Hay fever conjunctivitis:

An Antibody-mediated disease of the

eye
Criteria for Ab mediated diseaseases:
There should be:
1. Evidence of specific Ab in patient’s serum
2. Ag must be identified and characterized
o Ag must be shown to produce immunologic response in the eye of
experimental animals
o Produce similar lesion in animal passively sensitized with serum from
affected animal challenge with specific Ag

The disease can be regard as Ab – mediated

1. Ab to Ag present in high quantity in ocular fluid than serum
2. If abnormal accumulations of plasma cells in ocular lesion
3. If abnormal accumulations of Ig present at site of disease
4. If complement is fixed by Ig at the site of the disease
5. If accumulation of eosinophile is present at site of disease
6. If ocular disease is associated with inflammatory disease elsewhere in the
body
7. Any parasite infection / fungi / allergi can cause increase in eosinophile
concentration

What is Hay fever?

Allergic rhinitis triggered by the pollens of specific seasonal plants is
commonly known as "hay fever", because it is most prevalent during haying season.
However, it is possible to suffer from hay fever throughout the year. The pollen which
causes hay fever varies between individuals and from region to region; generally
speaking, the tiny, hardly visible pollens of wind-pollinated plants are the
predominant cause. Pollens of insect-pollinated plants are too large to remain airborne
and pose no risk. An estimated 90% of hay fever sufferers are allergic to grass pollen.
In addition to individual sensitivity and geographic differences in local plant
populations, the amount of pollen in the air can be a factor in whether hay fever
symptoms develop. Hot, dry, windy days are more likely to have increased amounts
of pollen in the air than cool, damp, rainy days when most pollen is washed to the
ground.

The time of year at which hay fever symptoms manifest themselves varies
greatly depending on the types of pollen to which an allergic reaction is produced.
The pollen count, in general, is highest from mid-spring to early summer. As most
pollens are produced at fixed periods in the year, a long-term hay fever sufferer may
also be able to anticipate when the symptoms are most likely to begin and end,
although this may be complicated by an allergy to dust particles.
People affected by hay fever and other seasonal allergies experience
symptoms involving the nose (rhinitis), throat and eyes (Hay fever conjunctivitis.)

Hay fever conjuctivitis

Immunologic Pathogenesis:
• It is associated with a type I immediate hypersensitivity reaction mediated by
the contact of antigens with IgE attached to mast cells lying beneath the
conjunctival epithelium and subsequent mast cell activation.
• Conjunctival mast cell degranulation liberates vasoactive amines (histamine)
and other inflammatory mediators into the tissues and tear film, causing
dilatation of conjunctival vessels (→red eye), increased permeability of blood
vessels (→edema), and itch.
• The reaction may be limited to the eye, or it may be part of a generalized
allergic reaction with nasal and respiratory symptoms.

Predisposing Factors
• Atopic disposition (40% of population of which only half manifest allergic
disease)
• Personal history of allergic disease (hay fever, asthma, eczema, food or drug
allergy)
• Family history of allergic disease
• Exposure to allergens

Manifestations:
Typically bilateral and consists of:
• Lid Swelling (edema) or puffiness of the eyes (periorbital edema in severe
cases)
• Redness (hyperemia) of the conjunctiva and lids that can progress to various
degrees of glassy chemosis with a papillary reaction of the superior tarsal and
bulbar conjunctiva
• Itching (main symptom)
• Tearing
• Watery or Mucoid “stringy”discharge
• Cornea: Uninvolved
Immunologic diagnosis:
• Scrapings of conjunctiva epithelium, stained with Giemsa stains shows many
eosinophils
• Scratch tests of skin with extract of pollens show the immediate type of
respons
• Biopsies of the skin test sites shown of Arthus reaction

Management by Optometrist :
I. Non-pharmacological
• Identify allergen(s)
• Advise avoidance of allergen(s)
• Cold compresses for symptomatic relief
II. Pharmacological
1. H1 receptor agonists
Ex: Levocabastine, emedastine difumarate
• Use for isolated, acute allergic attacks. Use alone or in combination
with mast cell stabilizers and nonsteroidal anti-inflammatory drug
(NSAID) medication

2. Mast cell stabilizers

Ex: Cromolyn sodium 2% qds, lodoxamide 0.1% BID ,pemirolast,
nedocromil sodium 2% BID,
• Most useful for chronic allergies. May take 1–2 weeks to be effective.
Pemirolast and nedocromil have antihistamine effects as well.
Nedocromil also reduces eosinophil and neutrophil chemotaxis

3. Antihistamines with mast cell-stabilizing activity

Ex: Olopatadine 0.1% BID, ketotifen fumarate 0.25% BID, azelastine
0.05% BID
• These medications combine the immediate effect of selective
antihistamines with the long-term effects of mast cell stabilization.
They have convenient twice-a-day dosing.
• Ketotifen and azelastine have anti-inflammatory properties as well

4. Topical NSAIDs
Ex: Ketorolac, diclofenac sodium 0.1% qds
• Can reduce itching but stings when applied
• Can be used to reduce the acute inflammatory response until the mast
cell stabilizers and antihistamines take effect.

5. Vasoconstrictors
Ex: Naphazoline/pheniramine,naphazoline/antazoline
• Available over the counter; instruction must be given to patients to
avoid chronic use and rebound redness
 6. Topical steroids
Ex: Loteprednol, fluorometholone, rimexolone
• May be useful in serious cases or until control is achieved with other
agents. Side effects limit chronic use

7. Oral antihistamines / Systemic antihistamines

Ex: Fexofenadine, loratadine OD, cetirizine OD
• Useful when systemic allergic symptoms are present but may cause
dry eyes
• effective also for other symptoms of hay fever

Possible Management by Ophthalmologist

• Not normally referred. Refer if diagnosis in doubt

Sources:
1. Vaughan & Asbury's General Ophthalmology, 17e
2. Owen CG, Shah A, Henshaw K, Smeeth L, Sheikh A. Topical treatments for
seasonal allergic conjunctivitis: systematic review and meta-analysis of efficacy and
effectiveness.
3. Yanoff & Duker: Ophthalmology, 3rd ed.
4. www.kellogg.umich.edu/patientcare/conditions/hayfever.html
5. http://www.medicineonline.com/articles/H/2/Hay-Fever-Conjunctivitis/Allergic-
Conjunctivitis.html