Serum Vitamin D and Immunoglobulin E Levels In Patients With Seasonal Allergic Conjunctivitis

Abstract

INTRODUCTION: Seasonal allergic conjunctivitis (SAC) is a mild but common immunoglobulin E (IgE) mediated ocular allergy. Low serum vitamin D levels have been related to some allergic disorders but such data in the clinical context of SAC are missing. Our study investigated serum IgE and vitamin D levels in SAC patients. MATERIALS AND METHODS: A cross-sectional case-controlled study was conducted at University of Hafr Al-Batin, Saudi Arabia involving patients with established diagnosis of SAC and age[1]matched healthy control subjects. Standard patient evaluation of eye dryness (SPEED) questionnaire was scored for the frequency and severity of symptoms. Blood samples were taken to quantify serum IgE and vitamin D levels. Mean +- SD were calculated and independent sample t-test was applied for comparison between groups. RESULT: A total of 52 subjects were recruited into the study in which 26 subjects were patients aged between 20-60 years with an established diagnosis of SAC and another 26 subjects were age-matched healthy controls without any allergy. Mean serum IgE, vitamin D level and SPEED scores were significantly higher in SAC patients than in healthy control (2181.09 IU/ml +- 1062.33 vs 54.83 IU/ml +- 26.67; 38.96 ng/ml +- 11.37 vs. 29.47 ng/ml+- 11.73; 19.42 +- 4.81 vs. 2.19 +- 1.49) with p-value 0.001, 0.005, and 0.001 respectively. Mean vitamin D levels in both groups were within normal range. CONCLUSION: Higher serum vitamin D levels may be linked with SAC, but further research is needed to eliminate irregularities in the existing evidence on the influence of vitamin D in SAC.

Full text

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IMJM Volume 20 No.3, July 2021
Serum Vitamin D and Immunoglobulin E Levels In
Patients With Seasonal Allergic Conjunctivitis
ORIGINAL ARTICLE
ABSTRACT
INTRODUCTION: Seasonal allergic conjunctivitis (SAC) is a mild but common
immunoglobulin E (IgE) mediated ocular allergy. Low serum vitamin D levels have been
related to some allergic disorders but such data in the clinical context of SAC are missing.
Our study investigated serum IgE and vitamin D levels in SAC patients. MATERIALS
AND METHODS: A cross-sectional case-control study was conducted at University of
Hafr Al-Batin, Saudi Arabia involving patients with established diagnosis of SAC and age-
matched healthy control subjects. Standard patient evaluation of eye dryness (SPEED)
questionnaire was scored for the frequency and severity of symptoms. Blood samples
were taken to quantify serum IgE and vitamin D levels. Mean +- SD were calculated and
independent sample t-test was applied for comparison between groups. RESULT: A total
of 52 subjects were recruited into the study in which 26 subjects were patients aged
between 20-60 years with an established diagnosis of SAC and another 26 subjects were
age-matched healthy controls without any allergy. Mean serum IgE, vitamin D level and
SPEED scores were significantly higher in SAC patients than in healthy control (2181.09
IU/ml +- 1062.33 vs 54.83 IU/ml +- 26.67; 38.96 ng/ml +- 11.37 vs. 29.47 ng/ml+-
11.73; 19.42 +- 4.81 vs. 2.19 +- 1.49) with p-value 0.001, 0.005, and 0.001 respectively.
Mean vitamin D levels in both groups were within normal range. CONCLUSION: Higher
serum vitamin D levels may be linked with SAC, but further research is needed to
eliminate irregularities in the existing evidence on the influence of vitamin D in SAC.
Khashim Alswailmi Fa, Ali Shah SIa, Al-Mazaideh GMa, Sikandar MZb
aUniversity of Hafr Al-Ban, Hafar Al Ban, Saudi Arabia.
bCentral Park Medical College, Lahore, Pakistan.
Keywords
Allergy, Vitamin D, Immunoglobulin E, Ocular
allergy, Seasonal allergic conjunctivitis
Corresponding Author
Dr. Syed Imran Ali Shah
Professor of Biochemistry,
University of Hafr Al-Batin, Hafar Al-Batin,
Sauid Arabia
Tel: +966534510690
e-mail: simranali@uhb.edu.sa
Received: 4 January 2021 ; Accepted: 7 April
2021
Doi: https://doi.org/10.31436/imjm.v20i3
INTRODUCTION
Ocular allergies are globally on the rise and constitute an
increasing proportion of allergic disorders that have an
adverse influence on health and economic productivity
the world over.1 Conjunctival vulnerability to allergen
exposure makes allergic conjunctivitis a common allergic
disorder. Allergic conjunctivitis is typically characterized
by inflammation of the conjunctiva leading to itching
(pruritus), pink eye (hyperaemia), gritty sensation,
conjunctival swelling (chemosis), visual blurring and
watery eyes.2
Regions with high temperatures and humid
climate have a high prevalence of allergic
conjunctivitis. Severe allergic conjunctivitis, including
vernal keratoconjunctivitis (VKC) and atopic
keratoconjunctivitis (AKC) accompanied by visual loss
through damage to ocular and corneal surfaces, is
common in many South Asian countries. Mild forms of
allergic conjunctivitis including seasonal allergic
conjunctivitis (SAC) and perennial allergic conjunctivitis
(PAC) account for nearly one-fifth of the worldwide
burden of ocular allergies.3
Seasonal fluctuations, air and water pollution, chemical
exposure, pollen, agricultural factors, genetic
predisposition and co-morbidities such as diabetes
mellitus have been linked to the development and
progression of allergic conjunctivitis.4,5 SAC is an acute
and short-term ocular allergy and its seasonality or
cyclic nature is due to airborne allergens released by
various plants on a seasonal basis. SAC is exclusively
caused by type I allergic reaction mediated by
immunoglobulin E (IgE).4 In type 1 allergic reactions,
exposure of sensitized individuals to allergens causes B-

