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For mild and moderately severe allergic eye disease, a topical histamine H1-receptor antagonist, such as levocabastine hydrochloride 005% or emedastine difumarate 005%, or ketorolac tromethamine, a nonsteroidal antiinflammatory agent, is applied topically four times daily Ketotifen 0025%, which has histamine H1-receptor antagonist, mast cell stabilizer, and eosinophil inhibitor activity, is applied two to four times daily; olopatadine 01%, applied twice daily, reduces symptoms by a similar mechanism Topical mast cell stabilizers, such as cromolyn sodium 4% or lodoxamide tromethamine 01%, applied four times daily, or nedocromil sodium 2%, applied twice daily, produce longer-term prophylaxis but the therapeutic response may be delayed Topical vasoconstrictors and antihistamines are advocated in hay fever conjunctivitis but are of limited efficacy and may produce rebound hyperemia and follicular conjunctivitis Systemic antihistamines may be useful in prolonged atopic keratoconjunctivitis Topical corticosteroids are essential to the control of acute exacerbations of both vernal and atopic keratoconjunctivitis Corticosteroid-induced side effects, including cataracts, glaucoma, and exacerbation of herpes simplex keratitis, are major problems Topical cyclosporine is also effective Systemic corticosteroid therapy and even plasmapheresis may be required in severe atopic keratoconjunctivitis In allergic conjunctivitis, specific allergens may be identifiable and thus avoidable In vernal keratoconjunctivitis, a cooler climate often provides significant benefit

Bielory L Allergic diseases of the eye Med Clin North Am 2006 Jan;90(1):129 48 [PMID: 16310527] Prabriputaloong T et al Atopic disease and herpes simplex eye disease: a population-based case-control study Am J Ophthalmol 2006 Nov;142(5):745 9 [PMID: 17056358]

Allergic eye disease takes a number of different forms but all are expressions of atopy, which may also manifest as atopic asthma, atopic dermatitis, or allergic rhinitis

Symptoms include itching, tearing, redness, stringy discharge and, occasionally, photophobia and visual loss

Pinguecula is a yellow elevated conjunctival nodule, more commonly on the nasal side, in the area of the palpebral

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Keay L et al Microbial keratitis predisposing factors and morbidity Ophthalmology 2006 Jan;113(1):109 16 [PMID: 16360210] Mah FS Fourth-generation fluoroquinolones: new topical agents in the war on ocular bacterial infections Curr Opin Ophthalmol 2004 Aug;15(4):316 20 [PMID: 15232471] Parmar P et al Comparison of topical gatifloxacin 03% and ciprofloxacin 03% for the treatment of bacterial keratitis Am J Ophthalmol 2006 Feb;141(2):282 286 [PMID: 16458681]

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fissure It is common in persons over age 35 years Pterygium is a fleshy, triangular encroachment of the conjunctiva onto the nasal side of the cornea and is usually associated with constant exposure to wind, sun, sand, and dust Pinguecula and pterygium are often bilateral Pingueculae rarely grow but may become inflamed (pingueculitis) Pterygia become inflamed and may grow No treatment is usually required for inflammation of pinguecula or pterygium, but artificial tears are often beneficial, and short courses of topical nonsteroidal antiinflammatory agents or weak corticosteroids (prednisolone, 0125% three times a day) may be necessary The indications for excision of pterygium are growth threatening vision by approaching the visual axis, marked induced astigmatism, or severe ocular irritation Recurrence is common and often more aggressive than the primary lesion

Herpes simplex keratitis is an important cause of ocular morbidity in adults The ability of the virus to colonize the trigeminal ganglion leads to recurrences precipitated by fever, excessive exposure to sunlight, or immunodeficiency The dendritic (branching) ulcer is the most characteristic manifestation More extensive ( geographic ) ulcers also occur, particularly if topical corticosteroids have been used These ulcers are most easily seen after instillation of fluorescein and examination with a blue light Such epithelial disease in itself does not lead to corneal scarring It responds well to simple debridement and patching More rapid healing can be achieved by the addition of topical antivirals such as trifluridine drops or acyclovir ointment Long-term oral acyclovir reduces the rate of recurrent epithelial disease, for which topical corticosteroids must not be used Stromal herpes simplex keratitis produces increasingly severe corneal opacity with each recurrence Topical antivirals alone are insufficient to control stromal disease Thus, topical corticosteroids are used in combination, but steroid dependence is a common consequence Corticosteroids may also enhance viral replication, exacerbating epithelial disease Oral acyclovir, 200 400 mg five times a day, may be helpful in the treatment of severe herpetic keratitis and for prophylaxis against recurrences, particularly in atopic or HIV-infected individuals Severe stromal scarring may require corneal grafting, but the overall outcome is relatively poor Caution: For patients with known or possible herpetic disease, topical corticosteroids should be prescribed only with ophthalmologic supervision

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