There are so many advantages to living in Hawaii – the sun, the outdoor sports, the sense of ohana.

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October in Hawaii! And, just a few blocks from our house on a public access beach – can’t beat that!

 

But, one thing which is not better here than on the mainland is the ALLERGIES!  I have lived in many places – North Carolina, Boston, New York – and my allergies are the absolute worst here in Hawaii.  This year seems to have hit allergy sufferers particularly hard – you may recognize the signs of hay fever – runny nose, clogged sinuses, headaches, coughing and sneezing. One-third of individuals who suffer from allergies also have ocular allergies – dry, itchy and red eyes. Allergic conjunctivitis occurs when the clear layer of tissue lining the eyelids and the white covering of the eyes, becomes inflamed. This causes tearing, discharge (makapiapia), itching, and redness. The most common cause of these symptoms is pollen during hay fever season, however, there are many allergens which can trigger symptoms year round. Cockroaches, dust mites, and animal fur or hair are just a few examples of triggers for sensitive individuals.

Symptoms of allergic conjunctivitis

  • tearing
  • discharge
  • itching 
  • redness

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A severe type of allergic conjunctivitis is called vernal conjunctivitis.  On the mainland, this usually only happens during summer and spring, but here in Hawaii, I see it year round.  So, these poor kids not only suffer from the redness, tearing, itching of typical allergy sufferers, but additional complaints.

Symptoms of vernal conjunctivitis

  • light sensitivity
  • thick pus like discharge
  • bumpy growths on the clear part of the eye or underneath the eyelid
Bumps on the pink part of the lower lid (conjunctiva), also known as papillae

Bumps on the pink part of the lower lid (conjunctiva), also known as papillae

I had one child from Maui who came in because her eye doctor that she needed eyelid surgery for a droopy eyelid.  I could barely examine the poor girl.  She was so light sensitive, she kept her right eye shut constantly and her vision was also terrible in that eye.

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Once I actually was able to flip her upper lid, I saw this.

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Huge bumps underneath her eyelid, just like in vernal conjunctivitis.

So, we started her on treatment.  The most common treatment for vernal conjunctivitis is:

  • Oral antihistamines (Claritin, Zyrtec)
  • Antihistamine drops (Pazeo, Padatay, Lastacaft)
  • Steroid drops to reduce swelling and redness (lotemax, prednisolone acetate, durezol)
  • Cold compresses
  • Avoidance of the allergen

She was also tested for allergies.  Turns out that she was allergic to dogs and cats and she had been visiting her grandmother’s farm every weekend which had tons of animals.  We reduced her visits to the farm, gave her Pataday and lotemax and several weeks later…

Screen Shot 2015-11-03 at 12.55.37 PMHer vision improved to a perfect 20/20 and she was able to open the eye again.   No surgery needed to elevate that upper lid. This was the only dog she could have now – but at least she could see!

Though classic teaching regarding vernal is that it mainly occurs during spring and summer months, I do see it year round here in Hawaii.  And, I can tell when allergens getting bad because all of my patients with vernal conjunctivitis will flare and make appointments in the same few weeks!  The most common allergens in Hawaii are dust mites, mold and cockroaches.  I lived in NYC for 8 years, I thought I was cool with roaches.  But, I tell you, NYC has nothing on Hawaii in terms of the sizes of our cockroach.  It was one of the deals I made with my husband before I moved here – he had to kill all of the roaches.  He gets super annoyed when I wake him up at midnight to tackle yet another flying roach (and I swear our house is clean!).  But a deal is a deal!

 

 

 

 

 

We live in Hawaii and allergies are a huge problem here compared to the mainland.  For 8 years, I lived smack in the middle of Manhattan and the pollution and dirt never caused a problem.  But, my first month of living here, the flora and VOG of Hawaii put my allergies on overdrive!  And along with allergies and the symptoms you think of  runny nose, sneezing, coughing, comes ocular allergies.

In children, allergic conjunctivitis can present like this:

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His eyes are only slightly red, but he has a little cough (which isn’t associated with a cold) and a little sneezing and there’s that non-stop blinking.