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cell stimulation and IgE production. IgE triggers mast
cell degranulation and release of allergic and
inflammatory mediators including histamine, cytokines,
leukotrienes and prostaglandins.6,7
The fat-soluble secosteroid vitamin D (cholecalciferol)
is primarily produced by the skin cells on exposure to
sunlight and also obtained through various animal and
plant-based food sources. Cholecalciferol undergoes
hydroxylation in the liver and kidney to yield its active
form calcitriol.8 Vitamin D has been recently
highlighted as a regulator of immunity and allergy
through multiple mechanisms including suppression of
interleukin and immunoglobulin production by T and B
-cells respectively.9-11 However, the clinical evidence on
the role of vitamin D in allergic disorders is
inconclusive and such data on allergic conjunctivitis are
particularly elusive.12
Although vitamin D deficiency has been linked with
many ophthalmologic disorders including diabetic
retinopathy, glaucoma, uveitis, myopia and age-related
macular degeneration, data on its role in allergic
conjunctivitis are scarce.13 The present study assessed
serum vitamin D levels in patients with SAC along with
serum IgE and complete blood count (CBC) testing
and made comparisons with healthy individuals.
MATERIALS AND METHODS
We conducted a cross-sectional, case-control study at
University of Hafr Al-Batin, Saudi Arabia in complete
accordance with the ethical practice guidelines of the
Declaration of Helsinki. Fifty-two adult subjects
between the ages of 20 to 60 years were recruited for
this study from the local population of Lahore,
Pakistan after obtaining written informed consent. The
participants were divided into 2 groups. Group 1
participants were subjects with established diagnosis of
SAC (n=26) and group 2 were age-matched healthy
control subjects without any known history of allergy
(n=26). Subjects with any other active ocular pathology
or past history of blepharitis, xeropthalmia, eye surgery
and wearers of contact lenses were excluded from the
study. Subjects using multivitamin supplements or
steroidal medications up to three months before the
time of enrolment were also excluded and so were
those with known history of systemic illnesses including
autoimmune, liver, kidney and/or bone diseases.
Demographic information and medical history were
recorded for all the study participants. 5 ml blood was
obtained in lavender-cap plastic tubes containing
ethylenediamine tetra-acetic acid (EDTA) for CBC test.
Another 5ml blood was obtained in red-cap plastic
tubes (BD Vacutainer®) and centrifuged at 3000
revolutions/minute for 10 minutes. Separated serum
was aliquoted and stored at -20ºC till further laboratory
analysis. Serum vitamin D (25-hydroxy cholecalciferol)
was measured using Elecsys® total vitamin D
electrochemiluminescence binding assay (Roche
Diagnostics, Switzerland) on Cobas® e411 analyser.
The serum vitamin D assay had a functional sensitivity
of 5 ng/ml with a measuring range of 3 - 70 ng/ml.
Serum IgE levels were quantified using Elecsys® IgE
double sandwich immunoassay double sandwich
immunoassay (Roche Diagnostics, Switzerland) on
Elecsys® immunoassay analyser. The functional
sensitivity of serum IgE assay was 0.5 IU/ml with a
measuring range of 0.1 - 2500 IU/ml.
All participants were asked to fill the 8-item validated
standard patient evaluation of eye dryness (SPEED)
questionnaire.14 The SPEED questionnaire was used to
assess the frequency and severity of ocular symptoms
including dryness, grittiness or scratchiness, soreness or
irritation, burning or watering and eye fatigue.
Additionally, the questionnaire also considered patients’
tolerability of ocular symptoms and their progression
over the last three months. The score range of the
questionnaire was from 0-28 with higher scores
indicating increased intensity of ocular symptomatology.
Datasheets with anonymized data were prepared in
Microsoft Excel 2013 (Microsoft Corporation, USA)
and imported for analysis using Statistical Package for
Social Sciences (SPSS), version 23. Descriptive data
were presented as frequencies and percentages. Group
mean difference were assessed using independent
sample t-test.
RESULTS
Out of the 26 subjects in each group, group 1 (patients
with SAC) had 21 males and 5 females while group 2

