Diagnosis and management of allergic conjunctivitis in

pediatric patients
William E. Berger, M.D., M.B.A.,1 David B. Granet, M.D.,2,3 and Alan G. Kabat, O.D.4

ABSTRACT
Background: Allergic conjunctivitis (AC), although one of the most common ocular disorders in pediatric patients, is
frequently overlooked, misdiagnosed, and undertreated in children.
Objective: To guide pediatric health care professionals in the optimal diagnosis and management of AC in pediatric patients.
Methods: To identify any existing best practice guidelines for the diagnosis and treatment of AC in pediatric patients, a
review of the literature published between 2004 and January 2015 was conducted. Diagnosis and treatment algorithms and

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guidelines for pediatric patient referrals were then developed.
Results: A literature search to identify best practice guidelines for the treatment of AC in pediatric patients failed to return
any relevant articles, which highlighted the need for best practice recommendations. Based on publications on adult AC and
clinical experience, this review provides step-by-step guidance for pediatric health care professionals, including recognizing

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clinical features of AC, establishing a comprehensive medical history, and performing a thorough physical examination to
ensure a correct diagnosis and the optimal treatment or referral to an eye care specialist or allergist when required. In addition
to established drug treatments, the role of subcutaneous and sublingual immunotherapy is discussed to inform pediatric health
care professionals about alternative treatment options for patients who do not tolerate pharmacotherapy or who do not respond

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sufficiently.
Conclusion: The diagnostic and treatment algorithms and guidelines provided in this review help address the current
literature and educational gap and may lead to improvements in diagnosis and management of pediatric AC.
(Allergy Asthma Proc 38:16 –27, 2017; doi: 10.2500/aap.2017.38.4003)

A llergic conjunctivitis (AC) is the response by con-

junctival tissue to allergens such as pollen and
animal dander, and to other environmental allergens.1
The disease begins with antigen exposure, which stim-
ulates mast cell degranulation, histamine release, and
activation of a downstream inflammatory cascade.2 AC
is the most prevalent ocular disorder encountered by
N O pediatric ocular disorder includes infectious conjuncti-
vitis, which can be caused by a virus but is most
commonly caused by bacteria and requires a careful
differential diagnosis to ensure prompt and suitable
treatment. Despite its common occurrence, AC is reg-
ularly overlooked, misdiagnosed, and, therefore, un-
dertreated in both adult3,4 and pediatric patients.5 It is
pediatric health care professionals, which peaks in late

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thought that AC goes undiagnosed in pediatric pa-
childhood and young adulthood.3 Another common tients to a greater extent than in adults because chil-
dren often do not give voice to symptoms. In addition,
other allergic conditions, such as asthma and allergic

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From the 1Division of Allergy and Immunology, Department of Pediatrics, University rhinitis (AR), are possibly more prevalent, more dis-
of California, Irvine, California, 2Department of Ophthalmology, University of Cali-
fornia, San Diego, California, 3Department of Pediatrics, University of California, San
ruptive to the child’s life, and extensively covered dur-
Diego, California, and 4Southern College of Optometry, Memphis, Tennessee ing medical training.
Supported by Alcon Research, Fort Worth, Texas The term “allergic conjunctivitis” encompasses many
W.E. Berger is a paid consultant for Alcon, Allergan, AstraZeneca, Boehringer
Ingelheim, Meda, Mylan, Merck, and Teva, and has received payment for lectures from
classified ocular conditions, including the acute sea-
Alcon, AstraZeneca, Boehringer Ingelheim, Meda, Mylan, and Teva; conducts clinical sonal AC (SAC) and perennial AC (PAC), which have
research for Anacor, AstraZeneca, Circassia, Genentech, Hoffmann la Roche, Janssen, been associated with an immunoglobulin E–mediated
Novartis, Roxane Laboratories (a Boehringer-Ingelheim company), and Teva. A.G.
Kabat is a paid consultant for Alcon Laboratories, Bio-Tissue (a subsidiary of
hypersensitivity reaction, and the more-severe chronic
TissueTech, Inc.), BlephEx, LLC, and Shire; serves on advisory boards for Alcon, forms, vernal keratoconjunctivitis (VKC) and atopic
Bio-Tissue, Essilor, NicOx, Ocusoft, Shire, TearScience, Inc., and Valeant; received keratoconjunctivitis (AKC), which have an eosinophilic
speaker fees from Alcon, Bio-Tissue, BlephEx, Ocusoft, Shire, and Valeant; has been
paid for the preparation of manuscripts of educational materials by Alcon, Bio-Tissue, component.6,7 SAC and PAC are the two most common
BlephEx, and TearScience; and has a grant from Thermi. D. Granet is a paid forms of AC, and, of the two, SAC is more prevalent.8
consultant for Alcon Laboratories and has received a royalty from the American Seasonal allergies are triggered by aeroallergens with
Academy of Pediatrics
Address correspondence to William E. Berger, M.D., Allergy and Asthma Associates, botanical periodicity, such as grass and tree pollens
27800 Medical Center Road, Suite no. 244, Mission Viejo, CA 92691 that peak in spring and in late summer and fall,8
E-mail address: [email protected]
whereas perennial allergies are triggered by environ-
Copyright © 2017, OceanSide Publications, Inc., U.S.A.
mental allergens such as dust-mite feces9 and animal

