This document summarizes different types of allergic conjunctivitis including acute, seasonal, and perennial allergic conjunctivitis. It also discusses phlyctenular keratoconjunctivitis, vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), non-allergic eosinophilic conjunctivitis, contact allergic blepharoconjunctivitis, and giant papillary conjunctivitis. For each type, it describes the etiology, clinical presentation, signs, complications, and treatment approaches. Management involves identifying and removing allergens, using mast cell stabilizers, antihistamines, NSAIDs, topical

1. ALLERGIC
CONJUNCTIVITIS

2. Types of Allergic Conjunctivitis
• Acute allergic conjunctivitis.
• Seasonal allergic conjunctivitis.
• Perennial allergic conjunctivitis.
• Phlyctenular Keratoconjunctivitis.
• Vernal keratoconjunctivitis.
• Atopic keratoconjunctivitis.
• Others ( Eosinophilic , Contact allergic , Giant papillary)

3. Acute allergic conjunctivitis.
Etiology :
Acute reaction(type 1) to environmental allergen (pollen)
Typical picture (children playing outside in spring/summer)
Especially patients with Asthma , Hay fever , Atopy
Clinical picture :
Acute itching, watering, lid swelling, Hyperemia and the hall mark is
CHEMOSIS
Mild
Severe

4. Acute allergic conjunctivitis.
Treatment :
First remove cause if known
Not usually required , Resolves in hours
In cases of severe chemosis :
1- Cool compresses.
2- Vasoconstrictor of 0.1 adrenaline.
3- Steroids & Anti- allergics.

5. Seasonal / perennial allergic conjunctivitis.
Etiology :
Subacute & common conditions cc by timing of exacerbation.
Seasonal
(hay fever eyes) Perennial
Worsen in spring and
summer.
Worsen in autumn.
Plants allergens. House dust mites,Animal &
Fungal allergens.

6. Seasonal / perennial allergic conjunctivitis.
Clinical picture :
Similar to acute allergic conjunctivitis, but occurs in transient
Attacks Which is less severe, subacute & accompanied by
Sneezing and nasal discharge.
Treatment :
Similar to acute allergic conjunctivitis.

7. Phlyctenular Keratoconjunctivitis.
Pathogenesis :
• Chronic allergic inflammation due to endogenous toxins.
• Incidence mainly in malnourished children.
• Type IV hypersensitivity reaction in following cases :
a- Septic focus .
b- Staphylococcus blepharo-conjunctivitis.
c- T.B
d- Toxins of intestinal parasites.
Symptoms :
• Diffuse pain ( Burning no Itching )
• Red eye .
• Watery mucoid discharge.
2ry
Bacterial
infection
Muco-
purulent
discharge
Corneal ulcer Reflex
Lacrimation
Photophobia
blepharospasm

8. Phlyctenular Keratoconjunctivitis.
Signs : A- Conjunctiva PHLYCTEN
• Grey nodule.
• Surrounded by hyperemia.
• Size : 1-3 mm.
• At limbus.
• One or multiple and may ulcerate leading to 2ry infection.

9. Phlyctenular Keratoconjunctivitis.
B- Cornea :
Corneal phlycten
Vascularize Ulcerate
Pannus Ulcer
Deep vascularization
INF cell infiltration
Marginal
limbal
Ring
Fascicular
(Serpiginous)

10. Phlyctenular Keratoconjunctivitis.
Complications :
• M.P.C (2ry bacterial infection).
• Corneal opacity.
• Recurrence
Treatment :
• Treat cause ( Anti-biotics & good nutrition ) .
• Steroids ( drops & ointments )
• Treatment of complications
• Infection ( Anti-biotics ).
• Corneal ulcer ( Atropine + Dark glasses ).
• Fascicular ulcer ( Topical steroids + Cautery ).

