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Allergies Eyes

Conjunctivitis - allergic

Last revised in May 2022

Allergic conjunctivitis is a term used to describe a group of ocular conditions associated with an immunoglobulin E (IgE) hypersensitivity reaction

Conjunctivitis - allergic: Summary

  • Allergic conjunctivitis is a term used to describe a group of ocular conditions associated with an immunoglobulin E (IgE) hypersensitivity reaction including:
    • Seasonal allergic conjunctivitis — occurs periodically and is associated with seasonal allergens (such as tree and grass pollen).
    • Perennial allergic conjunctivitis — associated with non-seasonal environmental allergens often found in the home (such as house dust mites, mould spores, or animal dander).
    • Vernal keratoconjunctivitis — most common and most severe in hot arid environments (such as the Mediterranean, West Africa, and India).
    • Atopic keratoconjunctivitis — severe and usually associated with atopic dermatitis of the eyelids.
    • Giant papillary conjunctivitis — also has a mechanical component and can occur as a result of chronic micro-trauma (for example from contact lens wear, ocular prostheses, or ocular sutures).
  • In most cases (excluding vernal and atopic keratoconjunctivitis) conjunctivitis does not cause permanent visual loss or structural damage.
  • The most consistent clinical feature of allergic conjunctivitis is itching. Other features include watery or mucoid discharge, conjunctival redness (injection), and oedema of the conjunctiva (chemosis) and eyelid.
  • Serious causes of red eye (such as acute glaucoma, corneal ulcer, keratitis, iritis, scleritis, and trauma) must be excluded — urgent referral to ophthalmology is required if any red flag features (such as pain, photophobia, change in visual acuity, and pupillary abnormality) are present.
    • Urgent referral to ophthalmology is also required if the person has a systemic disease associated with eye symptoms (such as rheumatoid arthritis or Sjogren's syndrome), wears contact lenses and corneal involvement is suspected, or a neonate presents with a red sticky eye. 
  • Ophthalmology should be consulted (with urgency dependent on the clinical situation) if there is diagnostic uncertainty, appropriate equipment is not available, atopic or vernal keratoconjunctivitis is suspected, or the person has severe or treatment-resistant allergic conjunctivitis.
  • Management in primary care includes:
    • Provision of patient information on allergic conjunctivitis.
    • Self-care advice on avoidance of allergens and eye rubbing, application of cold compresses and ocular surface lubricants.
    • Consideration of topical antihistamines and/or mast cell stabilizers, with topical diclofenac as adjunctive therapy if required.
    • Follow up and appropriate safety netting on red flag clinical features that indicate the need for urgent review in the interim.

Have I got the right topic?

From age 1 month onwards.

This CKS topic covers the primary care management of allergic conjunctivitis (seasonal allergic conjunctivitis, perennial allergic conjunctivitis, atopic keratoconjunctivitis, vernal keratoconjunctivitis, and giant papillary conjunctivitis).

There are separate CKS topics on Allergic rhinitis, Blepharitis, Conjunctivitis - infective, Corneal superficial injury, Dry eye syndrome, Herpes simplex - ocular, and Red eye.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

May 2022 — reviewed. A literature search was conducted in April 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.

Previous changes

October 2020 — minor update. A typographical error has been corrected.

May 2017 — reviewed. A literature search was conducted in March 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made.

August 2012 — reviewed. A literature search was conducted in August 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Changes to the recommendations include:

  • Olopatadine and epinastine are no longer black triangle drugs. This information has been removed from the text, and these drugs have been included in the recommendations. Prescriptions for olopatadine 0.1% eye drops and epinastine 500 micrograms per mL eye drops have been added.
  • The recommendation to prescribe oral corticosteroids in primary care has been removed to reflect the current literature and expert opinion from external reviewers.

March 2011 — minor update. A prescription for sodium cromoglicate 2% preservative-free eye drops (Catacrom®) has been included. 

February 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.

Feburary 2009 — minor update. Otrivin-Antistin® eye drops are no longer recommended for use in children under 12 years of age; text and prescriptions updated. 

August to November 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.

July 2006 — minor update. Levocabastine products discontinued and prescriptions removed. 

February 2006 — minor update. Black triangle removed from desloratadine. 

November 2005 — minor technical update. 

September 2004 — reviewed. Validated in November 2004 and published in February 2005.

August 2001 — reviewed. Validated in November 2001 and published in April 2002.

October 1998 — written, replacing guidance on Acute atopic conjunctivitis.

Update

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 May 2022.

HTAs (Health Technology Assessments)

  • NICE (2025) Betula verrucosa for treating moderate to severe allergic rhinitis or conjunctivitis caused by tree pollen – guidance TA1087. National Institute for Health and Care Excellence. [Free Full-text]

Economic appraisals

No new economic appraisals relevant to England since 1 May 2022.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 May 2022.

Primary evidence

No new randomized controlled trials in the major journals since 1 May 2022.

New policies

No new national policies or guidelines since 1 May 2022.

New safety alerts

No new safety alerts since 1 May 2022.

