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Allergic Eye Disease

Checked: 23-01-2020 by Vicky Ryan Next Review: 23-01-2021

Overview

Allergic eye disease is a broad term for several overlapping diseases. Allergic eye disease can be caused by:

Seasonal allergic conjunctivitis (hay fever) This is the most common type which present to GPs.

Vernal keratoconjunctivitis,- this is a severe form of chronic allergy. More common in males aged 5-15 years old, especially Afro-Caribbean and Middle Eastern patients.

Atopic keratoconjunctivitis,- this is a severe allergy in patients with atopic eczema, can also occur in adults who used to suffer from vernal keratoconjunctivits.

Contact lens associated papillary conjunctivitis,- this allergy to contact lens wear

Contact hypersensitivity/toxic conjunctivitis,- this is an allergy to eye medication or to the prolonged use of preserved eye drops.

Vernal keratoconjunctivitis and atopic keratoconjunctivitis are potentially serious as these both frequently affect the cornea surface. In most cases the patients may also suffer from other signs of allergy such as asthma, eczema or hay fever.

Symptoms include:

Itching is the most common symptoms
Redness
Redness
Mucus
Watering
Eyelid oedema
Conjunctival Chemosis
Can be seasonal
There is not always a clear causal allergy component.

Please see the attached diagnostic photographs

Who to refer

Outpatient referral can be made for patients with ongoing symptoms despite treatment. Consider referral in:

Persistent Symptoms despite treatment
Suspected Vernal Keratoconjunctivits or atopic keratoconjunctivitis
Lower threshold for younger patients.

Occasionally allergic eye disease can be particularly severe and cause sight-threatening disease. These patients should be referred to the BEH Emergency Department. See Red Flags Section.

Red Flags

If symptoms are severe, please refer directly to the BEH Emergency Department.

Light sensitivity (as this indicates corneal involvement)
Reduced vision
Suspected infection
Increasing pain

Before referral

Conservative Treatments

Cool compress will often help with acute allergic swelling of the eyelids and conjunctiva.

Identification and avoidance of allergens should be attempted

If contact lenses are implicated, suggest booking in with their optician to consider switching contact lenses.

Oral antihistamines

During periods of exposure oral antihistamine can be used.

Topical medications

These should be started in all patients. The common medication to start would be sodium

cromoglicate QDS. This is available over the counter. The pitfall of sodium cromoglicate is is it needs to be used four times a day and it can take several weeks to reach its full

effectiveness, this makes it very difficult for children to maintain compliance.

In the eye hospital we tend to use an antihistamine and mast-cell stabiliser combination topical medication such as g. Olopatanol BD for 3-4 months or Ketotifen BD for 3-4 months. These work more effectively than sodium cromoglicate and only need to be used twice a day, markedly improving compliance. These drops still take several weeks to build up to full effectiveness. If the patient has very predictable seasonal disease, these can be started in advance of the season.

Referral

If referral is required please submit to Ophthalmology via eRS requesting Cornea clinic.

Resources

These guidelines have been written by Rhys Harrison, consultant ophthalmologist at Bristol Eye Hospital, with thanks to the patients who have kindly given consent to use their photos.

For full ophthalmology guidelines see: Primary Care Ophthalmology Guidance Document

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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