Spector and Raizman
`
`DISCUSSION
`Our field study of the Der p I antigen in house
`dust indicates that a large amount of mite aller(cid:173)
`gen is present in the houses in the Taipei area.
`Remarkable seasonal variation of Der p I levels is
`demonstrated, with peaks occurring in November
`and December. The pattern of seasonal variation
`of the Der p I allergen observed in Taipei was
`different from that reported in the United States,
`with the highest levels in July. 3 Furthermore, the
`house dust samples from mattresses, bedroom
`floors, and living room floors contained higher
`concentrations of Der p I in June, November, and
`December than in August, February, and April. In
`addition, it is important to point out that the
`occurrence of peaked Der p I concentration in
`November corresponded to the highest hospital
`admission rate for bronchial asthma in November
`found in our previous study. 1
`Absolute humidity was shown as the best single
`guide for excess mite growth; however, no corre(cid:173)
`lation between absolute humidity and mite aller(cid:173)
`gen content was found in our study. Because the
`indoor absolute humidity in Taipei is always
`higher than 9 gm/kg, which has been suggested to
`be critical for mite growth,4 the humidity cannot
`be used as a determining factor for mite growth in
`subtropical climates.
`In summary, the mite allergen Der p I content
`varied with seasons but was not influenced by the
`change of indoor absolute humidity in the Taipei
`area. On average, the highest Der p I concentra(cid:173)
`tion was found in the mattresses, and the pattern
`of the seasonal variation was similar among mat-
`
`J ALLERGY CLIN IMMUNOL
`JULY 1994
`
`tresses, bedroom floors, and living room floors.
`Furthermore, more than 90% of the dust samples
`collected in November and December were found
`to contain Der p I with a concentration higher
`than 2 µ.,g/gm dust, the proposed critical level for
`an asthma attack. 5 Therefore procedures to re(cid:173)
`duce the mite allergen as much as possible might
`be a feasible way to prevent the continuing rise in
`the prevalence of asthma in this area. In addition,
`the marked seasonal variation of mite allergen
`content observed in this investigation indicates
`that monitoring mite allergen levels in individual
`houses will be of great benefit in studying the
`relationship between HDM exposure and the oc(cid:173)
`currence of asthmatic symptoms.
`
`We thank the occupants of the 12 houses who let us
`use their homes to conduct an extensive sampling
`throughout the year.
`
`REFERENCES
`
`1. Chang YC, Hsieh KH. The study of house dust mites in
`Taiwan. Ann Allergy 1989;62:101-6.
`2. Luczynska CM, Li Y, Chapman MD, Tae PM. A two-site
`monoclonal antibody ELISA for the quantification of the
`major Dermatophagoides spp. allergens, Der p I and Der f I.
`J Immunol Methods 1989;118:227-35.
`3. Lintner TJ, Brane KA. The effects of season, climate, and
`air-conditioning on the prevalence of Dennatophagoides
`mite allergens in household dust. J ALLERGY CuN IMMUNoL
`1993;9] :862-7.
`4. Korsgaard J. Mite asthma and residency. Am Rev Respir
`Dis 1983;128:231-5.
`5. Platts-Mills TAE, Ward GW, Sporik R, Gelber LE, Chap(cid:173)
`man MD, Heymann PW. Epidemiology of the relationship
`between exposure to indoor allergens and asthma. Int Arch
`Aller~, Appl Immunol 1991;94:339-45.
`
`Conjunctivitis medicamentosa
`
`S. L. Spector, MD, and M. B. Raizman, MD
`Los Angeles, Calif, and Boston, Mass
`
`Rhinitis medicamentosa is a well recognized
`condition of chronic nasal congestion associated
`with the overuse of vasoconstricting nose drops. It
`is thought to be due to rebound nasal mucosa!
`
`From Allergy Medical Clinical, Los Angeles.
`Reprint requests: Sheldon Spector, MD, Allergy Medical
`Clinic, 11620 Wilshire Blvd., Suite 200, Los Angeles, CA
`90025.
`J ALLERGY CLIN IMMUNOL 1994;94:134-6.
`Copyright© 1994 by Mosby-Year Book, Inc.
