One Up on the Tickles: Managing Allergy Affected Eyes

There I stood, on the consult room’s equivalent of ‘Hogwarts’ Platform nine and three-quarters’.

Splot… splot…splot… I could almost hear my beads of perspiration hit the floor. Anxiety flooded me.

“Herpes simplex?” I whispered to myself. “Really?”

Clinical examination aside, sometimes we need to be more than inquisitive – even if it means asking questions about a patient’s personal life

Rewind 2,880 minutes. I had scribbled out a prescription for hydrocortisone ointment that Mrs Andrews*, a 69-year-old woman, could apply on her periocular skin, two to three times a day.

Her left eyelid was scaly, erythematous and inflamed, coupled with pruritus. I’d seen it before. Umpteen times. She had eyelid dermatitis. My diagnosis was quickly confirmed when she informed me that she’d been using a new eyeliner for the past few weeks. Her vision was excellent. Clinical examination revealed mild bulbar conjunctival hyperaemia, but an otherwise quiet eye with a clear cornea.

Curiously, her right eye was not affected. In hindsight, I should have pursued the oddness of this unilaterality. One should expect the signs and symptoms of allergic contact dermatitis secondary to cosmetics to manifest in both eyes.

But I sent her on her way, script in hand.

Mrs Andrews returned two days later, but not before attending the hospital emergency department on the previous night because her condition had deteriorated. There, the ophthalmology registrar instructed her to stop using the ointment I’d prescribed and took a swab. He assured her the laboratory test would come back herpes simplex type 1 (HSV-1) positive in the next few days.

Ocular herpes simplex is typically caused by the type 1 virus. It can present as a primary infection or a recurrent one. It is not uncommon for the former to express itself as a unilateral blepharoconjunctivitis with associated follicular inflammatory response and skin vesicles.¹

We all know very well that herpes simplex viruses and corticosteroid are not the best of friends.

HSV blepharoconjunctivitis is self-limiting, but for Mrs Andrews, the ophthalmology registrar prescribed an oral antiviral therapy to speed up the resolution.1,2 On her second visit to my practice, I had a chance to look under the slit lamp again and indeed, there were follicles on the left eye’s palpebral conjunctiva lining up like soldiers on parade. Additionally, the skin vesicles were more prominent as they had worsened.

“Yeah, looks like it,” I thought to myself.

I’d walked straight into the barrier between platforms nine and ten. Ouch. Mr Potter did the same and was welcomed into the magical world… the outcome was starkly different for me.

THE OXYMORON

It has been estimated that 19% of Australia’s population suffers from hay fever, otherwise known as allergic rhinitis.³ An epidemiological study in the USA reported that close to two-thirds of patients with hay fever had ocular symptoms. This number was inflated to 95% after patients were asked specific diagnostic questions for allergic conjunctivitis (AC) and trialled on topical anti-allergic treatment in a bid to unveil the previously overlooked symptoms.⁴ 

Bearing this in mind, AC could well be described as prevalent but often missed – and as such could be added to the list of famous oxymorons like ‘small crowd’ and ‘jumbo shrimp’.

A globetrotter in his twenties, Mr Brent* spends just two months a year living with his parents in Perth. Although he undoubtedly missed his parents, that was not why he teared-up every time he went home.

Two years ago, this burly gentleman sat on my consult chair. “I can’t stop crying,” he croaked. “They’re bloody itchy.”

Itch is a hallmark symptom of ocular allergy. I investigated further and found out the sensation had started the day after he arrived in Perth. It was early October, spring in Australia, and the wattles were blooming. Seasonal allergic conjunctivitis is most common in spring6,7 and would have been an easy diagnosis, had Mr Brent not told me more.

“Something similar happened six months ago,” he sighed. “It wasn’t as bad, but it lasted for a month. I went back to Johannesburg and everything went back to normal.”

I blinked hard, and probed harder. This had happened twice before and only in Perth, but in different seasons. I asked about changes in Mr Brent’s living or working environment, and hit the jackpot: Mr Brent’s mum had adopted a Birman at the beginning of the year.

