History

Fact Explanation
Itching of the eyes Patients with seasonal allergic conjunctivitis (SAC) complain of worsening of symptoms during the spring and summer, whereas patients with perennial allergic conjunctivitis (PAC) can be symptomatic throughout the year. [1,3]
Redness of the eyes Patients complain of redness of the eyes. [1,3]
Tearing Excessive tearing occurs after being exposed to the allergen. [2,3]
History of allergic rhinitis Around 95% of the patients with allergic rhinitis have comorbid allergic conjunctivitis as well. [3,4]
History of recurrent headaches Patients with allergic conjunctivitis blink frequently and may have a squint. These factors may contribute for the development of recurrent tension headaches. [3]
References
  1. LA ROSA M, LIONETTI E, REIBALDI M, RUSSO A, LONGO A, LEONARDI S, TOMARCHIO S, AVITABILE T, REIBALDI A. Allergic conjunctivitis: a comprehensive review of the literature Ital J Pediatr [online] :18 [viewed 24 August 2014] Available from: doi:10.1186/1824-7288-39-18
  2. MISHRA GP, TAMBOLI V, JWALA J, MITRA AK. Recent Patents and Emerging Therapeutics in the Treatment of Allergic Conjunctivitis Recent Pat Inflamm Allergy Drug Discov [online] 2011 Jan, 5(1):26-36 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164156
  3. WILLIAMS DC, EDNEY G, MAIDEN B, SMITH PK. Recognition of allergic conjunctivitis in patients with allergic rhinitis World Allergy Organ J [online] , 6(1):4 [viewed 24 August 2014] Available from: doi:10.1186/1939-4551-6-4
  4. ALMALIOTIS D, MICHAILOPOULOS P, GIOULEKAS D, GIOULEKA P, PAPAKOSTA D, SIEMPIS T, KARAMPATAKIS V. Allergic conjunctivitis and the most common allergens in Northern Greece World Allergy Organ J [online] , 6(1):12 [viewed 24 August 2014] Available from: doi:10.1186/1939-4551-6-12

Examination

Fact Explanation
Conjunctival erythema Inflammatory reaction mediated by the activated mast cells causes erythema of the conjunctiva also referred to as conjunctival injection. [1]
Chemosis Conjunctival edema is caused by the inflammatory response, which causes dilatation and increased permeability of the vessels in the conjunctiva. [1]
Irritant dermatitis of the eye lids Patients with allergic conjunctivitis can develop irritant dermatitis of the eye lids due to frequent rubbing. [2]
References
  1. LA ROSA M, LIONETTI E, REIBALDI M, RUSSO A, LONGO A, LEONARDI S, TOMARCHIO S, AVITABILE T, REIBALDI A. Allergic conjunctivitis: a comprehensive review of the literature Ital J Pediatr [online] :18 [viewed 24 August 2014] Available from: doi:10.1186/1824-7288-39-18
  2. WILLIAMS DC, EDNEY G, MAIDEN B, SMITH PK. Recognition of allergic conjunctivitis in patients with allergic rhinitis World Allergy Organ J [online] , 6(1):4 [viewed 24 August 2014] Available from: doi:10.1186/1939-4551-6-4DD