First, I should back up – what is the conunctiva?  It’s the mucous membrane of your eye – the white part and the pink part on the inside of your eyelid.

 

6 Signs of Allergic Conjunctivitis:

1.  Itching

2.  Tearing

3.  Redness

4.  Mucous discharge from the eyes

5.  Allergic shiners (look like black eyes underneath the eyes)

Allergic shiners (under the eyes)

6.  Blinking

 

There are many different kinds of allergic conjunctivitis that your eye doctor can diagnose.  This is not the same as “pink eye”.  There is no infection and it’s not contagious.

Types of allergic conjunctivitis:

– Seasonal or year round (perennial) allergic conjunctivitis – some people are specifically allergic to mangoes or only to VOG

– Vernal conjunctivitis – I see this a lot.  Tends to happen in young boys and needs aggressive treatment.  These boys will have really red eyes, light sensitivity and are at risk for losing vision in advance stages of the disease.

– Giant papillary conjunctivitis – that’s for all you contact lens wearers out there.  If you overwear your contacts, you can develop a reaction to the material, making your eyes red and intolerant to wearing contact lenses.

 

I am mainly going to discuss seasonal/perennial allergic conjunctivitis in this post.

So, what causes allergies?  Allergies are mediated by a type of white blood cell, called a mast cell.  It has a special form in the conjunctiva.  And, when it gets activated by the thing you’re allergic to (also called the allergen), it releases chemicals.  These chemicals, such as histamine and prostaglandins, are what cause symptoms of allergies.  They cause blood vessels to become large and leaky, causing redness, swelling and itching.

Here’s the kind of chart that other opthalmologists like to show each other when explaining allergy.  I swiped it from my husband’s presentation he had given on allergy.

 

 

Allergic response

 

So, how do we treat allergic conjunctivitis?

  • Allergen avoidance – this is ideal, but it can be hard in Hawaii.  Can’t exactly avoid VOG, and did you know cockroaches are really allergenic?  Hard to find a place here without cockroaches.  However, I always tell patients to try avoiding touching and rubbing their eyes, which is how a lot of allergens get in the eyes in the first place.
  • Cold compresses (not warm!) – I know patients sometimes get confused, we tell them warm compresses for this, cold for that.  But for allergies, we want cold compresses to make the blood vessels smaller and leak less.
  • Systemic medications – Benadryl, Claritin (anti-histamine), Zyrtec.  These medications are taken orally, and may not be helpful for the eyes at all.  In fact, they can often cause dry eye, making the symptoms of allergic conjunctivitis even worse!
  • Eye drops

 

Let’s talk about eye drops for allergic conjunctivitis.  Many patients will self-treat with over-the-counter drops such as Visine, which constricts the blood vessels and takes away the redness, but does nothing to treat the allergic reaction.  Then there are over-the-counter drops such as Visine-A, Naphcon-A, and Opcon-A which have a weak antihistamine.  They are safe and effective for short term use, but the preservatives in these drops can be harsh and irritating to the eyes.  Also, the effect from these drops lasts only about 2 hours, so patients must overdose themselves in order to get all-day relief.

When I tell patients that they shouldn’t use Visine, they’re always quite surprised.  But, it really isn’t the best drop you can use.

There are also some people who use Similasan Eye Allergy homeopathic drops, however there is no scientific evidence that these drops work.  In general, most eye doctors discourage the use of these over-the-counter eye drops.

Fortunately, we have some much better prescription drops for allergic conjunctivitis.  Pataday, Lastacaft, Bepreve, and Elestat are some of the best drops for allergic conjunctivitis.  They not only block histamine’s nasty effects, but also prevent histamine from being released.  Pataday and Lastacaft only need to be given once a day.  All of these drops are very safe, and can be used long term.

If you have a red eye, you should see your eye doctor – don’t diagnose it yourself.  There are many different causes of red eyes which can be dangerous or vision threatening (like uveitis, corneal ulcers, trauma, angle closure glaucoma, corneal abrasions or foreign bodies).  There are also many different causes of blinking in children (tic, dry eyes, Tourette syndrome, irritation from eyelashes etc). Get it checked out first!
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