Ocular symptoms in nonspecific conjunctival hyperreactivity

doi:10.1016/j.anai.2011.03.002

Annals of Allergy, Asthma & Immunology

Volume 107, Issue 1, July 2011, Pages 29-34

https://doi.org/10.1016/j.anai.2011.03.002 Get rights and content

Background

Ocular symptoms can be triggered by nonspecific environmental factors, characterizing conjunctival hyperreactivity (CHR).

Objective

To examine CHR in subjects with ocular symptoms by means of a hyperosmolar conjunctival provocation test (HCPT).

Methods

Sixty-three subjects with ocular complaints (itching, redness, or tearing) were tested for allergy to a common panel of inhalant allergens (Alk Abelló-FDA Allergenic, Brazil). They were considered allergic if tests were positive to at least 1 allergen. HCPT with serial diluted glucose concentrations was positive if it produced conjunctival hyperemia up to a 50% solution. Digital images were analyzed by 2 observers who marked redness in the challenged eyes in red (GIMP 2.6.5 software). The number of red dots of the affected eye was compared with the number of blue dots of the control eye.

Results

HCPT was positive in 6 of 7 grass pollen–sensitive subjects, in 17 of 20 dust mite–sensitive subjects, and in 10 of 11 subjects who were sensitive to both allergens. HCPT was positive in 33 of 38 allergic subjects (87%) and in 4 of 25 (16%) non-allergic subjects; sensitivity was 87%, and specificity was 84%. Significant correlation (r = 0.96 Pearson; P < .0001) was seen between the number of red dots in 23 digitalized images marked by observers.

Conclusion

HCPT indentified CHR in allergic as well as in non-allergic subjects. Allergic subjects exhibited more CHR than did non-allergic subjects. Conjunctival hyperreactivity was present in allergic subjects even when they were asymptomatic. Digital images may be useful for objective evaluation of ocular hyperemia in HCPT.

Introduction

Allergic conjunctivitis (AC) is an immunoglobulin E–mediated hypersensitivity reaction of the eye triggered by environmental airborne allergens, mainly house dust mites and grass pollen.¹ Symptoms usually consist of low-grade ocular or peri-ocular itching, tearing, and red eyes that may be present year-round or seasonally. Nasal symptoms are usually associated with ocular symptoms as “rhinoconjunctivitis,” which is the most prevalent clinical form.²

The number of patients with ocular complaints is high, but epidemiologic studies usually address ocular symptoms as rhinoconjunctivitis, which might lead to the underestimation of AC cases³ and consequently the disease's prevalence.⁴ Approximately 16% of US citizens have allergic rhinitis,⁵ and 40% to 60% of the allergic population present with ocular symptoms combined with other atopic diseases such as asthma, rhinitis, or atopic dermatitis.⁶ In Brazil, no epidemiologic data are available on AC, but it seems to be high and increasing. Riedi et al⁷ found 13.9% prevalence of allergic rhinoconjunctivitis in 1995 (phase I) and 17.2% in 2001 (phase III) in 13- to 14-year-old students, using the International Study of Asthma and Allergies in Childhood written questionnaire, confirming a rise in prevalence of rhinoconjunctivitis in that interval. In Brazilian public ophthalmology reference centers, the chronic and severe forms of ocular allergy (vernal and atopic keratoconjunctivitis) are more frequent than benign forms such as seasonal or perennial allergic conjunctivitis,⁸ and many patients do not undergo any allergy workup for their symptoms in specialized clinics.⁹

Ocular discomfort has become more frequent. It is clinically manifested by conjunctival redness associated with mild and transient itching, burning, tearing, and abnormal light sensitivity that occur a few minutes after exposure to nonspecific stimuli such as wind, light, smoke, or cold or warm air/water. This condition is known as nonspecific conjunctival hyperreactivity,¹⁰ and it may reflect diseases of the ocular surface from different causes.

Nonspecific conjunctival hyperreactivity (CHR) often results from allergic inflammation, but it also may be present in normal subjects without allergy.¹¹ Conjunctival challenges with histamine¹² and hyperosmolar glucose solutions¹³ are used to detect CHR.

