• Symptoms...how do your eyes feel
• Medical treatment
  • Optichrom and Rapitil, Nedocromil, Lodoxamide
  • Opatanol
  • antihistamine tablets
  • Steroid drops
  • Severe allergic conjunctivitis..Restasis
  • Atopic keratoconjunctivitis
  • Immunotherapy
• Dust allergy: precautions
• Lifestyle issues
• Mediterranean diet
• Step-wise treatment plan
• GPC (giant papillary conjunctivitis) and vernal catarrah and shield ulcers
• treatment table
• Link: allergic conjunctivitis
• Links
• a 9mb PowerPoint presentation, 2008, for professionals
• recurrent angio-oedema
  

This page explains a stepwise treatment for patients with allergic conjunctivitis. For more information about allergic conjunctivitis itself, particularly if you wear contact lenses, visit the web sites below.

There are several types of allergic eye disease:

• allergic conjunctivitis (this page)
• atopic keratoconjunctivitis (a more severe type)
• GPC (giant papillary conjunctivitis) and vernal catarrh and shield ulcers

Allergic conjunctivitis is a common condition. Your eyes become red and very itchy, and generally your sight is good. You may notice a runny nose or feel unwell if you have a more severe allergy. The eyes then get better, and the condition then returns every now and again. 'Itchy red eyes' occurring now and again, particularly if you suffer from hey fever or other allergies, is the main symptom.

If the allergy occurs during the hay fever season, then it is related to hay fever, and termed 'seasonal allergic conjunctivitis'. But if it occurs all the year round you are probably allergic to dust, and termed 'perennial'.
Alternatively you may be allergic to cat fur, for instance. Pollution in the air increases allergy rates considerably.

Some people are allergic to contact lens solutions. 

This page outlines different treatments. Here is a step-wise treatment plan. If the condition is severe, advice from an ophthalmologist is essential.

Anyone with sore eyes should ideally not use more ham 4 eye drops containing preservative a day in an eye. People with dry eyes need preservative free drops.

Many people with allergic eye disease also have dry eyes and blepharitis, which may also be helped with treatment. 'Dry eyes' feel as though they are burning; eyes with blepharitis feel irritable and gritty.

Nedocromil  (Rapitil) and Lodoxamide are more modern and quicker acting forms of Optichrom and should tried if Optichrom has not helped enough.

Opatanol, US name is Patanol. It is a mast cell stabiliser/antihistamine, and can be very effective. It is proving very popular, and some data indicates it is more effective than other drugs see and see.

It is now the first choice for ophthalmologists who treat patients when the optichrom related drugs have not helped enough.

Antihistamine tablets such as Cetirizine can be very helpful, but there are many others. Levocetirizine (5mg >6y age), Others.

Try them if your allergy is bad. They may make you too tired but are generally safe, and they help your runny nose and the fever part of hay fever.

With hay fever it is best to start the treatment early before the condition gets hold, as this way it is easier to control.
There are many types of antihistamine tablets and some make more people tired than others. Ask your doctor and pharmacist for advice.

If Nedocromil or Olopatadine do not work, steroid drops may work. Again, they are usually used in addition to Nedocromil / Lodoxamide and Livostin or olopatadine.
However, at this stage you should pay detailed attention to avoiding the triggers to your allergy as below, especially if you have a dust allergy.

If you do have to use them, the main steroid drop is prednisolone minims, and this should not be used without an ophthalmologist's advice, unless your GP is experienced in its use and you only use it for short periods.

There are many ways to use the prednisolone drops. The 'minims' type have no preservative and are generally best for allergy patients.
If your eyes are red and itchy, you may need to use them quite often, perhaps 4 times a day. As soon as the redness fades, usually about 4 days, start to reduce the dose of the steroid to 3 and them 2 times a day.
Once the redness has faded, continue for a few days and then try to stop them.

If the redness and itch returns every time you stop, and as advised by your ophthalmologist, you may need to use a low dose regularly, such as once a day. This is reasonably safe during the hay fever season for short periods.

Steroid drops have many side effects if used in the wrong manner. You need to be certain that you do have 'allergic conjunctivitis' and not another condition, and most people can recognise when their eyes are red and itchy the condition has returned.
But if you have a scratchy and painful eye, you may have an ulcer and the drops should be stopped and you should get expert advice.
Similarly, if you need a lot of steroid drops for many months you may develop glaucoma, so you will need regular checks and expert advice. Long term use will lead to cataracts also. Even short term use of steroid drops can activate herpes simplex keratitis.

Very weak steroid drops, such as prednisolone 0.1 - 0.05% are available from Moorfields eye hospital and some others, and these may be safer and helpful.

The Moorfields product will be just as good as Restasis, but it has a different formulation and may be uncomfortable..

The lids need intensive treatment. Without meibomian gland secretions, tears do not spread, and so a dry eye effect results, leading to corneal disease and ulcers.

• check for allergens and if possible avoid allergens (discussed here for dust)

• maintain on mast cell stabilisers (nedocromil or ledoxamide) 2 or 3 times a day

• steroids only in acute exacerbations

• treat lids with oxytetracyline 250mg once or twice a day, or doxcycline 100mg once daily

• lubricate with preservative free tears (viscotears in milder cases)

• beware of herpes simplex keratitis when on steroids (also glaucoma, cataracts, corneal melting), but nevertheless steroid drops are often needed.

