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Purpose: This meta-analysis aimed to review the safety and efficacy of topical cyclosporine A (CsA) and topical tacrolimus in allergic eye disease., Methods: A systematic search identified thirteen studies and a total of 445 patients for inclusion, making this the largest meta-analysis published on the subject. The current review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)., Results: Thirteen randomized control trials were included in the meta-analysis. Eleven studies used CsA as the treatment, and two used Tacrolimus. In total, 445 participants were included, of whom 76.6% were male. The mean age of participants across the included studies was 14 years. All studies reported clinical signs as evaluated by an examining clinician. Signs were usually assessed by anatomical region, with the most common regions being the conjunctiva and the cornea, and the most common signs assessed were hyperemia and papillae. Three studies accounted for more than 50% of the meta-analysis's weight. Effect size (d) ranged from - 2.37 to - 0.03, negative values favoring immunomodulators. Fixed Effect Meta-Analysis returned an SMD of - 0.81 (95% CI [- 0.98, - 0.65]). However, there was significant heterogeneity (I 2  = 61%, Q w  = 30.76) in the outcome measure (P = 0.0021); therefore, a random-effect meta-analysis was also completed in which the pooled SMD was - 0.98 (95% CI [- 1.26, - 0.69], τ 2  = 0.16)., Conclusions: This study affirms the current scientific community's stance that immunomodulators effectively treat clinical signs, including blepharitis, conjunctival hyperemia, edema, papillae, and corneal damage in severe ocular allergic disease., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To explore the effects of cyclosporine A (CsA) in the management of atopic keratoconjunctivitis (AKC)., Methods: Open single-group interventional consecutive cohort study (case series) at a single eye care facility in the UK. We reviewed the electronic patient records of 99 children and young people (CYP) aged 3.4-18 years with AKC treated with topical CsA 1 mg/ml. Main outcome measures were number of prescriptions and hospital clinic visits over 12 months before and after the start of CsA and the proportion of CYP affected by adverse effects., Results: The median number of inflammatory episodes requiring treatment with topical corticosteroids (tCS) fell from 3 (interquartile range IQR 1-4) during the 12 months prior to CsA to 1 (IQR 0-3) during the 12 months after, excluding tCS prescriptions with the first CsA prescription (Wilcoxon signed ranks test, 2 tailed, p < 0.01). In the 12-month period following initiation of CsA 1 mg/ml with concomitant prescription of tCS (n = 66), daily dosage of steroids was reduced in 62 CYP (93.9%), and they were discontinued in 43 (65.2%). The median number of hospital visits fell from 4 (IQR 3-6) to 3 (IQR 2-5; Wilcoxon p < 0.01). Adverse events leading to discontinuation of CsA were stinging (instillation site pain; 9/99, 9%) and a transient skin rash (1/99, 1%)., Conclusions: Off-label use of commercial preparations of CsA 1 mg/ml significantly reduces the need for concomitant topical corticosteroids and hospital clinic visits in CYP with AKC. Stinging and skin rash can lead to discontinuation., (© 2022 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