The chronic and recurrent pattern of CHR symptoms is similar to those of allergic conjunctivitis, likely to be labeled as allergy. Approximately 60% to 70% of chronic diseases attributed to allergy may originate from structural defects or other non-allergenic factors.¹⁵ Thus, allergy must not be presumed only on signs and symptoms, because both allergic and non-allergic conditions may have similar clinical presentation.

The aim of this study was to detect CHR in subjects with ocular symptoms.

Section snippets

Methods

Sixty-three subjects (12–50 years old) with ocular or nasal complaints were selected for the study from the outpatient Allergy Clinic, Hospital de Clínicas, University of Paraná (Brazil). Inclusion criteria were history of nasal and ocular symptoms such as itching, tearing, red eyes, nasal congestion, aqueous rhinorrhea, and sneezing initiated for more than 1 year. Exclusion criteria were pregnant women, current active conjunctivitis or rhinitis, past or current history of other ophthalmic

Results

Of the 63 subjects, 38 were sensitized to common inhalant allergens (mean age, 31.4 years), and 25 (mean age, 34.4 years) were not sensitized. One nonsensitized subject was excluded from the study for showing intense conjunctival reaction to both the diluent and the glucose solution. In the sensitized group, the proportion of females to males was 60.5%:39.5%, and in the nonsensitized group, it was 84%:16%. Clinical diagnosis of rhinoconjunctivitis was more frequent in sensitized subjects (71%)

Discussion

Nonspecific CHR is characterized by mild ocular redness, itching, tearing, and burning after the ocular surface is exposed to nonspecific triggers such as wind, light, cold or warm air, smoke, water, dust, and other irritants.¹⁷ HCPT with increasing serial glucose concentrations has been used to detect CHR in both allergic and nonallergic subjects, because it reproduces the signs and symptoms of CHR. Although CHR is commonly associated with allergic conjunctivitis, it has also been shown in

