Ocular allergy encompasses a heterogeneous group of diseases with overlapping clinical features and complex immunopathological mechanisms. This often creates challenges in classification and, consequently, in optimizing patient management. The nomenclature published in 2023 by the European Academy of Allergy and Clinical Immunology (EAACI) addresses these issues by redefining these conditions and linking clinical phenotypes and environmental modifiers to underlying types of hypersensitivity. This framework enhances diagnostic precision and supports mechanism-guided management. This article applies the EAACI approach based on hypersensitivity types to ocular allergy. The examples addressed include seasonal and perennial allergic conjunctivitis, driven mainly by type I and IV hypersensitivity reactions; vernal and atopic keratoconjunctivitis, involving mixed type I, IVb and IVa pathways; giant papillary conjunctivitis, a tissue-driven type V reaction; and contact blepharoconjunctivitis, a type IVa delayed hypersensitivity reaction with additional components. Distinct endotypes-such as local or acute allergic conjunctivitis, dupilumab-induced ocular disease, and vernal keratoconjunctivitis/atopic keratoconjunctivitis overlap-further illustrate heterogeneity, with the ocular surface microbiome emerging as a modifier. Diagnostics are increasingly aligning with mechanisms, and the EAACI framework translates this complexity into a mechanism-indexed map; this supports the selection of responders for targeted interventions while minimizing overtreatment.

Morbidity of ocular allergic diseases has been growing all over the world alongside with other allergic diseases, especially the allergic rhinitis. Unfortunately epidemiologic data and studies about immunotherapy in ocular allergy have so far been scarce in comparison to extensive research of various aspects of allergic rhinitis. The author presents three studies of allergen-specific immunotherapy in ocular allergy and certain of numerous studies on allergic conjunctivitis (AC) and allergic rhinoconjunctivitis (ARC) that included separate evaluation of ocular symptoms. This article emphasizes the need for further research on the proper placement of ocular allergies in allergology and establishing indications for allergen-specific immunotherapy of allergic conjunctivitis

The rate of occurrence of CBC (Contact Blepharo-Conjuncitivis) has been increasing in recent years due to growing exposure of the population to allergens and chemical substances (pharmaceuticals, cosmetics, preservatives). Typical symptoms of CBC are as follows: itching and stinging of eyelids, erythema with possible lichenification of skin in the eye sockets area, conjunctival edema and hyperemia. Thorough analysis of patient's medical history is crucial for identification a cause of CBC, but whenever this is insufficient one needs to seek for IgE dependent allergies (allergic airborne eczema) or allergies to various chemical substances, which as haptens are responsible for type IV response according to Gell and Coombs (path tests). This article presents two cases of CBC.

In less than half a century, allergy, originally perceived as a rare disease, has become a major public health threat, today affecting the lives of more than 60 million people in Europe, and probably close to one billion worldwide, thereby heavily impacting the budgets of public health systems. More disturbingly, its prevalence and impact are on the rise, a development that has been associated with environmental and lifestyle changes accompanying the (Continued on next page) * Correspondence: ngp@allergy.gr Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece Full list of author information is available at the end of the article © 2012 Papadopoulos et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Papadopoulos et al. Clinical and Translational Allergy 2012, 2:21 http://www.ctajournal.com/content/2/1/21

Diagnosis and treatment of allergic diseases in people over 65 years of age require the physician to take into account the impact of aging. Immunosenescence affects the size of reactions in SPT and sIgE levels. The aging of lungs leads to an increase in RV and RV/TLC, which affects the value of FEV1/FVC. In people above 70 years of age the right values are below 0.65 and in people over 80 years old it is below 0.6. In elderly, above age 65, there coexist at least three and often five diseases requiring drug therapy. This is the main cause of polytherapy, which produces numerous side effects and increases the risk of frequent hospitalizations. For this reason, treatment of the elderly requires a holistic approach and the selection of essential and safe drugs. When planning treatment we should check vision, hearing, the efficiency of hands and adjust the treatment to the real possibility of an elderly person. For compliance in treatment it is important to assess the possible cognitive impairment, and if they are in this treatment, for such patients caregiver should participate. We should print out the saving treatment procedure and discuss it with the patient, taking into account patient's financial capabilities. The dosage of medication should be as simple as possible and, if possible, we should advise drugs effective in concomitant diseases and avoid drugs on demand. The article discusses the specificity of the diagnosis and treatment of allergic diseases in seniors.