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(healthy controls) had 17 males and 9 females. In group
1, the mean age was 42.00 +- 16.03 while in group 2,
the mean age was 45.50 +- 14.48, with no difference
between the groups (p=0.413). In group 2, SAC alone
was seen in 9 (35%) patients, SAC with allergic rhinitis
was seen in 12 patients (46%) and SAC with other
extraocular allergies was seen in 5 (19%) patients.
Ocular symptoms were much more common in group 1
as compared to group 2 (Table I). Hyperaemia was seen
in 80.76% of the group 1 subjects followed by pruritis
(69.23%) and watery eyes (57.69%). Other common
ocular symptoms in group 1 included grittiness (38.4%)
and chemosis (26.92%).
Ocular Symptom Group 1 (SAC),
n (%age)
Group 2 (Controls), n
(%age)
Hyperemia 21 (80.76%) 2 (7.69%)
Pruritis 18 (69.23%)) 2 (7.69%)
Watery Eyes 15 (57.69%) 3 (11.53%)
Grittiness 10 (38.4%) 0 (0%)
Chemosis 7 (26.92%) 0 (0%)
Visual blurring 7 (26.92%) 0 (0%)
Photophobia 0 (0%) 0 (0%)
Ophthalmalgia 0 (0%) 0 (0%)
Table I. Distribution of ocular symptoms in the study groups
Mean serum IgE levels were significantly higher in
group 1 (2181.09 IU/ml +- 1062.33) as compared to
group 2 (54.83 IU/ml +- 26.67) with a p-value of 0.001
(Table II). Mean serum vitamin D levels were within the
normal range in both the groups although levels were
higher in group 1 as compared to group 2 (38.96 ng/ml
+- 11.37 vs. 29.47 ng/ml +- 11.73, p=0.005) (Table II).
Scores on the SPEED questionnaire were also
significantly higher in group 1 as compared to group 2
(19.42 +- 4.81 vs. 2.19 +- 1.49, p=0.001). There was no
difference observed between the two groups in any CBC
parameter (Table II).
DISCUSSION
SAC, which is an acute short-term ocular allergy, is the
commonest form of allergic conjunctivitis. The present
study primarily examined the role of serum vitamin D in
SAC and studied its association with serum IgE through
biochemical evaluation. The study also evaluated the
Parameters Group 1 (Mean +-
SD)
Group 2
(Mean + SD)
p-value
Serum IgE
(IU/mL)
2181.09 +- 1062.33 54.83 +-26.67 0.001*
Serum
vitamin D
(ng/mL)
38.96 +- 11.37 29.47 +- 11.73 0.005*
SPEED score 19.42 +- 4.81 2.19 +- 1.49 0.001*
Hemoglobin
(g/dL)
13.42 +- 1.90 14.46 +- 2.02 0.062
RBC count
(1012/L)
5.03 +- 0.67 5.23 +- 0.64 0.283
Platelet count
(109/L)
202.76 +- 64.59 221.03 +- 47.29 0.250
WBC count
(109/L)
7.42 +- 1.52 7.39 +- 1.50 0.716
Neutrophils
(%)
54.65 +- 8.19 55.26 +- 8.03 0.786
Lymphocytes
(%)
35.80 +- 7.03 34.38 +- 7.36 0.491
Monocytes
(%)
6.65 +- 2.15 6.30 +- 1.84 0.537
Eosinophils
(%)
3.19 +- 2.09 4.84 +- 4.67 0.106
Table II. Group comparisons for mean serum IgE, vitamin D, SPEED
scores and CBC parameters
*Difference significant at p<0.05.
symptomatology of SAC using questionnaires and made
comparison between patients with SAC and healthy
individuals.
Allergic rhinitis was observed in nearly half of the SAC
patients recruited in our study. These findings are
consistent with those reported in existing literature
which suggest association of allergic conjunctivitis with
allergic rhinitis as well as other respiratory, dermal and
food allergies.3,4 The current data showed pink eye as
the most common ocular symptom seen in more than
four-fifths of the SAC patients, followed by ocular
itching and watery eyes which were observed in more
than two-thirds and more than half of the SAC patients
respectively.
The scores on the SPEED questionnaire, which reflect
severity and frequency of ocular symptoms, were
markedly higher in SAC patients as compared to
healthy individuals without SAC. Itching, redness and
watering of eyes have previously been highlighted as
common ocular symptoms of allergic conjunctivitis
with considerable overlap between symptoms.2,15
Our study shown serum IgE levels to be significantly
higher in patients with SAC as compared to healthy
people. These findings are concordant with numerous