The incidence of chronic keratoconjunctivitis, which potentially causes long-term loss of visual acuity due to corneal opacity, is considerably less common in children than in adults. It is therefore in danger of being overlooked. In children the appropriate treatment is therefore often introduced too late, or to an insufficient extent. In this article we would like to raise awareness about the diagnosis of chronic keratoconjunctivitis in children, and to present an effective treatment plan for severe stages of the disease. There are two forms of chronic keratoconjunctivitis that occur most frequently in children: hyperergic blepharokeratoconjunctivitis (hBKC) and vernal keratoconjunctivitis (VKC). With hBKC, the patient often has a history of recurring hordeolum and also presents with blepharitis; it is characterized by the marked presence of corneal neovascularization in the lower circumference of the cornea. VKC is typically characterized by changes under the upper eyelid, with marked changes to the superior limbus. If there is a risk of complications involving the cornea, or in the presence of such complications, a consistent long-term topical immunosuppressive and anti-inflammatory treatment is required. Both of these properties are combined in the active ingredient cyclosporine A. Other advantages of topical CSA treatment are its steroid-sparing effect and the long-term reduction of exacerbations. Parents need to be informed about the chronic nature of these two diseases and their tendency to recur; because of these characteristics, treatment, in most cases, should be envisaged for at least one year in order to effectively disrupt the complex immunologic processes. This safeguards the child's visual development and prevents amblyopia caused by scarring and astigmatism. We hope that the data presented will lower the barriers related to prescribing CSA for topical eye application in children., Competing Interests: Prof. Eter: Fa. Novartis: Research Funding, Speakerʼs Honoraria, Study grant to department, Advisory Board. Fa. Bayer: Research Funding, Speakerʼs Honoraria, Consultant fees, Advisory Board. Fa. Allergan: Research Funding, Speakerʼs Honoraria, Advisory Board. Fa. Roche: Advisory Board. Advisor: Apellis Pharmaceuticals, Alcon, Bayer, Novartis, Roche. Lecture fees: Apellis Pharmaceuticals, Bayer, Novartis, Roche. Research grant: Bayer, Novartis. Prof. Biermann: Santhera and Streamedup: Speakerʼs Honoraria. Bielschowsky-Gesellschaft: Research Funding./Prof. Eter: Forschungsförderung und Vortragshonorare von Novartis, Bayer, Allergan. Beratertätigkeit für Apellis Pharmaceuticals, Bayer, Novartis, Roche. Prof. Biermann: Vortragshonorar Santhera und Streamedup. Forschungsförderung der Bielschowsky-Gesellschaft., (Thieme. All rights reserved.)

Purpose: The aim of this study was to report corneal angiography features in subclinical limbitis in a patient with atopic keratoconjunctivitis., Methods: This is a case report., Results: A 22-year-old woman with a medical history of atopic keratoconjunctivitis was referred for bilateral corneal neovascularization with scarring. On examination, no signs of active disease were noticed at the slit lamp. Ocular surface angiography detected active corneal limbitis, showing as limbal leakage at fluorescein angiography in the early phase and leakage after indocyanine green angiography in the late phase. The patient was treated with topical corticosteroid. At follow-up, the fluorescein angiography and indocyanine green angiography no longer showed limbal leakage, whereas the slit lamp examination was unchanged., Conclusions: Active allergic corneal limbitis may present as subclinical inflammation, with no signs of activity at the slit lamp examination. Therefore, its diagnosis can be challenging without the use of corneal angiography., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the clinical improvement and safety of prolonged treatment of vernal (VKC) and atopic keratoconjunctivitis (AKC) using topical tacrolimus., Methods: We included 36 eyes of 36 patients who had VKC and AKC and were treated with topical tacrolimus ophthalmic suspension (0.1%) for 24 months. The demographic data of the enrolled patients were collected from their medical files. Clinical scores, remission rates, number of relapses, concomitant use of steroids, and refractory indices were assessed. Clinical outcomes were determined using papillae-limbus-cornea (PLC) scores and 5-5-5 exacerbation grading scale scores. Clinical characteristics associated with the need for concomitant steroid eye drops administration were determined using logistic regression analysis. All patients were classified into 3 subgroups using cluster analysis., Results: PLC scores recorded in the sixth month were significantly improved compared with those recorded at baseline. PLC scores recorded in the 18th, 21st, and 24th months were significantly improved compared with those recorded in the sixth month. The remission rates increased diachronically and significantly, reaching 92% in the 24th month. Logistic regression analysis showed that, for every 10-year increase in patient age, the risk for requiring concomitant administration of steroid eye drops was reduced by half (odds ratio, 0.53; 95% confidence interval, 0.29-0.96). Using cluster analysis, the patients were divided into 3 clusters: adolescent type, pediatric type, and adult type., Conclusions: Two years of treatment with topical tacrolimus ophthalmic suspension is an effective method for inducing and maintaining the stable stages of VKC and AKC., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC) are severe and potentially sight-threatening allergic eye diseases characterised by chronic inflammation of the ocular surface. Both topical and systemic treatments are used. This Cochrane Review focuses on systemic treatments., Objectives: To assess the effects of systemic treatments (including corticosteroids, NSAIDS, immunomodulators, and monoclonal antibodies), alone or in combination, compared to placebo or other systemic or topical treatment, for severe AKC and VKC in children and young people up to the age of 16 years., Search Methods: We searched CENTRAL, Ovid MEDLINE, Ovid Embase, the ISRCTN registry, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). There were no restrictions to language or year of publication. We last searched the electronic databases on 17 February 2020., Selection Criteria: We searched for randomised controlled trials (RCTs) that involved systemic treatments in children aged up to 16 years with a clinical diagnosis of AKC or VKC. We planned to include studies that evaluated a single systemic medication versus placebo, and studies that compared two or multiple active treatments., Data Collection and Analysis: We used standard methods expected by Cochrane., Main Results: No trial met the inclusion criteria of this Cochrane Review. No RCTs have been carried out on this topic., Authors' Conclusions: There is currently no evidence from randomised controlled trials regarding the safety and efficacy of systemic treatments for VKC and AKC. Trials are required to test efficacy and safety of current and future treatments. Outcome measures need to be developed which can capture both objective clinical and patient-reported aspects of the condition and treatments., (Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Introduction: Atopic keratoconjunctivitis (AKC) is a form of allergic eye disease that can have sight threating implications. Prevalence is underestimated due to scarce published data and treatment is expanding as a result of limitations of current strategies. This article aims to provide an up-to-date overview of AKC and summarize current and upcoming management., Areas Covered: The authors provide history, immunopathogenesis, and summary of the clinical manifestations of AKC as well as presenting a review of the evidence in relation to treatment options including mast cell stabilizers, antihistamines, corticosteroids, and immunomodulatory drugs based on clinical trials. Future trends, drug targets, and novel delivery drug systems are also highlighted in this review., Expert Opinion: Previously established treatment strategies of AKC had relied on corticosteroids, but the side effects of long-term therapy resulted in the expansion into the use of immunomodulatory drugs such as tacrolimus and ciclosporin. However, these too provide limited success due to the suboptimal structural properties of the current molecules. The ideal molecule should generate maximum permeability across the multi-layered structure of the cornea, be able to be formulated into eye drops for ease of application with minimal dosing and for maximal clinical effect.