L’allergie oculaire comporte plusieurs maladies cliniquement différentes, pouvant être en relation avec des dysfonctionnements de la sensibilité immunologique au niveau de la surface oculaire. La classification de ces pathologies est complexe. Du fait de l’absence d’une terminologie commune, il n’y a pas d’études épidémiologiques valables. Les symptômes d’allergie oculaire sont souvent, mais pas toujours, associés à d’autres manifestations allergiques, surtout à la rhinite. Toutefois, certaines allergies oculaires doivent être diagnostiquées et prises en charge par une équipe incluant un ophtalmologiste et un allergologue. Le diagnostic de l’allergie oculaire est essentiellement basé sur l’anamnèse ainsi que sur la symptomatologie. Des tests in vivo et in vitro sont pratiqués éventuellement lorsque l’identification de/ou des allergènes semble nécessaire pour la prise en charge du patient. Le rapport de ce groupe de travail a pour objectifs : (i) d’homogénéiser la terminologie et la classification des allergies oculaires, en associant des critères ophtalmologiques et allergologiques (voir ARIA. la rhinite allergique et son impact sur l’asthme) ; (ii) de décrire les méthodes de diagnostic courantes et (iii) d’énumérer les principales options thérapeutiques pour la prise en charge de l’allergique oculaire.

In less than half a century, allergy, originally perceived as a rare disease, has become a major public health threat, today affecting the lives of more than 60 million people in Europe, and probably close to one billion worldwide, thereby heavily impacting the budgets of public health systems. More disturbingly, its prevalence and impact are on the rise, a development that has been associated with environmental and lifestyle changes accompanying the continuous process of urbanization and globalization. Therefore, there is an urgent need to prioritize and concert research efforts in the field of allergy, in order to achieve sustainable results on prevention, diagnosis and treatment of this most prevalent chronic disease of the 21st century.The European Academy of Allergy and Clinical Immunology (EAACI) is the leading professional organization in the field of allergy, promoting excellence in clinical care, education, training and basic and translational research, all with the ultimate goal of improving the health of allergic patients. The European Federation of Allergy and Airways Diseases Patients' Associations (EFA) is a non-profit network of allergy, asthma and Chronic Obstructive Pulmonary Disorder (COPD) patients' organizations. In support of their missions, the present EAACI Position Paper, in collaboration with EFA, highlights the most important research needs in the field of allergy to serve as key recommendations for future research funding at the national and European levels.Although allergies may involve almost every organ of the body and an array of diverse external factors act as triggers, there are several common themes that need to be prioritized in research efforts. As in many other chronic diseases, effective prevention, curative treatment and accurate, rapid diagnosis represent major unmet needs. Detailed phenotyping/endotyping stands out as widely required in order to arrange or re-categorize clinical syndromes into more coherent, uniform and treatment-responsive groups. Research efforts to unveil the basic pathophysiologic pathways and mechanisms, thus leading to the comprehension and resolution of the pathophysiologic complexity of allergies will allow for the design of novel patient-oriented diagnostic and treatment protocols. Several allergic diseases require well-controlled epidemiological description and surveillance, using disease registries, pharmacoeconomic evaluation, as well as large biobanks. Additionally, there is a need for extensive studies to bring promising new biotechnological innovations, such as biological agents, vaccines of modified allergen molecules and engineered components for allergy diagnosis, closer to clinical practice. Finally, particular attention should be paid to the difficult-to-manage, precarious and costly severe disease forms and/or exacerbations. Nonetheless, currently arising treatments, mainly in the fields of immunotherapy and biologicals, hold great promise for targeted and causal management of allergic conditions. Active involvement of all stakeholders, including Patient Organizations and policy makers are necessary to achieve the aims emphasized herein.

Ocular allergy includes several clinically different conditions that can be considered as hypersensitivity disorders of the ocular surface. The classification of these conditions is complex, and their epidemiology has not been adequately studied because of the lack of unequivocal nomenclature. Ocular allergy symptoms are often, but not always, associated with other allergic manifestations, mostly rhinitis. However, specific ocular allergic diseases need to be recognized and managed by a team that includes both an ophthalmologist and an allergist. The diagnosis of ocular allergy is usually based on clinical history and signs and symptoms, with the support of in vivo and in vitro tests when the identification of the specific allergic sensitization is required for patient management. The aims of this Task Force Report are (i) to unify the nomenclature and classification of ocular allergy, by combining the ophthalmology and allergy Allergic Rhinitis and its Impact on Asthma criteria; (ii) to describe current methods of diagnosis; (iii) to summarize the therapeutic options for the management of ocular allergic inflammation.