Changes in product availability

No changes in product availability since 1 May 2022.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Make a diagnosis of allergic conjunctivitis in primary care.
  • Advise on self-care.
  • Manage the symptoms of allergic conjunctivitis.
  • Refer to ophthalmology or seek advice as appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

  • Conjunctivitis is inflammation of the conjunctiva due to allergic or immunological reactions, infection (viral, bacterial, or parasitic), mechanical irritation, neoplasia, or contact with toxic substances.
    • The conjunctiva is a thin, transparent mucous membrane lining the anterior part of the sclera (bulbar conjunctiva) and the under-surface of the eyelids (palpebral conjunctiva).
    • Inflammation or infection of the conjunctiva causes dilation of conjunctival vessels leading to hyperaemia and oedema of the conjunctiva which may be associated with discharge.
  • Conjunctivitis can be acute (persisting for less than 4 weeks), chronic (persisting for more than 4 weeks), or recurrent.
  • Allergic conjunctivitis is a term used to describe a group of ocular conditions associated with an immunoglobulin E (IgE) hypersensitivity reaction including:
    • Seasonal allergic conjunctivitis (hay fever conjunctivitis) — occurs periodically and is associated with seasonal allergens (such as tree pollen in spring and grass pollen in early summer).
    • Perennial allergic conjunctivitis — associated with non-seasonal environmental allergens often found in the home (such as house dust mites, mould spores, or animal dander). Occurs year-round but may have seasonal exacerbations.
    • Vernal keratoconjunctivitis — most common and most severe in hot arid environments (such as the Mediterranean, West Africa, and India). Clinical features typically worsen in springtime (vernal).
    • Atopic keratoconjunctivitis — more severe and usually associated with atopic dermatitis of the eyelids.
    • Giant papillary conjunctivitis is often grouped with ocular allergic conditions — it also has a mechanical component and can occur as a result of chronic micro-trauma for example from contact lens wear, ocular prostheses, or ocular sutures.

[Bielory, 2013; Ciolino, 2015; American Academy of Ophthalmology, 2016; Solomon, 2016; Berger, 2017; AAO, 2019; Azari, 2020; BMJ Best Practice, 2021; College of Optometrists, 2021a; College of Optometrists, 2021b]

How common is it?

  • Allergic conjunctivitis is a common condition estimated to affect up to 40% of the population.
    • Accurate epidemiological estimates are difficult as many people with allergic conjunctivitis self-medicate and it is often underdiagnosed.
    • Most cases of allergic conjunctivitis are seasonal and typically occur in spring and summer.
    • More than half of cases of allergic conjunctivitis are classified as seasonal or intermittent, which is less than 4 weeks in duration.
    • Allergic conjunctivitis is common in children — the International Study of Asthma and Allergy in Childhood found that allergic conjunctivitis affects 1.4–39.7% of children and adolescents.
  • Between 30–71% of patients with allergic rhinitis also have allergic conjunctivitis or conjunctival symptoms.
  • Estimates of the prevalence of vernal keratoconjunctivitis in European countries range from approximately 1 in 10,000 people (in Nordic countries) to 3 in 1000 people (in Italy).
    • It is more common in males.
    • Rates in African countries are estimated to be between 5–18%. In Japan, the rate is thought to be 1%.
  • The prevalence of allergic conditions, including seasonal and perennial allergic conjunctivitis, has been increasing over the past few decades.
    • The cause of this is not known and many contributory factors, such as industrialization, urbanization, air pollution, climate change, and low microbial exposure during childhood have been suggested.

[Bielory, 2012; Bielory, 2013; McLaurin, 2014; Leonardi, 2015; Berger, 2017; Azari, 2020; Miyazaki, 2020; BMJ Best Practice, 2021]

What causes it?

  • Allergic conjunctivitis is caused by an immunoglobulin E (IgE) response to an allergen.
    • Allergens bind to mast cells in the conjunctiva causing them to degranulate, which initiates an inflammatory cascade. Histamine and other inflammatory mediators are then released:
      • Activation of histamine H1 receptors in the conjunctiva leads to ocular itching (the predominant feature of ocular allergy).
      • Other allergic symptoms (such as redness and swelling [chemosis] of the conjunctiva and eyelid swelling) have been attributed to stimulation of H1 and H2 receptors on blood vessels.
  • Allergic conjunctivitis can be exacerbated by problems with the eyebrows, eyelids, or eyelashes which act as barriers to allergens. A normal tear film also helps to remove allergens from the eye surface.

[McLaurin, 2014; Abelson, 2015; Castillo, 2015; Ciolino, 2015; BMJ Best Practice, 2021; College of Optometrists, 2021b]

What are the complications?

  • In most cases, conjunctivitis does not cause permanent visual loss or structural damage.
  • Seasonal allergic conjunctivitis and perennial allergic conjunctivitis (the commonest forms of allergic conjunctivitis) can lead to:
    • Irritability, decreased concentration, and daytime fatigue.
    • Impaired performance at school, at work, and in social interactions.
      • One study of seasonal allergic conjunctivitis in the UK found a mean reduction of 2.3 hours of productive time per week during allergy season [Pitt, 2004].
    • Reduced quality of life.
  • Vernal and atopic keratoconjunctivitis are more severe forms of allergic conjunctivitis which can be sight-threatening:
    • Vernal keratoconjunctivitis can cause thickening of the eyelids; ptosis; conjunctival scarring; corneal neovascularization, thinning, ulceration, and infection; and loss of vision.
    • Atopic keratoconjunctivitis can cause thickening or tightening of the eyelids; loss of eyelashes; conjunctival scarring, neovascularization, thinning, ulceration, and infection; severe dry eye; loss of vision; and cataract.
  • Conjunctivitis associated with contact lens use:
    • Contact lens wear can lead to keratoconjunctivitis or giant cell papillary conjunctivitis. This is more likely to occur if lens hygiene is poor, lenses fit poorly, are worn for long periods of time or are replaced infrequently, and if allergy develops to contact lens solution.
    • Giant papillary conjunctivitis can lead to intolerance of contact lenses and other ocular foreign bodies such as prostheses and sutures.