Among the different forms of allergic conjunctivitis, atopic keratoconjunctivitis has distinct characteristics, defined by a more common onset in late adolescence or early adulthood, but also affecting the elderly, and with a higher prevalence in male individuals. However, the prevalence of atopic keratoconjunctivitis is scarcely investigated, and the data are often uncertain because other allergic nasal or respiratory disorders occur concomitantly. Mast cells, eosinophils, basophils, and T cells are involved in the pathogenesis of atopic keratoconjunctivitis. Despite its denomination as atopic, negative responses to skin tests or in-vitro immunoglobulin E tests are common. In fact, atopic keratoconjunctivitis can be attributed to a combination of T-helper-1 and T-helper-2 responses, but a higher prominence for T-helper-1 cells was found. The most common symptoms of atopic keratoconjunctivitis are bilateral ocular itching, burning, and tearing with a perennial presentation, although some patients may have seasonal exacerbations in winter or summer. Other symptoms such as photophobia, blurred vision, and mucous chewy discharge, owing to the accumulation of cells and mucin, may occur. The diagnosis of atopic keratoconjunctivitis is mainly clinical, as accepted diagnostic criteria or laboratory tests are not available. The treatment of atopic keratoconjunctivitis is aimed at controlling symptoms, decreasing relapse and exacerbations, and reducing vision loss. Therapeutic options comprise topical ophthalmic drops, including cromones, antihistamines, corticosteroids, and calcineurin inhibitors. Topical ointments are also available for corticosteroids and calcineurin inhibitors. Severe forms may require systemic medications including antihistamines, corticosteroids, and calcineurin inhibitors. Atopic keratoconjunctivitis therapy in the elderly does not differ from the adult population, but the occurrence of multi-morbidities and concomitant drug treatment, which are common in this age group, requires a careful evaluation to determine appropriate and personalized treatment.