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dander,8 which are present throughout the year. De- medications has enabled patients to attempt self-man-
spite some common markers of allergy, AKC and VKC agement of their condition,23 which has had a negative
have clinical and pathophysiologic features that are effect on patient outcomes due to delays in establishing
different from SAC and PAC.10 Both AKC and VKC a proper diagnosis and in receiving appropriate treat-
occur less frequently but are potentially more severe, ment. Self-management only provides symptomatic re-
which necessitates involvement of an eye care special- lief, without treating the underlying cause of the dis-
ist (optometrist and/or ophthalmologist) to ensure a ease, which can lead to less-effective overall treatment

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differential diagnosis and to avoid potential vision and disease progression and complications associated
loss.11 Furthermore, AKC can present in teenagers as with disease. Clinical experience indicates that a simi-
well as adults, and younger patients would need the lar trend is seen in pediatric patients.

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care of a pediatrician.12 Giant papillary conjunctivitis is The incidence of self-medication is well documented
often grouped alongside other ocular allergic condi- and indicates that current projections probably under-
tions, despite not having an allergic pathogenesis; it is estimate the true overall disease incidence world-
instead, a chronic ocular microtrauma-related condi- wide.23 Physicians, therefore, only see the tip of the

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tion, usually caused by irritating stimuli, such as con- iceberg in terms of incidence and frequency of AC. A
tact lenses and ocular prostheses.13 For the purpose of national cross-sectional study of clinical characteristics
this review, the term AC refers to the two subtypes, and QoL in Portugal demonstrated that most patients
SAC and PAC. experienced year-round episodes and inevitably

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Although some differences exist, ocular and nasal started AC self-management by using OTC medica-
tissues generally react to allergens in the same way, tions.20 A similar trend is observed in pediatric pa-
through the degranulation of mast cells secondary to tients, whereas parents usually treat their children’s
activation; most pediatric patients with AC also have AC symptoms with antihistamine syrup, and many

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AR. Owing to the strong association between AC and pediatric health care professionals rely on OTC medi-
AR, as documented by Berger et al.,14 the concept of cations, e.g., ocular decongestant eye drops, as first-line
“rhinoconjunctivitis” is now recognized by many treatment. However, topical ocular medications, in-
health care professionals, and the International Study cluding certain preserved artificial tears or ocular de-

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of Asthma and Allergies in Childhood has reported AC congestants, may irritate and inflame ocular surface
as rhinitis associated with itchy eyes (allergic rhinocon- tissues,24 –26 which makes a correct diagnosis more dif-
junctivitis) and not as an isolated ocular condition.15 ficult and lengthens the time to recovery.
AC is often underdiagnosed,5,16 inappropriately man- As the current impact of AC on general well being,

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aged, or missed altogether in pediatric patients with behavior, QoL, and socioeconomic costs demonstrates,
AR. there are clear unmet medical needs with regard to
It is known that immunoglobulin E–mediated aller- optimal diagnosis and treatment in pediatric patients.
gic diseases can cause neuropsychiatric symptoms, Although there are several reviews and publications
such as irritability, decreased concentration, and day- that discuss clinical management of AC in adults,27–31

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time fatigue in otherwise healthy individuals,17 and there is a lack of best-practice guidelines for pediatrics.
behavioral issues have been observed in pediatric pa- The aim of this review, therefore, was to guide pedi-
tients with AC. Although AC is not considered a “se- atric health care professionals in the optimal diagnosis
rious” entity, it is clinically relevant and can result in