[Bielory, 2012; Bielory, 2013; Ciolino, 2015; Berger, 2017; Blaiss, 2018; AAO, 2019; Ridolo, 2019; BMJ Best Practice, 2021]

What is the prognosis for allergic conjunctivitis?

  • Most people with allergic conjunctivitis respond well to treatment although seasonal exacerbations can occur.
  • Vernal conjunctivitis generally resolves spontaneously after puberty.
    • Complications such as corneal ulcers (reported in approximately 9.7%), cataract, and glaucoma can lead to permanent visual impairment.
  • Atopic keratoconjunctivitis is a chronic disease which persists for years. Corneal complications which can be sight-threatening have been reported in 60–70% of people.

[Foster, 1990; Power, 1998; Bonini, 2004; BMJ Best Practice, 2021]

Diagnosis of allergic conjunctivitis

What are the clinical features of allergic conjunctivitis?

Acute, seasonal, and perennial allergic conjunctivitis

  • Clinical presentation can be nonspecific but the hallmark symptom of allergic conjunctivitis is ocular itching (usually bilateral) — if itching is not present an alternative cause should be considered.
    • Itching may also be described as ‘burning or stinging'.
  • Other clinical features include:
    • Watery or mucoid discharge — sometimes referred to as 'tearing'. Discharge may be stringy or ropey due to the presence of a small amount of mucous.
    • Conjunctival redness (hyperaemia injection).
    • Conjunctival swelling (chemosis) — bulbar and tarsal conjunctiva may bulge over lid margin or limbus.
    • Conjunctival papillary reaction.
    • Eyelid oedema (swelling) — periorbital oedema can occur in severe cases.
  • Allergic conjunctivitis may coexist with other atopic conditions including:
    • Rhinitis and rhinosinusitis — nasal and ocular symptoms frequently occur together. For further information, see the CKS topic on Allergic rhinitis.
    • Asthma — for further information, see the CKS topic on Asthma.
    • Urticaria — for further information, see the CKS topic on Urticaria.
    • Eczema — for further information, see the CKS topic on Eczema - atopic.
  • Symptoms may be exacerbated by coexistence of other eye conditions such as blepharitis or dry eye.

Severe and chronic types of allergic conjunctivitis

  • Vernal keratoconjunctivitis — more common and more severe in hot arid areas of the world (such as the Mediterranean basin, East Africa, and India). It is more common in boys and typically resolves spontaneously after puberty.
    • Symptoms are typically worse in spring but may occur throughout the year and include severe itching and copious fibrinous discharge.
    • Signs include giant papillae on the superior tarsal conjunctiva (due to inflammation of the palpebral conjunctiva), yellow–white points on the limbus (Horner's points) or conjunctiva (Trantas dots), lower eyelid creasing (Dennie's lines), and pseudomembrane formation on the upper lid.
    • The cornea can become involved leading to significant visual impairment.
  • Atopic keratoconjunctivitis — a chronic condition usually occurring in people who have a personal or family history of atopy (such as eczema or asthma).
    • Symptoms include severe itching, tearing, and swelling.
    • The cornea can become involved leading to significant visual impairment.

Giant papillary conjunctivitis

  • Symptoms include moderate or severe itching, blurring of vision, intolerance of contact lenses, conjunctival injection, and discharge which is typically white, stringy, and worst in the morning.

Basis for recommendation

The information on the clinical features of allergic conjunctivitis is based on expert opinion in the American Academy of Ophthalmology guideline Conjunctivitis preferred practice pattern [AAO, 2019], the BMJ Best Practice guideline Acute conjunctivitis [BMJ Best Practice, 2021], the College of Optometrists guidelines Conjunctivitis (acute allergic) [College of Optometrists, 2021a] and Conjunctivitis (seasonal and perennial allergic) [College of Optometrists, 2021b], as well as a number of review articles [Bielory, 2012; Azari, 2013; Bielory, 2013; McLaurin, 2014; Berger, 2017; Azari, 2020].

Ocular itching as a cardinal feature

  • Expert opinion in a review article recommends that the diagnosis of allergic conjunctivitis be reconsidered if the person does not present with ocular itching [Berger, 2017].
  • A systematic review of 86 articles found that clinical presentation of allergic conjunctivitis is often non-specific, however, itching is the most consistent sign [Azari, 2013].
  • Itching is less commonly associated with other ocular inflammatory conditions — some people with blepharitis, dry eye, or other ocular conditions may describe itching in addition to other symptoms [Bielory, 2013].

Co-existence of other atopic conditions

  • Allergic conjunctivitis is strongly associated with atopic conditions including hay fever, atopic dermatitis, and asthma [BMJ Best Practice, 2021].
  • Systemic diseases including atopy may cause conjunctival inflammation [AAO, 2019].
  • Between 50–75% of people with allergic rhinitis also have ocular symptoms [Bielory, 2013].

How do I assess a person with suspected allergic conjunctivitis?

Assess all people presenting with a unilateral red eye for features indicating a serious and potentially sight-threatening cause (such as acute glaucoma, corneal ulcer, anterior uveitis, scleritis, or trauma) — for further information, see the CKS topic on Red eye.

