Background
Eye anatomy and immunologic function
Pathophysiology
Types of allergic conjunctivitis and other allergic eye diseases
Ocular allergy subtype | Demographics and/or associations | Primary symptoms and signs |
---|---|---|
Male predominance, 30–50 years of age Perennial, with potential exacerbation in the winter months Association with atopic dermatitis of the eyelids | Severe ocular itching (ocular surface, eyelids) Tearing, burning, photophobia, mucous discharge Significant hyperemia and edema of the conjunctiva (chronic inflammation) Corneal scarring, neovascularization Trantas’ dots Large cobblestone papillae on superior tarsus and/or limbus (chronic inflammation) | |
Male predominance, 3–25 years of age Associated with atopy in 50% | Severe ocular itching Photophobia, tearing mucous discharge Trantas’ dots (limbal form) Large cobblestone papillae on superior tarsus and/or limbus (chronic inflammation) Corneal ulcer (shield) may form in severe cases |
Characteristics of allergic conjunctivitis—impact and diagnosis
Importance of appropriate professional care
Symptoms and signs
Category | Question for patients |
---|---|
Ocular symptoms | What are your symptoms? How severe are they? Are your eyes itchy? Do they burn? sting? Are they painful? Is there discharge from your eyes? If so, is it watery or mucoid? Does it feel like there is a foreign body in your eyes? Do you rub your eyes? Are your eyes dry? When did your symptoms start? What is your worst season, if any? Have you had any previous episodes? Are your symptoms in one eye or both? Are there any exacerbating or relieving factors? Is your vision affected? Are you sensitive to lights? Do you wear contact lenses? Are they comfortable? Is there any history of trauma to your eyes? |
Health history | Is there associated atopy? Or a family history of atopy? Is there a diagnosis of ADHD? Are you on any medications? Are there any other past medical and surgical concerns (tonsillectomy, sinus surgery)? |
Exposures/Environment | Do you live with pets? Is the home carpeted? Forced-air heating? Air conditioning? Humidity level? Is there exposure to smoke (first- or second-hand)? Have there been any new exposures (e.g., new pet, renovations, new personal or home hygiene products)? Are there any potential occupational exposures? Infectious contacts (possibility of infectious cause of red eye)? |
Treatment | Have OTC topical products been used? If so, which product(s)? Have OTC oral agents been used? If so, which product(s)? Have prescription medications, including immunotherapy, been tried? How often were the therapies used and for how long? Has there been any relief of symptoms? |
Quality of Life | Are the symptoms interfering with school/work, activities of daily living or sleep? Has school/work been missed due to symptoms? |
Impact on quality of life
Differential diagnosis
Physical examination
Ocular structure | Associated findings |
---|---|
Lids/lashes | Lid hyperemia/edema Ptosis Allergic ‘shiner’ |
Tears | Watery, occasionally mucoid |
Bulbar conjunctiva | Superficial injection Chemosis (if severe, may cause ‘hour glass’ appearance) |
Palpebral conjunctiva | Injection Inferior or superior papillae (on lid eversion) |
Cornea | Clear |
Related ocular disease | Ocular signs |
---|---|
Allergic | |
Atopic keratoconjunctivitis | Eyelid atopic dermatitis often present Conjunctival injection and chemosis Conjunctival scarring Giant papillae may be present Infiltration of the limbus (region where the cornea meets the sclera) and cornea [15] |
Vernal keratoconjunctivitis | Tearing, profuse mucous discharge [28] Bulbar conjunctival injection Large papillae of superior palpebral conjunctiva, ‘cobblestone-like’ Corneal plaque/shield ulcer Trantas’ dots (infiltrates at the juncture of the cornea and the sclera) Corneal neovascularization and scarring |