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and management of AC in pediatric patients by pro-
significant morbidity, including impaired performance viding step-by-step guidance on recognizing clinical
of common daily activities such as attending school features, establishing a comprehensive medical history,
and interacting with other children.7 Multiple studies and performing a thorough physical examination. This
examined how AC reduces quality of life (QoL)18 –21 review also included diagnosis and treatment algo-
and increases economic costs that arise from health rithms, and guidelines for pediatric patient referrals.
care consultations and medication.19,21,22 Although The potential role of allergen-specific immunotherapy
these studies were not specifically conducted in pedi- as an alternative treatment option in specific patient
atric patients, it is thought that a significant impair- subgroups was also discussed.
ment of QoL and an economic burden of a different
kind also apply to children with AC.
One AC study showed that, among students with IDENTIFICATION OF BEST
nasal and ocular symptoms, 42% reported moderate- PRACTICE GUIDELINES
to-severe interference of daily activities, 24% reported
at least 1 day of absence from school, 36% reported a Methodology
visit to a pediatric health care professional, and 28% To identify best practice guidelines for the diagnosis
reported drug usage for rhinitis. In adults, easy access and treatment of AC in pediatric patients, a review of
to a variety of over-the-counter (OTC) ocular allergy the literature published between 2004 and January

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2015 was conducted by using PubMed searching with home or in school may point toward an infectious
the following search terms: cause.
Key questions to ask when obtaining the patient
• “allerg* and conjunctivitis and best practice and history from the child and parents or caregivers, in-
ped*” clude:4,23,27,32,33
• “allerg* and conjunctivitis and best practice and
paed*” • What are the symptoms, and when did they start?
•

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• “allerg* and conjunctivitis and best practice and Is presentation unilateral or bilateral?
child*” • Do the symptoms vary with location and season?
• “allerg* and conjunctivitis and guidelines and ped*” • Is it itchy? How itchy (mild, moderate, or severe)?
• “allerg* and conjunctivitis and guidelines and Does the child rub his or her eyes?

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paed*” • Does it hurt? Does it burn or sting?
• “allerg* and conjunctivitis and guidelines and • Is there any discharge? If yes, is it watery or mucoid?
child*” • Is the child’s vision affected?
• “allerg* and conjunctivitis and diagnos* and guide- • Does the child have photophobia?

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lines and ped*” • Have OTC products been used? If yes, which prod-
• “allerg* and conjunctivitis and diagnos* and guide- uct(s) and for how long?
lines and paed*” • Have there been previous episodes?

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• “allerg* and conjunctivitis and diagnos* and guide- • Is there a family history of AR, hay fever, asthma, or
lines and child*” atopic dermatitis?
• Does the child have food or drug allergies?
Only English language publications were included in • Are there exacerbating or relieving factors?
the search. For the purpose of this review, adults were • Have there been new pets; recent relocations; re-

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defined as patients ⬎12 years of age, pediatric patients modeling projects; or other household exposures,
were those ages ⱕ12 years. such as a change in cream, soap, shampoo, washing
powder, fabric conditioner, or cleaning agents?
• Has the child had recent contact with a patient with

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Search Results conjunctivitis? (This would indicate an infectious
Although we identified general clinical management origin.)
guidelines,27–31 no publications discussed pediatric AC
In pediatrics, establishing the medical history is gener-

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management, despite the broad search terms and time
frame. The American Academy of Ophthalmology, ally more challenging because the pediatric health care
American Academy of Allergy, Asthma & Immunol- professional is dependent on information provided by
ogy, American Optometric Association, College of Op- parents or caregivers and on determining the value
tometrists, and Japanese guidelines27–31 were also and accuracy of the information provided by the child.
found not to contain specific best practice recommen-

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dations for pediatric health care professionals. We, Signs and Symptoms of AC and Physical Examination.
therefore, created diagnostic and therapy algorithms Signs and symptoms of AC may fluctuate throughout
and guidelines based on existing publications on adult the year, with exacerbations most likely experienced by
patients with SAC during times of high pollen expo-

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AC as well as our clinical experience to fill this gap in
the literature and to address the unmet medical needs sure and in dry and windy weather. Patients with AC
of pediatric patients with AC. typically present with one or more signs and symp-
toms, including bilateral involvement, itching, redness,
tearing, burning, stinging, and chemosis (swelling of
BEST PRACTICE IN THE DIAGNOSIS AND the conjunctiva).4 The sine qua non of AC is itching, and
MANAGEMENT OF PEDIATRIC AC a diagnosis of AC should be queried if the patient does
not present with ocular itching.23,34 Ocular itching may
Diagnosis
be particularly strong in the nasal quadrant of the eye
Medical History. Establishing a comprehensive med- and can range from mild to moderate to severe.4 The
ical history of the patient can help identify conditions discharge is usually watery and may contain some
unrelated to ocular allergy as the cause of ocular in- mucus, which can occasionally lead to an erroneous
flammation and, therefore, significantly contribute to a diagnosis of bacterial conjunctivitis.4
correct diagnosis. It can further alert the pediatric Physical examination of patients suspected of having
health care professional to the need for a referral to an AC should involve inspection of periocular and ocular
eye care specialist. The presence of pain, for example, is tissues.35 Although ocular examinations in the pediat-
rarely associated with AC, and recent exposure to re- ric setting are often limited because of a lack of a slit
spiratory tract infections or infectious conjunctivitis at lamp, useful information may still be obtained with a