Background: Severe atopic keratoconjunctivitis (AKC) is a relatively rare disease, and some cases are refractory to conventional steroid treatment., Objective: To examine the efficacy of 0.1% tacrolimus ophthalmic suspension in treating severe AKC during a 1-year follow-up., Methods: This was a single-center, retrospective clinical study. Sixty eyes from 30 patients with severe AKC who were treated with 0.1% tacrolimus ophthalmic suspension 4 times per day, were included. The mean age of the patients was 21.5 ± 13.7 years. The severity of objective signs was observed at baseline (before treatment), at 2 weeks, and at 1, 2, 3, 6, and 12 months after treatment initiation. Ten objective signs of palpebral conjunctiva, bulbar conjunctiva, limbus, and cornea were assessed using 4 grades (0 = normal; 1+ = mild; 2+ = moderate; 3+ = severe). Safety was assessed based on the incidence and the severity of adverse events., Results: The total score of the 10 clinical signs significantly decreased from baseline 2 weeks after initiating tacrolimus eye drop treatment, except at 2 months. The mean total score of clinical signs was 13.6 ± 6.6 at the beginning of treatment, and decreased to 5.4 ± 4.8 12 months after initiation. Treatment was gradually tapered, with increasing intervals between applications. Additional medications were required to provide relief in 18 patients during follow-up. No patient discontinued treatment due to adverse drug effects. Herpes keratitis was observed in 3 cases during follow-up. However, these cases were completely controlled., Conclusion: The 0.1% tacrolimus ophthalmic suspension is effective for the treatment of severe AKC refractory to standard conventional treatments throughout a full year., (Copyright © 2019 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess differential roles of inflammatory cells in pathophysiology of severe atopic keratoconjunctivitis (AKC) and evaluate immunomodulatory effects of topical cyclosporine A (CsA)., Methods: A total of 10 patients with severe, steroid-dependent/resistant chronic active AKC were treated using frequent topical CsA 0.05% as monotherapy for 2 months. Conjunctival biopsy specimens before and after treatment were examined using immunohistochemistry. A total of 10 healthy age-matched adults served as the control group., Results: Baseline AKC samples revealed greater cluster of differentiation 4 (CD4), interferon gamma (IFNγ), human leukocyte antigen-D-related (HLA-DR) positive cell densities compared with healthy controls ( P  < 0.05), as well as interleukin (IL)-17 ( P  = 0.08). Topical CsA treatment induced a significant reduction in CD4 and IL-17 expressions ( P  < 0.05); post-treatment levels were same as normals ( P  > 0.05). Despite reduction after treatment ( P  = 0.06), HLA-DR expression remained higher than controls ( P  < 0.05)., Conclusions: AKC-related conjunctival inflammation appears to be mediated by delayed hypersensitivity. In this short-term trial, frequent topical CsA improved conjunctival inflammation.

Competing Interests: Competing interests: We have read and understood the BMJ policy on declaration of interests and have no relevant interest to declare.

Purpose:: Administration of eye drops containing antihistamines or sodium cromoglycate and its derivatives for the treatment of allergic keratoconjunctivitis is often insufficient and usually requires the addition of corticosteroids. However, the risk of complications, such as glaucoma and cataract, limits the use of corticosteroids to short courses, resulting in inadequate long-term treatment response. Immunosuppressive drugs have been considered as a valid alternative to steroids for atopic keratoconjunctivitis and vernal keratoconjunctivitis. This study aimed to evaluate the use of topical tacrolimus (TCL) in improving the clinical signs of severe allergic keratoconjuctivitis in children., Methods:: Patients with severe allergic keratoconjunctivitis associated with corneal epitheliopathy, gelatinous limbal infiltrates, and/or papillary reaction, along with a history of recurrences and resistance to conventional topical anti-allergy agents, were included in this open clinical trial. Patients were treated with 0.03% TCL ointment for ocular use. A severity score ranging from 0 to 9, with 9 being the highest and 0 being the lowest, was assigned based on signs observed on biomicroscopy prior to and following TCL treatment., Results:: Analyses included 66 eyes of 33 patients. After a mean follow-up period of 13 months (range, 12-29 months), TCL treatment significantly decreased the mean symptom score severity for the right (from 5.56 ± 1.18 to 2.76 ± 1.5; p<0.001) and left (from 5.94 ± 1.16 to 2.86 ± 1.64; p<0.001)., Conclusion:: Topical TCL was effective and significantly improved the clinical signs of allergic keratoconjuctivitis in children. Thus, it is a potential new option for severe and challenging cases of ocular allergy.

