Did you know eye or ocular allergies are commonly seen in young children around the age of 9 to 13 and during specific times of the year? Dr Anahita Kate informs us about this emerging allergic condition that is rapidly becoming widespread in India.
What is eye allergy or ocular allergy?
In our body, we all have an immune system which is responsible for fighting off pathogens, these can be bacteria or viruses. However, in some individuals instead of mounting a response to a microbe, normal antigens that are present in the environment (pollen or dander) are recognized as pathogens. An immune response is mounted against them and that is what constitutes an allergy. When this develops in the eye, the patient develops an ocular allergy.
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Typical signs and symptoms that people can expect if they have an eye allergy?
Allergy in the eye can have a very varied spectrum but across the board all the patients will have redness in the eye, watering and the most specific symptom for allergy which is itching, because of which the patient will say “I have this constant urge to rub my eyes”. Based on how severe the allergy is, the patient can also have blurring of vision and in very severe cases decreased vision. Sometimes, when the patient gets up in the morning they may complain of accumulation of mucoid discharge in the corners of the eyes, this is also very common in ocular allergy.
Are the symptoms different at different age groups such as babies, children and the elderly?
Symptoms are the same but since this disease affects young individuals (as early as two or three years of age), it depends on how well the child is able to express themselves. At that age, they may not be able to express that they have this grittiness or foreign body sensation so parents will notice that their child is constantly rubbing their eye and after that there is a lot of redness. In older children or young adults, they themselves will come and say that they have redness, discharge or watering. So the symptoms & signs don't differ it is just based on how old the child is and how they present.
In India, when there is some level of itchiness or redness, there is a strong tendency to self-medicate or to go to the local pharmacist for medicines. What are the risks associated with doing that?
There are a lot of medications that are available for the treatment of allergy but the major issue with self-medication is that any or every problem in the eye will actually manifest with redness and watering. A lot of symptoms overlap with dry eyes, allergies, infections, and raised intraocular pressure etc. All these patients will have some amount of redness, pain, grittiness or discharge and it is very difficult to tell by looking at the eye externally. Hence, we do not recommend and strongly discourage self-medicating for any eye problem.
Can you explain what grittiness means?
Typically, the patient says, “I have this feeling that there is mud in my eyes or when I blink, I can feel like there is a foreign body that is constantly rubbing.” Actually, there is no foreign body per se but it is just the inflammation in the eye because of the allergy and that is what causes the sensation that there is something in the eye.
Once you go see an ophthalmologist (not an optometrist), what is the diagnosis process?
As of now, most of the allergy testing is limited to systemic allergy as research continues in the field of ocular allergy. The diagnosis will be predominantly clinical. The ophthalmologist will have a look at your eye under a slit lamp machine that we use to examine the eye and based on the signs, a diagnosis is decided.
Once diagnosis is made, what is the typical management protocol that is suggested?
Allergy can have a spectrum but majority of eye allergy fits into the mild category. The patient can have allergy during one season of the year or a couple of times during a season. The allergy returns when the season comes again or the patient can have a mild allergy which comes on and off throughout the year. So there are some periods where the patient is symptomatic and some periods where the patient is fine and then it again recurs after a couple of months. At the first consult, we try to ascertain what type of allergy it is that you have and based on that the patient is typically given some topical medications (eye drops). Patient will be asked to review back based on how severe the disease is. It is important to understand that unlike an infection like conjunctivitis, there is no cure for allergies so significant proportion of the patients will have a recurrence or relapse. This does not mean that the primary treatment did not work it is just the nature of the disease, so everytime you have an allergy you should not get alarmed but go back to consult your ophthalmologist and they will restart you on the medications that are required. A smaller subset of patients who have allergic conjunctivitis, may have a more severe disease and will require something called topical corticosteroids. This will require more frequent follow-ups and it is very important that the patient complies to this. Most of the time, since the individuals who are affected are very young children, we are actually handling the parents who tend to be very apprehensive and very rightly so because their child keeps coming with recurrent episodes of redness and they're very tempted to use OTC topical corticosteroids because they get instant relief. We strongly discourage parents from doing this and understand that this is basically a chronic disease and requires right treatment.
If allergy is mild, does it go away on its own or will it always require treatment?
This is based on when they present to us. If the patient is a 5 or 6 year old, the disease limits by itself once the child crosses puberty. There is a very small fraction who continue to have the disease beyond say 20- 25 years of age but this is again extremely rare for most of the patients. Most patients will have a few cycles and then it self-resolves.
Are there specific seasons in India when these allergies play up more because we don't have the typical spring and pollen seasons in all cities? How do you determine how the seasonality affects people?
Typically, we see two crops of seasons where the incidence of allergy rises. There is a little bit of spike in the winter seasons but a majority of the patients present to us during summer. We also explain to the parents to be mentally prepared for the seasonal recurrence when it becomes in the months of March, April and May. In India, it is seen in the summer season or rather the switch from Spring to Summer and we do see energies even during the monsoon however, it is not as common or as severe as it is during the summer.
