Conjunctivitis Preferred Practice Pattern®

AMERICAN ACADEMY™ OF OPHTHALMOLOGY Protecting Sight. Empowering Lives.™ Conjunctivitis Preferred Practice Pattern®© 2018 by the American Academy of Ophthalmology Published by Elsevier Inc. https://doi.org/10.1016/j.ophtha.2018.10.020 ISSN 0161-6420/18 Secretary for Quality of Care Timothy W. Olsen, MD Academy Staff Ali Al-Rajhi, PhD, MPH Andre Ambrus, MLIS Rachel Lastra Flora C. Lum, MD Doris Mizuiri Medical Editor: Susan Garratt Approved by: Board of Trustees September 22, 2018 © 2018 American Academy of Ophthalmology® All rights reserved AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are registered trademarks of the American Academy of Ophthalmology. All other trademarks are the property of their respective owners. Preferred Practice Pattern® guidelines are developed by the Academy's H. Dunbar Hoskins Jr., MD Center for Quality Eye Care without any external financial support. Authors and reviewers of the guidelines are volunteers and do not receive any financial compensation for their contributions to the documents. The guidelines are externally reviewed by experts and stakeholders before publication. Correspondence: Ali A. Al-Rajhi, PhD, MPH, American Academy of Ophthalmology, P. O. Box 7424, San Francisco, CA 94120-7424. E-mail: . The Cornea/External Disease Preferred Practice Pattern® Panel members wrote the Conjunctivitis Preferred Practice Pattern® guidelines (PPP). The PPP Panel members discussed and reviewed successive drafts of the document, meeting in person twice and conducting other review by e-mail discussion, to develop a consensus over the final version of the document. Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 Divya M. Varu, MD Michelle K. Rhee, MD Esen K. Akpek, MD Guillermo Amescua, MD Marjan Farid, MD Francisco J. Garcia-Ferrer, MD Amy Lin, MD, Cornea Society Representative David C. Musch, PhD, MPH, Methodologist Francis S. Mah, MD, Co-chair Steven P. Dunn, MD, Co-chair The Preferred Practice Patterns Committee members reviewed and discussed the document during a meeting in June 2018. The document was edited in response to the discussion and comments. Preferred Practice Patterns Committee 2018 Robert S. Feder, MD, Chair Roy S. Chuck, MD, PhD Steven P. Dunn, MD Christina J. Flaxel, MD Francis S. Mah, MD Randall J. Olson, MD Bruce E. Prum, Jr., MD David K. Wallace, MD, MPH David C. Musch, PhD, MPH, Methodologist The Conjunctivitis PPP was then sent for review to additional internal and external groups and individuals in July 2018. All those returning comments were required to provide disclosure of relevant relationships with industry to have their comments considered. Members of the Cornea/External Disease Preferred Practice Pattern Panel reviewed and discussed these comments and determined revisions to the document. In compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies (available at www.cmss.org/codeforinteractions.aspx), relevant relationships with industry are listed. The Academy has Relationship with Industry Procedures to comply with the Code (available at www.aao.org/about-preferred-practice-patterns). A majority (70%) of the members of the Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 had no financial relationships to disclose. Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 Esen K. Akpek, MD: Allergan – Grant Support; Novartis Pharma AG – Consultant/Advisor Guillermo Amescua, MD: No financial relationships to disclose Steven P. Dunn, MD: No financial relationships to disclose Marjan Farid, MD: Allergan, Bio-Tissue, Inc. – Consultant/Advisor Francisco J. Garcia-Ferrer, MD: No financial relationships to disclose Amy Lin, MD: No financial relationships to disclose Francis S. Mah, MD: Alcon Laboratories, Inc., Allergan, Bausch & Lomb, iView, Mallinckrodt Pharmaceuticals, NovaBay – Consultant/Advisor David C. Musch, PhD, MPH: No financial relationships to disclose Michelle K. Rhee, MD: No financial relationships to disclose Divya M. Varu, MD: No financial relationships to disclose Preferred Practice Patterns Committee 2018 Robert S. Feder, MD: No financial relationships to disclose Roy S. Chuck, MD, PhD: Novartis Pharmaceuticals – Consultant/Advisor Steven P. Dunn, MD: No financial relationships to disclose Christina J. Flaxel, MD: No financial relationships to disclose Francis S. Mah, MD: Alcon Laboratories, Inc., Allergan, Bausch & Lomb, iView, Mallinckrodt Pharmaceuticals, NovaBay – Consultant/Advisor David C. Musch, PhD, MPH: No financial relationships to disclose Randall J. Olson, MD: No financial relationships to disclose Bruce E. Prum, Jr., MD: No financial relationships to disclose David K. Wallace, MD, MPH: No financial relationships to disclose Secretary for Quality of Care Timothy W. Olsen, MD: No financial relationships to disclose Academy Staff Ali Al-Rajhi, PhD, MPH: No financial relationships to disclose Andre Ambrus, MLIS: No