The levels of total protein in tears from healthy donors, conjunctivitis vernalis patients, and conjunctivitis follicularis patients, were 625, 1370 and 1160 mg% respectively. Serum albumin accounted for 3.3%, 43% and 67% of the total protein of tears from these groups, and the level of proteins probably synthesized by the lacrimal gland, was in tears from conjunctivitis follicularis patients only half the level in normal tears. By crossed immunoelectrophoresis with intermediate gel, 10 antigenic species could be recognized in normal tears, and of these the following were identified: Lysozyme, IgA, lactoferrin and serum albumin. In tears from patients with conjunctivitis vernalis three more immunoprecipitates were observed, of which one was due to IgG. No lysozyme could be demonstrated in tears from a case of conjunctivitis sicca by immunoelectrophoresis. In tears from healthy donors the mean level of IgA was 20 mg%, of IgG 3 mg%, and IgM could not be demonstrated. Rabbit anti-tear immunoglobulin did not precipitate a standard of human IgM in double immunodiffusion. In cases of conjunctivitis vernalis and follicularis the mean levels were increased to 80 and 114 mg% IgG, and 11 and 14 mg% IgM, but IgA was increased only to 32 and 41 mg%. It is assumed that the level of IgA in normal tears is almost entirely due to local synthesis, while serum albumin and other immunoglobulins may have escaped from the circulation by molecular sieving. The increased levels of immunoglobulins in inflammatory diseases is probably due to transudation. However, in blepharoconjunctivitis patients several tear samples with a high IgM and a low or zero level of IgG could be demonstrated. Possible explanations for this phenomenon are discussed.

Tears and sera of 53 patients of vernal conjunctivitis were examined for antibodies of the IgE type to a panel of 18 allergens. In 18 of the patients (34.0%) allergen-specific IgE was demonstrated in both tears and serum, in 3 (5.7%) in tears only, and in 4 (7.5%) in serum only. The antigen-specific reactions with tear fluid were found in patients with the highest total IgE levels, not only in tears but also in serum. This is evidence for a specific, local allergic reaction in these patients. Most positive reactions were to perennial allergens, particularly house dust mites, cat epithelium and Bermuda grass. This fact is in harmony with the lack of season-linked symptoms in most patients in this geographical area.

The possible causative relationship between exposure to house dust mite allergen (HDMA) and symptoms of vernal keratoconjunctivitis (VKC) was investigated. VKC patients were evaluated for an average of 18 months using patient reports of symptoms, physicians’ observations and assays of sera and tears for total and specific IgE to 10 inhalant allergens common in Israel, including HDMA. Tear and serum samples from a group of 8 patients reacted only with HDMA, and were compared with the tear and serum samples of a group of 11 patients not reacting to any of the above allergens. House dust samples from the homes of two VKC patients in the HDMA-reactive group were examined monthly for a year. While mites were detected throughout the year, they were approximately 3 times more abundant from June through September than at other times. 96.6% of the mites collected belonged to the family Pyroglyphidae; 91.0% were Dermatophagoides pteronyssinus and 5.5% Dermatophagoides farinae. Both the severity of VKC symptoms in HDMA-reactive patients and mite population levels peaked simultaneously in the summer. This relationship was not seen among the non-HDMA-reactive patients. Our results suggest that exposure to HDMA plays an important role in the aggravation of VKC symptoms in HDMA-reactive patients.

SUMMARY Vernal keratoconjunctivitis (VKC) is usually considered as an allergic eye disorder of type 1, and in most therapeutic trials it has been shown to yield to topical treatment with sodium cromoglycate. This has been confirmed in the present study of VKC patients from Israel. However, some of the cases seemed not to benefit from this treatment. In a survey of IgE levels in VKC patients in Israel tear IgE levels were significantly increased in 63.5%, but in 29% of the patients both tear and blood IgE levels were normal to low. The possibility that some of the cases diagnosed as VKC might have another cause than IgE-mediated atopy is discussed.Vernal keratoconjunctivitis (VKC) is usually considered to be an allergic, IgE-mediated disorder.'2 Outbreaks, exacerbations, and recurrences cluster in the spring together with hay-fever, spastic bronchitis, or asthma. A large proportion of VKC patients suffer from other atopic conditions or give a history of familial allergy. Microscopic examination of the inflammatory exudate shows consistently increased numbers of eosinophilic leucocytes. High levels of total IgE3 and of antipollen specific IgE4 in tears have been reported for VKC patients.In spite of the possibility that VKC might be only one facet of a multisystem atopic condition, therapeutic trials have put emphasis on topical treatment with anti-inflammatory drugs or even by surgical correction. The topical application of corticosteroids gives considerable benefit, but it must be restricted owing to their effect on the intraocular pressure' or to their suppression of the defence mechanism against infections. The use of vasoconstrictors and antihistamines seems reasonable but has often proved to be ineffective, at least in severe cases.Topical application of the nonsteroid antiallergic drug sodium cromoglycate (SCG) has been reported to be strikingly or moderately effective,5' comprehensive survey of patients from Israel'2 has indicated that the disease in this country is less dependent on season than has been reported elsewhere, and no connection with systemic atopy could be demonstrated. Similarly, in a report from Egypt only 5 out of 83 patients (6%) showed symptoms of other allergic conditions.5 If this indicates that VKC in this subtropical zone is not always an allergic disorder, no effect of SCG should be expected in some of the patients. It should also be noted that in the previous Israeli study" a 1% solution of SCG was used, whereas other studies have been carried out with a 2% solution.For these reasons a reappraisal of the nature of VKC in Israeli patients and of the therapeutic effect of topical SCG drops seemed to be needed. Materials and methods PATIENTSNineteen patients with VKC were treated with 2% sodium cromoglycate in a solution of 0-01% benzalkonium chloride, 0-4% phenylethyl alcohol, and water. The drops were instilled 4 times a day to one of the diseased eyes, and the fellow eye was concomitantly given a placebo solution-that is, the same preparation without SCG. No other medication was us...

Serum and tear levels of IgE were compared in patients with contact lens papillary conjunctivitis (CLPC), vernal keratoconjunctivitis (VC), healthy contact lens wearers (CLW), and healthy controls without lenses. The mean of serum IgE was elevated only in the VC group. Tear IgE levels were significantly higher for CLPC and VC than for CLW and healthy controls. Tear IgG levels were also increased in CLPC patients. With serum albumin (HSA) as a marker for leakage of proteins from the circulation to the tear fluid, the data indicated, that tear IgG was blood-borne whereas tear IgE was essentially a product of local synthesis. In one of the 10 CLPC patients, high titers of IgE type antibodies to housedust mites and cat epithelium were demonstrated in both serum and tears. We conclude that CLPC is usually an IgE mediated reaction to the lens material or to contaminations of allergenic material that sticks to the lenses.