What are the common allergens that we would see both in Metro cities as well as non-metro and indoors as well as outdoors?
Allergens are more clearly understood in terms of systemic allergy than ocular allergy. The major problem in India is that there is a lot of variation in the geography therefore a lot of variation in the pollen in the plants, and the insects present in our house. For indoor allergens, the most common ones are dust mites, animal dander (basically the epithelium from our household pets) and of course mold from fungus. When it comes to environmental or external allergens the most common ones are grass or weed pollen but again there is a lot of variation from the north, south, east, and west. They say the pollen changes every 200 kilometers so be aware of the geographical area that you are residing in.
Can the allergies lead to infections or do infections and allergies coexist?
A majority of patients have mild to moderate allergy and in these conditions infections are not common. However in severe allergies, the surface of the eye becomes vulnerable such that even the normal bacteria which are residing over the surface can infect these vulnerable areas and lead to a secondary infection. Commonly infection is not coexistent with allergy.
There are a lot of over-the-counter eye drops that are available, are these okay to use without consultation and why not?
We strongly discourage the use of over-the-counter medications and the primary reason for this is, it is very difficult without a complete examination to understand whether this is allergy or not and most of the over-the-counter medication contains steroids even when it is with an antibiotic. If an antibiotic steroid eye drop is used when it is not allergy, then the steroid is going to exacerbate the underlying problem. If it is an infection, it is going to worsen if the eye pressure is elevated.
The other thing is steroids are not safe at all! By themselves, steroids can result in a lot of complications which are very difficult to manage down the line. For instance, it increases the intraocular pressure and this can cause permanent damage to the nerve in the eye. Since most patients are young children and adults, they have to live with the consequences of these side effects for four or five decades minimum and it becomes very difficult to handle.
Many people in order to avoid allopathic and steroid treatment try all kinds of alternative treatments and even home remedies like ghee and oil. Is there any data on safety, efficacy or usefulness of any of these?
Unfortunately, we don't have any data on the safety or efficacy of any of these but the allergy causes the surface of the eye to become very vulnerable. Instilling these homemade remedies increases the risk of inducing a secondary infection in the eye.
For a lot of eye conditions like dry eyes, fomentation is recommended? Can we do that for ocular allergy too?
Warm fomentation is just putting warm or moist cloth over your eyes. Cold fomentation is more preferred for ocular allergies. For this, use water from the fridge on a clean cloth and place it over the eye. This not only to a certain degree reduces the inflammation but also prevents rubbing of the eye esp in children.
How do you help a child prevent eye rubbing and does using cool compress help?
You can make cool compresses at home, just take cold water on a kerchief. Sometimes you get these cool compressors in the market too. So anything that decreases the temperature irrespective of how that is achieved will help in improving the symptoms.
| Prevention of eye rubbing and counseling of parents is very important because although eye rubbing is a symptom of allergy it also causes progression of allergy. It is a vicious cycle and as long as the child continues to rub the eye, the disease will continue to progress irrespective of any medication given. One of the ways to stop the child is to use cool compresses as it provides momentary relief. |
Are some people more vulnerable to ocular allergies?
Yes, few individuals who are genetically predisposed do have a predilection to develop allergy. Most of us don't have a reaction to allergens which are present in the atmosphere but some people tend to develop an allergy to them and this is even more evident in those patients who have ocular allergy and a concomitant systemic allergy so this can be either asthma or dermatitis. Such patients are more prone to have the more severe variants of ocular energy or have more frequent relapses. They will require more treatment as compared to a patient who just has a mild allergy.
If somebody has an asthma flare-up at the same time as an ocular allergy, is there a common treatment that typically gets done or they will both need to be treated separately? Does the parent have to take the child to visit both Specialists simultaneously?
We very frequently see patients who are consulting two doctors and sometimes both doctors are not aware of it because parents may not realize that one thing is connected to the other. In terms of treatment whenever we feel that there is a concomitant allergy instead of treating with eye medications we may just directly allow the systemic allergy therapy to take care of the eye because it is the same therapy given in a different form. In order to avoid a double dose, the systemic treatment is sufficient.
It is not sufficient to get a consultation from just one of the doctors because the chronic allergy whether in the eye or the body may develop secretly and understanding if it requires a separate therapy is a call that has to be taken by that specific doctor. So, you have to consult both and when talking to the individual doctors describe the symptoms holistically and also inform the ophthalmologist about it.
Is there anything that as an individual we can do to help our child protect their eyes from these allergy causing agents?
To do this, first one has to identify the allergen and that is very difficult in a country as diverse as ours both in terms of our geography, and the socio-economic environment that the patient comes from. Once an allergen is identified, there are ways of avoiding it. For example, if it is a dust mite then we recommend washing all the linen in the house and the curtains more frequently with hot water.
