Acute Allergic Conjunctivitis
- Seasonal Allergic Conjunctivitis (SAC)
- 50% of cases of allergic conjunctivitis.
- Mildest, most common form of allergic conjunctivitis.
- Caused by ragweed, pollen, grass, etc. Worse during spring and fall. Known as "hayfever" conjunctivitis.
- Signs and symptoms
- Typically bilateral if sensitive to airborn allergens; unilateral if hand contact induces ocular allergy.
- Eyes can be white, itchy, and uncomfortable; may have gritty, foreign body sensation.
- Itching is the hallmark sign. Often itching is in much greater proportion than actual visible ocular signs. Eyes are not always red and inflamed--often symptoms are worse than signs.
- Hyperemia
- Conjunctival chemosis
- Tearing; ropy or string discharge
- Papillae on the lower lid
- Does not involve the cornea--unless associated with rubbing to relieve itch
- Eosinophils not in scrapings (eosinophils may be deep in the conjunctival tissue)
- Elevated tear histamine level
- Perennial Allergic Conjunctivitis (PAC)
Feathers, animal dander, house dust, foods, fabric softeners, dryer sheets, molds, etc.--may be worse during the winter months when forced heat is used
- Differential Diagnosis
- Bacterial conjunctivitis: chlamydia
- Viral conjunctivitis
- Toxic conjunctivitis
- Dry eye
- Blepharitis
- Acne rosaceae
Photo courtesy of Dr. Malinovsky
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Giant Papillary Conjunctivitis (GPC)
It is unknown whether GPC is a chronic inflammatory disorder or mechanical trauma. The disease is not associated with vision loss.
- Caused by
- Contact lenses: Often due to a combination of allergy to the lens deposits and to mechanical irritation provided by the deposited lens surface. Estimated incidence is 10-15 percent of SCL wearers and 1-5 percent of RGP wearers.
- Ocular prosthetics and exposed sutures
- Extruded scleral buckle
- Ocular foreign bodies
- Onset: Weeks to years; average is 18 months (earlier onset with SCL wearers)
- Patient symptoms
- Decreased contact lens tolerance
- Increased contact lens movement
- Foreign body sensation
- Discomfort often upon lens removal
- Signs
- Uniform cobblestone papillae on the upper lid
- Mild conjunctival injection, ptosis, coated or deposited lens
- Non-elevated tear histamine levels
- Conjunctival scrapings
- Elevated chronic inflammatory cells
- Low levels of eosinophils and mast cells
Based upon scraping findings, drops do not work well on GPC.
 
Photos courtesy of Dr. Victor E. Malinovsky
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Vernal Keratoconjunctivitis (VKC)
VKC, also known as chronic allergic conjunctivitis, affects males (predominantly boys) twice as often as females. Peak age incidence is teens to early 20s. It is most commonly seen in warm, dry climates. Condition worsens in warmer months.
- Symptoms
- Intense itching, irritation, redness
- Ropy discharge
- Photophobia
- Tight feeling
- Signs
- Conjunctival
- Palpebral VKC: large, non-uniform, flat-topped cobblestone conjunctival papillae on superior tarsus
- Limbal VCK: Trantas' dots or Horner-Trantas spots (clusters of necrotic eosinophils, neutrophils, and epithelial cells)
- Cornea: SPK, neovascularization, shield ulcers
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Shield ulcers are sterile ulcers which occur superiorly and happen because cobblestone papillae are rubbing on cornea; look like a shield because the inferior edge is pointed. |
- Scrapings: large number of eosinophils and mast cells in conjunctiva epithelium (actually more than atopic disease)
 
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Atopic Keratoconjunctivitis (AKC)
Atopy refers to a tendency for excess inflammation in the skin, linings of the nose, and lungs. It often affects patients with familial histories of allergic disease. These families may have allergies such as hay fever and asthma, but can also have sensitive skin and a history of eruptions called atopic dermatitis. While most people with atopic dermatitis have family members with similar problems, 20 percent of patients may be the only one in the family bothered by this condition. Patients have a strong association with eczema (95%) and asthma (87%) as well as family history of atopic disease.
AKC is a perennial disorder--exacerbated in winter due to dryness associated with home heating. It lacks seasonality seen in other ocular disorders. Age range is from late teens to 50 years with the age of peak incidence from 30 to 50 years. AKC can be sight threatening!
- Clinical diagnosis: Allergic conjunctivitis with associated periorbital dermatitis
- Symptoms
- Ocular itching
- Burning
- Tearing
- Mucous discharge
- Photophobia
- Signs
- Cornea
- SPK, epithelial defects, keratitis, shield ulcers, anterior stromal scarring, peripheral neovascularization
- Trantas' dots
- Higher incidence of keratoconus (16%) and recurrent herpes simplex
- Lids: red, swollen, thickened, eczematous, ptosis, macerated, fissured, staph blepharitis
- Conjunctiva
- Small- or medium-sized papillae predominantly on the lower palpebral conjunctiva
- Hyperemia, edema, excessive mucin
- Advanced disease--may be scarring, hypertrophy, keratinization, symblepharon
- Scrapings: Excessive mast cells, eosinophils, and goblet cells in conjunctival epithelium
- Lens: Anterior/posterior subcapsular cataracts
- Fundus: Degenerative vitreous changes and RD
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Differential Diagnosis: Vernal vs. Atopic |
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VKC |
AKC |
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Seasonal, hot weather |
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Younger age |
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Lasts longer |
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Mostly upper palpebral conj |
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Mostly lower palpebral conj |
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Conjunctival scarring |
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Eczema of eyelids |
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Fornical shrinkage |
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