Guideline sources The following summarized guidelines for the evaluation and management of allergic conjunctivitis are prepared by our editorial team based on guidelines from the American Academy of Ophthalmology (AAO 2022; 2019), the Japanese Society of Allergology (JSA/JSOA 2022), the Brazilian Pediatric Ophthalmology Society (SBOP 2021), and the Spanish Ocular Surface and Cornea Group (GESOC/SEAIC 2015). 1 2 3 4 5 Calculator DECA criteria for suspicion of all Guidelines 1. Screening and diagnosis Diagnostic criteria: Diagnose allergic conjunctivitis based on family and personal history of atopy, characteristic clinical signs and symptoms, and results of appropriate additional tests. B Use data of https://web.pathway.md/diseases/recSetUMBWeOOBYEY 1/5 6/23/23, 2:18 AM Allergic conjunctivitis Pathway response to topical antihistamines and/or mastocyte stabilizers to support the diagnosis of allergic conjunctivitis. A Consider using the DECA criteria for clinical suspicion of allergic conjunctivitis. C 2. Medical management Topical corticosteroids: As per AAO 2022 guidelines, consider offering topical corticosteroids in patients with acute exacerbations of vernal/atopic conjunctivitis. B As per JSOA 2022 guidelines, consider offering corticosteroid eye drops for the treatment of seasonal or allergic conjunctivitis, C , vernal keratoconjunctivitis, and atopic keratoconjunctivitis. B As per GESOC 2015 guidelines, do not use ocular corticosteroids as first-line therapy in patients with allergic conjunctivitis. Offer less potent corticosteroids (such as fluorometholone, medrysone, loteprednol, or rimexolone) for the treatment of moderate inflammation. Offer betamethasone, dexamethasone, or prednisolone in patients with severe inflammation. D Topical antihistamines: As per AAO 2022 guidelines, offer OTC antihistamines or second-generation topical H1RAs in patients with mild allergic conjunctivitis. B Offer mast cell membrane stabilizers if the condition is frequently recurrent or persistent. B As per GESOC 2015 guidelines, offer second-generation topical antihistamines (levocabastine, emedastine) in patients with allergic conjunctivitis due to their long half-life (4-6 hours) and a good safety and efficacy profile, even in pediatric patients. A Show 2 more Topical vasoconstrictors: As per AAO 2022 guidelines, offer OTC vasoconstrictors in patients with mild allergic conjunctivitis. B As per GESOC 2015 guidelines, do not use vasoconstrictors (naphazoline, oxymetazoline, phenylephrine, tetrahydrozoline) in patients with allergic conjunctivitis because of their short- lasting effect, limited efficacy, and poor tolerance. D Topical cyclosporine: As per AAO 2022 guidelines, consider offering topical cyclosporine in patients with severe vernal/atopic conjunctivitis. B As per JSOA 2022 guidelines: Consider offering cyclosporine eye drops for the treatment of vernal and atopic keratoconjunctivitis. C Consider offering combination therapy with cyclosporine and corticosteroid eye drops for vernal keratoconjunctivitis and atopic keratoconjunctivitis in patients with conjunctival proliferative changes. C https://web.pathway.md/diseases/recSetUMBWeOOBYEY 2/5 6/23/23, 2:18 AM Allergic conjunctivitis Pathway As per AAO 2019 guidelines, consider offering topical cyclosporin in patients with severe allergic/vernal/atopic conjunctivitis, as well as to prevent seasonal recurrences. C Topical tacrolimus: As per JSOA 2022 guidelines: Offer tacrolimus eye drops to improve the epithelial damage and giant papillae in patients with vernal keratoconjunctivitis and atopic keratoconjunctivitis. A Consider offering combination therapy with tacrolimus and corticosteroid eye drops for vernal keratoconjunctivitis and atopic keratoconjunctivitis in patients with severe conjunctival proliferative changes. C As per AAO 2019 guidelines, consider offering topical tacrolimus in patients with severe allergic conjunctivitis. C Topical NSAIDs: consider offering ophthalmic NSAIDs (diclofenac, flurbiprofen, and ketorolac) for conjunctival hyperemia and pruritus. B