financial relationships to disclose Susan Garratt: No financial relationships to disclose Rachel Lastra: No financial relationships to disclose Flora C. Lum, MD: No financial relationships to disclose Doris Mizuiri: No financial relationships to disclose The disclosures of relevant relationships to industry of other reviewers of the document from January to October 2018 are available online at www.aao.org/ppp. OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES P99METHODS AND KEY TO RATINGS P100HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE P101INTRODUCTION P102Disease Definition P102Patient Population P102Clinical Objectives P102BACKGROUND P102Prevalence and Risk Factors P104Natural History P104CARE PROCESS P118Patient Outcome Criteria P118Diagnosis P118History P118Physical Examination P119Diagnostic Tests P120Management P123Prevention P123Treatment P127Provider and Setting P146Counseling and Referral P147Socioeconomic Considerations P147APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA P151APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS (ICD) CODES P153APPENDIX 3. OCULAR SURFACE DYE STAINING P155LITERATURE SEARCHES FOR THIS PPP P156RELATED ACADEMY MATERIALS P157REFERENCES P159 As a service to its members and the public, the American Academy of Ophthalmology has developed a series of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care. Appendix 1 describes the core criteria of quality eye care. The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical trials are available, the data are particularly persuasive and provide clear guidance. In other instances, the panels have to rely on their collective judgment and evaluation of available evidence. These documents provide guidance for the pattern of practice, not for the care of a particular individual. While they should generally meet the needs of most patients, they cannot possibly best meet the needs of all patients. Adherence to these PPPs will not ensure a successful outcome in every situation. These practice patterns should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. It may be necessary to approach different patients' needs in different ways. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all of the circumstances presented by that patient. The American Academy of Ophthalmology is available to assist members in resolving ethical dilemmas that arise in the course of ophthalmic practice. Preferred Practice Pattern® guidelines are not medical standards to be adhered to in all individual situations. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any recommendations or other information contained herein. References to certain drugs, instruments, and other products are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved U.S. Food and Drug Administration (FDA) labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law. Innovation in medicine is essential to ensure the future health of the American public, and the Academy encourages the development of new diagnostic and therapeutic methods that will improve eye care. It is essential to recognize that true medical excellence is achieved only when the patients' needs are the foremost consideration. All Preferred Practice Pattern® guidelines are reviewed by their parent panel annually or earlier if developments warrant and updated accordingly. To ensure that all PPPs are current, each is valid for 5 years from the “approved by” date unless superseded by a revision. Preferred Practice Pattern guidelines are funded by the Academy without commercial support. Authors and reviewers of PPPs are volunteers and do not receive any financial compensation for their contributions to the documents. The PPPs are externally reviewed by experts and stakeholders, including consumer representatives, before publication. The PPPs are developed in compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies. The Academy has Relationship with Industry Procedures (available at www.aao.org/about-preferred-practice-patterns) to comply with the Code. Appendix 2 contains the International Statistical Classification of Diseases and Related Health Problems (ICD) codes for the disease entities that this PPP covers. The intended users of the Conjunctivitis PPP are ophthalmologists. Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network1Scottish Intercollegiate Guidelines Network (SIGN) SIGN 50: a guideline developer's handbook. SIGN, Edinburgh2015Available from URL: http://www.sign.ac.ukGoogle Scholar (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar (GRADE) group are used. GRADE is a systematic approach to grading the strength of the total body of evidence that is available to support recommendations on a specific clinical management issue. Organizations that have adopted GRADE include SIGN, the World Health Organization, the Agency for Healthcare Research and Quality, and the American College of Physicians.3GRADE Working Group Organizations that have endorsed or that are using GRADE.http://www.gradeworkinggroup.org/Date accessed: June 19, 2018Google Scholar ♦All studies used to form a recommendation for care are graded for strength of evidence individually, and that grade is listed with the study citation.