The guidelines from the New York State Workers Compensation Board provide general principles for managing allergic disorders, including Seasonal Conjunctivitis, Perennial Conjunctivitis, and Vernal Conjunctivitis. These directives aim to assist healthcare professionals in determining appropriate strategies for diagnosing and addressing various allergic conditions affecting the eyes throughout the seasons.
Healthcare practitioners specializing in allergic eye disorders can rely on the guidance from the Workers Compensation Board to make well-informed decisions about the most suitable approaches for assessing and managing conditions like Seasonal Conjunctivitis, Perennial Conjunctivitis, and Vernal Conjunctivitis in their patients.
It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the management of allergic eye disorders should involve collaboration between the patient and their healthcare provider.
Allergic Disorders: Seasonal Conjunctivitis, Perennial Conjunctivitis and Vernal Conjunctivitis
Allergic conjunctivitis, an inflammatory response of the conjunctiva to allergens, is estimated to impact about 40% of the general population. It spans a range of severity and chronicity, including seasonal allergic conjunctivitis (SAC), perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), and atopic keratoconjunctivitis (AKC). SAC and PAC are recognized as the most common types of ocular allergies, affecting 15-20% of the population. While some cases of allergic eye disease primarily affect the eyes, most also involve the upper respiratory tract. In more severe instances, asthma is often associated (refer to the Occupational/Work-Related Asthma Guideline).
Risk Factors
A history of atopy, whether in the upper respiratory tract or involving asthma, increases the risk of developing additional allergies, including those related to workplace allergens. Numerous studies support a lower risk of atopy among individuals raised in close proximity to animals or in buildings (known as the Hygiene Hypothesis), and recent data also indicate associations with microflora. For individuals with existing allergies, elevated exposures to allergens such as dust mites, tree pollen, and mold pose risks for exacerbations.
Allergic conjunctivitis can also manifest in response to various occupational exposures, such as those found in the presence of flour, and exposure to certain chemicals like thimerosal or specific perfumes. Work-related cases typically involve airborne allergens. For additional information, refer to the Occupational/Work-Related Asthma Medical Treatment Guideline.
Signs and Symptoms
Symptoms of allergic conjunctivitis can encompass:
– Bilateral itchy eyes (pruritus)
– Bilateral watery eyes
– Bilateral swollen eyelids (ocular edema)
– Bilateral erythematous eyes
– Bilateral eye pain (usually not severe)
– Bilateral eye inflammation
– Rhinorrhea (runny nose)
– Itchy nose, itchy roof of mouth
– Sneezing
In an occupational setting, the onset of symptoms may be either rapid or gradual. Generally, the higher the exposure dose, the faster and more intense the symptom development tends to be, though there is a wide range of variations. Subsequent symptom experiences typically mirror the frequency, intensity, and duration of exposures. Allergic conjunctivitis usually affects both eyes equally, unless there’s differential introduction of the allergen into the eyes (e.g., flour dust rubbed into one eye).
Red Flags
If symptoms worsen or persist, such as swelling and inflammation, there may be a more serious condition than allergic conjunctivitis. If there’s a decline in visual acuity, it is likely not of allergic origin. Other warning signs that suggest a more serious issue include:
– Acquired abnormal visual fields
– Presence of purulence
– Systemic diseases, particularly autoimmune conditions
These indicators should prompt further medical evaluation to identify and address any underlying issues that may be contributing to the persistent or worsening symptoms.
Diagnosis
Initial Assessment
The initial assessment involves a thorough history-taking and limited testing to exclude other potential conditions. The history-taking is centered around understanding the symptoms, their patterns, and potential allergens that may be contributing to the issue. This comprehensive approach helps in ruling out alternative explanations for the observed symptoms and guides further diagnostic steps.
Diagnostic Criteria
The American Optometric Association proposes criteria for diagnosing allergic conjunctivitis based on symptoms, signs, and limited testing. The diagnostic process begins with a comprehensive clinical history and an assessment of environmental factors. After the initial assessment, an allergy workup that includes skin tests and the determination of serum-specific IgE is generally recommended. In some cases, a conjunctival challenge may be performed. Indicators of allergic conjunctivitis include increased conjunctival sickle cells, frequent eosinophils in corneal scrapings, and a high total serum IgE.
Allergic eye diseases typically manifest as episodic bilateral pruritic (itchy), watery, erythematous eyes, and photophobia. Symptoms often fluctuate based on exposures, and persistent symptoms may occur with ongoing exposures. For those with intermittent symptoms, identifying a pattern of symptom development or aggravation after exposures can be crucial in assessing the causative allergen(s). The degree of pruritus (itchiness) is a valuable diagnostic clue, although infectious diseases may also present with some pruritus. Confirmatory testing for atopy is possible for specific allergens (refer to the Occupational/Work-Related Asthma Guideline).