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studies which have shown IgE-mediated
hypersensitivity reactions to be at the core of the
pathogenesis of SAC.4,16 A previous case-control study
in a Turkish cohort showed greater mean total serum
immunoglobulin E concentration in patients with type
1 allergic conjunctivitis as compared to healthy controls
and contact lens wearers.17
On exposure of conjunctiva to allergen, T-helper type 2
(Th2) and B cells interact leading to release of
interleukin-4 from Th2 cells which induces B cell
activation, proliferation and differentiation into allergen
-specific plasma cells that produce IgE. Binding of
allergen-specific IgE to membrane receptors on
conjunctival mast cells results in the priming of latter,
thus allowing mast cells to degranulate on subsequent
exposure to the same allergen and release contents
including histamine, prostaglandins, leukotrienes and
proteases that result in allergic manifestations.7
Our study also shown mean serum vitamin D levels
was higher in patients with SAC as compared to healthy
individuals. Data regarding the levels of vitamin D in
patients suffering from SAC are almost non-existent.
To-date, there is only a single published study by
Dadaci et al. which investigated serum vitamin D levels
in Turkish patients with SAC exclusively.
Our findings on serum vitamin D levels in SAC are
contradictory to those reported by Dadaci et al which
showed lower vitamin D levels in patients with SAC as
compared to age and sex-matched healthy individuals.18
In their study, vitamin D levels in both the SAC
patients and healthy non-allergic controls were in the
deficient range while our results demonstrated normal
vitamin D levels in both groups. Identical
electrochemiluminescence assay techniques were used
for the laboratory estimation of vitamin D and both
studies had comparable but small sample size.
The overall disparity in vitamin D levels between the
Turkish and the present cohorts may be due to
sampling issues (small number, convenience sampling)
or possibly due to ethnic, racial, geographical or
occupational variations.19-21 It is probable that higher
concentrations of vitamin D may be associated with
SAC in individuals with optimal vitamin D status
whereas in individuals with vitamin D deficiency, lower
levels may be associated with SAC. However, the
available evidence is highly insufficient to derive any
definitive conclusions about vitamin D levels in SAC
patients. In fact, there is still no clarity on the role of
vitamin D in allergic disorders which have been
relatively well studied22 and some studies have even
implicated high vitamin D levels in the development
and progression of various allergies.12,23
CONCLUSION
The current study adds novel data to the negligible
evidence-base regarding the involvement of vitamin D
in SAC. In contrast to the previous findings, the present
work suggests that higher serum vitamin D levels may
be linked with SAC, thus highlighting the dire need for
substantial further research to eliminate exiting
inconsistencies and yield unambiguous inferences on
the role of vitamin D in SAC.
CONFLICT OF INTEREST
The authors declare no conflict of interest for this
work.
ACKNOWLEDGEMENT
The authors extend their appreciation to the Deanship
of Scientific Research, University of Hafr Al-Batin for
funding this work through the research group project
No. G-103-2020.
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