Allergic Ocular Disease and Conjunctivitis

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Allergic Ocular Disease and Conjunctivitis

Allergy
Author Credentials 

Adrienne Laury, MD 
American Academy of Otolaryngic Allergy


Michael Platt, MD
American Academy of Otolaryngic Allergy

Module Summary

Ocular allergy can present as part of the common allergic rhinoconjunctivitis seen in seasonal or perennial allergies, or as a more severe inflammation in vernal keratoconjunctivitis or atopic keratoconjunctivitis, both of which have involvement beyond the conjunctiva.  Environmental allergen exposure results in deposition of particulates in the eye which triggers an IgE-mediation allergic inflammation cascade.  Diagnosis is made by physical examination of the eye in conjunction with testing for environmental sensitizations when indicated.  Treatment includes avoidance of allergens, and a variety of topical and systemic allergy medications including antihistamines, mast cell stabilizers, topical intranasal corticosteroids, and immunotherapy for refractory cases.  

Module Learning Objectives 
  1. Explain the differential diagnosis of ocular allergy.
  2. Recognize diagnostic and treatment modalities for ocular allergy.
  3. Review alternate diagnoses and side effects of treatment for ocular allergy that could lead to complications.

 

Pathogenesis
  1. Cite the different types of allergy that can affect the eye:
  • Ocular allergy
    • Seasonal and perennial allergic conjunctivitis
      • IgE mediated hypersensitivity reaction
      • Symptoms: ocular itching, watering, and redness
      • Signs: hyperemia and edema of the tarsal and conjunctival surfaces
      • Associations: allergic rhinitis
      • Causes: IgE stimulating allergens
    • Vernal keratoconjunctivitis
      • 60% IgE dependent hypersensitivity
      • Disease of childhood and early adolescence and occurs in warm climates and subtropical areas
      • Symptoms: watering, stickiness, itching, and difficulty with opening the eyes on awakening
      • Signs: papillary hyperplasia of the upper tarsal conjunctival surfaces, erosion of the corneal epithelium, and inflammation of the limbus
    • Atopic keratoconjunctivitis
      • Associated with atopic eczema and starts in the 3rd or 4th decade
      • Symptoms: itching, soreness, impaired vision, and sensation of dryness
      • Signs; lid margin infection, chronic conjunctivitis, eczema of the eyelids, tear abnormality, progressive scarring and vascularization of the cornea
  • Pathophysiology
    • Seasonal and perennial allergic conjunctivitis 
      • IgE mediated hypersensitivity reaction
      • Histamine release from conjunctival mast cells results in red, watery, edematous, and itchy eyes.  

 

References:

  1. Shaker M, Salcone E. An update on ocular allergy. Curr Opin Allergy Clin Immunol. 2016 Oct;16(5):505-10 
  2. Leonardi A, et al. Diagnostic tools in ocular allergy. Allergy. 2017; 72(10):1485-1498
Patient Evaluation
  1. Recognize that there is no specific clinical or lab test for diagnosis of ocular allergy. Clinical history of eye symptoms, presence of other allergic symptoms, and exposures helps diagnose ocular allergy.   
  • The mainstay of diagnosis includes a detailed history of ocular examination. The eyelid skin, lid margin, conjunctiva, and cornea should be evaluated.  
  1. Describe symptoms beyond allergic conjunctivitis:
  • Pain is often a sign of corneal involvement 
  • Purulent drainage suggests infectious causes
  • Photophobia is suggestive of Vernal keratoconjunctivitis or Atopic keratoconjunctivitis
  • Severe symptoms, unilateral symptoms, visual change, and significant pain should prompt ophthalmological consult

 

References: 

  1. Shaker M, Salcone E. An update on ocular allergy. Curr Opin Allergy Clin Immunol. 2016 Oct;16(5):505-10
  2. Leonardi A, et al. Diagnostic tools in ocular allergy. Allergy. 2017; 72(10):1485-1498
Measurement of Functional Status
  1. Cite that questionnaires and scoring systems are available for grading severity and monitoring treatments of ocular allergy.

 

References:

  1. Leonardi A, et al. Diagnostic tools in ocular allergy. Allergy. 2017; 72(10):1485-1498
Testing
  1. Explain the role for allergy testing in allergic conjunctivitis. Patients with refractory symptoms to medications can undergo testing to identify sensitizations which may be causing the allergic response.
  • Ocular sampling can be performed for tear fluid, cell, and tissue analysis in select cases to determine the type of inflammation and test for alternate diagnoses.

 

References:

  1. Leonardi A, et al. Diagnostic tools in ocular allergy. Allergy. 2017; 72(10):1485-1498

 

Case Studies
  1.  A 22-year-old student presents for itchy, red eyes and tearing.  She has a history of seasonal allergies to grass pollen.  It is currently grass pollen season.  She also reports nasal congestion, itching, and sneezing.  She is using benedryl as needed and Flonase. Physical exam shows mild edema and erythema of the conjunctiva with clear tear production.  The remainder of the exam is notable for findings consistent with allergic rhinitis.  She is diagnosed with allergic conjunctivitis and started on an ocular antihistamine drop.  
Review Questions
  1. What are signs that should prompt ophthalmology consult in patients presenting for ocular allergy?
Resources 

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