Ocular allergy represents one of the most common conditions encountered by allergists and ophthalmologists. Allergic conjunctivitis is often underdiagnosed and consequently undertreated. Basic and clinical research has provided a better understanding of the cells, mediators, and immunologic events, which occur in ocular allergy. New pharmacological agents have improved the efficacy and safety of ocular allergy treatment. An understanding of the immunologic mechanisms, clinical features, differential diagnosis, and treatment of ocular allergy may be useful to all specialists who deal with these patients. The purpose of this review is to systematically review literature underlining all the forms classified as ocular allergy: seasonal allergic conjunctivitis, perennial allergic conjunctivitis, vernal keratoconjunctivitis, atopic keratocongiuntivitis, contact allergy, and giant papillary conjunctivitis.

About 30% of people suffer from allergic symptoms, and 40% to 80% of them have eye symptoms. Atopic conjunctivitis is divided into seasonal allergic conjunctivitis and perennial allergic conjunctivitis. The treatment of seasonal allergic conjunctivitis is simple: antihistamines, anti-inflammatory agents, or cromoglycate. Perennial allergic conjunctivitis needs longer therapy with mast cell stabilizers and sometimes local steroids. Atopic keratoconjunctivitis requires long-term treatment of the lid eczema and keratoconjunctivitis. Vernal keratoconjunctivitis mainly affects children and young people. It commonly calms down after puberty. It demands intensive therapy, often for many years, to avoid serious complicating corneal ulcers. Giant papillary conjunctivitis is a foreign body reaction in contact lens users or patients with sutures following ocular surgery. Nonallergic eosinophilic conjunctivitis affects mostly middle-aged and older women with eosinophilic conjunctivitis and dry eye. Contact allergic blepharoconjunctivitis is often caused by cosmetics and eye medication. Work-related ocular allergies should be considered as a cause of resistant ocular symptoms in workplaces.

A 35-year-old patient received omalizumab (300 mg twice a month) for 2 years for a severe atopic keratoconjunctivitis (AKC) in order to reduce the risk for steroid-induced keratitis. After 4 months, quality of life and ocular symptoms improved, and the use of oral steroids was strongly reduced. The treatment was well tolerated. This observation suggests that omalizumab may be a good option for the treatment of severe AKC, especially to avoid side effects of immunosuppressive treatments, as suggested for other allergic diseases. Specific trials should be designed for allergic eye diseases.

Purpose of Review: This review will focus on the diagnostic features of atopic keratoconjunctivitis (AKC), its relationship to atopic dermatitis, the immunopathogenesis, and therapy, and will include strategies used for the management of severe disease unresponsive to conventional therapy., Recent Findings: Recent research has demonstrated the importance of various cytokines (IL-33), proteins (thymic stromal lymphopoetin) and effector cells (conjunctival epithelial cells, eosinophils and basophils) in the pathogenesis of chronic ocular inflammation. Current evidence supports the use of tacrolimus and cyclosporin A, topically or systemically, as well tolerated and effective steroid sparing agents., Summary: Recalcitrant AKC may be a blinding condition. Understanding the immunopathogenesis of atopic dermatitis and AKC has already influenced therapy and is essential to the development of future immunomodulatory treatments. The successful management of AKC requires the use of topical cromones, antihistamines and calcineurin inhibitors. Severely affected patients also require systemic immunosuppressive therapy. The current challenge is to find more specific topical and systemic immunomodulatory therapies with a better side-effect profile.