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simple penlight.36 Pediatric health care professionals AC needs to be distinguished from its more-severe
should examine eyelids for abnormalities, including forms, VKC and AKC, and from giant papillary con-
evidence of the following:4,23 junctivitis (Table 1), which can have similar clinical
characteristics. Although a differential diagnosis can be
• Blepharitis
difficult, it is crucial to recognize those conditions that
• Dermatitis
indicate underlying disease or are sight threatening.
• Meibomian gland dysfunction
For example, in patients with perennial symptoms and

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• Crab lice infestation
prolonged severe itching, it is crucial that a diagnosis
• Swelling
of AKC is ruled out because this condition can result in
• Discoloration
blindness due to corneal complications, whereas AC
• Spasm

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rarely permanently damages tissue.33 Corneal involve-
Pediatricians (and, when appropriate, eye care spe- ment can be detected by an eye care professional by
cialists) should further examine the conjunctiva (pal- using a fluorescein test viewed through the cobalt blue
pebral and bulbar) and the periorbital area for the filter on a biomicroscope33 or by using an external light

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following:4,23 source, such as direct ophthalmoscope.36 The signs and
symptoms of the different types of AC and giant pap-
• Hyperemia illary conjunctivitis, together with a description of the
• Papillae nature of discharge and status of preauricular node

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• Secretions involvement are detailed in Table 1 and should prove
• The presence of a dull bluish skin discoloration be- a useful tool in a differential diagnosis.
low the eye (the “allergic shiner”) AC further needs to be distinguished from infectious
• Mild-to-moderate conjunctival injection (redness) (bacterial and viral) conjunctivitis, which can also pres-
• Chemosis (swelling) that may seem out of propor-

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ent with similar symptoms. Bacterial conjunctivitis is
tion to the amount of redness present and that may further classified as acute or chronic, whereas viral
be most noticeable at the plica semilunaris conjunctivitis is largely either adenoviral or caused by
• Periorbital edema that results from AC (this may be the herpes simplex virus (Table 1). The clinical charac-

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more marked in the lower lid owing to the effects of teristics of different types of bacterial and viral con-
gravity) junctivitis, together with the nature of discharge and
Placing a finger on the superior maxillary prominence status of preauricular node involvement are included
in Table 1. Other conditions to consider in the differ-

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and tugging downward is generally well tolerated and
exposes the lower palpebral conjunctivae. However, it ential diagnosis of AC include blepharitis and meibo-
must be borne in mind that, other than conjunctival mian gland dysfunction (Table 2).4 A detailed patient
erythema, patients with AC frequently have unremark- history and thorough physical examination (as out-
able physical examination results. Therefore, the phys- lined above) will enable pediatric health care profes-
ical examination should also include the following33: sionals to differentiate AC from other ocular disorders

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and to decide which cases require referral to an eye
• Measurement of monocular best-corrected visual care specialist and/or allergist.
acuity (with glasses when applicable) A diagnostic algorithm (Fig. 1) has been included in
• Examination of pupils for evidence of afferent pu- this review as a supportive differential diagnostic tool

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pillary defect or asymmetry to be used in conjunction with the information pro-
• The appearance of the Bruckner (red) reflex (trans- vided in Tables 1–3. An etiologic diagnosis is necessary
mission of light reflecting off of the ocular fundus) to identify the most appropriate treatment choice.7 Al-
• Evaluation of the cornea for opacity though diagnosis is primarily clinical, there are tests
• Assessment of extraocular movements that can be useful in supporting the diagnosis.3 Aller-
• Palpation for preauricular or submandibular and gists can perform in vivo tests (skin-prick test and/or
cervical lymphadenopathy because these findings intradermal tests) and in vitro tests that measure im-
would be more consistent with an infectious origin munoglobulin E–specific serum antibodies.3,7
• Evaluation of the body for eczema or nasal mucous
membrane involvement
Management
Differential Diagnosis. A differential diagnosis in pe- Treatment Goals. The principal treatment goal of AC
diatric patients can be challenging, owing to overlap- is to control its symptoms and to improve the QoL of
ping signs and symptoms, and because younger pa- patients,4 which involves minimizing, or at least reduc-
tients will sometimes find it difficult to accurately ing, itching, redness, tearing, and edema of the con-
describe their symptoms, but it is necessary to ensure junctiva and eyelids. In the case of clinical trials, each
appropriate therapy, symptom control, and resolution. of these entities may be graded by using a variety of

