[Clinical case of anaphylaxis due to eye drops]. / Caso clínico de anafilaxia por gotas oftálmicas.

BACKGROUND: Anaphylaxis is a severe systemic allergic reaction that can be life-threatening, timely diagnosis and treatment is required in these patients, one of the most frequent triggers is pharmacological. OBJECTIVE: To report the case of a patient who presented anaphylaxis due to eye drops. CASE REPORT: A 7-year-old male with a history of rhinitis and asthma with good control. It started with itchy eyes, ophthalmic drops were administered, composition: Polyethylene glycol 400, 0.4%, Propylene glycol 3 mg, polyquad 0.001%, presenting at 15 minutes an episode of anaphylaxis initially characterized by pruritus and intense conjunctival erythema, later nausea, vomiting, sweating, weakness, urticaria/facial angioedema and dyspnea were added, this episode was controlled opportunely with Levocetirizine 5 mg sublingual and Betametasona 4 mg intramuscular, progressively improving over the next 2 hours. The patient was evaluated by the Allergist, written recommendations were given to the mother in case this reaction occurred again, the use of the drops was prohibited, and the performance of skin test and a probable conjunctival provocation protocolized with the ophthalmic drops were pending. Accidentally 2 months later the patient was re-exposed with the same eye drops, presenting a similar reaction 15 minutes after the administration of the medication, they went to the emergency room where he received antihistamine and corticosteroid intravenous treatment, after this re-exposure is confirmed to the ophthalmic drops mentioned above as a trigger of anaphylaxis in this patient. CONCLUSIONS: We present a case of conjunctival anaphylaxis after application of eye drops, confirmed by re-exposure to the drug. It is essential to give diagnoses, recommendations with treatments and avoidance of the probable triggering agent of the reaction. The administration of immediate medication when the allergic episode begins in these patients can be vital, even more so when they live far from a health center, as was the case in this patient.

ANTECEDENTES: La anafilaxia es una reacción alérgica sistémica severa que puede llegar a comprometer la vida. Se requiere de un diagnóstico y tratamiento oportuno en estos pacientes, uno de los desencadenantes más frecuente es el farmacológico. OBJETIVO: Reportar el caso de un paciente que presentó anafilaxia a gotas oftálmicas. REPORTE DE CASO: Varón de siete años de edad con antecedentes de rinitis y asma con buen control. Inició con picor ocular, se le administraron gotas oftálmicas, composición: Polietilenglicol 400, 0,4%, Propilenglicol 3 mg, polyquad 0,001%, y a los 15 minutos presentó un episodio de anafilaxia caracterizado, inicialmente, por prurito y eritema conjuntival intenso; posteriormente, presentó náuseas, vómito, sudoración, debilidad, urticaria/angioedema facial y disnea. Este episodio fue controlado en el momento, con tratamiento de Levoceterizina 5 mg s.l. y Betametasona 4 mg i.m., con mejoría progresiva en las siguientes dos horas. El paciente fue evaluado por la especialidad de alergología. A su madre se dieron recomendaciones por escrito, por si se presentaba nuevamente la reacción. Se prohibió la utilización de las gotas, y quedó pendiente la realización de las pruebas cutáneas y una probable provocación conjuntival protocolizada con las gotas oftálmicas. Accidentalmente, dos meses después se reexpuso al paciente con las mismas gotas oftálmicas, y a los 15 minutos de la administración del medicamento, presentó una reacción similar, por lo que acudieron a emergencias donde recibió tratamiento antihistamínico y corticoides vía i.m.; tras esta reexposición, se confirma a las gotas oftálmicas mencionadas anteriomente, como desencadenantes de anafilaxia en el paciente. CONCLUSIONES: Presentamos un caso sobre anafilaxia por vía conjuntival tras aplicación de gotas oftálmicas, confirmado por la reexposición al fármaco. Es esencial dar diagnósticos, recomendaciones con tratamientos y evitar el probable agente desencadenante de la reacción. La administración de medicación inmediata cuando inicia el episodio alérgico en estos pacientes, puede ser vital, más aún cuando viven lejos de un centro de salud, como era el caso referenciado.