Differential Diagnoses

Fact Explanation
Acute conjunctivitis Patients with acute bacterial and viral conjunctivitis present with purulent discharge, redness and itching of the eyes. [1]
Giant papillary conjunctivitis Giant papillary conjunctivitis is the chronic inflammation of the upper tarsal conjunctiva. It is common among contact lens users. Itching, redness, mucous discharge, and blurred vision are common presenting complains. [2]
Atopic keratoconjunctivitis Atopic keratoconjunctivitis refers to chronic, non-infectious inflammatory condition. Atopic keratoconjunctivitis is common in patients with atopic dermatitis. This usually does not resolve spontaneously and may lead to corneal injury. [3]
Episcleritis Episcleritis is the inflammation of the eposclera. This is often self-limiting. Patients complain of pain and redness of the eye. [4]
Scleritis Scleritis refers to the inflammation of the sclera. This can be either infectious or secondary to trauma. [4,5]
Foreign body Presence of foreign bodies in the eye should be suspected especially in children presenting with pain and redness of an eye.
Anterior uveitis Anterior uveitis refers to intraocular inflammation. Patients usually present with pain and photophobia of the affected eye. Circumlimbal redness, presence of anterior chamber cells and flare are suggestive of the diagnosis.[6]
Blepharitis Blepharitis is an inflammation of the eyelids. It can be infectious (staphylococcal blepharitis) or associated with atopic dermatitis. Patients complain of burning sensation, itching, and foreign-body sensation in the eye. On examination eyelids are swollen and hyperemic. [7,8]
References
  1. TARABISHY A. B., JENG B. H.. Bacterial conjunctivitis: A review for internists. Cleveland Clinic Journal of Medicine [online] 2008 July, 75(7):507-512 [viewed 24 August 2014] Available from: doi:10.3949/ccjm.75.7.507
  2. DONSHIK PC, PORAZINSKI AD. Giant papillary conjunctivitis in frequent-replacement contact lens wearers: a retrospective study. Trans Am Ophthalmol Soc [online] 1999:205-220 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1298261
  3. KITNET KWANPORNSAN. Topical cyclosporin for atopic keratoconjunctivitis. International Journal of Evidence-Based Healthcare [online] 2013 March [viewed 24 August 2014] Available from: doi:10.1111/1744-1609.12009
  4. WATSON PG, HAYREH SS. Scleritis and episcleritis. Br J Ophthalmol [online] 1976 Mar, 60(3):163-91 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1268179
  5. PRADHAN ZS, JACOB P. Infectious scleritis: clinical spectrum and management outcomes in India. Indian J Ophthalmol [online] 2013 Oct, 61(10):590-3 [viewed 24 August 2014] Available from: doi:10.4103/0301-4738.121085
  6. AGRAWAL RV, MURTHY S, SANGWAN V, BISWAS J. Current approach in diagnosis and management of anterior uveitis Indian J Ophthalmol [online] 2010, 58(1):11-19 [viewed 24 August 2014] Available from: doi:10.4103/0301-4738.58468
  7. BEZDETKO PA, SERGIENKO N, DYOMIN Y, KOROL A, NIKITIN N, MERZBACHER M, GRO├č D, KOHNEN R. Successful treatment of blepharitis with bibrocathol (Posiformin┬« 2 %) Graefes Arch Clin Exp Ophthalmol [online] 2012 Dec, 250(12):1869-1875 [viewed 24 August 2014] Available from: doi:10.1007/s00417-012-2001-0
  8. ASANO-KATO N, FUKAGAWA K, TAKANO Y, KAWAKITA T, TSUBOTA K, FUJISHIMA H, TAKAHASHI S. Treatment of atopic blepharitis by controlling eyelid skin water retention ability with ceramide gel application Br J Ophthalmol [online] 2003 Mar, 87(3):362-363 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1771555

Investigations - for Diagnosis

Fact Explanation
Skin testing Skin testing (scratch tests or intradermal injections of allergen) can be done to identify potent allergens. [1]
References
  1. LA ROSA M, LIONETTI E, REIBALDI M, RUSSO A, LONGO A, LEONARDI S, TOMARCHIO S, AVITABILE T, REIBALDI A. Allergic conjunctivitis: a comprehensive review of the literature Ital J Pediatr [online] :18 [viewed 24 August 2014] Available from: doi:10.1186/1824-7288-39-18