Allergy and Asthma Proceedings 19

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Table 1 Summary of signs and symptoms of common types of conjunctivitis*
Image Type and subtype Symptoms Discharge Signs Preauricular nodes
Allergic

Seasonal acute Itching No

and perennial Burning hyperemia: pink

chronic Lid swelling

Y
Conjunctival swelling
Thin, white Papillae (7–8 mm diameter) No

Foreign body fibrinous Trantas dots

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sensation discharge Dennie’s line

Tearing

O
No

Burning Conjunctival scarring

Tearing Keratitis

C
Lid eczema Associated with herpes

Chronic blepharitis simplex virus infection and

staphylococcal infection
Mechanical/irritative

Irritation

Foreign body

T
O
sensation
Bacterial

Purulent/ Conjunctiva very hyperemic No

N
Lid swelling mucopurulent Papillae on palpebral

Lids stuck together conjunctiva

in morning

Profuse purulent Conjunctival hyperemia Yes

Tenderness or mucopurulent Keratitis

O
Lid and

conjunctival swelling

No

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Burning Inflamed lid margins

Foreign body Irregular lashes

sensation Crusting Flakes at base of lashes

Viral

Usually

Irritation pink/purple near plica

Tearing Follicular conjunctivitis

Red, swollen lids

Occasional

Irritation Vesicles on eyelids

Photophobia Conjunctival injection

*Adapted from Ref. 23.

#The images were provided courtesy of A. Kabat.

20 January–February 2017, Vol. 38, No. 1

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Table 2 Additional conditions in the differential diagnosis of allergic conjunctivitis: Blepharitis* and
meibomian gland dysfunction#
Ocular Disorder Symptoms
Blepharitis Itchiness, redness, flaking, and crusting of eyelids
Meibomian gland dysfunction Dryness, burning, itching, stickiness, foreign body sensation, watering,

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photophobia, and intermittent blurred vision
*From Ref. 48.
#From Ref. 49.

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D O Figure 1. Algorithm for differential diagnosis of AC in pediatric patients. AC ⫽ Allergic conjunctivitis.

methods, including simple descriptions (e.g., slight

itching, moderate itching, persistent itching) or numer-
ical values by using a visual analog scale. There are
treatment algorithm has been provided in Fig. 2 and is
intended as a useful guide for pediatric health care
professionals confronted with pediatric patients with
questionnaires that may be used to gauge the overall AC.
impact of symptoms on daily life, e.g., the Rhinocon-
junctivitis Quality of Life Questionnaire but, again, Nonpharmacologic Treatments. Nonpharmacologic treat-
these approaches are typically used for clinical studies ments aim to minimize contact of allergens with the
rather than in a clinical setting.37 An additional treat- eye and should be considered as a first part of any
ment aim is the interruption and prevention of the approach.4,7 Complete allergen avoidance is the best
inflammation cycle in patients with prolonged allergen approach; however, this is often impossible for both
exposure and/or long symptom duration.4 indoor and outdoor allergens.7 Strategies to reduce
allergen exposure include dust mite, animal dander,
Treatment Modalities. The treatment modalities for and mold control measures through lifestyle modi-
pediatric patients are largely the same as for adult fications. Application of cold compresses to the eye-
patients and are summarized below. In addition, a lids may also relieve itching in some patients. Ocular

Allergy and Asthma Proceedings 21

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 22
Table 3 Summary of pharmacologic treatments and allergen-specific immunotherapy*
Drug Class Examples of Medications Mode of Action Adverse Effects
within the drug class
Topical decongestants Cyclopentamine, ephedrine, Vasoconstriction via ␣- Long-term use or discontinuation can lead to
phenylephrine, adrenoreceptor stimulation, conjunctivitis medicamentosa, follicular

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tetrahydrozoline reduced redness, and edema reactions, contact dermatitis, rebound
hydrochloride, naphazoline redness, dilation, and intolerance to the
hydrochloride drug; contraindicated in narrow angle
glaucoma owing to the mydriatic effect

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Systemic Promethazine, hydroxyzine, or Inverse agonists of histamine Ocular dryness, sedation, potential systemic
antihistamines alimemazine; cetirizine; receptors; blocking endogenous adverse effects, including cardiotoxicity
loratadine; chlorpheniramine histamine; reducing histamine-
induced ocular signs and
symptoms, particularly itching
Topical Emedastine, levocabastine Similar to systemic antihistamines Local irritation, increased sensitivity,

