Allergic
Conjunctivitis
Introduction
Allergic conjunctivitis is a condition characterized by
inflammation of the conjunctiva, which is the thin,
transparent layer of tissue that covers the white part of the
eye and lines the inner surface of the eyelids.
Ocular allergy is estimated to affect at least 20 percent of
the population on an annual basis, and the incidence is
increasing . It is predominantly a disease of young adults,
with an average age of onset of 20 years.
Seasonal conjunctivitis represents more than 90% of cases
of allergic conjunctivitis.
Perennial conjunctivitis is less common, but 80% of
patients experience seasonal flares.
Pathophysiology
The allergen binds to mast
Allergic conjunctivitis
cells, prompting IgE cross-
stems from a type I
linking and mast cell
hypersensitivity reaction
degranulation, initiating an
triggered by an allergen.
inflammatory response.
The early phase lasts 20 to
Released mediators include 30 minutes, inducing
histamine, tryptase, itching, increased vascular
leukotrienes, and permeability, vasodilation,
prostaglandins. redness, and conjunctival
injection.
Hours later, the late phase
sees infiltration of
inflammatory cells like
neutrophils, lymphocytes,
basophils, and eosinophils.
Acute Allergic Conjunctivitis: A sudden hypersensitivity reaction triggered by environmental
exposure to known allergens like cat dander. Symptoms develop rapidly, typically within 30
minutes, and resolve within 24 hours. It is characterized by intense itching, redness, tearing,
chemosis, and eyelid swelling.
Allergic Seasonal Allergic Conjunctivitis (SAC): Also known as hay fever-type conjunctivitis or allergic
rhino-conjunctivitis when nasal symptoms are present. It is associated with outdoor airborne
conjunctivitis Types pollens and has a less abrupt onset, developing over days to weeks. Symptoms correspond to
specific pollen seasons, such as tree pollens in spring, grass pollens in summer, and weed
pollens in late summer and fall.
Perennial Allergic Conjunctivitis (PAC): A mild, chronic condition characterized by fluctuating
symptoms related to year-round exposure to indoor allergens like dust mites, animal danders,
and molds.
Clinical manifestation
Ocular itching (prominent symptom)
Blurred vision
Sensation of eyelid swelling
Mild crusting upon awakening
Watery and nonpurulent discharge
Mild photophobia
Absence of eye pain (characteristic, distinguish from other conditions)
Concomitant nasal symptoms in allergic conjunctivitis patients (e.g., pale
bluish hue of nasal mucosa, nasal turbinates edema, clear rhinorrhea)
Diagnosis and Differentials:
Clinical diagnosis is primarily based
on a history of bilateral ocular
itching or burning with watery, non-
purulent discharge.
Conjunctival injection, chemosis,
and eyelid edema are common
findings.
Absence of eye pain is a
characteristic feature.
Symptoms typically correlate with
exposure to environmental allergens
like pollen or animals.
Treatment
Which types of symptoms
require medical therapy??
Which class of
medications to use ??
Topical or systemic ??
Treatment
Topical :
Vasoconstrictor/antihistamine combinations: example : example:
naphazoline 0.025% , pheniramine 0.3%,duration :short period or episodic
(rebound hyperemia, if used regularly),4 times a day,(Single-agent topical
products ( vasoconstrictors or antihistamines only) are also available
without a prescription, although the combination products usually work
better.
Antihistamines with mast cell-stabilizing properties: example : Olopatadine
(0.2% and 0.7%) and alcaftadine0.25% and Ketotifen 0.025%, epinastine 0.05 ,
duration : at least 2 weeks ( twice a day )
Treatment
Topical :
Mast cell stabilizers: cromolyn sodium 4%, lodoxamide tromethamine 0.1%,
nedocromil2%, duration :2 weeks, four times a day. Maximum effi cacy day 5-14.
Nonsteroidal anti-infl ammatory drugs: example : ketorolac %4,duration short time ( 4
times a day)
Corticosteroids: prednisolone (1%) and dexamethasone phosphate (0.1%), Loteprednol
(0.2%,0.5%) , duration : two to four times per day for approximately two weeks.
Administered for patients with refractory symptoms. Side effect :cataract formation,
elevated intraocular pressure ,glaucoma, and secondary infections
Systemic :
oral anti histamine : example :fexofenadine 180mg,loratadine 10mg. Duration: usually
once a day as long as esential.
Treatment
Patient
subtyped :
Moderate Severe
Mild allergy
allergy allergy
Mild allergy
Symptoms:
Treatment:
Itchy eyes • Use of artificial tears
• Application of cool compresses
Watery eyes
• Wearing sunglasses
Redness in the eyes • Avoiding eye rubbing and known
Seasonal occurrence Supportive allergens
measures • Hypoallergenic bedding
• Using eyelid cleansers
• showering before bedtime
• Frequent washing of clothes
Definition:
Moderate allergy
Moderate allergic
conjunctivitis is Treatment:
characterized by itchy, •Topical antihistamines with mast cell
watery, and red eyes stabilizers
that typically occur •Short-term use of oral antihistamines
Symptoms:
•Simultaneous use of artificial tears to
seasonally. It responds •Itchy eyes
improve tear deficiency and dilute
to treatment with topical •Watery eyes
allergens
antihistamines and/or •Redness in the eyes
•Mast cell stabilizers
mast cell stabilizers, with •Seasonal occurrence
•Topical NSAID for additional anti-
short-term use of oral inflammatory effect
antihistamines
sometimes necessary.
Severe allergy
Definition: Symptoms: Treatment:
•Persistent •Referral to a consultant eye physician for severe or resistant cases
Severe allergic
symptoms •Consideration of additional treatment with a short course (1 to 2
disease is
characterized by throughout the weeks) of topical corticosteroids, prescribed only by ophthalmic
year-round year clinicians
symptoms and is •Increased •Use of corticosteroids in combination with topical or oral
associated with more inflammation antihistamines and mast cell stabilizers
significant . •Addition of topical NSAIDs if further anti-inflammatory effect is needed
inflammation •Use of topical ciclosporin as a second-line treatment with
compared to corticosteroid-sparing effects, especially in severe atopic or vernal
moderate disease. conjunctivitis cases
•Consideration of allergen-specific immunotherapy for patients with
uncontrolled disease despite topical medications and oral
antihistamines
References
Hamrah, P., Dana, R., Jacobs, D. S., & Feldweg, A. M. (2024). Allergic conjunctivitis: Clinical
manifestations and diagnosis. Literature review. Retrieved from(
[Link]
BMJ
Hamrah, P., Dana, R., Jacobs, D. S., & Feldweg, A. M. (2024). Allergic conjunctivitis:
Management. Literature review. Retrieved from(
[Link]
Villegas, B. V., & Benitez-Del-Castillo, J. M. (2021). Current Knowledge in Allergic
Conjunctivitis. Turkish journal of ophthalmology, 51(1), 45–54.
htt ps://[Link]/10.4274/[Link].2020.11456
Rathi, V. M., & Murthy, S. I. (2017). Allergic conjunctivitis. Community eye health, 30(99), S7–
S10.
La Rosa, M., Lionetti, E., Reibaldi, M., Russo, A., Longo, A., Leonardi, S., Tomarchio, S.,
Avitabile, T., & Reibaldi, A. (2013). Allergic conjunctivitis: a comprehensive review of the