Intranasal corticosteroids: consider offering intranasal corticosteroids (such as mometasone furoate, and fluticasone furoate) to improve ocular symptoms by diminishing the nasal-ocular reflex in patients with allergic rhinoconjunctivitis. B Oral antihistamines: do not use first-generation H1RAs in patients with allergic conjunctivitis because of their sedative effect and anticholinergic activity. Recognize that second-generation H1RAs (bilastine, cetirizine, desloratadine, ebastine, fexofenadine, levocetirizine, loratadine, mizolastine, or rupatadine) have similar efficacy but a more manageable sedation profile and fewer adverse effects. D Oral leukotriene receptor antagonists: consider offering leukotriene receptor antagonists (mainly montelukast) for nasal symptoms in patients with allergic rhinoconjunctivitis. B Systemic immunosuppressants: consider offering systemic immunosuppressants (such as montelukast, aspirin, interferons, cyclosporine, or tacrolimus) in rare circumstances. C Specific immunotherapy: as per AAO 2022 guidelines, offer allergen-specific immunotherapy in patients with allergic conjunctivitis, recognizing that it is more effective in pediatric than adult patients. B 3. Nonpharmacologic interventions Avoidance of allergens: As per AAO 2022 guidelines, advise environment modifications in patients with vernal/atopic conjunctivitis. B As per GESOC 2015 guidelines, advise general preventative measures including specific actions to reduce exposure to house dust mite, molds, animal dander, and pollen. A Eye hygiene: As per AAO 2022 guidelines, advise applying cold compresses and ocular lubricants in patients with vernal/atopic conjunctivitis. B https://web.pathway.md/diseases/recSetUMBWeOOBYEY 3/5 6/23/23, 2:18 AM Allergic conjunctivitis Pathway As per GESOC 2015 guidelines: Advise applying cold (compresses soaked in water, preservative-free artificial tears, and saline solution) and washing allergens from the conjunctiva to relieve edema and hyperemia. A Consider advising to wear large wraparound sunglasses to prevent contact with aeroallergens and improve photophobia. B 4. Specific circumstances Pediatric patients (nonpharmacological measures): Advise the following nonpharmacological measures: general environmental measures to reduce exposure to allergens (such as elimination of domestic dust, fungi, and pollen) specific actions such as the use of cold-water compresses, preservative-free artificial tears, and local cleansing with saline solution to wash the allergens from the conjunctiva and to contract the conjunctival vessels to relieve edema and hyperemia. A Consider advising to wear sunglasses to prevent contact with suspended allergens and for photophobia relief. B Pediatric patients (pharmacotherapy): avoid offering first-generation topical antihistamines because of poor tolerance and limited effect and potency. D Show 8 more Pediatric patients, immunotherapy: As per AAO 2022 guidelines, offer allergen-specific immunotherapy in pediatric patients with allergic conjunctivitis. B As per SBOP 2021 guidelines, offer specific immunotherapy to improve ocular symptoms in patients with allergic rhinoconjunctivitis. A References 1. M C S nchez-Hern ndez, J Montero, C Rondon et al. Consensus document on allergic conjunctivitis DECA . J Investig Allergol Clin Immunol. 2015;25 2 94 106. Open 2. AAO PPP Cornea/External Disease Panel, Hoskins Center for Quality Eye Care. Cornea/External Disease Summary Benchmarks 2022. AAO. 2022 Dec. Open 3. Divya M Varu, Michelle K Rhee, Esen K Akpek et al. Conjunctivitis Preferred Practice Pattern . Ophthalmology. 2019 Jan;126 1 P94 P169. Open 4. Cristiana Soares Ronconi, Dayane C Issaho, Fabio Ejzenbaum et al. Brazilian guidelines for the monitoring and treatment of pediatric allergic conjunctivitis. Arq Bras Oftalmol. 2021 Nov 29;85 4 415 425. Open 5. Dai Miyazaki, Atsuki Fukushima, Eiichi Uchio et al. Executive summary: Japanese guidelines for allergic conjunctival diseases 2021. Allergol Int. 2022 Oct;71 4 459 471. 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