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
310-652-1133
e-mail drschwartz@foreyesight.com
First Published: February 2000
Updated: September 2003
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