Alergia ocular: tipos, edad de aparición, prevalencia y morbilidad / Ocular allergy: types, age of onset, prevalence and morbidity

Introducción: La alergia es el desorden más común del sistema inmunitario. En las últimas décadas, la prevalencia de las enfermedades alérgicas ha aumentado de forma considerable en todos los países. Objetivo: Describir el contexto actual de la alergia ocular para la realización de un diagnóstico precoz, una identificación temprana de los subtipos, un adecuado manejo terapéutico y un control de la severidad. Métodos: Se realizó una búsqueda sistemática de la literatura científica de mayor impacto con el uso de las palabras clave. Se limitó la búsqueda por tipo de diseño (revisiones, series de casos, estudios descriptivos, analíticos y experimentales, metaanálisis). No se tuvo en cuenta el idioma de la publicación. Las bases de datos utilizadas fueron: PubMed, Ebsco Host, Lilacs y Science Direct. Se identificaron y se evaluaron 114 artículos, de los cuales se seleccionaron 24 por su pertinencia para el estudio. Conclusiones: La alergia ocular es uno de los trastornos oculares más comunes encontrados en las consultas pediátricas y oftalmológicas. Si bien en la mayoría de los casos se trata de formas leves, estas pueden interferir en la calidad de vida del paciente. Es importante que estos pacientes con manifestaciones oftalmológicas de alergia se remitan al alergólogo para detectar otra patología, que, asociada al padecimiento alérgico, origine los síntomas que suelen ser graves, con una duración y frecuencia importantes(AU)

Introduction: Allergy is the most common disorder of the immune system. In recent decades, the prevalence of allergic diseases has increased considerably in all countries. Objective: To describe the current context of ocular allergy in order to make an early diagnosis, an early identification of subtypes, establish an adequate therapeutic management and control of severity. Methods: A systematic search of the scientific literature with the highest impact was performed using keywords. The search was limited by type of design (reviews, case series, descriptive, analytical and experimental studies, meta-analysis). The language of the publication was not taken into account. The databases used were: PubMed, Ebsco Host, Lilacs and Science Direct. A total of 114 articles were identified and evaluated, of which 24 were selected for their relevance to the study. Conclusions: Ocular allergy is one of the most common ocular disorders encountered in pediatric and ophthalmology consultations. Although in most cases these are mild forms, they can interfere with the patient's quality of life. It is important that these patients with ophthalmologic manifestations of allergy are referred to the Allergist to detect other pathology, which associated with the allergic condition originate the symptoms that are usually severe, with a significant duration and frequency(AU)

Diretriz Latino-americana sobre o Diagnóstico e Tratamento da Alergia Ocular ­ Em nome da Sociedade Latinoamericana de Alergia, Asma e Imunologia (SLAAI) / Latin American Guideline on the Diagnosis and Treatment of Ocular Allergy ­ On behalf of the Latin American Society of Allergy, Asthma and Immunology (SLAAI)

A alergia ocular, também conhecida como conjuntivite alérgica (CA), é uma reação de hipersensibilidade mediada por imunoglobulina E (IgE) do olho desencadeada por aeroalérgenos, principalmente ácaros da poeira doméstica e pólen de gramíneas. Os sintomas geralmente consistem em prurido ocular ou periocular, lacrimejamento e olhos vermelhos que podem estar presentes durante todo o ano ou sazonalmente. A alergia ocular tem frequência elevada, é subdiagnosticada e pode ser debilitante para o paciente. É potencialmente danosa para a visão, nos casos em que ocasiona cicatrização corneana grave, e na maioria dos pacientes associa-se a outros quadros alérgicos, principalmente rinite, asma e dermatite atópica. É classificada em conjuntivite alérgica perene, conjuntivite alérgica sazonal, ceratoconjuntivite atópica e ceratoconjuntivite vernal. O diagnóstico procura evidenciar o agente etiológico e a confirmação se dá pela realização do teste de provocação conjuntival. O tratamento baseia-se em evitar o contato com os desencadeantes, lubrificação, anti-histamínicos tópicos, estabilizadores de mastócitos, imunossupressores e imunoterapia específica com o objetivo de obter o controle e prevenir as complicações da doença.

Ocular allergy, also known as allergic conjunctivitis, is an immunoglobulin E-mediated hypersensitivity reaction of the eye triggered by airborne allergens, primarily house dust mites and grass pollen. Symptoms usually consist of ocular or periocular itching, watery eyes, and red eyes that may be present year-round or seasonally. Ocular allergy has a high frequency, is underdiagnosed, and can be debilitating for the patient. It is potentially harmful to vision in cases of severe corneal scarring, and in most patients, it is associated with other allergic conditions, especially rhinitis, asthma, and atopic dermatitis. It is classified as perennial allergic conjunctivitis, seasonal allergic conjunctivitis, atopic keratoconjunctivitis, and vernal keratoconjunctivitis. Diagnosis seeks to identify the etiologic agent, and confirmation is given by conjunctival provocation testing. Treatment is based on avoiding contact with triggers, lubrication, topical antihistamines, mast cell stabilizers, immunosuppressants, and specific immunotherapy with the aim of achieving control and preventing disease complications.

Vernal Keratoconjunctivitis as the Only Clinical Manifestation of HIV Infection.