N
antihistamines with a localized effect aggravated allergy, severe adverse effects
when using older agents
Mast cell stabilizers Cromolyn sodium, Prevent degranulation of mast cells; Concerns regarding minimal tolerability
lodoxamide, pemirolast prevent release of inflammatory because of stinging and burning on
sodium, nedocromil mediators; decrease redness, instillation, works best when used before

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hyperemia, itching and irritation symptom development
Antihistamine and/or Naphazoline–pheniramine Inverse agonists of histamine Irritation, possible conjunctivitis
decongestants maleate, naphazoline- receptors plus vasoconstriction via medicamentosa, takes longer to relieve
antazoline ␣-adrenoreceptor, reduced symptoms, sedation, excitability, dizziness

Antihistamine and/or
mast cell stabilizers
Olopatadine, ketotifen,
azelastine, bepotastine,
epinastine, alcaftadine
T
itching, redness, and edema

Inverse agonists of histamine

receptors plus mast cell-
stabilizing activity, providing
relief of redness, hyperemia,
or disturbed coordination, effect may last
only a few hours, mydriatic effect
Stinging, burning, distinctive bitter taste,
headache, cold symptoms, takes longer to
relieve symptoms, sedation, excitability,
dizziness or disturbed coordination, effect
C
itching, and irritation may last only a few hours

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Nonsteroidal anti- Ketorolac Block cyclooxygenase and Discomfort on instillation, stinging and
inflammatory production of prostaglandins, burning
drugs reduced itching

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Corticosteroids Loteprednol etabonate General anti-inflammatory effects, Increased intraocular pressure, glaucoma,
attenuation of activity of cataract formation, delayed wound healing

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inflammatory cells, reduction of
most ocular signs and symptoms
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January–February 2017, Vol. 38, No. 1

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 surface lubricating agents (including saline solution

compared with sublingual immunotherapy

Oral itching and swelling, which decreases

and/or artificial tears, ointments, and time-release

Higher rate of systemic allergic reactions

tear replacements) can be used to dilute and remove

in frequency as treatment progresses

antigens and inflammatory mediators from the ocu-
lar surface, and to soothe irritation.4 However, be-
cause these agents neither treat the underlying aller-
Adverse Effects

gic response nor modify the activity of inflammatory

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mediators, their use is limited to mild cases of AC.
Patients and caregivers of pediatric patients should
also try to eliminate or at least minimize eye rubbing

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as much as possible because this mechanical action
exacerbates eye irritation and may also self-inoculate
the eye with allergen. Furthermore, many clinicians
recommend washing hair before going to sleep to

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prevent allergens from hair irritating the patient’s
eyes. The health care professional must educate the
family as to how to successfully approach avoidance
in a practical manner.

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Pharmacologic Treatments. Pharmacotherapy becomes
immunoglobulin E and inhibition
allergic immune response; results
causative allergens by modifying

of inflammatory cells (mast cells,

necessary when allergen avoidance and lifestyle mod-

ifications, including avoidance of outdoor activities, do
basophils, and eosinophils)

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Induces clinical tolerance to

not provide adequate symptom relief. The potential

in the decrease in specific
Mode of Action

consequences of not starting pharmacotherapy can in-

clude an increased impact on QoL, additional expense
for the purchase of inadequate nonpharmacologic ther-

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apies, lost productivity in the workplace (or school, for
children), and poor cosmesis.19 Because the allergic
response is dependent on the phase of exposure rather
than the nature of the triggering allergen, treatment is

N
best devised according to the duration and severity of
signs and symptoms, regardless of whether allergen
exposure is classically “seasonal” or “perennial.”4
Therefore, the primary goal for AC management is
always to prevent or alleviate the symptoms as rapidly

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Examples of Medications

as possible with the fewest number of pharmacologic

within the drug class

agents and the regimen that is least disruptive to the

patient’s life. The secondary goal is to identify the
specific allergens (if not already known) and recom-

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mend avoidance and/or immunotherapy for patients
—

with more severe atopic disease. Broadly, the different

classes of drugs indicated in the treatment of AC in
pediatric patients include topical decongestants (not
approved for children ⱕ2 years old), systemic antihis-
tamines, topical antihistamines (not approved for chil-
dren ⱕ2 years old), mast cell stabilizers, combined
antihistamine and decongestants, combined antihista-
mine and mast cell stabilizers, nonsteroidal anti-in-
flammatory drugs, and corticosteroids.1,3,4,7,11,33 These
*Adapted from Ref. 1.
Table 3 Continued

immunotherapy

immunotherapy

immunotherapy

drug classes, example medications within each drug

Drug Class

Allergen-specific

Subcutaneous

class, and their modes of action have been the subject

Sublingual

of several recent reviews1,3,4,7,11,33 and are summarized

in Table 3. The preferred drug classes for first-line
therapy are combined antihistamine and mast cell sta-
bilizers. These drugs offer the most convenient dosing
(once or twice daily) as well as the benefit of both

Allergy and Asthma Proceedings 23

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 P Y
Figure 2. Algorithm for treatment

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of allergic conjunctivitis in pediatric
patients.

