Ocular allergy is one of the most common conditions encountered by pediatricians and ophthalmologists and is characterized by bilateral injection with itching as the predominant symptom. Risk factors include history of atopy (asthma, eczema, seasonal allergies). Basic and clinical research have provided insight into the immunologic mechanisms, clinical presentation, differential diagnosis, and pharmacologicmanagement of this condition. New pharmacologic agents have improved the efficacy and safety of ocularallergy treatment. This article discusses the classification of ocular allergy diagnosis and management, and addresses clinical symptoms and signs that indicate more severe allergic disease or alternative diagnosis that should prompt expeditious referral to an ophthalmologist.
Key points
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Allergic eye disease is almost always bilateral, and itching is the predominant symptom.
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Allergic eye disease can be clinically and pathophysiologically classified as seasonal allergic conjunctivitis, perennial allergic conjunctivitis, vernal keratoconjunctivitis, atopic keratoconjunctivitis, contact blepharoconjunctivitis, and giant papillary conjunctivitis.
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The first step in management is avoidance of allergen and cessation of eye rubbing.
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For mild cases without evidence of corneal involvement, treatment with a combination of topical antihistamines mast cell stabilizers is highly effective, and topical nonsteroidal anti-inflammatory drugs and steroids should be prescribed by an ophthalmologist.
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The presence of pain, visual impairment, or evidence of corneal involvement should prompt referral to an ophthalmologist for further management.
Introduction
Ocular allergy, affecting approximately 10% to 20% of the US population, is one of the most common ocular disorders encountered by pediatricians and ophthalmologists. Patients with ocular allergy often present with bilateral inflammation of the eyelid and conjunctiva that may be associated with rhinitis, asthma, or other atopic conditions. Allergic eye disease is classified into seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), contact blepharoconjunctivitis, and giant papillary conjunctivitis ( Table 1 ). The predominant symptom is itching and redness, and mucinous discharge or photophobia may be present. If pain is present, vision is impaired, the cornea is involved, or symptoms do not improve with treatment, the clinician should refer the patient to an ophthalmologist. A basic understanding of eye surface anatomy is required to fully appreciate key diagnostic elements. Initial treatment involves a combination of topical antihistamines and mast cell stabilizers. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and occasionally short-term use of topical steroids should be prescribed ideally by an ophthalmologist, because both medications can have complications that are difficult to recognize without a detailed ophthalmic examination.
| Characteristic | SAC | PAC | VKC | AKC | CBC | GPC |
|---|---|---|---|---|---|---|
| Age | All ages | All ages | <20 y (male>female) | Adulthood (male>female) | All ages | All ages |
| Onset | Childhood | Childhood | Preadolescence | Any age | Any age | Any age |
| Allergens | Tree pollens (early spring) Weed pollen (August–October) Outdoor molds Grasses (May–July) | Dust mites Animal dander Mold Air pollutants | Seasonal allergens | Any can contribute | Cosmetics Ophthalmic eye drops Inert chemicals | Foreign body Contact lenses Suture material Prosthesis |
| Seasonal | Yes | No | Yes | No | No | No |
| Personal or family history of atopy | Common | Common | Possible | Always | Possible | Possible |
| Contact lens wear | No | No | No | No | Possible | Yes |
| Symptoms | Itching Tearing Photophobia | Itching Tearing Photophobia | Itching Copious mucous Photophobia | Itching Burning Photophobia | Itching Burning Photophobia | Itching Tearing Photophobia |
| Pathophysiology | IgE-mediated Type I hypersensitivity | IgE-mediated Type I hypersensitivity | IgE-mediated Type I and IV hypersensitivity | IgE-mediated Type I and IV hypersensitivity | Type IV hypersensitivity | IgE-mediated Type I and IV hypersensitivity |
| Conjunctival eosinophilia | Yes | Yes | Always | Always (acute phase) | Occasional | Rare |
| Serum IgE | Mildly elevated | Mildly elevated | Elevated | Elevated | Variable | Variable |
| Goblet cells | Elevated | Elevated | Marked elevation | Decreased | Variable | Variable |
| Periocular skin involvement | Sometimes edema | Sometimes edema | Sometimes edema | Sometimes edema, sometimes eczema | Dermatitis, sometimes edema | Sometimes edema |
| Visual impairment | +/− | +/− | ++ | +++ | +/− | +/− |
| Conjunctival reaction | Papillary | Papillary | Giant papillary reaction (upper tarsus) | Papillary reaction/thickened (upper tarsus) | Papillary or follicular response | Giant papillary reaction |
| Corneal involvement | +/− | +/− | ++ | ++++ | + | + |
| Skin tests | Positive | Positive | Positive | Positive | Variable | Variable |
| Natural history | Self-limited; symptomatic treatment | Self-limited; symptomatic treatment | Requires treatment; usually resolves by age 20 y | Chronic | Short-term; requires treatment | Chronic; contact lens associated |
| Concurrent ocular complications | None | None | Shield ulcer (sterile ulcer) | Cataracts Secondary infections (HSV, staphylococcal) Glaucoma | None | Peripheral corneal pannus |
