Spring is in the air: Make sure that doesn't also mean itchy red eyes

While many Australians think of trips to the beach and weekend picnics at this time of year, those who suffer from seasonal allergic conjunctivitis are more likely to associate spring with other, less pleasurable experiences. For seasonal conjunctivitis sufferers, spring is the time of year when uncomfortable, itchy, red eyes are most common.¹

But don't despair! While allergic conjunctivitis causes considerable discomfort, many treatment options are available. They are suitable for both adults and children, and include simple measures as well as medicines.²

Seasonal allergic conjunctivitis

Seasonal allergic conjunctivitis (also called hayfever conjunctivitis) is an allergic eye condition. It is caused by the eye's hypersensitivity reaction to seasonal allergens in the air, such as pollen.¹

Itchy, red eyes: The most common symptom

Allergic conjunctivitis is usually not painful, although it causes considerable eye discomfort. The most common symptom is itchy eyes. Other common symptoms include red eyes, swelling of the eye, burning sensations in the eye, puffy eyelids, excessive tears and mucous discharge from the eyes.^1,3

People who do not have itchy eyes but have other allergic symptoms are unlikely to be suffering from allergic conjunctivitis, and may have another condition instead. It is very important that these people consult a doctor about their eye symptoms, especially if they experience eye pain or vision loss, as these typically indicate more serious conditions.⁴

It occurs in warm, windy weather and spring

As the name suggests, seasonal allergic conjunctivitis is a seasonal condition. It is most prevalent in spring when the airborne allergens which cause hypersensitivity or allergic reactions are more common.⁵ Warm, windy weather also increases the likelihood of allergic conjunctivitis, compared to cool or rainy conditions.⁶

How the eye responds to allergens

Seasonal allergic conjunctivitis occurs when the conjuctiva (the membrane that covers and protects the eyeball) is exposed to an allergen.^5,7 Airborne allergic pathogens enter the eye through the tear film and activate antibodies in the eye.¹

Activation of the antibodies disrupts other cells in the eye, in particular mast cells. Mast cells contain and regulate the release of chemicals that respond to allergic or inflammatory conditions, including histamine, serotonin and heparin.¹ These chemicals are released to protect the eye from the airborne allergen, but they also cause itching and inflammation.^5,7

The most common allergic eye condition

Seasonal allergic conjunctivitis is the most common allergic eye condition.¹ Up to 40% of adults experience some type of allergic eye condition,⁸ and the majority of these (90%) experience seasonal allergic conjunctivitis¹ (although the prevalence varies depending on the season⁹).The number of people with allergic seasonal conjunctivitis (and other allergic conditions) appears to be increasing.²

Children also experience seasonal allergic conjunctivitis. It is estimated that 17% of children aged 12–13 years experience allergic conjunctivitis.¹⁰ Children who have other allergic conditions are even more likely to experience allergic conjunctivitis. Almost all children (97%) with hayfever also suffer from allergic conjunctivitis, as do many children with asthma (56%) and eczema (33%).¹¹

How it affects quality of life

The discomfort and vision impairment associated with allergic seasonal conjunctivitis can considerably affect a person's quality of life.

For children, the discomfort can be distressing and may interfere with their day to day activities, including school attendance and performance.¹²

Adults who experience the condition work less hours and earn less money than those who don't. They also experience greater pain and perceive their health to be poorer than individuals who do not have seasonal allergic conjunctivitis. In addition, there are considerable costs associated with managing and treating the condition, and in some cases these are borne by the individual rather than the health system.¹³

Treatment options

There are many treatments that can effectively relieve the symptoms of seasonal allergic conjunctivitis. The treatments are safe and effective for both adults and children.¹² The best treatment option depends on the severity of the symptoms,² and individuals with conjunctivitis should consult their doctor about which treatment is most appropriate for them.

Preventing exposure to allergens

The simplest way of preventing itchy red eyes is to avoid the allergens causing it in the first place. Sometimes this is very difficult. But even in spring when allergen levels are highest, exposure to them can be reduced by wearing sunglasses or using hypoallergenic bedding, which makes it more difficult for allergens to enter the eyes.⁴

There are also some simple ways to reduce the discomfort of seasonal allergic conjunctivitis. For example, placing a cold compress over the eyes is a good way to reduce itching and inflammation. Avoiding rubbing the eyes is very important, because rubbing the eyes can cause more severe symptoms.³

Over-the-counter medicines to relieve symptoms

A range of medications are available over the counter at pharmacies which can reduce the symptoms of allergic seasonal conjunctivitis. Your doctor or pharmacist will be able to advise which medication is best for you. If your symptoms persist or become worse, seek your doctor's advice immediately.

Ocular lubricants

Ocular lubricants, also known as artificial tears, are eye drops that lubricate the eye's surfaces (e.g. Genteal eye drops or gel (hypromellose)) and Cellufresh (carmellose)). With additional lubrication, the eyes can often remove allergens from their surfaces, thus preventing the itching and other symptoms of allergic conjunctivitis.

Eye drops known as mucolytics can reduce the excessive mucous discharge sometimes caused by allergic conjunctivitis.² Mucolytics (such as mucolytic acetylcysteine) are only available from tertiary centres.

