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    What clinicians should know about ocular allergies

    Taking a fresh look at up-to-the-minute treatment modalities for managing patients’ symptoms

    Allergy season is upon us, and soon patients will be looking for solutions to their red and itchy eyes. Let's brush up on how to recognize these patients with ocular allergies, how to confirm their diagnosis, and how best to manage what is beneath the surface of these troubled seas. 

    Differential diagnosisPatient with a known history
    of allergic conjunctivitis 15 to 20 minutes after conjunctival allergan challenge (Ora-CAC).
    (Image courtesy of Ora Inc.)

    An ocular allergy diagnosis is old fashioned and no frills. No high-powered kits, tear samplings, biomarkers, or other expensive accoutrements are needed for confirmation of allergic conjunctivitis.

    Related: How punctal plugs may influence tear osmolarity and aid in dry eye therapies

    The foremost symptom of itching must be present as it is pathognomonic for this disease. Rarely do we find one symptom that is necessary and almost exclusive to one disease, and this makes our job as clinicians easier.

    Other allergic symptoms—burning, stinging, tearing, and mucous discharge—can all be signs of dry eye, and hyperemia is the red flag of many inflammatory and/or infectious conditions. Still, certain patterns of redness suggest dry eye (horizontal, within the palpebral fissure), meibomian gland dysfunction (MGD) (inferior and lid proximal), or even bacterial (diffuse and severe) or viral (violet red) infection in a way that does not bring to mind allergy.

    Eyelid swelling with the watery ballooning of chemosis points the arrow in the direction of allergy; crusting and purulent discharge is clearly bacterial; and profuse tearing with violet red hyperemia is probably viral (but should be explored further).

    Recent: When old, new technologies converge for dry eye diagnosis

    I have seen thousands of allergic eyes, and the telltale heart of allergic redness is the watery shimmer on the chemotic conjunctival bed. Eyelid swelling is also characteristic, as it is more generalized than that seen in MGD or chalazion.

    The slit lamp examination is needed more for differential diagnosis and ruling out of other causes of a red and swollen eye. Any corneal involvement indicates either more severe forms of ocular allergy, such as atopic (AKC) or vernal keratoconjunctivitis (VKC), particularly if the patient complains of photophobia.

    To view table of drug classes for allergy treatment, click here

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