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abortive therapy (i.e., rapid relief of itching) and pro- comply with the treatment. Therefore, a well-toler-
phylactic therapy (i.e., stabilization of mast cells to ated drug that provides effective prevention or relief
prevent future allergic “attacks”). with minimal daily dosing becomes even more im-
Refer to Fig. 2 for guidance on which agents to use portant in the pediatric age group.

T
as first- or second-line pharmacotherapy. Of the
aforementioned drug classes, topical decongestants Allergen-Specific Immunotherapy. For pediatric pa-
and nonsteroidal anti-inflammatory drugs are only tients whose symptoms are not adequately controlled
rarely recommended and used. Nonsteroidal anti- with pharmacotherapy or who do not tolerate medica-

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inflammatory drugs are not specifically antiallergy tion, allergen-specific immunotherapy can be an op-
medications based on their mechanism of action. tion.42,43 Traditionally, allergen immunotherapy has
Corticosteroids should only be prescribed by an eye been delivered via subcutaneous injections of the aller-
care specialist after an eye examination for severe gen (subcutaneous immunotherapy [SCIT]).3 Sublin-

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presentations or when conventional therapy failed. gual immunotherapy (SLIT), in contrast, in which al-
Moreover, corticosteroids should only be used by lergen extract in liquid or dissolvable tablet form is
practitioners who are able to evaluate the child for placed under the tongue for a defined amount of time
complications such as herpes, pseudomonas, cataract and then swallowed, is a more recent method. The first
formation, and elevated intraocular pressure. In this U.S. Food and Drug Administration–approved prod-

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context, it is worth noting that pediatric patients uct for SLIT (sublingual tablets) became available re-
have the greatest propensity to experience abrupt cently, and additional allergen products are in devel-
and acute intraocular pressure elevation after the use opment.44 SCIT involves once or twice weekly allergen
of topical corticosteroids (these patients are referred injections for many weeks to build up the dose, fol-

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to as “steroid responders”).38 – 41 Moreover, pediatric lowed by a gradual decrease in frequency to once
patients are often the most difficult to examine for monthly injections. Owing to the potential risk of ana-
these same complications. phylaxis, SCIT injections are administered by a physi-
The symptoms of AC are often unresponsive to cian with appropriate expertise or training in allergy
oral drugs because these do not reach therapeutic and who also has emergency medications present.
concentrations in the eye.4 As a rule, topical solu- Maximum long-term benefit occurs when the treat-
tions of antihistamines or mast cell–stabilizing ment is continued for 3–5 years; however, not all par-
agents and their combinations are more effective in ents and caregivers are able to commit to such a de-
achieving good symptom control. The prescriber manding course of treatment. It should also be
must take into account several social issues related to considered that many pediatric patients will have an
pediatric care. Children may battle parents with re- aversion to injections, although most patients who re-
lation to eye drop instillation, which disrupts the ceive SCIT overcome this fear within the first few
household, decreases effectiveness of the medication weeks of treatment.45
if not placed in the eye, and decreases compliance The advantage of SLIT, in comparison, is that it does
with the suggested regimen. Thus, failure of treat- not involve injections and that only the initial dose is
ment may not be related to the theoretic effectiveness administered at the allergist’s office, with all subse-
of the medication offered but rather the ability to quent doses being given at home. The dosing is daily as

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opposed to weekly. However, although it has been • Patients with prolonged or recurrent manifestations
shown to relieve ocular allergy, the use of SLIT for the of AC
relief of AC symptoms requires further evaluation, • Patients with comorbid conditions, e.g., asthma, rhi-
because ocular symptoms may respond less well to nitis, recurrent sinusitis
SLIT than do nasal symptoms.3,46 Optimal dosage and • Patients with symptoms that interfere with QoL
treatment duration are also yet to be definitively estab- and/or the ability to function
lished. • Patients in whom medications were ineffective or

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who have had adverse reactions to previously pre-
Prognosis and Follow-up. Once the patient has been scribed medications.
correctly diagnosed and appropriate treatment has

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been initiated, follow-up care is required.29 The fre- AC Sequelae. Resolution of the condition depends on
quency of follow-up visits depends on the following allergen avoidance (when possible) and/or compliance
factors: etiology and severity of the condition, potential with optimal treatment.33 The most serious sequelae of
for ocular morbidity, and response to treatment. Fol- AKC and VKC are corneal involvement that can lead to