INTRODUCTION: This case report describes an 8 year old boy unsuccessfully treated for years for Vernal Keratoconjunctivitis. CASE REPORT: We report a VKC resistant to all types of treatment known in the literature, such as topical and oral corticosteroids, topical and oral cyclosporine, immunotherapy, and third generation anti-histamine eye drops, due to unknown HIV co-infection. During further laboratory tests, patient tested positive for HIV even though he did not present any clinical manifestation of HIV disease. Only after antiretroviral treatment was started the allergy symptoms completely regressed. CONCLUSION: This case report suggests considering investigation of HIV infection in patients with refractory allergic conjunctivitis.

Development and in vitro/in vivo evaluation of thermo-sensitive in situ gelling systems for ocular allergy

Ocular allergy is one of the most common disorders of the eye surface. Following diagnosis this condition is typically treated with preparations containing antihistamines. However, anatomy of the eye and its natural protective mechanisms create challenges for ocular drug delivery. Rapid elimination of antihistamine substances due to short residency times following application can lead to insufficient treatment of ocular allergies. With this in mind, the aim of this study was to prepare a controlled ocular delivery system to extend the retention time of olopatadine hydrochloride (OLO) and in doing so to reduce the need for frequent application. We developed extended-release ocular in situ gelling systems for which in vivo retention times were determined in sheep following in vitro characterization and cytotoxicity studies. In vivo results were then compared to commercially available Patanol eye drops. the transparent gels formulated using appropriate amounts of polymers and having longer ocular retention times appear to be a viable alternative to commercially available eye drops.

Alergia ocular / Ocular allergy

Resumen La alergia ocular consiste en un grupo de enfermedades caracterizadas por inflamación de la conjuntiva ocular, dentro de las que podemos encontrar a la conjuntivitis alérgica estacional (CAE) o perenne (CAP), la queratoconjuntivitis vernal, la queratoconjuntivitis atópica y la blefaroconjuntivitis de contacto. Aqueja aproximadamente al 10% de la población mundial, y los más afectados son pacientes con otras patologías alérgicas. El diagnóstico es clínico y se integra mediante los síntomas y hallazgos encontrados durante la exploración física oftalmológica presentes en el sujeto al momento de la visita. Los principales objetivos del tratamiento en la conjuntivitis alérgica son minimizar y controlar los signos y síntomas de la enfermedad, incluyendo la reducción del prurito, de la hiperemia y del edema de la conjuntiva y párpados, así como mejorar la calidad de vida del paciente. El tratamiento incluye medidas no farmacológicas, como evitar estímulos irritantes, el uso de lágrimas artificiales, la aplicación de compresas frías y medicamentos como vasoconstrictores, antihistamínicos, estabilizadores de mastocitos, agentes de acción dual, esteroides y fármacos inmunomoduladores, así como inmunoterapia alérgeno específica. Los cambios desencadenados por la inflamación de la conjuntiva, producen daño corneal mecánico, y en los casos graves y crónicos de la enfermedad, el daño corneal puede resultar en la disminución de la agudeza visual, lo cual disminuye la calidad de vida del paciente.

Abstract Ocular allergy is a group of diseases characterized by inflammation of the ocular conjunctiva and include seasonal allergic conjunctivitis, perennial allergic conjunctivitis, vernal keratoconjunctivitis, atopic keratoconjunctivitis and contact blepharoconjunctivitis; affects approximately 10% of world population being most affected those patients with other allergic diseases; the diagnosis is clinical and is integrated through the symptoms and findings found during the physical examination. The main goals of treatment in allergic conjunctivitis are minimize and control the signs and symptoms of the disease, including the reduction of pruritus, hyperemia and edema of the conjunctiva and eyelids as well as improving the quality of life of the patient; treatment includes non-pharmacological measures such as avoiding irritant stimuli, use of artificial tears, application of cold compresses and medications such as vasoconstrictors, antihistamines, mast cell stabilizers, dual acting agents, steroids and immunomodulatory drugs, as well as specific allergen immunotherapy. Changes triggered by inflammation of the conjunctiva produce mechanical corneal damage and in severe and chronic cases of the disease, corneal damage can result in decreased visual acuity, which results in a decrease patient's quality of life.

Beneficial effect of annexin A1 in a model of experimental allergic conjunctivitis.

