Purpose: Ocular allergy is an ocular surface disease deteriorates the patient’s quality of life. This situation continues and repeats inflammation via allergen contacts. Inflammation disrupted the tear film instability and may lead to dry eye. The aim of our study is to investigate concurrently appearing signs and symptoms of dry eye in a group of patients with symptomatic allergic conjunctivitis.
Methods: To be evaluated 141 patients with ocular allergy and 138 patient without ocular allergy in terms of dry eye symptoms and signs by Oxford scheme, OSDI scores, Break up time (BUT) and Schirmer test.
Result: There was a statistically significant difference was detected between the dry eye scores of the two groups.
Conclusion:> It may be related that ocular allergy and dry eye. Because of this relation, patients have ocular allergy evaluated in terms of dry eye simultaneously.
Keywords: Dry eye; Allergic conjunctivitis; Break up time; Schirmer; OSDI
Ocular allergy does not cause major tissue damage, but it detoriates patient’s quality of life grossly and its prevalence in general population might go up to 30% . Certain factors such as industrialization, air pollution, global climate change and changes in personal hygiene contribute to individuals contact with the allergens and shapes their reaction to such . Contact with allergens trigger an immune response which disrupts the corneal and conjunctival cell stability, especially the stability of goblet cells . Environmental factors and cell loss due to inflammation impair tear components, which may lead to dry eye disease . This can explain why dry eye disease and ocular allergy are frequently reported together in the literature .
Ocular allergy and dry eye disease can co-exist but usually their signs and symptoms mimic each other. This may lead to delay in proper treatment and even failure of treatment in patients who are not diagnosed accurately. Therefore, the aim of our study is to investigate concurrently appearing signs and symptoms of dry eye in a group of patients with symptomatic Allergic Conjunctivitis (AC).
This was a retrospective study conducted between April 2017 and June 2017. We collected data from the medical record files
of the patients who were examined for itching, photophobia, irritation, and ocular pain and who were diagnosed as having seasonal and perennial AC at the Maltepe University Medical Faculty Hospital. Our institutional review board (the Ethics Committee of Maltepe University) approved the study protocol that adhered to the tenets of the Declaration of Helsinki.
141 patients with allergic symptoms constituted the case group and 138 patients without any allergic symptoms were included in the study as the control group. Inclusion criteria were no previous history of ocular surgery, no previous history of topical or systemic treatment for Dry Eye Disease (DED) and AC and having no acute or chronic diseases other than ocular allergy.
We extracted the data for Ocular Surface Disease Index (OSDI) scores, Breakup Time (BUT) values, Oxford scheme scores, before treatment for all enrolled patients. The OSDI test is a 12-question questionnaire that evaluates the symptoms of ocular irritation and its visual-related functions to assess DED severity with scores ranging from 0 to 100 . The Schirmer test I measures the tear amounts on the eye surface by placing filter papers (SNO* Strips, Lab Chauvin, Aubenas, France) in the inferior fornix without topical anesthesia. The amount of wetting on the filter paper after 5min is recorded as the test result. For our study, we defined the results < 10mm in the Schirmer test as positive for DED .
In the tear BUT test, the inferior fornix is touched using saline-
soaked fluorescein sticks (Fluorescein, Haagen–Streit International,
Koeniz, Switzerland). The patients are asked to blink and
then abstain from blinking until told to do so. The time from the
first blink to the detection of dry area formation on the cornea is
recorded as the BUT value. We used the BUT values < 8s to detect
DED . The Oxford scheme is a test to assess the state of the ocular
surface using a fluorescein stick to stain the cornea, and the
results are graded from 0 (no staining) to 5 (severe staining) .
Gender and age distribution of the patients included in the
study were shown in Table 1. There was no statistically significant
difference between two groups for age and gender. Dry eye scores
of participants were shown in Table 2. Statistically significant difference
was detected between the dry eye scores of two groups.
m: Mann-whitney u test,
OSDI: Ocular surface disease index; BUT: Break up time; Case group: Patients with allergy; Control group: Patient without allergy.
30.49% of patients with ocular allergies had mild corneal
staining, and 1.72% had severe corneal staining. All patients
without ocular allergies had slight corneal staining and none of
them had severe corneal staining. It was statistically significant.
Dry eye syndrome is a disease of the ocular surface and it is
multifactorial. Activation of the inflammatory cascade is the reason
lying beneath the diseases. Vernal and a topical conjunctivitis
are considered among the causes for DED and dry eye like symptoms
[9,10]. Inflammatory diseases of the ocular surface cover a
wide spectrum in which ocular allergy, asthma, rinit and DED are
also included. Most of the times signs and symptoms of allergic
conjunctivitis and dry eye diseases are intervened [11-13].
Previously in the literature it has been reported that dry eye
symptoms tend to alleviate during autumn season, and this has
been linked to allergic activation . Itching is one of the most
prominent symptoms of AC and studies have found that AC and
DED are the primary reason underlying the itching . In another
study, it was found that tear breakup time was shorter in
patients who had allergic conjunctivitis during childhood . In
a study conducted with 35 children with vernal conjunctivitis, it
was reported that dry eye symptoms are more severe in vernal
conjunctivitis, and even during the times of inactive signs and
symptoms for ocular allergy, dry eye continued .
In another study, it has been shown that response to allergens
is more severe individuals who are predisposed to ocular pathologies
such as DED and AC . In the other study, IgE levels were
investigated, it has found dry eye symptoms to manifest more
severely in patients who has ocular allergy signs and symptoms
and it has been speculated that DED is a sub type of dry eyes syndrome
without antigen and antibody positivity . Additionally,
it has been shown that tear stability is decreased in not only in
individuals with AC but also in individuals with atopic dermatitis
and allergic asthma . The present study patients have allergic
conjunctivitis had worse BUT, oxford score and Schirmer test than
nonallergic patient and had lower OSDI questionnaire scores. So,
these findings support the previous studies.
Ocular allergy and dry eye disease are two surface disorders
that frequently co-exist. In symptomatic patients, a through approach
is required and in order to reduce morbidity both disorders should be included in the diagnostic workup, treatment and