• severe cases may need systemic treatment and advice from an ophthalmologist.

• Topical tacrolimus can be very helpful Eye 2011.

• Cyclosporine drops are available now and can be very helpful. They enable the dose of steroid drops to be reduced.

• Any patient using steroid drops regularly for this condition should consider alternatives such as tacrolimus and cyclosporine drops/ointment.

In many parts of the country immunotherapy is available for hay fever sufferers, but is difficult to access in Birmingham. Some people dispute the effectiveness of immunotherapy, but it is probably very helpful for some people, and slightly less helpful for others.

Your GP will need to advise you about immunotherapy in your specific case, but if your hay fever is bad the medical literature advises it should be available to you and recommends you consult an immunologist.
Homeopathic remedies help some people, but not others, and are not suitable as a replacement for immunotherapeutic advice if your symptoms are severe and you need steroid tablets.

See  www.asthma.org.uk, especially if you have asthma.

If you have a dust allergy there is plenty you can do. Visit the websites below for more details. This page has many details....although written for asthma patients, advice may be helpful.

• Try a new pillow or ultra-clean towel over your pillow in bed. This might be particularly helpful if you have your conjunctivitis at night or when you wake up. Any regular pillow collects dust inside that after a while, and you can become allergic to it. If this helps buy a non-allergenic pillow with a special outer cover. After 5 years most pillows are 50% dust mite!
  Similarly, sleep on an ultra-clean towel, and if this helps buy special mattress and duvet covers. These can be expensive but can be very, very, helpful.

• The dust mite is killed by freezing. Therefore, putting your pillow in the freezer for a few hours will kill all the mites. Try this, and if it helps it confirms you are allergic to dust. The dust mites accumulate, so you may need to repeat this every month. It may also help if you can put your mattress cover in the freezer, and your duvet and duvet cover, if they fit.

• Washing bedding at high temperatures also kills the dust mite.

• When hoovering..try to get someone else to do it...but if you cannot, try to dampen the floor first with a spray of water. When dusting, use a damp cloth.

• Keep your rooms ventilated, and perhaps turn the heating down, especially when you are out. The dust mite (which is what people are allergic to) likes centrally heated non-ventilated rooms.

• New carpets, or some people say wooden floors, help some people. Some people are allergic to their old sofa (any excuse for a new one, and a leather sofa is less allergenic). The current evidence concerning wooden floors is that they generally do not make all that much difference.

• To diagnose your dust allergy, a trip abroad can be helpful! If you are allergic to the dust in your home a trip to the Bahamas can make you feel much better!
  If your allergy returns as soon as you come back, you have made the diagnosis, but the solution is more complex!
  

Lifestyle issues are critically important

• Pollution aggravates allergies, so the less we all cause, the less others will suffer. The cleaner the air the better, so a beach holiday can be very helpful. Pollution in cities significantly increases allergies.   
  Diesel pollution is harmful.  We should stop driving?

• An interesting paper pointed out that pro-biotics can reduce allergy rates This is a controversial area...partly because there are many different formulations. Nevertheless, they have no side effects and can be bought in health food shops.

• Generally a healthy diet is important. Fruits, vegetables, fish and the Mediterranean diet helps.

• A damp home certainly makes matters worse.

• Indoor chemicals increases allergies, a controversial area. No   Yes. This author suggests that no chemicals are used in the home such as aerosols and cleaners, especially where ventilation is poor.

• Physical exercise reduces allergy rates

• Smoking in the home is very harmful.

• living on a farm...fewer allergies
  

Antihistamine tablets help. You may need a slightly higher than recommended dose if your hey fever is very bad.

I am not expert in treating these conditions, but

• they often affect Asian children in the UK (less so in hot climates)

• topical tacrolimus can be very helpful Eye 2011

• triamcinolone injection in the upper eyelid can treat these conditions effectively see

• shield ulcers need debriding under anaesthetic (children)

• combined therapy may be needed for shield ulcers

sodium chromoglycate
(many other names e.g. Optichrom)

fluromethalone

• for general and contact lens advice www.contactlenses.co.uk

• a link for professionals/interested patients for more information here

• for allergy avoidance (see this page on asthma)

• atopic keratoconjunctivitis, not really discussed on this page, see

• severe atopic lid disease, tacrolimus or cyclosporin.

• vernal eye disease in Palestinians

• for a basic leaflet http://familydoctor.org/handouts/678.html

• buying anti-allergenic sheets, here is one company I found
  www.westonshealth.co.uk

• see Allergic Rhinitis in Children (BMJ)

• Pollution in the air increases allergy rates considerably. Our driving makes matters much worse.

BMJ 11

• presence of urticaria with angio-oedema suggests mast cell mediation

• in recurrent angio-oedema without urticaria, consider conditions aa caused by ACE; C1 inhibitor deficiency; Screen for C1 inhibitor deficiency in these patients including those on ACE by measuring C4 levels....if levels low refer for confirmation of diagnosis.

• antihistamines help if mast cell mediated

• others may be bradykinin mediated

• local triggers include infections, heat/cold, alcohol, pressure, trauma, stress

• family history suggests C1 inhibitor deficiency

• C1 inhibitor deficiency..unexplained abdominal pain

• ask: NSAI, ACE, bupropion