Children are affected by some common external diseases, including allergic conjunctivitis and blepharokeratoconjunctivitis. This workshop aims to familiarize readers with the clinical features of each along with common presentations and to discuss strategies for managing these conditions, with emphasis on newer drugs and therapies. The other group of external diseases that commonly present in children comprises persistent punctate erosions and persistent epithelial defects. Etiology is varied, and making the correct diagnosis requires a systematic approach with close inspection of the microenvironment of the eye. Common causes and treatment modalities will be discussed. Types of lubrication and how they may best be used also will be outlined., (Copyright (c) 2010 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To evaluate the effectiveness and safety of a novel cyclosporine 0.1% aqueous ophthalmic solution in a large population with vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC)., Methods: A prospective observational postmarketing study was initiated in Japan. A total of 594 patients with VKC or AKC were started on this drug within 1 year after market launch (January 2006) and completed a 6-month follow-up. These patients were observed clinically, and subjective ocular symptoms (itching, discharge, tearing, photophobia, foreign body sensation, and pain), objective signs (hyperemia, swelling, follicle, papillae, and giant papillae for the tarsal conjunctiva; hyperemia and edema for the bulbar conjunctiva; Trantas dots and swelling for the limbus; and corneal involvement), and adverse events were recorded., Results: All scores for symptoms and signs significantly decreased from Month 1 through Month 6 of treatment in both VKC and AKC. Median total symptom scores at baseline, Month 1, and Month 6 were 6, 2, and 1, respectively, for VKC, and 7, 3, and 2, respectively, for AKC. Similarly, median total sign scores were 12, 7, and 5, respectively, for VKC, and 14, 10, and 7, respectively, for AKC. The percentage of patients able to complete topical cyclosporine 0.1% therapy within 6 months due to alleviation of symptoms was higher for VKC (44.4%) than for AKC (21.9%). In both VKC and AKC, approximately 30% of steroid users were able to discontinue topical steroids. Adverse drug reactions (ADRs) were found in 12.0% of patients, and the most common ADR was eye irritation (4.4%). Infectious corneal complications were observed in five AKC patients, including two cases of bacterial corneal ulcer and three cases of herpetic keratitis; all of these patients were concomitantly using topical steroids., Conclusions: Topical cyclosporine 0.1% is an effective and safe treatment for VKC and AKC.

Purpose of Review: A 1-year systematic review in the field of ocular allergy was carried out to select new information which may be useful for a practical approach to allergic conjunctivitis., Recent Findings: Out of the 56 articles listed by PubMed, 27 papers were included in the review following a consensus achieved among the authors who had independently reviewed all abstracts. Selected articles were classified according to their main focus: antihistamines, omalizumab, new treatments for vernal keratoconjunctivitis and inflammatory ocular disorders, and sublingual immunotherapy., Summary: The data reviewed are discussed with the aim of underlining unmet needs and making recommendations for future studies on diagnosis and treatment of ocular allergy which may better guide clinical practice in this important area of allergy and clinical immunology.

Purpose: To study the corneal topographic response to IOP reduction in vernal keratoconjunctivitis (VKC) with steroid-induced glaucoma., Methods: A total of 42 eyes of 21 patients with VKC and steroid-induced glaucoma (Group I) and 66 eyes of 33 patients with VKC without glaucoma (Group II) underwent an evaluation by Orbscan topography. In eyes with glaucoma, the IOP was controlled medically and the corneal topography was repeated at 3 months to evaluate effect on corneal parameters., Results: The mean baseline IOP was 36.40+/-13.08 mmHg in Group I, 14.67+/-4.62 mmHg in Group II (P<0.0001). The IOP after treatment at 3 months follow-up was 15.00+/-5.41 mmHg in Group I (P<0.0001). In Group I, the mean maximum Sim K decreased from 44.86+/-3.21 D to 43.87+/-2.62 D (P=0.031) and mean posterior corneal elevation decreased from 64.9+/-22.36 microm to 35.7+/-28.91 microm at 3 months after reduction of IOP (P=0.001). There was a significant positive correlation between the reduction in the IOP and the decrease in the posterior corneal elevation (r=0.664, P=0.001)., Conclusion: Eyes with VKC with and without glaucoma have similar corneal topography. Increased IOP associated with steroid-induced glaucoma and VKC may contribute to an increase in the corneal curvature and posterior corneal elevation. These changes may be reversed by a reduction in the IOP with medical therapy.

Allergies occur frequently in all pediatric age groups, affecting up to 40% of children. Allergic conjunctivitis is the most common ocular allergy syndrome among children, with atopic keratoconjunctivitis and vernal keratoconjunctivitis comprising less common, but potentially more severe, forms of ocular allergy. In this article, we review the impact, diagnosis, potential complications, and treatment of these ocular allergic pediatric conditions. Early detection is necessary to prevent potentially serious consequences of pediatric ocular allergy. Involvement of pediatric ophthalmologists may be necessary to avoid preventable vision loss in severe cases.