Atopic dermatitis | Periocular scaly, dry skin Eyelid thickening Lash loss Papillary hypertrophy of palpebral conjunctiva May be accompanied by conjunctival injection, watery/mucoid discharge [28] |
Demodex-associated conjunctivitis (hypersensitivity to lid mites) | Heavy lash debris (lash collarettes) Bulbar conjunctival injection, may show papillae Eyelid hyperemia |
Others | |
Contact-lens associated papillary conjunctivitis, CLPC (often termed Giant papillary conjunctivitis, GPC) | Mucoid discharge Excessive movement of contact lenses Papillary hypertrophy of superior palpebra conjunctiva; if severe: lid swelling, ptosis [28] Clear cornea |
Anterior blepharitis (staphylococcal, seborrheic) Posterior blepharitis (Meibomian gland dysfunction, ocular rosacea) | Lash debris, lid hypertrophy/hyperemia [15] Conjunctival injection and staining (lissamine green) Corneal staining (fluorescein) Evaporative dry eye disease |
Dry eye disease (aqueous deficiency, evaporative) | Inadequate tear volume (low tear meniscus) (aqueous deficiency) Lash debris, lid hypertrophy/hyperemia, Meibomian gland dysfunction, ocular rosacea (poor tear film stability; evaporative dry eye) Conjunctival injection [15] and staining (lissamine green) Conjunctival chalasis (redundancy of the conjunctiva from loss of adherence to the sclera) Corneal staining (fluorescein) |
Ocular toxicity (due to ophthalmic agents, usually preservatives) | Conjunctival injection Corneal staining |
Others: e.g. superior limbic keratoconjunctivitis, floppy eyelid syndrome, etc. | Chronic symptoms and signs, some of which may overlap with AC |
Supportive diagnostic testing
Management
Agents (brand name) | Availabilitya | OTC/Rx | Year of market availabilityb | Age indicationc | Dosing schedule |
---|---|---|---|---|---|
Topical ocular vasoconstrictors | |||||
Naphazoline hydrochloride | Both | OTC | Established | Maximum QID, short term | |
Tetrahydrozoline hydrochloride | Both | OTC | Established | Maximum QID, short term | |
Ocular antihistamines | |||||
Antazoline (only found in combination) | Both | OTC | Before 1980 | N/Ad | QID |
Pheniramine (only found in combination) | Both | OTC | Before 1980 | N/Ad | QID |
Emedastine 0.05% (Emadine®) [104] | U.S. only | Rx | 1998 | ˃ 3 years | QID |
Mast-cell stabilizers | |||||
Lodoxamide 0.1% (Alomide®) [105] | Both | Rx | 1992 | ≥ 4 years | QID |
Both | OTC/Rx | 1993 | ≥ 5 years | QID | |
Dual-activity agents | |||||
Olopatadine 0.1% (Patanol®)[108] | Both | Rx | 1998 | ≥ 3 years | BID |
Olopatadine 0.2% (Pataday®) [109] | Both | Rx | 2011 | ≥ 16 years | Daily |
Olopatadine 0.7% (Pazeo®) [110] | Both | Rx | 2017 | ≥ 2 years | Daily |
Both | Rx (OTC in U.S) | 2000 | ˃ 3 years | BID to TID | |
Ketotifen 0.025% preservative free | U.S. only | OTC | 2000 | ˃ 3 years | BID to TID |
Bepotastine besilate 1.5% (Bepreve®)[113] | Both | Rx | 2017 | ≥ 3 years | BID |
Alcaftadine 0.25% (Lastacaft®) [114] | U.S. only | Rx | 2014 (U.S. only) | ≥ 3 years | Daily |
Epinastine 0.05% (Elestat®) [115] | U.S. only | Rx | 2004 (U.S. only) | ≥ 3 years | BID |
Azelastine 0.05% (Optivar®) [116] | U.S. only | Rx | 2009 (U.S. only) | ˃ 3 years | BID |
Ophthalmic steroids (only some most commonly used in ocular allergy) | |||||
Fluorometholone acetate 0.1% (FML®)e [117] | Both | Rx | 1972 | ˃ 2 years | BIDf |
Prednisolone acetate 1.0% (Pred Forte®)e [118] | Both | Rx | 1974 | All ages | BIDf |
Loteprednol etabonate 0.2% (Alrex®)[119] | Both | Rx | 2009 | ≥ 18 years | QIDf |
Loteprednol etabonate 0.5% (Lotemax® (or Lotemax gel®))e [120] | Both | Rx | 2009 | ≥ 18 years | QIDf |
NSAIDs | |||||
Diclofenac 0.1% (Voltaren Ophtha®)e [121] | Both | Rx | 1991 | ≥ 18 years | QID |
Ketorolac 0.4% (Acular LS®) and 0.5% (Acular®)e [75] | Both | Rx | 1992 (0.5%) 2004 (0.4%) | ≥ 18 years | QID |
Nepafenac 0.1% (Nevanac®)e [122] | Both | Rx | 2008 | ≥ 18 years | TID |
Bromfenac 0.7% (Prolensa®)e [123] | Both | Rx | 2015 | ≥ 18 years | Daily |