11. Vernal keratoconjunctivitis.
Pathogenesis :
• Recurrent bilateral disorder.
• IgE and cell mediated immune response are involved.
• Primarily affects boys from the age of 5 years onwards.
• There is remission by the late teens in 95% of cases.
• Common in warm dry climate such as Africa and Middle East.
• Occurs on a seasonal basis (late spring and summer).
Classification
Palpebral Limbal Mixed

12. Vernal keratoconjunctivitis.
Clinical picture :
1- Symptoms:
Intense itching , Photophobia , Lacrimation , Burning
Increased blinking and thick mucous discharge (Ropy) .
2-Signs
Conjunctiva
Palpebral Limbal
Cornea Eyelid

13. Vernal keratoconjunctivitis.
Conjunctiva Palpebral type :
1. Conjunctival hyperemia & Diffuse velvety hypertrophy on STP.
2. Macro papillae with flat-topped polygonal appearance (COBBLESTONES).
3. Whitish inflammatory infiltrates.
1 2 3

14. Vernal keratoconjunctivitis.
Conjunctiva Palpebral type :
4. Giant papillae.
5. Mucous deposition between giant papillae.
6. Decreased disease activity is characterized by milder
conjunctival injection and decreased mucus production.
4 5 6

15. Vernal keratoconjunctivitis.
Conjunctiva B- Limbal type :
1. Gelatinous limbal conjunctival papillae (Horner–Trantas dots)
2. In tropical regions, limbal disease may be severe.

16. Vernal keratoconjunctivitis.
Keratopathy :
1. Superior punctate epithelial erosions.
2. Epithelial macroerosions.(caused by inflammatory toxins and mechanical erosion by papillae)

17. Vernal keratoconjunctivitis.
Keratopathy :
3. Plaques & SHIELD ulcer :
May develop in palpebral or mixed disease when the exposed bowman membrane
becomes coated with mucus and calcium phosphate, leading to inadequate witting
and delayed re-epithelialization. This development is serious and requires urgent
attention to prevent 2ry bacterial infection.
4. Sub epithelial scars.

18. Vernal keratoconjunctivitis.
Keratopathy :
5. Pseudogerontoxon :
In recurrent limbal disease cc by paralimbal band of superficial scarring
resembling arcus senilis .
6. Vascularization (especially superiorly) .

19. Vernal keratoconjunctivitis.
Keratopathy :
7. Corneal ectasia (Keratoconus).
8. Herpes simplex keratitis (Dendritic ulcer).
8

20. Atopic Keratoconjunctivitis
Pathogenesis :
• Bilateral rare disease.
• Develops in adulthood (30-50 years).
• Follows long history of Eczema & Asthma which is common in these patients.
• No gender preponderance.
• Chronic , unremitting and with low expectation of eventual resolution.
• Associated with significant visual morbidity.
• Patients are sensitive to wide range of airborne allergens.
• Perennial disease which is worse in winter.
VKCAKC
ChildhoodAdults
SeasonalPerennial
SpringWinter

21. Atopic Keratoconjunctivitis
Clinical picture :
1- Symptoms :
Similar to VKC but more severe and unremitting
2-Signs
Eye lid Conjunctiva Keratopathy Cataract
Retinal
Detachment

22. Atopic Keratoconjunctivitis
A- Eye lid :
1. Skin changes (Eczema , Erythema , Dryness ).
2. Lower lid Ectropion & Epiphora due to facial skin tightening.
3. Ptosis not uncommon.
Important note :
Differentiation between AKC&VKC
is essentially clinical ,but eosinophils
is less in conjunctival scraping in
AKC.

23. Atopic Keratoconjunctivitis
B- Conjunctiva :
1. Watery discharge& Hyperemia& Chemosis.
2. Papillae which is initially smaller than VKC.
3. Whitish , Featureless appearance.
4. Cicatricial changes leading to :
a- Moderate symblepharon b- Forniceal shortening c- Caruncle Keratinization
5. Limbal involvement Horner-Trantas dots .

24. Atopic Keratoconjunctivitis
C- Keratopathy :
1. Punctate erosions over lower 1/3.
2.
Persistent
epithelial
defects
Corneal
thinning
Descematocele

25. Atopic Keratoconjunctivitis
3. Plaque formation.
4. Peripheral vascularization & Stromal scarring.
5. Keratoconus ( about 15% )
6. Predisposition to Fungal , Bacterial & HS Keratitis.