Take a history asking about:

  • Onset and duration of symptoms.
  • Clinical features including:
    • Variation of symptoms with geographic location, season, and exposure to specific triggers, and whether symptoms are unilateral or bilateral.
    • Amount and type (watery, purulent, or mucopurulent) of discharge, and when it is most troublesome (for example on waking from sleep).
    • Itching.
    • Changes in vision such as blurring.
    • Eyelid changes such as swelling and flaking.
  • Recent exposure to a person with similar symptoms — suggestive of an infective cause.
  • Red flags indicating the need for urgent ophthalmology assessment such as:
    • Reduced visual acuity.
    • Marked eye pain, headache, or photophobia — always consider serious systemic conditions such as meningitis in a person presenting with photophobia. For further information, see the CKS topic on Meningitis.
    • Inability to open the eye or keep it open.
    • Red sticky eye in a neonate (within 30 days of birth) — suggestive of ophthalmia neonatorum. 
    • History of trauma (mechanical, chemical, or ultraviolet) or possible foreign body.
    • Copious rapidly progressive discharge — may indicate gonococcal infection.
    • Possible infection with a herpes virus:
      • Herpes simplex — may present as unilateral red eye with vesicular lesions on the eyelid. For further information, see the CKS topic on Herpes simplex - ocular.
      • Herpes zoster — assume ocular involvement if lesions are present on the tip of the nose (Hutchinson's sign). For further information, see the CKS topic on Shingles.
    • Soft contact lens use with corneal symptoms (such as photophobia and watering).
  • Associated symptoms such as:
    • Nasal congestion, nasal itch, rhinorrhoea, and sneezing.
    • Upper respiratory tract infection.
    • Enlarged tender lymph nodes — suggestive of an infective cause.
  • Past medical history including:
    • History of atopy, allergy, and similar episodes.
    • Immunocompromise for example HIV, chemotherapy, or immunosuppressant therapy.
    • Systemic conditions which can present with clinical features of conjunctivitis such as rheumatoid arthritis, Sjögrens syndrome, systemic lupus erythematous, and reactive arthritis.
    • Ophthalmic surgery.
  • Drug history including prescribed and over-the-counter mydriatics, anticholinergics, and anticoagulants.
  • Social history including smoking, occupation, hobbies, sexual activity, and travel.

Examine the person assessing the:

  • Conjunctiva — look for injection, chemosis (swelling), follicles, papillae, and membranes. Pull on the lower eyelid and evert the upper lid to examine the palpebral conjunctiva.
    • Follicles (small yellowish elevations of lymphocytes) can be associated with adenovirus and chlamydia.
    • Papillae (small conjunctival elevations with central vessels) can be associated with allergic conjunctivitis and contact lens intolerance.
    • Conjunctival membranes (yellow/white layer of fibrin adherent to underlying conjunctival tissue) can form in severe viral or bacterial infections and cause complications such as conjunctival scarring and severe dry eye.
  • Cornea — look for ulceration and opacities.
    • If available, consider evaluating the cornea with a Wood lamp and fluorescein staining to identify abnormalities (for example corneal dendrites [HSV keratitis] and corneal ulcers).
  • Sclera — look for localized or widespread oedema and erythema which indicates a serious cause such as scleritis.
  • Pupil — assess shape, size, and pupillary reaction (with a pen torch) looking for asymmetric or unreactive pupils.
  • Visual acuity (using a Snellen chart) and visual fields. Compare to previous levels of visual acuity, if possible. 
  • Eyelids — look for discharge, swelling, inflammation, malposition, nodules, loss of lashes (may indicate sebaceous gland carcinoma), vesicles (herpes), lice infestation, or blepharitis.
  • Periorbital area — look for swelling and erythema which may indicate orbital or periorbital cellulitis.
    • Periorbital cellulitis can develop from conjunctivitis in young children.
    • A dull blue discolouration below the eye sometimes called the ‘allergic shiner’ resulting from venous congestion may be present in some people with allergies.
  • Lymph nodes — look for regional lymphadenopathy in the periauricular, submandibular, and cervical areas (more consistent with infectious cause).

Investigations:

  • Investigations are not normally required.

Basis for recommendation

The recommendations on assessment of a person with suspected allergic conjunctivitis are largely based on expert opinion in the American Acadamy of Ophthalmology guideline Conjunctivitis preferred practice pattern [AAO, 2019], the BMJ Best Practice guidelines Acute conjunctivitis [BMJ Best Practice, 2021] and Assessment of red eye [BMJ Best Practice, 2022], as well as a number of review articles [Azari, 2013; Bielory, 2013; Wong, 2014; Alfonso, 2015; Drew, 2015; McAnena, 2015; Pflipsen, 2016; Berger, 2017; Azari, 2020].

Red flags

  • One systematic review [Narayana, 2015] found that the most useful clinical features indicating serious eye disease were:
    • A smaller pupil in the red eye (difference between pupil diameters greater than 1 mm; likelihood ratio, 6.5; 95% CI 2.6–16.3).
    • Photophobia on direct illumination (likelihood ratio 8.3; 95% CI 2.7–25.9), indirect illumination (likelihood ratio 28.8; 95% CI 1.8–459), or ‘finger-to-nose convergence test’ (likelihood ratio 21.4; 95% CI 12–38.2).
  • Use of soft contact lenses increases the risk of infective conjunctivitis with corneal involvement [BMJ Best Practice, 2021].
  • Hyperacute presentation of conjunctivitis with copious mucopurulent discharge in a sexually active person should be considered to be Neisseria gonorrhoeae (GC), until proven otherwise [Azari, 2013; BMJ Best Practice, 2021].
  • Neonatal (less than 4 weeks) sticky eye with redness must always be referred urgently to ophthalmology to prevent serious complications [College of Optometrists, 2021c].

