Ocular Allergies Eye allergies and allergic eye symptoms and causes by Lawrence Schwartz, M.D.

Did you realize that many of the eye irritations you experience are allergic in nature? Here Dr. Lawrence Schwartz unravels the mysteries of eye allergies and gives some recommendations for treatment based on his patients he sees in his practice in Los Angeles.

Q. What exactly are eye allergies?

A. The eye and eyelid are a very common site for allergic reactions. About 50 % of conjunctivitis (inflammation of the whites of the eye) seen by primary physicians is allergic in nature. The eyelid is connected directly to the covering of the white of the eye called the conjunctiva. Because the skin of the eyelid is so thin (because it has to stretch) it is especially prone to minimal irritants, such as cosmetics or even detergents used on pillowcases. Allergic eye conditions may be significantly under diagnosed. The symptoms may persist long after the allergic exposure.

Q. When do allergic eye symptoms occur?

A. Allergic eye symptoms may be seasonal, usually in the late spring or fall when pollen counts are the highest. This is called Vernal Conjunctivitis (vernal for summer). This is common in persons with allergic rhinitis, asthma, and eczema or hay fever. Up to 80% of hay fever patients may have allergic eye conditions. Ocular allergy comes when histamine is released from mast cells. Pollen and dust come in contact with the mast cells of the conjunctiva producing what is called a type one hypersensitivity reaction with release of histamine and other mediators leading to inflammation. The symptoms include burning, itching, watery discharge that is often thick and is accompanied by nasal discharge and other allergic symptoms.

Q. What causes allergy of the eye? Are there different types?

A . There are many causes and types of ocular allergies. Eczema refers to an allergic eyelid inflammation, with redness, vesicles, crusts, oozing, scales, and itching of the lids. Psoriasis and seborrhea dermatitis are related conditions. Allergic lid edema may be part of a systemic allergic reaction to drugs, bacteria or parasites, food such as shellfish, or generalized urticaria or angioneurotic edema. Many patients give a history of eating shrimp and then the eyes swell. Insect bite, ultra violet exposure or sunlamp, contact with irritants can lead to severe eyelid swelling. Because of the thinness and laxity of the skin of the lids, this swelling may be more extreme than in other parts of the body, but is usually benign and will respond to appropriate treatment. Contact Dermatoconjuncticviatis involves the conjunctiva and the surrounding skin. It is often secondary to eyedrops or cosmetics. Neomycin-containing preparations are the most commonly implicated ophthalmic antibiotics. Atropine, local anesthetics, and some glaucoma medications, including alphagan, Iopidine, and Trusopt are occasional offenders. Various sprays, colognes, clothing, jewelry, metals, and plastics, as well as soaps and detergents mat also be offending antigens, and can be eliminated after careful detective work. There is usually no family allergic history. Blepharitis is an inflammation of the eyelid margins, often from a combination of an infectious agent (bacterial, viral or fungal) and an allergic reaction to the organism or it's protein deposits. Stapylococcus aureus or epidermidis are the most frequently involved bacteria. The lid margins may be scaly and red with dandruff or crusts on the lashes, Burning, itching, tearing, and light sensitivity are common symptoms. This is a common condition that can be controlled with local treatment, but usually not cured, and requires daily treatment including washing and rinsing. Vernal conjunctivitis usually occurs in children and is most common in warm weather. It is often in both eyes and may be recurrent. It is characterized by severe itching, and a thick mucous discharge, which contains many allergic cells, called eosinophils. Large papillae may form on the conjunctiva under the upper lid and white dots or spots may form on the cornea. Vernal ulcers may be present on the upper part of the cornea. This comes with the summer weather. Contact lens conjunctivitis is known as Giant Papillary Conjunctivitis (GPC) and is quite common. It is believed due to an allergic reaction to either the contact lens, protein deposits on the lens, or sometimes, the preservative in the contact lens solution. It is characterized by increased mucous discharge in the morning, burning and itching, slight blurring of vision after a few hours wearing time, and progressively increasing lens intolerance. It is more common in hard contact lens wearers and least common in those with disposable lenses, especially the one-day or one week types. Sleeping in contacts greatly increases the risks of developing GPC.

Q. How are allergies for the eyes treated?

A. Although the etiology may vary, the treatment for ocular allergic problems is the same. The first goal is prevention, as allergies are often chronic. The second goal is relief of the major symptom of itching, and the third is the cosmetic relief of the red eye. First and foremost are appropriate behavioral modifications when appropriate. Ocular hygiene is also very important. Avoidance of exposure to offending allergens is critical. This may involve avoiding pets if sensitive to animal dander, staying inside when the pollen count is high, eliminating rugs or drapery from the bedroom, frequent vacuuming or the use of special electrostatic air cleaners. Offending foods, clothing, makeup, detergents, sprays, or medications should be avoided. Hands should be washed frequently, and care should be taken to avoid touching the eyes. Dust proofing the bedroom may be needed. Drive only with windows closed. Close bedroom window because plants pollinate at 5 AM. Patients with GPC may have to temporarily discontinue their contact lens wear, change their type of lens or lens solution, reduce their wearing time, or switch to a daily disposable contact lens for occasional use. The giant papillae under the lid may persist for months despite these measures. Ocular medications, such as Cromolyn or Alomide, which prevent degranulation of the mast cells, preventing histamine release, are often used in this condition, sometimes for several months. These medications should not be used while contact lenses are worn. Cold compresses may be useful in providing initial symptomatic relief, as are artificial tears, readily available over the counter (OTC) to dilute the allergens. Patients often try OTC drops first to relieve their symptoms of red, itchy eyes. While these may be effective, they don't get to the underlying inflammatory process. The relief is often temporary, and there may be a rebound effect, with further release of histamine from the mast cell with continued redness and itching. The OTC drops are often a combination of vasoconstrictors and anti-histamines, and include drugs such as Vasicon A, Naphccon-A, AlbalonA and Ak-Con-A. More effective prescription medications include mast cell stabilizers, such as Alomide and Crolon which are helpful in GPC and seasonal allergic conjunctivitis, and Livostin, which is a potent anti-histamine. Alomide is a non-steroidial anti-inflammatory (NSAID) which stabilizes the mast cell and serving as a histamine antagonist. It is used two to three times daily and provides up to eight hours of relief. All of these drops may cause burning and stinging upon installation. Allergic eye conditions that are unresponsive to the above or are part of a systemic condition may require topical or even systemic steriods. HMS, FML, and Vexol are lower strength steroids that have been used, but caution must be taken because of potential long term steroid side effects, including elevated introcular pressure and cataracts. Alrex is a new short-acting steroid with fewer side effects and shows great promise in allergic eye disease. In summary, try to discover what is causing you eye allergy and then avoid it as you would for any allergy product. It may take considerable trial to find the mascara preparation that agrees with you. But it doesn't mean that the more it costs the better. Often it is the reverse. Immediately use cold compresses for itching and swelling.
Lawrence J Schwartz, MD
Board Certified in Ophthalmology
Staff Cedars Sinai Hospital
8635 W. 3rd St. Suite 390W
Los Angeles, Ca 90048
e-mail drschwartz@foreyesight.com