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low-up care should monitor disease progression and scarring and visual acuity impairment. With the break-
verify that the selected treatment regimen is effective. down of the epithelium with corneal involvement, the
Regular reevaluation of the condition and response to patient has increased susceptibility to bacterial and
other opportunistic infections of the cornea. Evidence

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therapy, alteration of therapy when necessary, and
recognition of adverse effects are integral to successful of corneal involvement or impaired vision, therefore,
patient management. After a diagnosis of AC and ther- requires immediate referral to an eye care specialist.
apy initiation, the first follow-up should occur after a
DISCUSSION
week to assess compliance and therapeutic response.

T
Subsequently, the patient may be recalled after another Although AC is one of the most common ocular
disorders in pediatric patients, the condition is often
week or 1, 3, or 6 months, depending on the disease
not recognized and is misdiagnosed and under-
course. On average, patients with AC are recalled two
treated, whereas other allergic conditions such as
to three times in the first year after diagnosis and one

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asthma and AR receive greater attention and care.
to two times per year thereafter.
This is due to the challenge of obtaining a full and
accurate medical history from children, combined
Referral Guidelines. AC can generally be managed ef-
with a lack of specific guidance on an optimal diag-

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fectively by the pediatric health care professional, but, as
nosis and management of AC for pediatric health
always, a thorough understanding of the disease process
care professionals. A literature search to identify
is essential in recognizing situations that require referral
guidelines for the treatment of AC in pediatric pa-
to an eye care specialist and/or allergist.23 Some practi-
tients failed to return any relevant articles, which
tioners even advocate the referral to an allergist of every highlighted the need for best practice recommenda-

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pediatric patient with an initial diagnosis of AC. To aid tions that advise pediatric health care professionals
pediatric health care professionals, we summarized the on recognizing clinical features of AC, establishing a
most important referral guidelines below. Although these comprehensive medical history, and performing a
recommendations are aimed at adults, they are also of thorough physical examination to ensure correct di-

D
value in relation to pediatric patients. Pain, photophobia, agnosis and optimal treatment or referral to an eye
and reduced and/or blurred vision are commonly asso- care specialist or allergist when required.
ciated with more serious ocular disorders, such as uveitis, The aim of this review was to help address the cur-
keratitis, corneal abrasions, and acute closed angle glau- rent literature and educational gap, and to provide
coma.23 Any patient who presents with these symptoms pediatric health care professionals with tools to help
should be referred to an eye care specialist.47 In addition, them accurately diagnose or refer pediatric patients to
patients should be referred to an eye care specialist if ensure timely and optimal therapy of pediatric AC. In
there is no improvement after 1 week.36 Consultation addition to established drug treatments, the place of
with an allergist or a dermatologist may be helpful for SCIT and SLIT in the treatment of AC has also been
patients whose condition cannot be adequately con- discussed to inform pediatric health care professionals
trolled with topical medications and/or oral antihista- of alternative treatment options for pediatric patients
mines.27 Coordinated care among the eye care specialist, who do not tolerate pharmacotherapy or who do not
dermatologist, and allergist will support the family and respond sufficiently.
child.
The American Academy of Allergy, Asthma & Im- CONCLUSION
munology referral guidelines28 advise that the follow- The diagnostic and treatment algorithms and guide-
ing individuals should be referred to an allergist: lines provided in this review will prove useful to pe-

Allergy and Asthma Proceedings 25

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diatric health care professionals and lead to improve- sation in allergic rhinitis patients—An observational, cross sec-
ments in the diagnosis and management of pediatric tional study in four countries in Europe. J Med Econ 14:305–314,
2011.
AC, which will ultimately result in a noticeable reduc-
20. Palmares J, Delgado L, Cidade M, et al. Allergic conjunctivitis:
tion in the burden of disease in time. A national cross-sectional study of clinical characteristics and
quality of life. Eur J Ophthalmol 20:257–264, 2010.
ACKNOWLEDGMENTS 21. Smith AF, Pitt AD, Rodruiguez AE, et al. The economic and
quality of life impact of seasonal allergic conjunctivitis in a
The authors thank Yamini Khirwadkar, Ph.D., of DJE Science,

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Spanish setting. Ophthalmic Epidemiol 12:233–242, 2005.
London, United Kingdom, for the editorial assistance provided dur-
ing the preparation of this manuscript, with support from Alcon 22. Blaiss MS. Allergic rhinoconjunctivitis: Burden of disease. Al-
Research, Fort Worth, Texas. lergy Asthma Proc 28:393–397, 2007.
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