Conjunctival and corneal manifestations of atopic keratoconjunctivitis (AKC) are chronic, disabling and may be blinding. In common with other allergic diseases, such as asthma and atopic dermatitis, AKC is characterised by an allergen-induced immune response mediated through expression of IgE. The humanised monoclonal IgE antibody Xolair (omalizumab) complexes with free circulating IgE, thereby preventing binding of IgE to FcepsilonRI receptors on immune cells. Omalizumab effectively alleviates the signs and symptoms of asthma. Given the pivotal role of IgE in the allergic cascade, it is hypothesised that omalizumab has potential as an entirely new therapeutic approach to AKC.

Purpose: To report 4 cases of patients treated with topical tacrolimus ointment 0.03% for ocular inflammatory conditions refractory to traditional treatment., Methods: Four patients were treated topically with tacrolimus 0.03% ointment twice daily: 2 patients with blepharokeratoconjunctivitis, 1 patient with severe atopic keratoconjunctivitis, and 1 patient with chronic follicular conjunctivitis., Results: Three patients had a dramatic improvement of their ocular condition as early as 2 weeks after starting tacrolimus ointment. One patient developed a herpes simplex virus dendrite after 1 week of tacrolimus use., Conclusion: Tacrolimus ointment appears to be an effective alternative for certain ocular inflammatory conditions refractory to traditional treatments. There may be an increased risk of herpes simplex virus keratitis associated with topical use. Our results support previous literature of patients benefiting from topical tacrolimus use.

Recent developments indicate that ocular allergy is more than an IgE-mediated allergic conjunctivitis. Ocular allergy is a disease affecting the entire ocular surface including conjunctiva, lids, cornea, lacrimal gland and tear film. Besides an IgE-mediated reaction, a complex chronic inflammation is involved in the pathogenesis of many ocular allergies. According to their pathogenesis and clinical picture, ocular allergies are classified into mild forms, such as seasonal and perennial allergic conjunctivitis as well as giant papillary conjunctivitis, and chronic, potentially blinding forms such as atopic keratoconjunctivitis and vernal keratoconjunctivitis. New therapeutics act on the entire inflammatory process or try to modulate the allergic reaction early and specifically. The association with non-ocular allergic symptoms requires an interdisciplinary approach.

Purpose of Review: The goal of this article is to evaluate developments in the knowledge of inflammatory mechanisms and treatments of ocular allergy., Recent Findings: Research developments in ocular allergy summarized in this article include the following findings: (1) ocular epithelial cells play a role in inflammation; (2) respiratory syncytial virus is a pathogen in allergic conjunctivitis; (3) transglutaminase inhibitors reverse allergic related inflammation; (4) eosinophils and neutrophils both play a role in ocular allergy; (5) eotaxin-1 and eotaxin-2 play a role in eosinophilic recruitment; and (6) loteprednol etabonate, desonide phosphate, and cyclosporine have been shown to be effective and safe in the treatment of ocular allergy., Summary: This article summarizes the research conducted for each of the above recent findings and outlines their clinical applications.

Cromolyn sodium is a highly effective topical anti-allergenic solution for the treatment of vernal, giant papillary, ragweed, and atopic conjunctivitis. It acts by inhibiting the release of histamine and thereby prevents the inflammatory response by subacute type I hypersensitivity reactions. The following paper reviews the drug action of cromolyn sodium and discusses its value in the treatment of type I ocular allergic diseases.

The primary care physician may be the first physician to evaluate conjunctivitis caused by allergy or infection. A proper diagnosis can usually be made by asking the patient a few simple questions. Treatment with eyedrops is not always necessary. When the diagnosis is uncertain, treatment is best withheld, because "shotgun" therapy is seldom beneficial. Corticosteroid eyedrops are rarely necessary. When they are used, the physician must monitor intraocular pressure and examine the eye with a slit-lamp microscope for signs of cataract and opportunistic infection. Because there is a tendency to overtreat eye disorders, improvement of ocular inflammation is more often accomplished by stopping drug administration than by starting it.

Disodium cromoglycate has recently been approved for ophthalmic treatment of certain types of conjunctivitis in the United States. This mast cell inhibitor is effective in the treatment of vernal keratoconjunctivitis, allergic conjunctivitis, chronic conjunctivitis, and giant papillary conjunctivitis, especially when a history of atopic disorders or moderately low blood IgE levels are present. This literature review provides a foundation for understanding the balance between the therapeutic efficacy, clinical benefits and side effects in treating IgE-mediated conjunctivitis with disodium cromoglycate.