a therapeutic effect on conjunctiva and cornea. Typically, the cream is applied bid and, over time, applications can be reduced to the level that keeps the patient's disease under control. Elidel is safe for children 2 years of age. Side effects include itching and burning at the application site (which improves over time) and could reactivate herpes eye disease. |
Case 4
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19-year-old white male complaining of "right eye watering, stinging, eyes matted all the time." History of seasonal and "skin" allergies (no history of eczema or asthma). History of acute allergic and bacterial conjunctivitis since age 6. Current diagnosis of chronic allergic conjunctivitis.
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Using Patanol bid OU x 1 year. Wearing contact lenses since age 11. Currently wearing Acuvue 2 OU; replaces every 2 weeks.
Assessment: Vernal keratoconjunctivitis (VKC).
Plan: Continue Patanol bid OU; add Vexol qid for exacerbations.
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Vernal keratoconjunctivitis (VKC)
Acute treatment:
- Author recommends mast cell stabilizing antihistamine (Optivar may be least expensive) OR
- Topical steroid plus mast cell stabilizer.
Long-term treatment: Mast cell stabilizer. |
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