The effects of systemic medication on ocular allergic disease.

In discussing the topic of systemic treat-ment of immunologic disease, it is im-portant to examine the treatment of ocu-lar allergic disorders, Type I hypersensit-ivity reactions. Surgeons who performcorneal transplants and treat externalocular diseases, commonly employ sys-temic medications in the treatment of im-mune-mediated ocular diseases that arenot Type I hypersensitivity diseases.There are four types of hypersensitivityreactions discussed by the Gell andCoombs and labeled as types I throughIV. Speciﬁcally, Type I is associated withIgE immunoglobulin, Type II is associ-ated with antigen-dependent cell cytotox-icity, Type III disease results from anti-gen-antibody complex deposition insmall blood vessels, and Type IV reac-tions are T cell-mediated diseases.Type I diseases are typiﬁed in the eyeby seasonal allergic conjunctivitis, vernalkeratoconjunctivitis, atopic keratocon-junctivitis, and giant papillary conjuncti-vitis. Type II hypersensitivity are seen inthe eye as Mooren’s ulceration and ocularcicatricial pemphigoid. Type III hyper-sensitivity reactions in the eye includerheumatoid arthritis, systemic lupus, po-lyarteritis nodosa, and Wegener’s Granu-lomatosis. Lastly, type IV reactions aretypiﬁed in the eye by corneal transplantrejection to endothelial cells as seen as aKhodadoust line with T lymphocytes.The differential diagnosis of allergicocular disease is important. Seasonal al-lergic conjunctivitis is the most commonocular allergy and is associated withother forms of allergic diseases, such asallergic rhinitis, sinusitis, and asthma. It’susually seasonal, occurring in the fall andspring, but may be panseasonal. Ad-ditionally, it can last for many years. Typ-ically symptoms and signs are itching,burning, redness, lid edema, and mucousdischarge.Treatment of seasonal allergic conjunc-tivitis usually consists of topical eyedropsincluding antihistamines, topical vaso-constrictors, combination antihistamineand vasoconstrictor medications, mastcell stabilizers, nonsteroidal anti-in-ﬂammatory drugs, and topical steroids invery severe cases.Vernal keratoconjunctivitis is a bilat-eral recurrent disease seen in youngmales, typically between 5 and 14 years ofage with associated atopic disease. Uponeversion of the upper eyelid, one can seethe giant papillae or giant cobblestones.There is another subtype known as thelimbal form. One can observe aggre-gations of eosinophils in a gelatinousconﬁguration at the limbus known asHorner’s dots or Trantas’ dots. Bothpresentations are the same disease, butthe ﬁndings occur in a different location.Children can present with ptosis be-cause the eyelids are very edematous andboggy, and hence heavy. Patients presentwith stringy, ropy mucous discharge, redeyes, cobblestone papillae of the uppereyelid and Trantas’ dots at the limbus.Additionally, patients may have cornealinvolvement with keratopathy as well asshield ulcerations. Patients complain ofmarked itching, tearing, burning, and as-sociated atopic diseases of sinusitis andasthma.Treatment of vernal keratoconjunc-tivitis is typically topical, with a combi-nation of antihistamines, mast cell stabil-izers, topical steroids in pulsed doses,nonsteroidal agents, and cyclosporin A,however, one must be careful when usingthese in children. Systemic treatment be-comes more important in this disease,with oral antihistamines and oral pred-nisone being added. As the diseases be-come more complex and threaten the cor-nea, the oral medications become ofparamount importance.Atopic keratoconjunctivitis is achronic disease. Unfortunately, many ofthese patients are diagnosed very late inlife. Patients have multiple complaintssuch as chronic itching, burning, redness,discomfort.Slit-lamp examination demonstratessubconjunctival scarring from thechronic inﬂammation; the meibomianglands may become totally occluded; andthe tear glands of Zeis and Wolfring maybecome scarred or nonfunctioning be-cause of the subconjunctival ﬁbrosis. Pa-tients have chronically red eyes. As thedisease progresses, one may observe theformation of corneal abrasions becauseof the poor tear ﬁlm.The ocular symptoms in these individ-uals are chronic itching, burning, mucousdischarge, photophobia, and tearing. Theocular signs are symblepharon forma-tion, corneal ulcerations, dry eye, and