Annexin A1 (ANXA1), a 37 kDa glucocorticoid-regulated protein, is a potent anti-inflammatory mediator effective in terminating acute inflammatory response, and its role in allergic settings has been poorly studied. The aim of this investigation was to evaluate the mechanism of action of ANXA1 in intraocular inflammation using a classical model of ovalbumin (OVA)-induced allergic conjunctivitis (AC). OVA-immunised Balb/c mice, wild-type (WT) and ANXA1-deficient (AnxA1(-/-)), were challenged with eye drops containing OVA on days 14-16 with a subset of WT animals pretreated intraperitoneally with the peptide Ac2-26 (N-terminal region of ANXA1) or dexamethasone (DEX). After 24 h of the last ocular challenge, WT mice treated with Ac2-26 and DEX had significantly reduced clinical signs of conjunctivitis (chemosis, conjunctival hyperaemia, lid oedema and tearing), plasma IgE levels, leukocyte (eosinophil and neutrophil) influx and mast cell degranulation in the conjunctiva compared to WT controls. These anti-inflammatory effects of DEX were associated with high endogenous levels of ANXA1 in the ocular tissues as detected by immunohistochemistry. Additionally, Ac2-26 administration was effective to reduce IL-2, IL-4, IL-10, IL-13, eotaxin and RANTES in the eye and lymph nodes compared to untreated WT animals. The lack of ANXA1 produced an exacerbated allergic response as detected by the density of the inflammatory cell influx to the conjunctiva and the cytokine/chemokine release. These different effects observed for Ac2-26 were correlated with diminished level of activated ERK at 24 h in the ocular tissues compared to untreated OVA group. Our findings demonstrate the protective effect of ANXA1 during the inflammatory allergic response suggesting this protein as a potential target for new ocular inflammation therapies.

Immunomodulatory effects of galectin-1 on an IgE-mediated allergic conjunctivitis model.

PURPOSE: Galectin (Gal)-1, a lectin found at sites of immune privilege with critical role in the inflammation, has been poorly investigated in the ocular inflammatory diseases. Here, we evaluated the therapeutic potential of Gal-1 in ocular allergy using a model of ovalbumin (OVA)-induced AC. METHODS: OVA-immunized BALB/c male mice were challenged with eye drops containing OVA on days 14 through 16 with a subset of animals pretreated intraperitoneally with recombinant Gal-1 (rGal-1) or dexamethasone (Dex). RESULTS: Recombinant Gal-1 and Dex administration on days 14 through 16 was effective in reducing the clinical signs of allergic conjunctivitis (AC), plasma anti-OVA IgE levels, Th2 (IL-4 and IL-13), and eotaxin/RANTES levels in the lymph nodes. Four hours after the last OVA challenge, rGal-1 markedly increased Gal-1 endogenous levels in the conjunctiva, and provoked eosinophilia, which persisted at 24 hours. Recombinant Gal-1 had no effect on eosinophil activation, as evidenced by the similar pattern of peroxidase eosinophil expression between cells of rGal-1-treated and untreated AC groups. Conjunctival migrated eosinophils and neutrophils exhibited high levels of Gal-1 and ß2-integrin, with points of colocalization, in the rGal-1-treated groups. These different effects observed for rGal-1 were correlated with elevated levels of activated ERK and p38 at 4 hours, and diminished levels of activated JNK and p38 at 24 hours in the eyes. CONCLUSIONS: Gal-1 has an important role in ocular allergic inflammation and represents a potential target for the development of new therapeutic strategies in eye diseases.

Alergia ocular / Ocular allergy

En el presente artículo revisaremos los aspectos más relevantes de la alergia ocular: su epidemiología, fisiopatología, cuadros clínicos y su terapéutica. Se encontrará una descripción más detallada de la fisiopatología ya que es, sin duda, la base del éxito terapéutico

In the present article we will review the most important aspectsof ocular allergy: its epidemiology, physiopathology, clinicalcharacteristics and treatment. A more detailed description ofthe physiopathology is addressed because is the basis for asuccessful treatment.

Alergia ocular: un reto diagnóstico: [revisión] / Ocular allergy: a diagnostic challenge: [review]

El ojo es uno de los órganos más sensibles y está permanentemente expuesto a diversos agentes ambientales. Dado que la conjuntiva es un tejido inmunológicamente activo, no es sorprendente que sea un sitio común de respuestas alérgicas. Las alergias oculares son un grupo de enfermedades que afectan la superficie conjuntival y están asociadas usualmente a reacciones de hipersensibilidad tipo 1. Pueden ser divididas en varias categorías: conjuntivitis alérgica estacional, conjuntivitis alérgica perenne, queratoconjuntivitis vernal y queratoconjuntivitis atópica.La inflamación de la superficie ocular produce prurito, lagrimeo, edema conjuntival y fotofobia. Como en otras enfermedades alérgicas, se puede desarrollar una condición crónica, acompañada de remodelación de los tejidos oculares. Las estrategias para el tratamiento de la alergia ocular han aumentado exponencialmente y los clínicos disponen de un inventario cada vez mayor de agentes dirigidos a la protección del ojo contra la inflamación. En este trabajo presentamos una revisión sobre las principales formas de alergia ocular, haciendo énfasis en el cuadro clínico, el diagnóstico y las nuevas opciones terapéuticas disponibles en la actualidad.