Nasal-Ocular Reflexes and Their Role in the Management of Allergic Rhinoconjunctivitis With Intranasal Steroids

Abstract

Allergic rhinitis is a common disorder and involves the reaction to environmental allergens with resultant nasal and eye symptoms. The pathophysiologic mechanisms of the eye symptoms in allergic conjunctivitis include a direct effect on the eye by deposited allergen and indirect effects related to the deposition of allergen in the nasal mucosa. One of these proposed mechanisms is the existence of a nasal-ocular reflex whereby the nasal allergic reaction leads to an afferent reflex response, the efferent limb of which results in eye symptoms. Among the treatments available for allergic rhinitis, intranasal steroids are most efficacious for nasal symptoms and have also shown sizeable efficacy related to eye symptoms. We speculated that the effect of intranasal steroids on eye symptoms in allergic rhinitis was related to their inhibition of the nasal-ocular reflex and present data previously generated from our laboratory to support this assumption in a nasal challenge model. Key Words: Nasal-ocular reflex, allergic rhinoconjuctivitis, nasal challenge, intranasal steroids (WAO Journal 2011; 4:S1-S5) A llergic rhinitis is characterized by an IgE-mediated reaction to environmental allergens. It is a common disorder affecting up to 40 million Americans with adult prevalence estimates ranging from 10 to 30% and pediatric prevalence estimates as high as 40% rendering it the most common chronic condition in children. 1 Several reports also support substantial increases in the prevalence of allergic rhinoconjunctivitis (AR) in developed countries in recent decades making it an important health problem. [1][2][3] Although often referred to as allergic rhinitis, this disease actually involves eye symptoms in addition to the nasal symptoms, hence the more appropriate term, AR. In fact, recent epidemiologic data has shown that ocular symptoms, defined as 'episodes of watery, itchy eyes,' affected 40% of the adult population of the United States during a 12-month period. 4 Another study showed that the incidence of conjunctivitis was high (ϳ88%) in patients experiencing allergic rhinitis during the cypress pollen season. 5 Ocular symptoms are not only common, but also distressing for allergy sufferers, with more than 50% stating that watery and red/itchy eyes were moderately to extremely bothersome in the Allergies in America survey. 6 Furthermore, in 15% of sufferers, the ocular component of the allergic hypersensitivity reaction was the most bothersome symptom. 6 In addition to the typical nasal and eye symptoms, AR leads to a significant impairment of the quality of life of its sufferers when measured by both generic and specific quality of life instruments. 7,8 Also associated with the disease are fatigue and daytime sleepiness, 7,9 reduced work productivity, 10 -12 impaired cognitive functioning, 13,14 reduced learning abilities, 15 and impaired sleep. 16 The high prevalence of this benign, but chronic, condition, its adverse effects on quality of life, work performance, and productivity on the job, and the treat...

Local allergic rhinitis: Implications for management

“…8,11 However, it is still not clear if the involvement of the conjunctiva in LAR is a true ocular sensitisation or an activation of nasal-ocular reflexes after allergen exposure in the nose. 46 The conjunctival epithelium hosts a robust population of immune cells, such as mast cells and T and B lymphocytes, 47 and in allergic conjunctivitis resident B cells produce sIgE that sensitise conjunctival mast cells. 48 Whether conjunctival sensitisation in addition to nasal-ocular reflexes work synergistically in LAR patients to induce ocular symptoms is not sufficiently investigated.…”

“…Ocular symptoms are more common in pollen‐reactive LAR patients than in those sensitised to HDMs . However, it is still not clear if the involvement of the conjunctiva in LAR is a true ocular sensitisation or an activation of nasal‐ocular reflexes after allergen exposure in the nose . The conjunctival epithelium hosts a robust population of immune cells, such as mast cells and T and B lymphocytes, and in allergic conjunctivitis resident B cells produce sIgE that sensitise conjunctival mast cells .…”

The Anatomical and Functional Relationship between Allergic Conjunctivitis and Allergic Rhinitis

“…56 Two double-masked crossover clinical trials investigated the nasal ocular reflex with a nasal allergen challenge and AC. 52,57,58 The authors theorized histamine release from the nasal mucosa mast cells initiated rhinitis and AC. The afferent limb of the nasal ocular reflex was located in the nasal mucosa and resulted in nasal and ocular symptoms within minutes of the challenge.…”

“…As previously mentioned, nasal sprays have shown an added advantage on ocular allergy by reduction of symptoms. 52,57,58 The nasolacrimal apparatus is considered the conduit for many pharmaceutical treatments to potentially reach either the nose or the eye. Nasal sprays have been reported to have a positive impact on ocular symptoms, but that appears to be predominantly through a neurogenic mechanism.…”

“…Pretreatment with fluticasone furoate nasal spray reduced sneezing, nasal secretion weights, amount of eosinophils in nasal secretions, and ocular symptoms. 52,57,58 One study showed the first ocular symptoms impacted were tearing on day 2 followed by itching and redness on day 4 with intranasal corticosteroids. 59 The naso-ocular reflex is not without controversy.…”