Expert discusses anti-inflammatory agents for atopic, vernal conjunctivitis
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SAN FRANCISCO — Stephen Pflugfelder, MD, professor and James and Margaret Elkins Chair in Ophthalmology at Baylor College of Medicine, discussed using topical anti-inflammatory agents to manage atopic and vernal conjunctivitis in a presentation at Cornea Subspecialty Day at the American Academy of Ophthalmology annual meeting.
“The pathology of allergic conditions varies between seasonal allergy conjunctivitis and atopic and vernal conjunctivitis,” he said. “Seasonal/allergy involves innate inflammatory cells and mediators. There’s an immediate reaction with itching and edema due to histamine release and a late phase reaction with histamine and other inflammatory mediators. Atopic and vernal conjunctivitis involve innate plus adaptive immunity, including cytokines produced by TH1.”
Atopic dermatitis is a significant cause of ocular morbidity; eye or eyelid involvement can occur in up to 43% of patients. Also, many patients with chronic keratoconjunctivitis (AKC) develop corneal epithelial disease (70%) and corneal neovascularization, according to Pflugfelder.
For treatment, Pflugfelder recommended antihistamine/mast-cell stabilizing agents for mild and episodic seasonal allergic conjunctivitis and a low-dose corticosteroid or calcineurin inhibitors for acute and chronic conditions; however, treatment is based on severity for vernal conjunctivitis.
Topical antihistamines, both over the counter and prescription options, are commonly used for non-severe acute and chronic allergic conjunctivitis, according to the presentation.
“The newer formulations, such as olopatadine, have mast-cell stabilizing, and some of them have both H1 and H2 receptor antagonists and anti-inflammatory properties,” Pflugfelder said. “You can also consider pulsed or low-potency corticosteroid for the most severe cases.”
For very severe cases, he said to consider dexamethasone or triamcinolone injection. Also, both cyclosporine and tacrolimus, which are calcineurin inhibitors, have been reported to improve signs and symptoms of AKC. Neovascularization can be treated with photocoagulation and nemolizumab.
“We have increased knowledge of the pathogenesis of these conditions that involve both innate and adaptive immune mediators and adequate management often requires combined therapy,” Pflugfelder said. – by Savannah Demko
Reference: Pflugfelder, SC. What's new in topical anti-inflammatory agents / management of atopic and vernal conjunctivitis. Presented at: American Academy of Ophthalmology annual meeting; Oct. 11-15, 2019; San Francisco.
Disclosure: Pflugfelder reports consulting for Allergan, Senju and Shire; grant support from Shire; and owning equity in Immuneyez.