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Allergic Conjunctivitis

Subjective
A 30-year-old female presents with a chief complaint of mild redness and itching to both eyes for a week.

Objective

• 1+ bulbar and tarsal conjunctival injection
• Minimal chemosis
• Mild mucus excess (Fig. 1).
  
  

  Fig. 1 These mildly injected, mildly chemotic conjunctivae are classicallyseen in garden-variety seasonal allergic conjunctivitis.

Assessment

• Allergic conjunctivitis

Plan

• Ketotifen fumarate 0.025% (Zaditor) ophthalmic solution to use b.i.d. OU for a week, then once or twice daily as needed to maintain symptomatic control.
• We usually give two refill authorizations to use if the patient needs it
  

Comments: Had her symptoms been "itching and burning," it would be very important to quantify the history, i.e., "Which is the main symptom, itching or burning?" If it is itching, then the differential diagnosis leans towards allergy; however, if burning is the preponderant symptom, carefully evaluate for ocular surface dryness. The patient may well have opportunistic allergy secondary to the dry eye state.

General Observations

• Can be acute, seasonal, or chronic with the first two being the most common
• History of itching, especially in the nasal canthal areas is very common
• Clinical findings can include: chemosis: bullous or flaccid/redundant. Usually mild, however, can be profound in acute allergic reactions and is known as "watch-glass chemosis".
  • lid erythema and edema is a commonly associated finding
    
  • discharge, if any, is a scant mucoid discharge
    
  • the cornea is not involved in acute allergic processes
• About one-third of patients who present with "ocular allergy" actually have a primary tear film dysfunction (dry eye), so be sure to first rule out primary tear deficiency in all patients with mild to moderate itching. Severe itching is almost always allergy.
• Ocular allergy is usually bilateral. However, if the causative agent contacted only one side, then unilateral involvement is seen
• Always try to determine the etiologic agent
  
• Treatment is achieved with a wide array of topical pharmaceuticals. Common approaches are:
  • antihistamine: levocabastine (Livostin), emedastine difumarate (Emadine)
  • antihistamine/mast cell stabilizers: ketotifen fumarate (Zaditor), olopatadine (Patanol), azelastin (Optivar), epinastine (Elestad)
  • antihistamine/decongestants: (multiple - OTC)
    
  • mast cell stabilizer: Alomide, Crolom, Opticrom, nedocromil sodium (Alocril), pemirolast potassium (Alamast)
  • nonsteroidal anti-inflammatory: ketorolac (Acular-LS), diclofenac (Voltaren)
  • corticosteroids: loteprednol etabonate (Lotemax 0.5% or Alrex 0.2%)
• For most patients, the antihistamine/mast cell stabilizers work well and can be used b.i.d. for one week, then p.r.n. thereafter. The site-specific steroid loteprednol etabonate 0.2% is approved for the treatment of seasonal allergic conjunctivitis. When using Alrex, we generally prescribe it at q.i.d. for a week, then b.i.d. for a month or two. If symptoms persists after a couple of months, we would then consider switching to a mast cell stabilizer. We would continue both the Alrex b.i.d. and the mast cell stabilizer for two weeks, then stop the Alrex and continue on indefinately (prn) with the mast cell stabilizer.
• Remember, in any allergic/inflammatory condition, cold compresses help to vasoconstrict and stabilize the pathophysiologic response. At your discretion, supplement medical therapy with cold compresses when the presentation is acute and severe.