In less than half a century, allergy, originally perceived as a rare disease, has become a major public health threat, today affecting the lives of more than 60 million people in Europe, and probably close to one billion worldwide, thereby heavily impacting the budgets of public health systems. More disturbingly, its prevalence and impact are on the rise, a development that has been associated with environmental and lifestyle changes accompanying the (Continued on next page) * Correspondence: ngp@allergy.gr Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece Full list of author information is available at the end of the article © 2012 Papadopoulos et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Papadopoulos et al. Clinical and Translational Allergy 2012, 2:21 Page 2 of 23 http://www.ctajournal.com/content/2/1/21 (Continued from previous page) continuous process of urbanization and globalization. Therefore, there is an urgent need to prioritize and concert research efforts in the field of allergy, in order to achieve sustainable results on prevention, diagnosis and treatment of this most prevalent chronic disease of the 21 century. The European Academy of Allergy and Clinical Immunology (EAACI) is the leading professional organization in the field of allergy, promoting excellence in clinical care, education, training and basic and translational research, all with the ultimate goal of improving the health of allergic patients. The European Federation of Allergy and Airways Diseases Patients’ Associations (EFA) is a non-profit network of allergy, asthma and Chronic Obstructive Pulmonary Disorder (COPD) patients’ organizations. In support of their missions, the present EAACI Position Paper, in collaboration with EFA, highlights the most important research needs in the field of allergy to serve as key recommendations for future research funding at the national and European levels. Although allergies may involve almost every organ of the body and an array of diverse external factors act as triggers, there are several common themes that need to be prioritized in research efforts. As in many other chronic diseases, effective prevention, curative treatment and accurate, rapid diagnosis represent major unmet needs. Detailed phenotyping/endotyping stands out as widely required in order to arrange or re-categorize clinical syndromes into more coherent, uniform and treatment-responsive groups. Research efforts to unveil the basic pathophysiologic pathways and mechanisms, thus leading to the comprehension and resolution of the pathophysiologic complexity of allergies will allow for the design of novel patient-oriented diagnostic and treatment protocols. Several allergic diseases require well-controlled epidemiological description and surveillance, using disease registries, pharmacoeconomic evaluation, as well as large biobanks. Additionally, there is a need for extensive studies to bring promising new biotechnological innovations, such as biological agents, vaccines of modified allergen molecules and engineered components for allergy diagnosis, closer to clinical practice. Finally, particular attention should be paid to the difficult-to-manage, precarious and costly severe disease forms and/or exacerbations. Nonetheless, currently arising treatments, mainly in the fields of immunotherapy and biologicals, hold great promise for targeted and causal management of allergic conditions. Active involvement of all stakeholders, including Patient Organizations and policy makers are necessary to achieve the aims emphasized herein.

Allergic diseases in children and adults have been studied for many years In contrast, in older subjects. they are not well known, in particular with regard to ocular pathology The particularity of these conditions in older subjects is a result of the interaction of all aging and co-morbidities It can be assumed that an individual over 60 years of age suffers from at least three different diseases and that he takes medications for them (Fabbri et Ferrari. 2006 [1]) The aging process favours. for example. the dry eye syndrome, accommodation disorders. and dysfunctioning of the meibomian gland As a result. the clinical picture of ocular allergy can be atypical, and other diseases, such as meibomitis. blepharitis. acne rosacea. or a toxic drug reaction can resemble an allergy (Baudouin [2]. Ramkissoon et al [3]) The diagnostic work-up should be based on very detailed medical history followed by ophthalmologic and allergic examinations Skin prick tests and specific serum IgE have an uncertain diagnostic value in older patients (Simola et al [4]. Bozek et al [5]. King et al [6]) Management is based on the choice of a small number of agents which have a good therapeutic index. the risk of adverse effects is great in older patients (Hanlon et al [7]) (C) 2010 Elsevier Masson SAS All rights reserved

To cite this article: Zuberbier T, Oanta A, Bogacka E, Medina I, Wesel F, Uhl P, Antépara I, Jáuregui I, Valiente R, the Bilastine International Working Group. Comparison of the efficacy and safety of bilastine 20 mg vs levocetirizine 5 mg for the treatment of chronic idiopathic urticaria: a multi‐centre, double‐blind, randomized, placebo‐controlled study. Allergy 2010; 65 : 516–528. Abstract Background: Bilastine is a novel nonsedative H 1 ‐receptor antagonist, which may be used for the symptomatic treatment of chronic idiopathic urticaria (CU). The aim of this study was to compare the clinical efficacy and safety of bilastine 20 mg vs levocetirizine 5 mg and placebo in CU patients with moderate‐to‐severe symptoms. Methods: Overall 525 male and female subjects aged 18–70 years were randomized to receive bilastine 20 mg, levocetirizine 5 mg or placebo, once daily for 28 days, in double‐blind manner, in 46 centres across Europe and Argentina. Patients rated symptoms of pruritus, number of wheals, and maximum size of wheals (on predefined scales) as reflective (over past 12 h) symptoms twice daily, for assessment of change from baseline in the total symptoms scores (TSS) over 28 days as the primary efficacy measure. Changes in reflective and instantaneous symptoms scores, Dermatology Life Quality Index (DLQI), and CU‐associated discomfort and sleep disturbance were assessed as secondary outcomes. Safety was assessed according to adverse events, laboratory tests and electrocardiograms. Results: Bilastine reduced patients’ mean reflective and instantaneous TSS from baseline to a significantly greater degree than placebo ( P < 0.001); from day 2 onwards of treatment. The DLQI, general discomfort, and sleep disruption were also improved significantly in bilastine‐treated patients as compared with placebo‐treated patients ( P < 0.001 for all parameters). Comparison with levocetirizine indicated both treatments to be equally efficacious as well as equally safe and well tolerated as compared with placebo. Conclusions: Bilastine 20 mg is a novel effective and safe treatment option for the management of CU.