`0091-6749/94 $3.00 + 0 1/54/55254
`
`edema, which may occur after use of topical nasal
`vasoconstrictors even for a short period of time. 1
`An analogous clinical condition in the eye is
`associated with the overuse of vasoconstricting
`drops. This results in increased conjunctiva! injec(cid:173)
`tion and often a rebound hyperemia that persists
`despite discontinuation of eye drops. The Physi(cid:173)
`cian's Desk Reference product information cau(cid:173)
`tions about persistent redness or irritation and
`suggests discontinuation of the drops should the
`condition worsen or persist. 2 These warning signs
`
`134
`
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`

`J ALLERGY CLIN IMMUNOL
`VOLUME 94, NUMBER ;
`
`Spector and Raizman 135
`
`FIG. 1. Hyperemia immediately after cessation of Alba(cid:173)
`Ion- A administration.
`
`can be interpreted as a persistence or worsening
`of the underlying condition. We describe five
`patients with a distinct clinical pattern, suggesting
`"conjunctivitis medicamentosa."
`
`CASE REPORTS
`Patient 1
`Patient l, the prototype patient, is a 19-year-old
`student who sustained an injury to one eye initially but
`had underlying allergic rhinitis and conjunctivitis. He
`was very self-conscious about his red eyes and had
`sought help from many ophthalmologists. His program,
`when he was first seen, included naphazoline and
`antazoline (AJbalon-A), which he used repeatedly
`throughout the day. The drops appeared to be required
`at shorter and shorter intervals to obtain relief. Oph(cid:173)
`thalmologists had prescribed steroid eye drops, which
`successfully improved the condition; but because he
`was told to use them sparingly, when they were stopped,
`the condition reappeared. A thorough allergic evalua(cid:173)
`tion revealed strongly positive skin test results. Skin test
`responses to the drops themselves were negative. An
`eye smear was positive for eosinophils. Immunotherapy
`and administration of cromolyn eye drops were started.
`After a few weeks, all vasoconstricting drops could
`be discontinued, and with long-term follow-up the pa(cid:173)
`tient continued to be free of symptoms. Fig. 1 shows the
`hyperemia seen immediately after cessation of Alba(cid:173)
`lon-A administration .
`
`Patient 2
`Patient 2 is a 37-year-old man who went sailing each
`week without proper protection for his eyes. He had
`marked redness of his eyes caused by sun exposure and
`three
`tetrahydrozoline hydrochloride (Visine)
`used
`times a day for 5 days. When he stopped using the eye
`drops, his eyes became "redder than they had ever been
`before." The drops appeared to be required at shorter
`and shorter intervals to obtain relief. He was given
`
`FIG. 2. Jt Appearance of eye within hours after use of
`eye drops. B, Appearance after cessation of drops for
`sever a I clays.
`
`artificial tears without preservatives, and after a few
`days his problem resolved. Fig. 2, A shows the appear(cid:173)
`ance of his eye within hours after the use of the eye
`drops, and Fig. 2, B shows appearance after cessation of
`the drops for several days.
`
`Patient: 3
`Patient 3 is a 44-year-old man with chlamydia! con(cid:173)
`junctivitis, which caused 5 months of bilateral ocular
`redness. Naphazoline and pheniramine maleate solu(cid:173)
`tion (Naphcon-A) was prescribed 3 to 4 times per day
`for 1 month. On the advice of his physician, Naphcon-A
`was stopped, and doxycycline, 100 µ.g 2 times per day,
`was started. An office visit 3 days later revealed eyes
`that were redder than before. After the drops had been
`discontinued for a longer time, the hyperemia was
`minimal. He restarted the drops, and the process re(cid:173)
`curred.
`
`Patient 4
`Patient 4 is a 32-year-old woman with seasonal
`allergic rhinitis and conjunctivitis. An eye smear was
`examined for eosinophilia, but the result was negative.
`Naphazoline and polyethylene glycol 2%, along with
`the cxcipicnts found in Allergy Drops by Bausch and
`
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`

`

`136 Spector and Raizman
`
`Lomb, was her treatment. When the drops were
`stopped, increasing tearing and redness occurred. After
`the patient was warned of a possible association be(cid:173)
`tween the eye drops and redness, she was able to stop
`using them on her own.
`
`Patient 5
`Patient 5 is a 32-year-old woman who had excision of
`bilateral pterygia resulting in revasculization of the
`larger vessels at the site of surgery. Naphazoline helped
`redness to clear completely in 20 to 30 minutes; how(cid:173)
`ever, 12 to 24 hours after the eye drops were discon(cid:173)
`tinued, the redness returned and became more intense.