If you feel that your child has an allergy for a couple of years or with frequent relapses within a year, it is recommended that you consult an Allergist and ocular allergy Specialist so that allergy tests are carried out. In a normal case of allergy, we do not carry out any specific allergy tests as it is predominantly a clinical diagnosis, but in these rare cases it is better to undergo an allergy test to understand what are the allergens and how to avoid them. For example, if it is due to a certain food substance, then you need to avoid that food in your daily diet.
Is pollution also an allergen?
Pollution per se maybe not but it carries the pollen which can be an allergen so this is a predominant reason why some individuals get allergy in one season but don't get in another season because the pollen is different in different seasons. So during the pollination season if it is a city which is more polluted then you know the air is not going to flow very easily the pollen is just going to remain there so you may have an exacerbation longer than you expected in those days.
Qt from a Scleroderma patient also has Sjogren's along with Keratoconus and is facing severe allergy since the last one year. “ I get severe itching which then results into super sticky discharge which gets stuck in the eye and becomes painful. I've been told I have allergic conjunctivitis, this keeps happening on and off and I can't use my scleral lens due to this. What can I do?
We first need to understand whether the allergy is truly an allergy or whether it is a reaction to the scleral lenses because contact lenses very frequently induce a reaction in the eye. If it is allergy to the contact lens, simply avoiding the contact lens may bring the symptoms down then. However if symptoms persist even after 2-3 weeks without use of the lens then you probably do have allergic conjunctivitis. Fluorometholone or FML is a steroid it will provide quick and rapid relief, but the moment you stop the steroid the effect is going to wash away. We have topical medications which do the same work of the steroids but they do not have any of the side effects of the steroids. I recommend that you consult a specialist who looks at these conditions and they will be able to start you on these medications, which are available topically as eye drops, eye ointments and oral pills.
Can ocular allergy lead to temporary or permanent loss of vision?
A small fraction of patients develop the severe form of allergy and these patients can develop sequelae
because of this. A very common sequelae of ocular allergy is Keratoconus, because of the chronic eye rubbing which leads to corneal changes. The shape of the cornea is typically spherical but it starts becoming conical and this affects vision. It can also be progressive and cause other complications. In addition, it can also affect the stem cells, cause infection and because of that there can be scarring and permanent drop in vision.
Every time the child has an acute episode parents tend to take the child to a new doctor thinking that the previous regimen did not work. The new doctor starts the patient afresh because Ophthalmaologists cannot directly start the patient with high-end medications so the child again receives a course of topical steroids. This causes complications and may not be sufficient to control the inflammation but we have to go through that stepwise process to understand whether it is sufficient or not. So not following the regime, you are going back and resetting the process every time you consult a new doctor. To stop this from happening, stick to one doctor so that when one therapy has not worked that doctor will know this is not working and they can switch over to the next course of therapy.
Should the patient switch doctors during course of their ongoing treatment?
Sometimes we see signs which are indicative of the fact that the patient has had this disease for a very long time. Some medications that work the same way as steroids do have a latent phase, which means the effect of the medication will set in only after six to eight weeks. During this latent phase, the patient will have to continue steroids otherwise that acute exacerbation will not get controlled. When the patient goes to another doctor, they stop all these medications so that latent period they have waited for has to be restarted.
In case for any reason, a patient needs to change a doctor, when is the right time to make the switch?
If the switch has to be made, it is definitely not going to be determined by the allergy but it is important is that you get a good referral letter from the current Doctor who has been treating you so that the next Doctor understands your course of treatment including the things that worked for you and didn’t. It will save you from going through the trial and error method all over again and you can just start off where the previous doctor left.
Do children who have chronic asthma or dermatitis continue or are more likely to have eye allergies into adulthood?
Not only such patients but even few patients who have just ocular allergy can continue to have the disease into adulthood and we are also seeing patients who are now developing ocular allergy in adulthood for the first time. As an adult, this allergy tends to be more severe unlike the allergy in childhood which is self limiting by the age of 10-15 years. In childhood, a majority of the patients have a very mild disease maybe once or twice every other year and then it resolves with medications. That doesn't happen in adult allergy as it tends to be more severe and also increases the risk of developing a complication.
Final message:
Patients who have had multiple attacks (2nd or 3rd third time), please refrain from getting over-the-counter medications because there is no way for you to monitor what that medication is doing inside the eye. Although it may be difficult especially for those who have a chronic disease with very frequent relapses to visit the doctor frequently but please do because there are a lot of other things that doctors are constantly checking before giving the medication. Doctors also monitor any changes in the shape of your cornea, complications or whether the therapy needs to be ramped up or down. So please do not use over-the-counter medications!
For parents, the one thing that you can do is to stop the child from rubbing the eye. That itself will contribute a great way in helping or preventing the progression of the disease and preventing the formation of sequelaae that can result in blindness.