Perennial allergic conjunctivitis is a mast cell-mediated hypersensitivity reaction which involves interaction of IgE antibodies with allergens such as dust mites and pet dander.^6,8

In the case of Mr Brent, slit lamp biomicroscopy revealed bilateral conjunctival injection with mild chemosis and tarsal papillae.

I prescribed the dual acting eye drop Ketotifen dosed two times a day, for its antihistamine properties and the ability to sustain the integrity of mast cells.9 Two weeks later Mr Brent returned a happier man; his eyes were white and quiet, and the itchiness was gone.

As Mr Brent set out on the next leg of his journey, I offered some parting advice. Anticipating that his itchy eyes would return on his next trip home, I advised him to commence topical mast cell stabiliser therapy (i.e. lodoxamide) a few weeks prior to his arrival. This prophylactic treatment plan was still working effectively when I last saw him a few months ago.

In dealing with AC, I typically reserve corticosteroids for severe presentations or corneal-involving conditions such as vernal keratoconjunctivitis (VKC). This is because of their potential side effects, such as elevated intraocular pressure and the formation of cataracts.10 Often, we can consider prescribing them with a tapering schedule in conjunction with another longer term anti-allergy agent.¹¹ Having said that, I have switched a handful of cases from antihistamine/mast cell stabiliser drops to topical corticosteroids. Miss Cattell* was one such example. Ketotifen drops were initiated to treat her AC but she was forced to stop using them after two days as she was experiencing headaches. Ultimately, fluorometholone eye drops were used when she found that olopatadine hydrochloride also gave her the same grief. Headache is a known adverse reaction of ketotifen and olopatadine.¹² 

Importantly, before we can battle this oxymoron, we need to uncover it and find its root cause. Clinical examination aside, sometimes we need to be more than inquisitive – even if it means asking questions about a patient’s personal life.

CONCLUSION

Allergen avoidance is a foolproof antidote for AC. The search for it commonly begins with a conversation revolving around the disease pattern or, in the instance of Mr Brent, a change in pattern. In recalcitrant or recurring cases, a referral to an allergist for allergen identification and immunotherapy can be considered.

My cousin Daniel* was eleven and suffering from eczema when an allergist, citing dust mites as the culprit, recommended ripping up the entire carpet covering the floors of his parents’ home in London.

Daniel also had VKC – a bilateral recurrent ocular inflammatory disorder which primarily affects boys before puberty and is accompanied by atopic conditions.^8,13

In the case of Daniel, once the carpets were removed, the frequency of the acute phases of VKC and eczema reduced dramatically.

Non-pharmaceutical management aside, we do have a variety of options in our potion chest. Antihistamines and/or mast cell stabilisers are usually our first line of defence. Steroids, though effective, should only be used moderately when required, or when other more conservative treatments prove to be inadequate.^6,8,13 Patients should also be educated on the potential recurrent nature of AC, the need for long term follow-up, and the importance of complying with pre-emptive or maintenance therapy if prescribed.

The ocular surface has imperfect mechanical deterrence in warding off intruding allergens, such as pollen, but this does not put us, the guardians of the eye, on the back foot. The manifestations of AC may be bothersome but with the array of treatment options available, we ought to be able to get one-up on these tickles.

*Names changed for patient anonymity. 

Perry Yeow graduated from University of Queensland with a Master in Optometry (Distinction) in 2015. He completed a specialist certificate in anterior and dry eye disorders at University of Melbourne in 2018. Mr Yeow is an optometrist with Laubman & Pank Booragoon, Perth in Western Australia. 

References 

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10. Renfro L, Snow JS. Ocular effects of topical and systemic steroids. Dermatol Clin 1992; 10:505–512. 
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13. Jun J, Bielory L, Raizman MB. Vernal conjunctivitis. Immunol Allergy Clin N Am 2008;28:59–82.