Conjunctiva

Allergic Conjunctivitis

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Allergic Conjunctivitis, Hay fever Conjunctivitis, Irritant Conjunctivitis

  • See Also
  1. Medication induced Conjunctivitis
  2. Vernal Conjunctivitis
  3. Conjunctivitis
  4. Bacterial Conjunctivitis
  5. Viral Conjunctivitis
  • Epidemiology
  1. High Prevalence (up to 40% of the U.S. population)
  • Pathophysiology
  1. Mast Cell and IgE mediated Allergic Reaction
  • Causes
  1. See Vernal Conjunctivitis
  2. Related to seasons or environmental change (esp. spring, summer, fall)
    1. Recent outdoor exposure to pollen, grass
    2. Perennial, indoor allergens (e.g. animal dander, Dust mites) may also cause Allergic Conjunctivitis
  3. Irritants
    1. Smog
    2. Chlorine
    3. Dust
    4. Cigarette smoke
  4. Iatrogenic: Topical Antibiotics
    1. May also cause chemical Conjunctivitis
    2. Gentamicin and other Aminoglycoside eye preparations
    3. Sulfonamide eye preparations
    4. Neomycin eye preparations
  • Symptoms
  1. Typically bilateral involvement
  2. Eye itching
    1. Pathognomonic for Allergic Conjunctivitis
  3. Eye tearing with stringy discharge
  4. Eye Fullness Sensation
  • Signs
  1. Marked Conjunctival Hyperemia
  2. Marked Chemosis
  3. Red hypertrophic papillae on lid Conjunctival lining
    1. Best seen with Fluorescein
    2. Appears as cobblestoning
  4. Conjunctival edema
    1. Eye may appear to sink into Conjunctiva
  • Management
  • Approach
  1. General Measures
    1. Discontinue offending agents or medications
    2. Avoid allergan exposures
    3. Consider Allergic Rhinitis management (oral Antihistamines, Intranasal Corticosteroids)
    4. Avoid Topical Decongestants
  2. Mild Symptoms
    1. Cold compress to eyes
    2. Artificial tears (preservative-free agents)
  3. Moderate Symptoms
    1. Ocular Antihistamines AND
    2. Ocular NSAIDs OR Ocular Mast Cell Stabilizers
  4. Severe Symptoms
    1. Continue agents used for mild and moderate symptoms as above AND
    2. Consider Topical Corticosteroid (e.g. loteprednol 0.2% or fluorometholone 0.1%)
      1. Exercise caution (exclude infection first) and refer to ophthalmology
    3. Other agents
      1. Topical NSAIDs (see below)
      2. Systemic Corticosteroids (short course)
      3. Immunomodulators (by ophthlamology or allergist)
        1. Omalizumab (Xolair)
        2. Cyclosporin A
        3. Tacrolimus
  • Management
  • Medications
  1. Ocular Mast Cell Stabilizers (preferred)
    1. Cromolyn Sodium (Crolom) 1 drop 4-6x/day
    2. Lodoxamide 0.1% (Alomide) 1-2 drops each eye four times daily
    3. Olopatadine 0.1% (Patanol, OTC in 2020) 1-2 drops each eye twice daily
    4. Ketotifen 0.025% (Alaway OTC, Zaditor) 1-2 drops each eye twice daily
      1. Less expensive and over-the-counter
  2. Ocular Antihistamines
    1. Naphazoline (Vasocon, Naphcon) 1 drop twice to four times daily prn
    2. Epinastine (Elestat) 0.05% 1 drop each eye twice daily
    3. Bepotastine (Bepreve) 1.5% 1 drop each eye twice daily
    4. Alcaftadine (Lastacraft, OTC as of 2022) 0.25% (2.5 mg/mL) one drop in each eye daily
  3. Ocular NSAIDs
    1. Ketorolac 0.5% (Acular) 1 drop four times daily for 7 days
    2. Diclofenac 0.1% (Voltaren) 1 drop four times daily
  4. Oral Antihistamine
    1. Mild to moderate: Non-Sedating Antihistamine (e.g. Cetirizine)
    2. Severe: Diphenhydramine (Benadryl)
  5. Consider Intranasal Steroid
  6. Consider short course of oral Corticosteroids (3-5 days)
    1. Indicated for severe, refractory cases
  1. Information from your Family Doctor
    1. http://www.familydoctor.org/handouts/678.html
  • References
  1. Williams (2017) Crit Dec Emerg Med 31(2): 3-12
  2. Bielory (2020) Ann Allergy Asthma Immunol 124(2):118-34 +PMID: 31759180 [PubMed]
  3. Cronau (2010) Am Fam Physician 81(2): 137-44 [PubMed]
  4. Winters (2024) Am Fam Physician 110(2):134-44 [PubMed]