Over-the-counter and prescribed medications

  • Topical ocular medications (such as preserved artificial tears or decongestants) may cause inflammation of the ocular surface. Oral medications (such as first generation antihistamines) may cause ocular dryness [Bielory, 2013].

Co-existent conditions

  • Systemic autoimmune diseases (for example rheumatoid arthritis and Sjögren's syndrome) can present with keratoconjunctivitis sicca or dry eye.
  • Dry eye disease and allergic conjunctivitis often coexist — dry eye may exacerbate allergic conjunctivitis as a normal tear film is needed to dilute and remove environmental allergens from the eye surface. Lower concentrations of allergens on the eye surface are less likely to provoke an allergic response [Bielory, 2013].

What else might it be?

There are many causes of red eye, some of which are serious or sight-threatening and require same day assessment by ophthalmology — for further information, see the CKS topic on Red eye. The differential diagnosis for allergic conjunctivitis includes:

  • Serious conditions such as:
    • Acute glaucoma.
    • Episcleritis and scleritis.
    • Keratitis.
    • Iritis/uveitis.
    • Corneal ulcer, abrasion, or foreign body.
    • Preseptal or preorbital cellulitis.
  • Other types of conjunctivitis such as:
    • Infective conjunctivitis — may be caused by viruses, bacteria, parasites, or fungi.
    • Toxic conjunctivitis — for example due to drop allergy, preservative-related, or chemical trauma.
      • Overuse of cosmetic drops to whiten the conjunctiva can lead to permanently dilated vessels and red eyes.
    • Irritative or mechanical conjunctivitis — for example due to contact lens use, floppy eyelid syndrome, pediculosis palpebrarum (Phthirus pubis), or medication.
    • Immune-mediated conjunctivitis such as Stevens-Johnson syndrome, graft-versus-host disease, or ocular mucous membrane pemphigoid.
    • Neoplastic such as sebaceous carcinoma or melanoma.
  • Other conditions affecting the eye such as:
    • Subconjunctival haematoma.
    • Dry eye.
    • Blepharitis and blepharokeratoconjunctivitis.
    • Thyroid eye disease.

Basis for recommendation

The information on differential diagnoses of allergic conjunctivitis is based on expert opinion in the American Academy of Ophthalmology guideline Conjunctivitis preferred practice pattern [AAO, 2019], the BMJ Best Practice guidelines Acute conjunctivitis [BMJ Best Practice, 2021] and Assessment of red eye [BMJ Best Practice, 2022], the College of Optometrists guidelines Conjunctivitis (acute allergic) [College of Optometrists, 2021a] and Conjunctivitis (seasonal and perennial allergic) [College of Optometrists, 2021b], as well as a number of review articles [Bielory, 2013; Alfonso, 2015; Drew, 2015; O'Gallagher, 2017; Azari, 2020].

Management

Scenario: Referral

From age 1 month onwards.

Who should I refer to secondary care?

  • Note: guidance from the College of Optometrists on urgency of referral includes advice relating to people with different causes of red eye.
  • Arrange urgent assessment by ophthalmology if the person:
    • Has any clinical features suggestive of a serious cause of red eye. For further information, see the CKS topic on Red eye.
    • Has suspected periorbital or orbital cellulitis. For further information, see the CKS topic on Cellulitis.
    • Has severe disease for example corneal ulceration, significant keratitis, or presence of pseudomembrane.
    • Has had recent intraocular surgery.
    • Has conjunctivitis associated with a severe systemic condition such as rheumatoid arthritis or other reasons for immunocompromise.
    • Has corneal involvement associated with soft contact lens use:
      • Do not give antibiotics in the interim as this may interfere with corneal culture.
      • Advise the person to take their contact lenses with them to eye casualty as special diagnostic tests may be required.
    • Is a neonate with red sticky eye (suggesting ophthalmia neonatorum) — for further information, see the CKS topic on Conjunctivitis - infective.
  • Discuss with or refer to ophthalmology (with urgency dependent on clinical situation) if:
    • There is diagnostic uncertainty or the appropriate diagnostic equipment is not available.
    • The person is suspected of having atopic keratoconjunctivitis, vernal keratoconjunctivitis, or giant papillary conjunctivitis.
      • If the person has suspected mild papillary conjunctivitis due to contact lens wear, assessment by an optometrist for modification of contact lens use is needed. Specialist management by an ophthalmologist is required for more severe cases.
    • The person has severe or resistant allergic conjunctivitis:
      • Atopic keratoconjunctivitis and vernal keratoconjunctivitis must be excluded.
      • Resistant cases of perennial and seasonal allergic conjunctivitis may require specialist treatments, such as topical corticosteroids or immunotherapy.
  • Consider referral to an allergy specialist if:
    • The person has multisystem disease (for example nasal and respiratory symptoms) — allergen identification may help with avoidance.
    • Symptoms interfere significantly with quality of life and ability to function.

