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Diagnosis and management of allergic conjunctivitis in pediatric patients

Article in Allergy and Asthma Proceedings ? January 2017

DOI: 10.2500/aap.2017.38.4003

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Diagnosis and management of allergic conjunctivitis in pediatric patients

William E. Berger, M.D., M.B.A.,1 David B. Granet, M.D.,2,3 and Alan G. Kabat, O.D.4

ABSTRACT

Background: Allergic conjunctivitis (AC), although one of the most common ocular disorders in pediatric patients, is frequently overlooked, misdiagnosed, and undertreated in children.

Objective: To guide pediatric health care professionals in the optimal diagnosis and management ofAC in pediatric patients. Methods: To identify any existing best practice guidelines for the diagnosis and treatment of AC in pediatric patients, a review of the literature published between 2004 and January 2015 was conducted. Diagnosis and treatment algorithms and guidelines for pediatric patient referrals were then developed. Results: A literature search to identify best practice guidelines for the treatment of AC in pediatric patients failed to return any relevant articles, which highlighted the need for best practice recommendations. Based on publications on adult AC and clinical experience, this review provides step-by-step guidance for pediatric health care professionals, including recognizing clinical features of AC, establishing a comprehensive medical history, and performing a thorough physical examination to ensure a correct diagnosis arid the optimal treatment or referral to an eye care specialist or allergist zvhen required. In addition to established drug treatments, the role of subcutaneous and sublingual immunotherapy is discussed to inform pediatric health care professionals about alternative treatment options for patients who do not tolerate pharmacotherapy or who do not respond sufficiently. Conclusion: The diagnostic and treatment algorithms and guidelines provided in this review help address the current literature and educational gap and may lead to improvements in diagnosis and management of pediatric AC.

(Allergy Asthma Proc 38:16-27, 2017; doi: 10.2500/aap.2017.38.4003)

A llergic conjunctivitis (AC) is the response by con junctival tissue to allergens such as pollen and animal dander, and to other environmental allergens.1 The disease begins with antigen exposure, which stim ulates mast cell degranulation, histamine release, and activation of a downstream inflammatory cascade.2 AC is the most prevalent ocular disorder encountered by pediatric health care professionals, which peaks in late childhood and young adulthood.3 Another common

From the 1Division o f Allergy and Immunology, Department o f Pediatrics, University o f California, Irvine, California, 2Department o f Ophthalmology, University of Cali fornia, San Diego, California, 3Department o f Pediatrics, University o f California, San Diego, California, and 4Southern College o f Optometry, Memphis, Tennessee Supported by Alcon Research, Fort Worth, Texas W.E. Berger is a paid consultant fo r Alcon, Allergan, AstraZeneca, Boehringer Ingelheim, Meda, M ylan, Merck, and Teva, and has received payment for lecturesfrom Alcon, AstraZeneca, Boehringer Ingelheim, Meda, Mylan, and Teva; conducts clinical research fo r Anacor, AstraZeneca, Circassia, Genentech, Hoffmann la Roche, Janssen, Novartis, Roxane Laboratories (a Boehringer-Ingelheim company), and Teva. A.G. Rabat is a paid consultant fo r Alcon Laboratories, Bio-Tissue (a subsidiary of TissueTech, Inc.), BlephEx, LLC, and Shire; serves on advisory boards fo r Alcon, Bio-Tissue, Essilor, NicOx, Ocusoft, Shire, TearScience, Inc., and Valeant; received speaker fees fro m Alcon, Bio-Tissue, BlephEx, Ocusoft, Shire, and Valeant; has been paid for the preparation of manuscripts of educational materials by Alcon, Bio-Tissue, BlephEx, and TearScience; and has a grant from Thermi. D. Granet is a paid considtant fo r Alcon Laboratories and has received a royalty from the American Academy of Pediatrics Address correspondence to William E. Berger, M .D ., Allergy and Asthm a Associates, 27800 Medical Center Road, Suite no. 244, Mission Viejo, CA 92691 E-mail address: zveberger@uci.edu Copyright ? 2017, OceanSide Publications, Inc., U.S.A.

pediatric ocular disorder includes infectious conjuncti vitis, which can be caused by a virus but is most commonly caused by bacteria and requires a careful differential diagnosis to ensure prompt and suitable treatment. Despite its common occurrence, AC is reg ularly overlooked, misdiagnosed, and, therefore, un dertreated in both adult3,4 and pediatric patients.5 It is thought that AC goes undiagnosed in pediatric pa tients to a greater extent than in adults because chil dren often do not give voice to symptoms. In addition, other allergic conditions, such as asthma and allergic rhinitis (AR), are possibly more prevalent, more dis ruptive to the child's life, and extensively covered dur ing medical training.