♦To rate individual studies, a scale based on SIGN1Scottish Intercollegiate Guidelines Network (SIGN) SIGN 50: a guideline developer's handbook. SIGN, Edinburgh2015Available from URL: http://www.sign.ac.ukGoogle Scholar is used. The definitions and levels of evidence to rate individual studies are as follows: Tabled 1I++High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of biasI+Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of biasI-Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of biasII++High-quality systematic reviews of case-control or cohort studiesHigh-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causalII+Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causalII-Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causalIIINonanalytic studies (e.g., case reports, case series) Open table in a new tab ♦Recommendations for care are formed based on the body of the evidence. The body of evidence quality ratings are defined by GRADE2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar as follows: Tabled 1Good qualityFurther research is very unlikely to change our confidence in the estimate of effectModerate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimateInsufficient qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate Any estimate of effect is very uncertain Open table in a new tab ♦Key recommendations for care are defined by GRADE2Guyatt GH Oxman AD Vist GE et al.GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar as follows: Tabled 1Strong recommendationUsed when the desirable effects of an intervention clearly outweigh the undesirable effects or clearly do notDiscretionary recommendationUsed when the trade-offs are less certain—either because of low-quality evidence or because evidence suggests that desirable and undesirable effects are closely balanced Open table in a new tab ♦The Highlighted Findings and Recommendations for Care section lists points determined by the PPP panel to be of particular importance to vision and quality of life outcomes.♦All recommendations for care in this PPP were rated using the system described above. Ratings are embedded throughout the PPP main text in italics.♦Literature searches to update the PPP were undertaken in February 2017 and June 2018 in PubMed and the Cochrane Library. Complete details of the literature search are available at www.aao.org/ppp. Conjunctivitis rarely causes permanent visual loss or structural damage, but the economic impact of conjunctivitis is considerable and largely due to lost work or school time and the cost of medical visits, testing and treatment.4Smith AF Waycaster C Estimate of the direct and indirect annual cost of bacterial conjunctivitis in the United States.BMC Ophthalmol. 2009; 9: 13Crossref PubMed Scopus (54) Google Scholar, 5Zegans ME Sanchez PA Likosky DS et al.Clinical features, outcomes, and costs of a conjunctivitis outbreak caused by the ST448 strain of Streptococcus pneumoniae.Cornea. 2009; 28: 503-509Crossref PubMed Scopus (12) Google Scholar Chronic and/or recalcitrant conjunctivitis may be indicative of an underlying malignancy, such as sebaceous or squamous cell carcinoma. The ophthalmologist plays a critical role in breaking the chain of transmission of epidemic adenoviral conjunctivitis, primarily by educating the patient and family about proper hygiene. Infected individuals should be counseled to wash hands frequently and use separate towels, and to avoid close contact with others during the period of contagion. Dilute bleach soak (sodium hypochlorite) at 1:10 concentration is an effective disinfectant for tonometers.6Rutala WA Weber DJ Healthcare Infection Control Practices Advisory Committee (HICPAC)Guideline for disinfection and sterilization in healthcare facilities.https://www.cdc.gov/infectioncontrol/pdf/guidelines/disinfection-guidelines.pdfDate: 2008Date accessed: June 21, 2018Google Scholar, 7Junk AK Chen PP Lin SC et al.Disinfection of Tonometers: A Report by the American Academy of Ophthalmology.Ophthalmology. 2017; 124: 1867-1875Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Notably, 70% isopropyl alcohol (e.g., alcohol wipes), 3% hydrogen peroxide, and ethyl alcohol are no longer recommended for tonometer disinfection.7Junk AK Chen PP Lin SC et al.Disinfection of Tonometers: A Report by the American Academy of Ophthalmology.Ophthalmology. 