In some cases, patients with allergic eye disease may also experience systemic symptoms, such as asthma. It is crucial to assess all patients with allergic eye disease for systemic manifestations, especially in those with asthma and ongoing exposures. Continuous exposure in individuals with asthma may lead to progressive pulmonary impairments that can become permanent (refer to the Occupational/Work-Related Asthma Guideline). Occupational asthma also raises the risk of a potentially fatal outcome (refer to the Occupational/Work-Related Asthma Guideline). Regular monitoring and appropriate management are essential to address both ocular and systemic aspects of allergic conditions.
Classification
The consensus classification for allergic conjunctivitis (AC) takes into consideration the frequency and severity of ocular signs and symptoms. AC typically affects both eyes and is classified as intermittent when ocular signs and symptoms (conjunctival pruritus, tearing, burning sensation, blurred vision, photophobia, and hyperemia) are present for up to 4 days a week or up to 4 consecutive days. AC is deemed persistent when these ocular signs and symptoms occur more than 4 days per week or more than 4 consecutive days.
The severity of AC is categorized as mild when signs and symptoms are: 1) not bothersome, 2) do not affect vision, 3) do not interfere with activities of daily living, and 4) do not interfere with school or work tasks. It is considered moderate when 1-3 of these conditions are met and severe when all conditions are fulfilled.
History
The patient’s history involves seeking both positive responses to identify a probable allergic disease process and searching for pertinent negatives to rule out other conditions, including other immunological disorders. An essential aspect of the history for allergic conjunctivitis is understanding exposure to likely allergens. Additionally, a thorough exploration of occupational exposures is crucial to identify potential allergens.
The timing of both the onset and relief of symptoms plays a key role in determining the likelihood of allergic conjunctivitis. This comprehensive approach helps in establishing a clearer understanding of the patient’s condition and aids in accurate diagnosis and management.
A medical history questionnaire is an effective tool to gather crucial information for evaluating allergic conjunctivitis. Here are some key questions to include:
1. Do you have a history of allergies? If so, which ones? At what age of onset?
2. Do you experience itchy eyes (pruritis)? Is it bilateral?
3. Are your eyes watery or teary?
4. Do you notice pink or red eyes? Is it bilateral?
5. Do you have any eye pain? Is it bilateral? How severe?
6. Is there any eye inflammation?
7. Does your nose run (rhinorrhea)?
8. Do you have an itchy nose or itchy roof of the mouth?
9. Do you experience sneezing?
10. Do these symptoms coincide with spring or fall pollen seasons?
11. Are the symptoms associated with specific activities or exposures at work?
12. Are symptoms perennial (year-round)?
13. Are both eyes equally affected?
14. Have you ever been diagnosed with pink eye?
15. Are you allergic to certain animals, like cats?
16. Do you have any known food allergies?
17. Do your eyes tear when exposed to certain perfumes or cosmetics?
18. Do you need to use decongestants or antihistamines to control sneezing, coughing, and congestion?
19. Has your visual acuity been affected?
20. Is your peripheral vision normal?
21. Have you experienced discharge from your eyes, such as mucous or purulence?
22. Do you have systemic diseases, especially autoimmune conditions like rheumatoid arthritis, lupus, or Reiter’s syndrome?
23. Do you have glaucoma?
These questions provide a comprehensive overview of the patient’s symptoms, triggers, and relevant medical history to aid in diagnosing and managing allergic conjunctivitis.
Physical Exam
The physical examination for allergic conjunctivitis involves several components to assess and diagnose the condition. Here are key aspects of the examination:
- Visual Acuity and Visual Fields: Testing visual acuity and assessing visual fields helps evaluate the impact of allergic conjunctivitis on vision.
- Slit Lamp Examination: A slit lamp examination is often performed to closely inspect the eyes, eyelids, and conjunctiva. It aids in identifying signs such as conjunctival pruritus, tearing, a burning sensation, blurred vision, photophobia, hyperemia, and other ocular symptoms.
- Tonometry: Tonometry is conducted to measure intraocular pressure, helping rule out glaucoma, a condition that can present with eye symptoms.
- Evaluation of Joints and Mucous Membranes: In some cases, a broader examination may include joint and mucous membrane evaluations, especially if there are symptoms suggestive of autoimmune diseases. This is particularly relevant if systemic manifestations are present.
- Slit Lamp Examination Need: While slit lamp examination is a valuable tool, it may not be required for every initial evaluation. In mild cases, a preliminary diagnosis and treatment plan can be established without it.
By incorporating these elements into the physical examination, healthcare professionals can gather comprehensive information to diagnose allergic conjunctivitis and formulate an appropriate treatment plan based on the severity and characteristics of the condition.