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Patients with VKC show hyper-responsiveness to non-specific, non-allergic challenges such as histamine, air pollution or other environmental agents [1057-1060]. Similarly, in DED, both in experimental models and in humans, signs of ocular surface damage are induced by oxidative stress [767,770,772,1062,1063] or commonly encountered environmental factors such as air conditioning and dust, or pollutants such as smoke [772,1061]. Both allergy and DED show a favorable response to topical anti-inflammatory agents such as steroids and cyclosporine.
The TFOS DEWS II Pathophysiology Subcommittee reviewed the mechanisms involved in the initiation and perpetuation of dry eye disease. Its central mechanism is evaporative water loss leading to hyperosmolar tissue damage. Research in human disease and in animal models has shown that this, either directly or by inducing inflammation, causes a loss of both epithelial and goblet cells. The consequent decrease in surface wettability leads to early tear film breakup and amplifies hyperosmolarity via a Vicious Circle. Pain in dry eye is caused by tear hyperosmolarity, loss of lubrication, inflammatory mediators and neurosensory factors, while visual symptoms arise from tear and ocular surface irregularity. Increased friction targets damage to the lids and ocular surface, resulting in characteristic punctate epithelial keratitis, superior limbic keratoconjunctivitis, filamentary keratitis, lid parallel conjunctival folds, and lid wiper epitheliopathy. Hybrid dry eye disease, with features of both aqueous deficiency and increased evaporation, is common and efforts should be made to determine the relative contribution of each form to the total picture. To this end, practical methods are needed to measure tear evaporation in the clinic, and similarly, methods are needed to measure osmolarity at the tissue level across the ocular surface, to better determine the severity of dry eye. Areas for future research include the role of genetic mechanisms in non-Sjögren syndrome dry eye, the targeting of the terminal duct in meibomian gland disease and the influence of gaze dynamics and the closed eye state on tear stability and ocular surface inflammation.
Epidemiology of ocular allergy and co-morbidities in adolescents
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In a case-control study involving 102 subjects, more than three episodes of ocular itching in the last 12 months was predictive of OA with sensitivity of 85.4% and specificity of 85.1%.8 Although not pathognomonic, recurrent ocular itching is the most frequent symptom of OA9 and it is the first symptom observed in allergen conjunctival challenge.10 Patients with blepharitis, eczema, keratoconjunctivitis sicca, and other types of conjunctivitis may occasionally present with ocular itching.11
The prevalence of allergic conjunctivitis (AC) has not been established. Estimates suggest that ocular allergies affect 15% to 20% of the worldwide population, yet most epidemiological studies encompass nasal and ocular allergy symptoms and have not been specific to AC. The aim of this study was to verify the prevalence of ocular allergy symptoms, co-morbidities, and their impact on adolescents.
Adolescents were selected from a sample of schools, and completed in classrooms a previously validated questionnaire on symptoms of AC. AC diagnosis was considered when more than three episodes of ocular itching were reported in the past 12 months. Related symptoms such as tearing, photophobia, foreign body sensation, impact on daily activities, and diagnosis of AC were analyzed.
Questionnaires were obtained from 3,120 adolescents (mean age 13.3 ± 1.1 years). Ocular itching in the past 12 months occurred in 1,592 (51%). The most frequently associated symptom was tearing (74%), followed by photophobia (50.1%) and foreign body sensation (37.1%). The prevalence of AC was 20.7%, affecting more females than males (56.1% versus 45.9%; p = 0.01). The risks of an adolescent with ocular allergy to present asthma, rhinitis, and atopic eczema were (OR = 5.7; 95% CI: 4.5 to 7.1), (OR = 3.6; 95% CI: 3.0 to 4.3), and (OR = 2.6; 95% CI: 2.0 to 3.5), respectively. Severe interference in daily activities was reported by 30.5%.
Symptoms of ocular allergy are common, frequently associated to other allergic diseases, and impact the daily activities of adolescents.
A prevalência de conjuntivite alérgica (CA) não foi estabelecida. Estimativas sugerem que alergias oculares afetam de 15 a 20% da população mundial, ainda que a maioria dos estudos epidemiológicos abranjam sintomas de alergia nasal e ocular e não sejam específicos a respeito da CA. O objetivo deste estudo foi verificar a prevalência de sintomas, comorbidades e o impacto da alergia ocular em adolescentes.
Os adolescentes foram selecionados de uma amostra de escolas e preencheram, em sala de aula, um questionário previamente validado sobre os sintomas da CA. O seu diagnóstico foi considerado quando mais de três episódios de prurido ocular foram relatados nos últimos 12 meses. Sintomas relacionados, como lacrimejamento, fotofobia, sensação de corpo estranho, impacto sobre as atividades diárias e diagnóstico de conjuntivite alérgica, foram analisados.
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Sintomas de alergia ocular são comuns, frequentemente relacionados a outras doenças alérgicas, e causam impacto sobre as atividades diárias de adolescentes.
Adverse reactions to the allergen conjunctival provocation test
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Prevalence of ocular symptoms in patients with allergic rhinitis: Korean multicenter study
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: Funding Sources: Allergenic extracts were a courtesy of ALK Abelló and FDA Allergenic, Rio de Janeiro, RJ, Brazil.

: Disclosures: The authors have nothing to disclose.

View full text

Original articleSystemic allergic disorderOcular symptoms in nonspecific conjunctival hyperreactivity

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Rev Fr Allergol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Immunol Allergy Clin North Am

Immunol Allergy Clin North Am

Rev Fr Allergol

J Allergy Clin Immunol

J Allergy Clin Immunol

Prevalence of perennial and seasonal allergic rhinitis with atopic sensitization to Dermatophagoides pteronyssinus (Dp) e Lolium multiflorum (LOLIUM) in schoolchildren and adults in Curitiba

Rev Bras Alerg Imunopatol

Prevalence of allergic conjunctivitis: a missed opportunity?

Allergy

Prevalence of allergic rhinitis in the United States

J Allergy Clin Immunol

Original article
Systemic allergic disorder
Ocular symptoms in nonspecific conjunctival hyperreactivity