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Contact dermatitis and allergic conjunctivitis common problems in the ophthalmology office
Contact dermatitis and allergic conjunctivitis are common problems that confront every ophthalmologist.
Contact dermatitis is rarer, with an incidence estimated at one per 1,000, or about 360,000 cases a year in the United States. Cosmetics are a common offender, as are topical medications such as neomycin, the preservative benzalkonium chloride, the adhesive tape we use for an eyepatch or shield, and even the latex-containing gloves we wear in the clinic or operating room. Common irritants include many metals such as nickel, gold or chromium used in jewelry and the ingredients and solvents used in cosmetics and perfume.
Irritant dermatitis is a rash with associated inflammation of the epidermis and dermis with secondary burning and itching just in the localized area where the irritant contacts the skin. Contact urticaria is an allergic reaction with erythema and often edema and a wheal that occurs within minutes of exposure and often covers a larger area. Chronic exposure to an allergen usually results in erythema, xerosis, lichenification, hyperkeratosis and fissures and is associated with pruritus. Patch tests, usually performed by an allergist but in recent years by some ophthalmologists, can identify the offending agents.
The basis of treatment is avoidance of contact with the offending agent. Acute episodes can be treated with cold compresses, oral antihistamines and topical steroid cream. Usually the widely available over-the-counter 1% hydrocortisone cream is sufficient, but loteprednol 0.5% and fluorometholone ophthalmic ointment 0.1% are available for cases with periocular lid involvement.
Conjunctivitis can also occur and can be toxic or allergic. Allergic conjunctivitis is common, with as many as 40% of the population exhibiting some level of symptoms every year. Most episodes of allergic conjunctivitis are treated by the patient themselves with OTC remedies, but the more severe and chronic cases usually find their way into our offices.
The differential diagnosis of a red eye is familiar to every ophthalmologist, but toxic or allergic conjunctivitis caused by chronic exposure to cosmetics, perfumes, the metal ions in jewelry, drugs, preservatives, solvents, soaps or detergents, facial cleansers, and surfactants needs to be considered in the differential diagnosis. Toxins and allergens are often transmitted to the periocular skin, lids, conjunctiva and cornea from eye rubbing or just by casually touching the eye with contaminated fingers or fingernails.
We are all used to treating acute, seasonal and perennial allergic conjunctivitis. I like the topical combined antihistamine/mast cell stabilizers. Cold artificial tears can be soothing. In severe cases with significant edema and chemosis, a short course of topical steroids can be helpful. The often-associated rhinitis also deserves treatment with oral antihistamines and nasal sprays.
Most of us engage an allergist to assist in treatment when significant rhinitis or sinusitis is present. The allergist can also help many patients with desensitization. We also need to be on the lookout for vernal keratoconjunctivitis in children, atopic keratoconjunctivitis and its associated eczema in young male adults, and giant papillary conjunctivitis in the contact lens wearer.
Disclosure: Lindstrom reports he is a consultant for Alcon/Novartis, Allergan, Bausch + Lomb and Imprimis.