Basis for recommendation

The recommendations on when to refer a person with suspected allergic conjunctivitis are largely based on expert opinion in the American Academy of Ophthalmology guideline Conjunctivitis preferred practice pattern [AAO, 2019]; the BMJ Best Practice guideline Acute conjunctivitis [BMJ Best Practice, 2021]; the College of Optometrists guidelines Conjunctivitis (acute allergic) [College of Optometrists, 2021a], Conjunctivitis (seasonal and perennial allergic) [College of Optometrists, 2021b], and Ophthalmia neonatorum [College of Optometrists, 2021c]; the College of Optometrists Urgency of referrals table [College of Optometrists, 2022]; as well as a number of review articles [Azari, 2013; Bielory, 2013; O'Brien, 2013; Usher, 2014; Wong, 2014; Alfonso, 2015; Drew, 2015; Pflipsen, 2016; Solomon, 2016; Berger, 2017].

Referral to ophthalmology
  • The Royal College of General Practitioners recommends having a low threshold for urgent referral to ophthalmology in people presenting with red flags for a serious cause of red eye [RCGP, 2013a].
  • Opthalmia neonatorum:
  • Herpes infection:
  • Conjunctivitis associated with contact lens use:
    • If topical fluorescein reveals corneal staining (epithelial defect) — urgent referral is required as this can be a sight-threatening condition [RCGP, 2013b; Drew, 2015].
    • Bacterial keratitis can also occur in contact lens wearers [Azari, 2013].
  • Recurrent and persistent conjunctivitis — discussion with ophthalmology is recommended as prolonged severe itching may be due to atopic keratoconjunctivitis or vernal keratoconjunctivitis which require specialist management to avoid sight-threatening complications [Berger, 2017]. 
Referral to an allergy specialist
  • Allergen identification may help with avoidance in people who have multisystem disease (for example nasal and respiratory symptoms) [Bielory, 2013].

Scenario: Management in primary care

From age 1 month onwards.

How do I manage a person with allergic conjunctivitis in primary care?

If referral to secondary care is not required:

  • Advise the person on non-pharmacological management including:
    • Avoidance of allergens for example through dust mite, mould, and animal dander control, avoidance of pets and proper ventilation of home and office environments.
      • Washing the hair before going to bed may help reduce allergen exposure.
    • Avoidance of eye rubbing.
    • Application of cold compresses to the eyes (for 5–10 minutes once or twice daily) to relieve symptoms.
    • Application of ocular surface lubricants such as saline solution or artificial tears.
      • Note: certain products cannot be used with contact lenses and the manufacturer's literature on product characteristics should always be consulted prior to application.
      • Advise the person that after using eye drops or eye ointments, they should not drive or perform other skilled tasks until vision is clear.
  • If non-pharmacological measures do not provide adequate relief, consider prescribing a topical antihistamine or dual action mast cell stabilizer/topical antihistamine.
    • Note: certain products are not licenced in young children.
    • Some topical antihistamines are combined with a vasoconstrictor agent — chronic use of these products is associated with rebound vasodilation once the product is stopped.
    • Mast cell stabilizers can be used if symptoms are recurrent or persistent.
      • Advise the person that a long loading period is required and mast cell stabilizers need to be applied routinely for at least 2 weeks to provide prophylactic benefit.
    • Advise the person that after using eye drops or eye ointments, they should not drive or perform other skilled tasks until vision is clear.
    • If the person is a contact lens wearer, advise them that contact lens use should be avoided for the duration of topical treatment.
  • Topical ocular diclofenac can be prescribed as adjunctive therapy if further symptomatic relief is required.
  • See the section on Prescribing for further information on use of topical ocular agents to treat allergic conjunctivitis.
  • Provide patient information, for example:
  • Arrange review in 1 week to assess therapeutic response — safety net in the interim and ensure the patient is aware of red flag symptoms that indicate the need for urgent review.

Basis for recommendation

The recommendations on the management of allergic conjunctivitis in primary care are largely based on expert opinion in the College of Optometrists guidelines Conjunctivitis (acute allergic) [College of Optometrists, 2021a] and Conjunctivitis (seasonal and perennial allergic) [College of Optometrists, 2021b], as well as a number of review articles [Bielory, 2012; Bilkhu, 2012; Bielory, 2013; O'Brien, 2013; Wong, 2014; Abelson, 2015; Alfonso, 2015; Berger, 2017; Leonardi, 2019; Azari, 2020].

