Contact allergic dermatitis and contact urticaria due to topical ophthalmic preparations.

A patient with chronic glaucoma and a history of contact allergic dermatitis to topical ophthalmic , adrenergic blocking drugs developed persistent ocular symptoms despite avoidance of , blockers. He was further investigated for possible allergy to pilocarpine. Case report A 70-year-old man presented with a persistent itch involving his eyes and a stinging and burning sensation aggravated by instillation of his pilocarpine eyedrops. The patient had a long history ofglaucoma and had bilateral trabeculec-tomies carried out in 1978. He still required therapy and had been treated with (3 blockers and pilocarpine since 1984. Treatment with I6 blockers had been discontinued owing to the development of contact allergic dermatitis which apparently developed sequentially to timolol, betaxolol, and metipranolol as described previously .' Examination revealed periorbital oedema with erythema and swelling of the lid Other blockers tested propranolol practolol timolol atenolol oxprenolol pindolol sotalolol penbutolol propranolol oxprenolol betaxolol pindolol timolol hydroxypropranolol metoprolol levobunolol carteolol betaxolol timolol timolol carteolol timolol timolol carteolol levobunolol carteolol levobunolol atenolol metoprolol propranolol Cross sensitisation propranolol practolol timolol ? penbutolol levobunolol * Figures in parentheses indicate the number(s) of patients studied. Reference 5 6 7 8 9 margins. There was no evidence of conjunctivitis. Previous patch tests with the European standard series, a preservative series, a face and eye series, a contact lens series, and pilocarpine 4% eyedrop had shown a plus/minus reaction to benzalkonium chloride and a plus/minus reaction to pilocarpine eyedrops which contained benzalkonium chloride as a preservative. Treatment was changed to unpreserved pilocarpine eyedrops, and his eyelids treated with a mild topical corticosteroid preparation. After initial improvement in the appearance and swelling of the eyelids the patient represented with a recrudescence of the burning and stinging sensation of his eyes. Patch testing with unpreserved pilocarpine (Minims 1%, 2%, and 4%) was negative at 2 and 4 days. Subcutaneous and intradermal testing with unpreserved pilocarpine 4% was negative at 2, 4, and 7 days, making delayed hypersensitivity unlikely. However, prick tests showed a positive reaction with the development of a lOx 10 mm weal at 10-30 minutes. Prick tests in seven controls (three atopic, four non-atopic) resulted in small weals measuring up to 3 mm in diameter (four controls), or erythema only (three controls). We therefore considered that the reaction seen in our patient was significant. Pilocarpine was discontinued and substituted with levobunolol hydrochloride. The patient's ocular and peri-ocular symptoms improved dramatically, and his intraocular pressure …