eMedicine Specialties > Ophthalmology > Conjunctiva

Conjunctivitis, Allergic: Differential Diagnoses & Workup

Author: Parag A Majmudar, MD, Fellowship Co-Director, Department of Ophthalmology, Cornea and Refractive Surgery Service, Assistant Professor, Rush-Presbyterian-St Luke's Medical Center
Contributor Information and Disclosures

Updated: Oct 16, 2009

Differential Diagnoses

Conjunctivitis, Bacterial
Conjunctivitis, Giant Papillary
Conjunctivitis, Viral
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Superior Limbic
Keratoconus

Workup

Laboratory Studies

  • Seasonal and perennial allergic conjunctivitis
    • Superficial conjunctival scrapings may help to establish the diagnosis by revealing eosinophils, but only in the most severe cases, since eosinophils are typically present in the deeper layers of the substantia propria of the conjunctiva. Therefore, the absence of eosinophils on conjunctival scraping does not rule out the diagnosis of allergic conjunctivitis.
    • Many investigators have described measurement of tear levels of various inflammatory mediators, such as IgE, histamine, and tryptase, as indicators of allergic activity.
    • Additionally, skin testing by an allergist may provide definitive diagnosis and pinpoint the offending allergen(s).
  • Vernal keratoconjunctivitis: Conjunctival scrapings of the superior tarsal conjunctiva and of Horner-Trantas dots show an abundance of eosinophils.

Histologic Findings

Vernal keratoconjunctivitis

Conjunctival scrapings of the superior tarsal conjunctiva show an abundance of eosinophils. Conjunctival biopsy reveals that there are a large number of mast cells within the substantia propria. Histochemical analysis of mast cells present in VKC reveals neutral proteases tryptase and chymase. There is enhanced fibroblast proliferation, which leads to deposition of collagen within the substantia propria resulting in conjunctival thickening.

B-cell and T-cell lymphocytes are present locally, which combine to produce IgE. Specific IgE and IgG as well as the inflammatory mediators histamine and tryptase have been isolated from tears of patients with VKC. Although VKC is typically recognized as a type I hypersensitivity reaction, evidence has been found that supports some involvement of type IV hypersensitivity reaction.

Atopic keratoconjunctivitis

Conjunctival scrapings of patients with AKC may demonstrate the presence of eosinophils, although the number is not as significant as that seen in VKC. Additionally, free eosinophilic granules, which are seen in VKC, are not seen in AKC. Mast cells also may be found within the substantia propria of the conjunctiva in greater numbers.

There is an increased amount of IgE in the tears of patients with AKC. Although AKC is typically recognized as a type I hypersensitivity reaction, evidence has been found that supports some involvement of type IV hypersensitivity reaction, as is the case in VKC.

Giant papillary conjunctivitis

Histologic findings in GPC consist of cellular infiltration of the conjunctiva by a number of cell types. Plasma cells, lymphocytes, mast cells, eosinophils, and basophils have been identified within the substantia propria. Mast cells also may be found in the epithelium.

Tear levels of immunoglobulin, especially IgE and tryptase also are elevated, as in AKC and VKC, indicating that a combination of type I and type IV hypersensitivity reactions may be responsible for the pathogenesis of GPC. It is believed that the stimulus for development of GPC is an immunologic reaction to a specific antigen in predisposed individuals. Mechanical trauma to the conjunctiva may be a contributing factor.

More on Conjunctivitis, Allergic

Overview: Conjunctivitis, Allergic
Differential Diagnoses & Workup: Conjunctivitis, Allergic
Treatment & Medication: Conjunctivitis, Allergic
Follow-up: Conjunctivitis, Allergic
References
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Further Reading

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Keywords

atopic keratoconjunctivitis, AKC, giant papillary conjunctivitis, GPC, perennial allergic conjunctivitis, PAC, seasonal allergic conjunctivitis, SAC, vernal keratoconjunctivitis, VKC, eye allergies, ocular allergies

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Contributor Information and Disclosures

Author

Parag A Majmudar, MD, Fellowship Co-Director, Department of Ophthalmology, Cornea and Refractive Surgery Service, Assistant Professor, Rush-Presbyterian-St Luke's Medical Center
Parag A Majmudar, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, International Society of Refractive Surgery, and Phi Beta Kappa
Disclosure: Allergan Honoraria Speaking and teaching; AMO Honoraria Speaking and teaching; Alcon Honoraria Speaking and teaching; Inspire Honoraria Review panel membership

Medical Editor

Jerre Freeman, MD, Founder, Chairman, Memphis Eye and Cataract Associates; Clinical Professor, Department of Ophthalmology, University of Tennessee Health Science Center
Jerre Freeman, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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