`Immediate and delayed skin test responses to the drops
`were negative. She required no other medications after
`she stopped using the eye drops.
`
`RESULTS
`Skin test responses to the drops themselves, for
`both immediate and delayed hypersensitivity re(cid:173)
`activity, were negative in the three patients tested.
`Skin tests for possible pollen, dust, or mold aller(cid:173)
`gies were done in those patients with allergic
`rhinitis and helped to confirm the diagnosis. An
`eye smear for eosinophils was done in patient 1,
`and the result was positive.
`
`DISCUSSION
`Certain characteristics of the patients described
`should be noted. All patients had an underlying
`ocular problem that prompted the use of vasocon(cid:173)
`strictor eye drops. The vasoconstrictor drops
`helped the redness, prompting continuation of
`their use. In some patients the vasoconstrictor
`ocular drops appeared to be required at shorter
`and shorter intervals to obtain relief. Attempts to
`discontinue the drops after days, weeks, or
`months without additional treatment caused hy(cid:173)
`peremia, thought to be due to a rebound phenom(cid:173)
`enon. Artificial tears, corticosteroid drops, or
`long-term therapy with ocular cromolyn and/or
`immunotherapy may help terminate dependence
`on the vasoconstrictor drops, depending on the
`underlying condition. The most common agent
`used by the patients described was naphazoline,
`but other agents such as tetrahydrozoline hydro(cid:173)
`chloride can be responsible for the phenomenon
`described.
`The cause of these problems is unclear. Preex(cid:173)
`isting conjunctiva! disease may be a prerequisite
`condition for the development of medicamentosa.
`
`J ALLERGY CUN IMMUNOL
`JULY 1994
`
`Abelson et al.,3 using a histamine model to pro(cid:173)
`duce ocular redness, did not observe rebound
`vasodilation after administration of naphazoline
`or tetrahydrozoline in 11 normal volunteers after
`single use or 10 days of exaggerated use. Perhaps
`an underlying medical problem is necessary, as
`was the c:ase in our patients, for its development.
`Skin testing done with the components of the
`drops in three of the patients did not indicate
`immediate hypersensitivity or delayed hypersensi(cid:173)
`tivity reactivity. Additionally, patient 1 did not
`show reactivity by skin testing to the preservative
`benzalkonium, tested by itself.
`The use of vasoconstrictor eye drops has re(cid:173)
`cently increased in the United States because of
`the nonavailability of cromolyn sodium. This
`could help explain why more patients have been
`using the ocular formulation of vasoconstrictor
`drops. The analogy between rhinitis medicamen(cid:173)
`tosa and conjunctivitis medicamentosa is obvious.
`We think that physicians should be made more
`aware of the two entities. In a British study 26%
`of practitioners prescribed topical nasal deconges(cid:173)
`tants as a first-line therapy in allergic rhinitis. 4 We
`suspect that the ocular equivalent is more com(cid:173)
`mon than physicians realize and that most pa(cid:173)
`tients just stop using the drops because they think
`that they are not helping or because the situation
`is getting slightly worse. Often, patients do not
`bring their ocular problem to the attention of the
`physician because many over-the-counter prepa(cid:173)
`rations are available. They might conclude that
`the eye drops are not working rather than that
`there is an actual worsening of the condition. If
`the diagnosis of conjunctivitis medicamentosa is
`considered, the vasoconstrictor eye drops should
`be discontinued in favor of more appropriate
`treatment of the underlying condition.
`
`REFERENCES
`1. Fennenbaum JI. Allergic rhinitis. In; Paterson R, ed. Al(cid:173)
`lergic diseases: diagnosis and management. 2nd ed.
`Philadelphia: JB Lippincott, 1980:87.
`2. Physicians desk reference for ophthalmology. 20th ed.
`Montvale, NJ: Medical Economics Co., 1992.
`3. Abelson MB, Butrus SI, Weston J, Rosner B. Tolerance
`and absence of rebound vasodilation following topical oc(cid:173)
`ular decongestant usage. Ophthalmology 1984;91:1364-7.
`4. Jones HS. Allergic rhinitis: a study on the prescribing pref(cid:173)
`erences in general practice. Br J Clin Pract 1989;43:30-2.
`
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