Non-pharmacological measures
  • Avoidance of eye rubbing — eye rubbing causes mast cell degranulation and may self-inoculate the eye with allergen [Berger, 2017].
  • Artificial tears, lubricant eye drops, and saline solution irrigate the eye, dilute and remove antigens, form a barrier, and soothe the ocular surface — this may provide adequate relief in mild ocular allergy but does not treat the underlying allergic response or modify inflammatory mediators [Bielory, 2012; Abelson, 2015].
Pharmacological measures
  • The College of Optometrists advises that a variety of topical treatments are available for example topical mast cell stabilizers (such as sodium cromoglicate), topical antihistamine (such as antalozine), dual action topical antihistamine/mast cell inhibitor (such as olopatadine or ketotifen), and topical diclofenac, but there is insufficient evidence to recommend use of one over another [College of Optometrists, 2021b].
    • Topical antihistamines have been found to be more effective in alleviating ocular symptoms than systemic antihistamines [Abelson, 2015].
      • Topical antihistamines are applied directly to the ocular surface providing localized and more rapid relief than systemic antihistamines [Bielory, 2012].
      • Systemic antihistamines may cause drying of the ocular surface and are not recommended for treatment of allergic conjunctivitis in people who do not have concurrent rhinitis or sinusitis [Bielory, 2012; Abelson, 2015] — for further information, see the CKS topic on Allergic rhinitis.
    • Mast cell stabilizers:
      • Mast cell stabilizers prevent degranulation of mast cells and release of pre-formed inflammatory mediators — they require a long loading period and need to be applied routinely for several weeks to attain optimal prophylactic benefit [Butrus, 2005; Azari, 2020]. 
      • This potentially long lead time for therapuetic benefit is likely to decrease patient compliance and expert opinion in a review article suggests that for this reason, they are rarely used in isolation as treatment for acute allergic conjunctivitis [Bielory, 2013].
    • Combination topical antihistamine and mast cell stabilizers such as olopatadine and ketotifen provide relief of symptoms through inhibition of mast cell degranulation in addition to competitive binding of the H1 receptor blocking histamine binding [Bielory, 2012; BMJ Best Practice, 2021].
      • A Cochrane review (n = 30 studies) found that topical antihistamines and mast cell stabilizers, alone or in combination, are safe and effective in reduction of symptoms of seasonal and perennial allergic conjunctivitis when compared to placebo in the short term. No long-term data on efficacy was identified and there was insufficient evidence on which topical antihistamines and mast cell stabilizers are most effective [Castillo, 2015].
      • Pooled estimates from four studies found that olopatadine may be more effective than ketotifen in improving ocular itching, but not tearing, after 14 days of treatment [CADTH, 2016].
      • A systematic review and meta-analysis found that olopatadine was inferior to alcaftadine in reducing ocular itch (p < 0.00001) but comparable with epinastine and ketotifen [Kam, 2016].
      • Expert opinion in a pharmacy update on antihistamine use in children is that olopatadine eye drops are superior to sodium cromoglicate, more cost effective, and reduce general practitioner attendances [Fitzsimons, 2015].
      • As dual agents usually have a rapid onset of antihistamine action (within minutes following application) patient compliance is improved compared with use of mast cell stabilizers alone [Bielory, 2012].
    • Topical nonsteroidal anti-inflammatory drugs (NSAIDs):
      • A meta-analysis of data from eight randomized controlled trials found that topical NSAIDs are more effective than placebo in reducing ocular itching and redness [Swamy, 2007].
      • Topical NSAIDs are, however, rarely used in the treatment of allergic conjunctivitis due to burning/stinging after application [Leonardi, 2019].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Be aware that:

  • Certain preparations cannot be used with contact lenses or in young children and individual product literature should always be consulted [Bielory, 2012; Bielory, 2013; Berger, 2017; BMJ Best Practice, 2017].
  • The person must be advised that after using eye drops or eye ointments, they should not drive or perform other skilled tasks until vision is clear [BNF 73, 2017].

Topical ocular antihistamines and mast cell stabilizers

Which topical ocular antihistamine or dual action topical antihistamine and mast cell stabilizer can be prescribed?

  • Preparations that have mast cell stabilizing properties include:
    • Sodium cromoglicate — licenced for use in allergic conjunctivitis and seasonal keratoconjunctivitis in adults and children, apply eye drops 4 times daily.
    • Lodoxamide — licenced for use in allergic conjunctivitis in adults and children over 4 years, apply eye drops 4 times daily.
  • Preparations that have antihistaminergic properties include: 
    • Antazoline — note: the only available preparation also contains xylometazoline. Licenced for use in seasonal allergic conjunctivitis in adults and children over 12 years, apply twice to three times daily; maximum duration of treatment 7 days.
  • Preparations that have both mast cell-stabilizing and antihistaminergic properties include:
    • Azelastine — licenced for use in seasonal allergic conjunctivitis in adults and children over 4 years, apply twice daily, increased if necessary to 4 times daily; licenced for use in perennial conjunctivitis in adults and children over 12 years, apply twice daily, increased if necessary to 4 times daily; maximum duration of treatment 6 weeks.
    • Epinastine — licenced for use in seasonal allergic conjunctivitis in adults and children over 12 years, apply twice daily; maximum duration of treatment 8 weeks.
    • Ketotifen — licenced for use in seasonal allergic conjunctivitis in adults and children over 3 years, apply twice daily.
    • Olopatadine — licenced for use in seasonal allergic conjunctivitis in adults and children over 3 years, apply twice daily; maximum duration of treatment 4 months.

[Azari, 2020; BMJ Best Practice, 2021; College of Optometrists, 2021b; BNF, 2022]

What are the contraindications and cautions?

  • All agents:
    • Use should be avoided in people who are hypersensitive to the active substances or to any of the excipients.
    • Soft contact lenses should not be worn during the treatment period.
    • Use with caution in pregnancy (especially during the first trimester) and only when there is a clear need — however systemic absorption (and therefore level of fetal exposure) is generally expected to be low.
  • Antazoline/xylometazoline:
    • Do not use in people:
      • With narrow-angle glaucoma.
      • Who are receiving monoamine oxidase inhibitors, or within 14 days of treatment cessation.
    • Use with caution in people:
      • Who are elderly with severe cardiovascular disease, including arrhythmia, poorly controlled hypertension, or diabetes.
      • With hypertension, cardiac irregularities, hyperthyroidism, diabetes mellitus, or phaeochromocytomas.
      • With long QT syndrome — may be at increased risk of serious ventricular arrhythmias.
      • With conditions causing urinary retention such as prostatic hypertrophy.
      • Who are receiving other sympathomimetic drugs.
      • Who have dry eyes — rebound hyperaemia may follow prolonged frequent use.