Ocular decongestants

Ocular decongestants such as Zincfrin (pheneylephrine/zinc sulfate) cause vasoconstriction of the eye's blood vessels. In doing so, they reduce blood flow into the eye and reduce the inflammatory symptoms of allergic conjunctivitis.²

Antihistamines

Histamine-1 (H₁) receptor agonists prevent histamine-induced itching. Histamine is released in response to allergens entering the eye (and other body systems). Histamine binds to cells in the eye and causes them to itch. Antihistamines work by preventing histamine from binding to other cells. Although histamine is still released into the eyes when a person takes antihistamines, the histamine does not cause itching because it is prevented from binding to other eye cells.²

Antihistamines are available in tablet (e.g. Telfast (fexofenadine)) and eye drop (e.g. Livostin (levocabastin)) formulations. They relieve symptoms quickly, although eye drops provide faster symptom relief than tablets.² They are suitable for short-term symptom relief (2–6 weeks), but do not prevent the symptoms from reappearing in the future.⁶

Some antihistamines also contain ocular decongestants (e.g. Naphcon A (naphazoline/pheniramine) or Antistine Privine (antazoline/naphazoline)). These combination medications are more effective than either decongestants or antihistamines used alone.² However, they should not be used for more than 14 days.⁶

Mast cell inhibitors

Mast cell inhibiting medications (e.g. Alamast (pemirolast), Alocril (nedocromil), Lomide (lodoxamide)) stabilise cells in the eye known as mast cells, and in doing so prevent the release of histamine and other chemicals that cause the eyes to itch and swell. These medications are used to prevent allergic eye reactions. However, they do not provide immediate symptom relief, usually taking 3–7 days to have an effect.⁶

Combined mast cell inhibitors and antihistamines

Mast cell inhibitors that contain the active ingredient ketotifen fumarate (e.g. Zaditen) are also available over the counter in Australia. Ketotifen fumarate–antihistamine combination medications work in three different ways to reduce the symptoms of allergic eyes. First, they function as antihistamines, preventing histamine from binding to cells in the eyes and causing itching.¹⁴ Second, they stabilise mast cells, and third, they prevent eosinophils (cells also involved in allergic reactions) from infiltrating the eyes.¹² These medications are safe and effective in adults and children aged three years or older.¹⁴

Mast cell stabilisers combined with antihistamines start working within minutes of use, and the effects of a dose last for 8–12 hours.¹⁴They can be taken by people experiencing periodic episodes of allergic conjunctivitis to prevent recurrence, as well as to treat current syptoms.⁶

No excuse for putting up with itchy eyes!

There is no excuse for putting up with itchy red eyes this spring. There are many ways to prevent or treat the symptoms of allergic seasonal conjunctivitis, and consulting a doctor will help you find out which treatment option is most suitable for you. People with severe symptoms may be referred to a specialist.¹⁵

Find out about your treatment options so you can spend this spring enjoying the great outdoors.

References

Greiner JV, Mundorf T, Dubiner H, et al. Efficacy and safety of ketotifen fumarate 0.025% in the conjunctival antigen challenge model of ocular allergic conjunctivitis. Am J Ophthalmol. 2003;136(6):1097-105. [Abstract]
Schmid KL, Schmid LM. Occular allergy: Causes and therapeutic options. Clin Exp Optom. 2000; 83(5):257-70. [Abstract]
Griggs PB. Allergic conjunctivitis [online]. Bethesda, MD: MedlinePlus, US National Library of Medicine; 22 August 2008 [cited 2 August 2010]. Available from: URL link
Moloney G, McCluskey PJ. Classifying and managing allergic conjunctivitis. Medicine Today. 2007;8(11):16-21. [Full text]
Khurana AK. Comprehensive Ophthalmology (4th edition). New Delhi: New Age International Publishers; 2007.
Allergic conjunctivitis [online]. Balgowlah, NSW: Australasian Society of Clinical Immunology and Allergy; January 2010 [cited 2 August 2010]. Available from: URL link
Bielory L, Friedlaender MH. Allergic conjunctivitis. Immunol Allergy Clin North Am. 2008;28(1):43-58. [Abstract]
Singh K, Bielory L. Ocular allergy: A national epidemiologic study. J Allergy Clin Immunol. 2007; 119(1 Suppl): S154. [Abstract]
Ono SJ, Abelson MB. Allergic conjunctivitis: Update on pathophysiology and prospects for future treatment. J Allergy Clin Immunol. 2005;115(1):118-22. [Abstract | Full text]
Hesselmar B, Åberg B, Eriksson B, Åberg N. Allergic rhinoconjunctivitis, eczema, and sensitization in two areas with differing climates. Pediatr Allergy Immunol. 2001;12(4):208-15. [Abstract]
Gradman J, Wolthers OD. Allergic conjunctivitis in children with asthma, rhinitis and eczema in a secondary outpatient clinic. Pediatr Allergy Immunol. 2006;17(7):524-6. [Abstract]
Abelson MB, Farzola NJ, McWhirter MC, Cramptom HJ. Efficacy and safety of single- and multiple-dose ketotifen fumarate 0.025% ophthalmic solution in a pediatric population. Pediatr Allergy Immunol. 2004:15(6):551-7. [Abstract]
Pitt AD, Smith AF, Lindsell L, et al. Economic and quality of life impact of seasonal allergic conjunctivitis in Oxfordshire. Ophthalmic Epidemiol. 2004;11(1):17-33. [Abstract]
Product Information: Zaditen. North Ryde, NSW: Novartis Pharmaceuticals Australia Pty Ltd; 27 January 2009.
Eye drugs: Allergic conjunctivitis [online]. Adelaide, SA: Australian Medicines Handbook. July 2010 [cited 10 August 2010]. Available from: URL link