Management - General Measures

Fact Explanation
Health education Patients with atopic conjunctivitis should be advised to avoid the potent allergen as far as possible. [1]
References
  1. LA ROSA M, LIONETTI E, REIBALDI M, RUSSO A, LONGO A, LEONARDI S, TOMARCHIO S, AVITABILE T, REIBALDI A. Allergic conjunctivitis: a comprehensive review of the literature Ital J Pediatr [online] :18 [viewed 24 August 2014] Available from: doi:10.1186/1824-7288-39-18

Management - Specific Treatments

Fact Explanation
Artificial tears Artificial tears are useful in creating a tear film which acts as a barrier minimizing the contact of allergens with the conjunctiva. They also dilutes the allergens and help to washout the allergens. [1]
Antihistamines With the exposure to the potential allergens IgE is bound to the mast cell membranes which causes mast cell degranulation and release of histamine. Histamine in turn exerts the allergic reaction. Topical antihistamines (levocabastine hydrochloride, 0.1% olopatadine hydrochloride) block the histamine release, by competitive and reversible blocking of histamine receptors thus minimizing the allergic response. However this action is short lasting and frequent administration of the drug is necessary (up to 4 times a day). Prolonged use can cause irritation of the eye. Oral antihistamines may be necessary to control severe symptoms. [1,2,3]
Topical decongestants Decongestants cause vasoconstriction and reduce erythema and conjunctival swelling. Burning sensation, mydriasis, and rebound hyperemia (conjunctivitis medicamentosa) are possible side effects. Often combination of antihistamines and decongestants is used for better symptom control. [1]
Mast cell stabilizers Mast cells are responsible for the release of histamine and other chemotactic factors. Mast cell stabilizers decrease the degranulation of mast cells and reduce the inflammation. It should be applied before being exposed to the allergen. [1,2]
Ketotifen This is a novel topical agent which has inhibitory action over eosinophil activation, generation of leukotrienes and cytokine release. [1]
Azelastine This is a selective second generation H1 receptor blocker. Azelastine also inhibits platelet activating factor (PAF) and blocks the expression of intercellular adhesion molecule 1. [1]
Epinastine Epinastine blocks the H1 and H2 receptors and reduce the eyelid swelling. It also exerts mast-cell stabilizing and anti-inflammatory effects. [1]
Non-steroidal anti-inflammatory drug (NSAIDs) NSAIDs inhibit the synthesis of prostaglandin D2 and prostaglandin E2 and reduce the conjunctival hyperemia and the pruritus. This can be combined with topical medications for better symptom control. [1]
Corticosteroids Corticosteroids are immunosuppressive drugs which is helpful in suppressing the immune response to allergens. Secondary infection, elevated intraocular pressure, and formation of cataract are possible side effects of corticosteroids. Due to these side effects corticosteroids are only recommended for a short period of time (up to 2 weeks). If it is necessary to prescribe it for a long time it should be done with close follow up by an ophthalmologist. [1]
Allergen-specific immunotherapy This treatment option is effective in inducing a clinical tolerance to a particular allergen. The production of specific IgG and IgA is increased and production of IgE is reduced with this treatment. [1]
References
  1. LA ROSA M, LIONETTI E, REIBALDI M, RUSSO A, LONGO A, LEONARDI S, TOMARCHIO S, AVITABILE T, REIBALDI A. Allergic conjunctivitis: a comprehensive review of the literature Ital J Pediatr [online] :18 [viewed 24 August 2014] Available from: doi:10.1186/1824-7288-39-18
  2. MISHRA GP, TAMBOLI V, JWALA J, MITRA AK. Recent Patents and Emerging Therapeutics in the Treatment of Allergic Conjunctivitis Recent Pat Inflamm Allergy Drug Discov [online] 2011 Jan, 5(1):26-36 [viewed 24 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3164156
  3. WILLIAMS DC, EDNEY G, MAIDEN B, SMITH PK. Recognition of allergic conjunctivitis in patients with allergic rhinitis World Allergy Organ J [online] , 6(1):4 [viewed 24 August 2014] Available from: doi:10.1186/1939-4551-6-4