The phenomenon of population aging has led to a significant rise in the chronic disease rate compared to other human pathologies. Elderly people are usually affected by > or =2 chronic diseases concomitantly, mainly cardiovascular, pulmonary, and central nervous system diseases, metabolic disturbances and cancer. Chronic comorbidities in elderly patients may worsen their clinical status, making both the diagnosis and treatment more difficult. Meanwhile, contemporary medicine is focused on its subspecialties, thus turning away from the tradition of great, academic-based, general internal medicine. Clinical practice is dominated by a specific approach to a single disease rather than a patient with comorbidities. Therefore, an accurate diagnosis, ensuring effective treatment in the case of a complex and ambiguous clinical picture, is based on an attempt to combine multiple expert consultations rather than make a holistic evaluation, so characteristic of traditional internal medicine. For that reason, pathophysiology and clinical picture of a chronic disease in the elderly requires the revival of internal medicine, which is also essential to the development of geriatrics.

Allergic conjunctivitis and dry eye are major ocular surface disorders affecting millions of people. Although neither of them is a sight-threatening disease, they have a serious impact on patients' quality of life. A typical clinical symptom of allergic conjunctivitis is itching, whereas the symptoms of dry eye are burning sensation, irritation or ocular fatigue, but allergic conjunctivitis and dry eye sometimes share very similar symptoms. Allergies are often associated with ocular surface diseases and in particular with dry eye syndrome. Reduced quantity or quality of tears increases the number of allergens, limits their evacuation through the canaliculi and increases inflammation, which is an aggravating factor for allergy. Allergic eye diseases, even SAC, are associated with advanced tear instability and thickening of the lipid layer of the tear film. In allergic conjunctivitis we observed decreased break-up time caused in part by decreased goblet cell density. Severe allergies may cause permanent dry eye state and sometimes the exact frontier between the two pathologies is unknown. It is obvious that both cause inflammation and both aggravate each other. Patients with dry eye tend to develop more eye allergies; they may not have a sufficiently large tear volume to wash the allergen out quickly enough to prevent the symptoms of allergy. Patients with both dry eye and allergy should be treated for both concomitantly, because treating only one may not produce the desired results. Tear film disturbances, inflammatory damage of the conjunctival epithelium and sometimes conjunctival fibrosis may be produced by eye drop preservatives; artificial tears with safe preservative or preservative-free drops should be used. Even the newer systemic antihistamines through action on the muscarinic-3 receptors reduce tear production from the lacrimal glands and mucin secretion from the goblet cells, so when used, additionally artificial tears should be applied locally.

The eye is exposed to many foreign substances, and ocular tissues have a complete array of immune cells to initiate an immunological response. The external eye represents an ideal site for allergic reactions because of the high number of mast cells and potential local synthesis of IgE. Mild allergic diseases such as IAC and PAC are classical example of type I hypersensitivity. The central mechanism in the pathogenesis of these diseases is IgE-mediated reactions and then T lymphocytes, eosinophils and conjunctival structural cells activation. But the severest forms of ocular allergy are more complicated and involve a cellular, neurogenic and hormonal response. Knowledge about these differences between different kinds of allergic eye diseases is necessary to decide about appropriate therapy. The pharmacotherapy of eye allergy consists of successive classes of drugs: antihistamines, mast cell stabilizers, dual-acting antihistamines, NSAIDs, corticosteroids, immunomodulators and immunotherapy.

Red eye is a common condition of contemporary people. We have to remember that allergy is not the only cause of red eye. Most frequently, conjunctivitis is infective in origin, but both allergic and infective conjunctivitis may coexist with dry eye syndrome. To investigate and solve this problem, collaboration of the ophthalmologist and allergologist is often necessary. This article is a guide proposition first of all for general practitioners, but also for other specialists. It consists of two steps: the questions which should be asked to the patient, and basic examination of the eye. In this way most mild allergic conjunctivitis can be diagnosed and treated successfully. The differential diagnosis of "red eye" and the urgent causes of this sign are also presented in this article.