[Abelson, 2015; UKTIS, 2019; ABPI, 2020a; ABPI, 2020b; ABPI, 2020c; ABPI, 2020d; ABPI, 2021a; ABPI, 2021b; ABPI, 2022; BNF, 2022]

What are the adverse effects?

  • Topical eye preparations may cause transient blurring of vision — advise the person to wait until this resolves before driving or performing other skilled tasks such as operating machinery.
  • Adverse effects include:
    • Sodium cromoglicate — burning and stinging. 
    • Lodoxamide — dry eye, eye discomfort, eye disorders, and vision disorders.
    • Azelastine — mild transient irritation and bitter taste.
    • Antazoline and xylometazoline — drowsiness, eye irritation, headache, hyperhidrosis, hypertension, mydriasis, nausea, palpitations, vascular disorders. Systemic absorption can cause systemic sympathomimetic effects.
    • Epinastine — burning. Less commonly taste disturbance, headache, conjunctival hyperaemia, dry eye, eye pruritus, visual disturbance, increased lacrimation, eye pain, nasal irritation, and rhinitis.
    • Ketotifen — transient burning or stinging, punctate keratitis, punctate corneal epithelial erosion. Less commonly dry eye, subconjunctival haemorrhage, photophobia; headache, drowsiness, skin reactions, and dry mouth.
    • Olopatadine — local irritation. Less commonly keratitis, dry eye, local oedema, photophobia, headache, asthenia, dysgeusia, fatigue, dizziness, and dry nose.

[ABPI, 2020a; ABPI, 2020b; ABPI, 2020c; ABPI, 2020d; ABPI, 2021a; ABPI, 2021b; ABPI, 2022; BNF, 2022]

Topical ocular diclofenac

How can topical ocular diclofenac be used?

Topical ocular diclofenac is licensed for use in adults for the relief of the ocular signs and symptoms of seasonal allergic conjunctivitis — the dose is 1 drop 4 times daily for as long as is required.

[ABPI, 2020e; BNF, 2022]

What are the contraindications and cautions?

  • Avoid use in people who:
    • Are hypersensitive to the active substances or to any of the excipients.
    • Have a history of asthma, urticaria, or acute rhinitis precipitated by acetylsalicylic acid or other drugs with prostaglandin synthetase inhibiting activity.
    • Are pregnant women, particularly in the third trimester where nonsteroidal anti-inflammatory drug (NSAID) exposure can cause premature closure of the ductus arteriosus.
  • Use with caution in:
    • People with, or at risk of, an eye infection — the anti-inflammatory effects may mask the onset or progression of ocular infection.
    • People using ocular corticosteroids with significant pre-existing corneal inflammation — concurrent use may increase the risk of developing corneal complications.
      • Advise the person to leave an interval of at least 5 minutes between the application of the different products.
  • Note: advise the person that soft contact lenses should be removed during application and not reinstated until at least 15 minutes afterwards.

[ABPI, 2020e]

What are the adverse effects?

  • Adverse effects of topical ocular diclofenac include:
    • Eye pain (common).
    • Transient eye irritation.
    • Eye pruritus.
    • Ocular hyperaemia.
    • Blurred vision immediately after instillation.
    • Rhinitis.
    • Punctate keratitis or corneal disorders.
      • In people with risk factors for corneal disorders (including use of corticosteroids or concomitant diseases such as infections or rheumatoid arthritis) use of diclofenac (usually for prolonged periods) has been associated, in rare cases, with ulcerative keratitis, corneal thinning, punctuate keratitis, corneal epithelium defect, and corneal oedema, which might become sight-threatening.
    • Dyspnoea and asthma exacerbation (rare).

[ABPI, 2020e; BNF, 2022]

Supporting evidence

This CKS topic is largely based on the American Academy of Ophthalmology guideline Conjunctivitis preferred practice pattern [AAO, 2019], the BMJ Best Practice guideline Acute conjunctivitis [BMJ Best Practice, 2021], and the College of Optometrists guidelines Conjunctivitis (acute allergic) [College of Optometrists, 2021a] and Conjunctivitis (seasonal and perennial allergic) [College of Optometrists, 2021b]. A brief summary of the available evidence is given in the relevant basis for recommendation sections. CKS has not summarized the evidence for secondary care investigations and management as they are beyond the scope of this topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of conjunctivitis - allergic.

Search dates

May 2017 - April 2022

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

  • exp Conjunctivitis, Allergic/, (allergic ADJ conjunctivitis).tw., exp Conjunctivitis/, conjunctivitis.tw., exp Dermatitis, Allergic Contact/, giant papillary conjunctivitis.tw.
  • (allergic conjunctivitis or allergic keratoconjunctivitis or contact blepharoconjunctivitis or vernal keratoconjunctivitis or atopic keratoconjunctivitis or ocular allergy).ti,ab. NOT (Stevens OR dacryo* OR retina OR uveitis OR gvh OR optic nerve).ti,ab.

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
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Principles of the consultation process

  • The process is inclusive and any individual may participate.
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  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
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  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
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  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
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  • First draft internal review
  • Second draft internal review
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Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
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Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

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