| First-line prophylaxis | Avoidance Mast cell stabilizers | Avoidance Mast cell stabilizers | Mast cell stabilizers | Avoidance Mast cell stabilizers | Avoidance | Avoidance Mast cell stabilizers |
| First-line acute treatment | Topical antihistamine/mast cell stabilizers | Topical antihistamine/mast cell stabilizers | Should be treated by ophthalmologist Topical antihistamine/mast cell stabilizers Topical cyclosporine Topical mild steroid Allergist referral Possible systemic treatment Topical corticosteroid pulse | Should be treated by ophthalmologist Topical antihistamine/mast cell stabilizers Topical cyclosporine Topical mild steroid Allergist referral Possible systemic treatment May require chronic treatment Topical corticosteroid pulse | Mild topical corticosteroid to periocular skin | Topical antihistamine/mast cell stabilizers |
Introduction
Ocular allergy, affecting approximately 10% to 20% of the US population, is one of the most common ocular disorders encountered by pediatricians and ophthalmologists. Patients with ocular allergy often present with bilateral inflammation of the eyelid and conjunctiva that may be associated with rhinitis, asthma, or other atopic conditions. Allergic eye disease is classified into seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), contact blepharoconjunctivitis, and giant papillary conjunctivitis ( Table 1 ). The predominant symptom is itching and redness, and mucinous discharge or photophobia may be present. If pain is present, vision is impaired, the cornea is involved, or symptoms do not improve with treatment, the clinician should refer the patient to an ophthalmologist. A basic understanding of eye surface anatomy is required to fully appreciate key diagnostic elements. Initial treatment involves a combination of topical antihistamines and mast cell stabilizers. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and occasionally short-term use of topical steroids should be prescribed ideally by an ophthalmologist, because both medications can have complications that are difficult to recognize without a detailed ophthalmic examination.
| Characteristic | SAC | PAC | VKC | AKC | CBC | GPC |
|---|---|---|---|---|---|---|
| Age | All ages | All ages | <20 y (male>female) | Adulthood (male>female) | All ages | All ages |
| Onset | Childhood | Childhood | Preadolescence | Any age | Any age | Any age |
| Allergens | Tree pollens (early spring) Weed pollen (August–October) Outdoor molds Grasses (May–July) | Dust mites Animal dander Mold Air pollutants | Seasonal allergens | Any can contribute | Cosmetics Ophthalmic eye drops Inert chemicals | Foreign body Contact lenses Suture material Prosthesis |
| Seasonal | Yes | No | Yes | No | No | No |
| Personal or family history of atopy | Common | Common | Possible | Always | Possible | Possible |
| Contact lens wear | No | No | No | No | Possible | Yes |
| Symptoms | Itching Tearing Photophobia | Itching Tearing Photophobia | Itching Copious mucous Photophobia | Itching Burning Photophobia | Itching Burning Photophobia | Itching Tearing Photophobia |
| Pathophysiology | IgE-mediated Type I hypersensitivity | IgE-mediated Type I hypersensitivity | IgE-mediated Type I and IV hypersensitivity | IgE-mediated Type I and IV hypersensitivity | Type IV hypersensitivity | IgE-mediated Type I and IV hypersensitivity |
| Conjunctival eosinophilia | Yes | Yes | Always | Always (acute phase) | Occasional | Rare |
| Serum IgE | Mildly elevated | Mildly elevated | Elevated | Elevated | Variable | Variable |
| Goblet cells | Elevated | Elevated | Marked elevation | Decreased | Variable | Variable |
| Periocular skin involvement | Sometimes edema | Sometimes edema | Sometimes edema | Sometimes edema, sometimes eczema | Dermatitis, sometimes edema | Sometimes edema |
| Visual impairment | +/− | +/− | ++ | +++ | +/− | +/− |
| Conjunctival reaction | Papillary | Papillary | Giant papillary reaction (upper tarsus) | Papillary reaction/thickened (upper tarsus) | Papillary or follicular response | Giant papillary reaction |
| Corneal involvement | +/− | +/− | ++ | ++++ | + | + |
| Skin tests | Positive | Positive | Positive | Positive | Variable | Variable |
| Natural history | Self-limited; symptomatic treatment | Self-limited; symptomatic treatment | Requires treatment; usually resolves by age 20 y | Chronic | Short-term; requires treatment | Chronic; contact lens associated |
| Concurrent ocular complications | None | None | Shield ulcer (sterile ulcer) | Cataracts Secondary infections (HSV, staphylococcal) Glaucoma | None | Peripheral corneal pannus |
| First-line prophylaxis | Avoidance Mast cell stabilizers | Avoidance Mast cell stabilizers | Mast cell stabilizers | Avoidance Mast cell stabilizers | Avoidance | Avoidance Mast cell stabilizers |
| First-line acute treatment | Topical antihistamine/mast cell stabilizers | Topical antihistamine/mast cell stabilizers | Should be treated by ophthalmologist Topical antihistamine/mast cell stabilizers Topical cyclosporine Topical mild steroid Allergist referral Possible systemic treatment Topical corticosteroid pulse | Should be treated by ophthalmologist Topical antihistamine/mast cell stabilizers Topical cyclosporine Topical mild steroid Allergist referral Possible systemic treatment May require chronic treatment Topical corticosteroid pulse | Mild topical corticosteroid to periocular skin | Topical antihistamine/mast cell stabilizers |
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