The term "allergic conjunctivitis" encompasses many classified ocular conditions, including the acute sea sonal AC (SAC) and perennial AC (PAC), which have been associated with an immunoglobulin E-mediated hypersensitivity reaction, and the more-severe chronic forms, vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC), which have an eosinophilic component.6,7SAC and PAC are the two most common forms of AC, and, of the two, SAC is more prevalent.8 Seasonal allergies are triggered by aeroallergens with botanical periodicity, such as grass and tree pollens that peak in spring and in late summer and fall,8 whereas perennial allergies are triggered by environ mental allergens such as dust-mite feces9 and animal

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dander,8 which are present throughout the year. De spite some common markers of allergy, AKC and VKC have clinical and pathophysiologic features that are different from SAC and PAC.10 Both AKC and VKC occur less frequently but are potentially more severe, which necessitates involvement of an eye care special ist (optometrist and/or ophthalmologist) to ensure a differential diagnosis and to avoid potential vision loss.11 Furthermore, AKC can present in teenagers as well as adults, and younger patients would need the care of a pediatrician.12Giant papillary conjunctivitis is often grouped alongside other ocular allergic condi tions, despite not having an allergic pathogenesis; it is instead, a chronic ocular microtrauma-related condi tion, usually caused by irritating stimuli, such as con tact lenses and ocular prostheses.13 For the purpose of this review, the term AC refers to the two subtypes, SAC and PAC.

Although some differences exist, ocular and nasal tissues generally react to allergens in the same way, through the degranulation of mast cells secondary to activation; most pediatric patients with AC also have AR. Owing to the strong association between AC and AR, as documented by Berger et al.,14 the concept of "rhinoconjunctivitis" is now recognized by many health care professionals, and the International Study of Asthma and Allergies in Childhood has reported AC as rhinitis associated with itchy eyes (allergic rhinocon junctivitis) and not as an isolated ocular condition.13 AC is often underdiagnosed,5,18 inappropriately man aged, or missed altogether in pediatric patients with AR.

It is known that immunoglobulin E-mediated aller gic diseases can cause neuropsychiatric symptoms, such as irritability, decreased concentration, and day time fatigue in otherwise healthy individuals,17 and behavioral issues have been observed in pediatric pa tients with AC. Although AC is not considered a "se rious" entity, it is clinically relevant and can result in significant morbidity, including impaired performance of common daily activities such as attending school and interacting with other children.7 Multiple studies examined how AC reduces quality of life (QoL)18-21 and increases economic costs that arise from health care consultations and medication.19,21,22 Although these studies were not specifically conducted in pedi atric patients, it is thought that a significant impair ment of QoL and an economic burden of a different kind also apply to children with AC.

One AC study showed that, among students with nasal and ocular symptoms, 42% reported moderateto-severe interference of daily activities, 24% reported at least 1 day of absence from school, 36% reported a visit to a pediatric health care professional, and 28% reported drug usage for rhinitis. In adults, easy access to a variety of over-the-counter (OTC) ocular allergy

medications has enabled patients to attempt self-man agement of their condition,23 which has had a negative effect on patient outcomes due to delays in establishing a proper diagnosis and in receiving appropriate treat ment. Self-management only provides symptomatic re lief, without treating the underlying cause of the dis ease, which can lead to less-effective overall treatment and disease progression and complications associated with disease. Clinical experience indicates that a simi lar trend is seen in pediatric patients.

The incidence of self-medication is well documented and indicates that current projections probably under estimate the true overall disease incidence world wide.23 Physicians, therefore, only see the tip of the iceberg in terms of incidence and frequency of AC. A national cross-sectional study of clinical characteristics and QoL in Portugal demonstrated that most patients experienced year-round episodes and inevitably started AC self-management by using OTC medica tions.20 A similar trend is observed in pediatric pa tients, whereas parents usually treat their children's AC symptoms with antihistamine syrup, and many pediatric health care professionals rely on OTC medi cations, e.g., ocular decongestant eye drops, as first-line treatment. Flowever, topical ocular medications, in cluding certain preserved artificial tears or ocular de congestants, may irritate and inflame ocular surface tissues,24-26 which makes a correct diagnosis more dif ficult and lengthens the time to recovery.

As the current impact of AC on general well being, behavior, QoL, and socioeconomic costs demonstrates, there are clear unmet medical needs with regard to optimal diagnosis and treatment in pediatric patients. Although there are several reviews and publications that discuss clinical management of AC in adults,27-31 there is a lack of best-practice guidelines for pediatrics. The aim of this review, therefore, was to guide pedi atric health care professionals in the optimal diagnosis and management of AC in pediatric patients by pro viding step-by-step guidance on recognizing clinical features, establishing a comprehensive medical history, and performing a thorough physical examination. This review also included diagnosis and treatment algo rithms, and guidelines for pediatric patient referrals. The potential role of allergen-specific immunotherapy as an alternative treatment option in specific patient subgroups was also discussed.

IDENTIFICATION OF BEST PRACTICE GUIDELINES

Methodology

To identify best practice guidelines for the diagnosis and treatment of AC in pediatric patients, a review of the literature published between 2004 and January

Allergy and Asthma Proceedings

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2015 was conducted by using PubMed searching with the following search terms:

? "allerg* and conjunctivitis and best practice and ped*"

? "allerg* and conjunctivitis and best practice and paed*"

? "allerg* and conjunctivitis and best practice and child*"

? "allerg* and conjunctivitis and guidelines and ped*" ? "allerg* and conjunctivitis and guidelines and

paed*" ? "allerg* and conjunctivitis and guidelines and

child*" ? "allerg* and conjunctivitis and diagnos* and guide

lines and ped*" ? "allerg* and conjunctivitis and diagnos* and guide

lines and paed*" ? "allerg* and conjunctivitis and diagnos* and guide

lines and child*"

Only English language publications were included in the search. For the purpose of this review, adults were defined as patients >12 years of age, pediatric patients were those ages ................
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