26. Atopic Keratoconjunctivitis
D- Cataract :
1. Pre-senile shield-like ant or post sub-capsular cataract.
2. Because of high lid margin carriage of S.aureus , Cataract surgery
carries an increased risk of endophthalmitis.
ANT POST

27. Atopic Keratoconjunctivitis
E- Retinal Detachment :
More common than in the general population, and there is a particular risk
following cataract surgery.

28. Management of VKC and AKC
Management
General
Measures
Local
Treatment
General
Treatment
Surgery

29. Management of VKC and AKC
1- General Measures :
Allergen Avoidance, Cold Compresses, Lid Hygiene, BCL
2- Local Treatment :
• Mast cells stabilizers.
• Topical Anti-Histamines ( not for long term ).
• Anti-Histamines + Vasoconstrictors.
• Anti-Histamines + Mast cells stabilizers.
• NSAIDs ( replacement for Anti-Histamines ).
• Topical steroids
- For Keratopathy and severe conjunctivitis .
- Short intensive term ( 2 hours initially )
- Monitor IOP as there is a minimal risk of steroid induced glaucoma
except with prednisolone 1% which is high.
• Steroid ointment.
• Antibiotics.

30. Management of VKC and AKC
• Acetylcysteine.
• Immune modulators.
- If steroids ineffective , inadequate , poorly tolerated .
- Calcineurin inhibitors ( Tacrolimus )
Shows great promises in AKC treatment as steroid alternative.
• Supratarsal steroid injection
- In severe disease or non-compliant patients.
3- Systemic Treatment :
• Oral Anti-Histamines.
• Antibiotics.
• Immuno-suppressive agents.

31. Management of VKC and AKC
4- Surgery :
• Superficial Keratectomy :
- Required to remove plaques or debride shield ulcers.
- Excimer laser phototherapeutic keratectomy is an alternative.
• Restoration Surgery :
- Amniotic membrane overlay grafting or lamellar keratoplasty.
- Eyelid procedures for severe persistent epithelial defects or ulceration.
- Gluing may be appropriate for focal corneal perforations.

32. Non-allergic eosinophilic conjunctivitis
• Recently proposed chronic non-atopic condition.
• Occur predominantly in middle-aged women in whom dry eye is also common.
• Thought to be of similar pathogenesis to non-allergic eosinophilic rhinitis.
• Conjunctival eosinophilia is present without significant IgE levels in the serum or
tear film.
• Symptoms are similar to those of allergic conjunctivitis.
• Treatment is with a 1–2 week course of
topical steroid.

33. Contact allergic blepharoconjunctivitis
• Analogous to contact dermatitis.
• Acute or sub acute T-cell-mediated delayed hypersensitivity reaction.
• Seen most commonly by ophthalmologists as a reaction to eye drop constituents
and by optometrists as a reaction to contact lens solutions.
• Signs predominantly involve the eyelid skin: erythema, thickening, induration and
sometimes fissuring.
• Treatment is by removal or discontinuation of the precipitant, sometimes with a
mild topical steroid ointment.

34. Giant papillary conjunctivitis
Pathogenesis :
• Secondary to a variety of mechanical stimuli of the tarsal conjunctiva.
• Most frequently encountered with contact lens (CL) wear.
• The risk is increased by the build-up of proteinaceous deposits and cellular
debris on contact lens surface.
Symptoms :
• Foreign body sensation, redness, itching.
• Increased mucus production.
• Blurring and loss of CL tolerance.
• Symptoms may be worse after lens removal.
• Patients should be questioned about CL cleaning and maintenance.

35. Giant papillary conjunctivitis
Signs :
• Variable mucous discharge.
• Substantial CL protein deposits.
• Excessive CL mobility due to upper lid capture.
• Superior tarsal hyperemia and papillae.
• Focal apical ulceration and whitish scarring.
• Ptosis may occur.

36. Giant papillary conjunctivitis
Treatment :
• Removal of the stimulus.
• Ensure effective cleaning of CL or prosthesis.
• Topical
1. Mast cell stabilizers.
2. Antihistamines.
3. NSAIDs.
4. Topical steroids.

37. References
• Kanski's Clinical Ophthalmology 8th edition.
• Tanta Ophthalmology department textbook.
• Ramadology 6th edition