2017; 124: 1867-1875Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Surfaces should be disinfected with an EPA-registered hospital disinfectant in accordance with the directions and safety precautions on the label. Indiscriminate use of topical antibiotics or corticosteroids should be avoided. Viral conjunctivitis will not respond to anti-bacterial agents, and mild bacterial conjunctivitis is likely to be self-limited. No evidence exists demonstrating the superiority of any topical antibiotic agent.8Epling J Bacterial conjunctivitis.BMJ Clin Evid. 2012; 2012PubMed Google Scholar [I+, Good, Strong] In adults, conjunctivitis caused by ocular mucous membrane pemphigoid (OMMP), graft-versus-host disease (GVHD), gonococcus, and chlamydia are important to detect early because it is necessary to treat the concomitant systemic disorder. Diagnosis of superior limbic keratoconjunctivitis (SLK) may lead to further investigations that reveal a thyroid disorder. Early detection of conjunctivitis associated with neoplasms may be lifesaving. Herpes Zoster vaccination should be strongly recommended in patients 50 years or older.9Cornea Society AAO Recommendations for Herpes Zoster Vaccine for Patients 50 Years of Age and Older.Ophthalmology. 2018; (In Press.)Google Scholar Conjunctivitis is an inflammation that primarily affects the conjunctiva. The patient population includes individuals of all ages who present with symptoms and signs suggestive of conjunctivitis, such as red eye or discharge. ♦Establish the diagnosis of conjunctivitis, differentiating it from other causes of red eye♦Identify the cause(s) of conjunctivitis♦Establish appropriate therapy♦Relieve discomfort and pain♦Prevent complications♦Prevent the spread of communicable diseases♦Educate and engage both the patient and the referring healthcare providers in conjunctivitis management Conjunctivitis, or inflammation of the conjunctiva, is a general term that refers to a diverse group of diseases/disorders that affect primarily the conjunctiva. Most varieties of conjunctivitis are self-limited, but some progress and may cause serious ocular and extraocular complications. Conjunctivitis can be classified as noninfectious or infectious and as acute, chronic, or recurrent. Noninfectious types of conjunctivitis include allergic, mechanical/irritative/toxic, immune-mediated, and neoplastic, and these types may overlap. The causes of infectious conjunctivitis include viruses and bacteria. It is important to differentiate among primary conjunctival disease and conditions in which conjunctival inflammation is secondary to systemic or ocular diseases. For example, dry eye and blepharitis are the most frequent causes of conjunctival inflammation, and the treatment for each of these entities should be directed at correcting the underlying problems.10McCulley JP Dougherty JM Deneau DG Classification of chronic blepharitis.Ophthalmology. 1982; 89: 1173-1180Abstract Full Text PDF PubMed Google Scholar, 11American Academy of Ophthalmology Cornea/External Disease Panel Preferred Practice Pattern®. Dry Eye Syndrome. American Academy of Ophthalmology, San Francisco, CA2018www.aao.org/pppGoogle Scholar Systemic diseases such as gonorrhea or atopy may also cause conjunctival inflammation, and treatment of conjunctivitis must include addressing the underlying systemic disease. This PPP addresses the following types of conjunctivitis that are either most common or are particularly important to detect and treat: ♦Allergic♦Seasonal/perennial allergic conjunctivitis♦Vernal conjunctivitis♦Atopic conjunctivitis♦Mechanical/irritative/toxic♦Superior limbic keratoconjunctivitis (SLK)♦Blepharoconjunctivitis♦Keratoconjunctivitis sicca (dry eye)♦Rosacea conjunctivitis♦Contact lens–related keratoconjunctivitis♦Giant papillary conjunctivitis (GPC)♦Floppy eyelid syndrome♦Giant fornix syndrome♦Pediculosis palpebrarum (Phthirus pubis)♦Medication-induced/preservative-induced keratoconjunctivitis♦Conjunctival chalasis♦Immune-mediated♦Ocular mucous membrane pemphigoid (OMMP)♦Graft-versus-host disease (GVHD)♦Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN)♦Graves disease ophthalmopathy♦Vasculitis♦Neoplastic♦Sebaceous carcinoma♦Ocular surface squamous neoplasia♦Melanoma♦Viral♦Adenoviral conjunctivitis♦Herpes simplex virus (HSV) conjunctivitis♦Varicella (herpes) zoster virus (VZV) conjunctivitis♦Molluscum contagiosum♦Bacterial♦Bacterial conjunctivitis (including nongonococcal and gonococcal)♦Chlamydial conjunctivitis♦Other♦Ligneous conjunctivitis Conjunctivitis is a diagnosis that encompasses a diverse group of diseases that occur worldwide and affect all ages, all social strata, and both genders. Although there are no reliable figures that document the incidence or prevalence of all forms of conjunctivitis, this condition has been cited as one of the most frequent causes of patient self-referral.12Chiang YP Wang F Javitt JC Office visits to ophthalmologists and other physicians for eye care among the U.S. population, 1990.Public Health Rep. 1995; 110: 147-153PubMed Google Scholar Conjunctivitis infrequently causes permanent visual loss or structural damage, but the economic impact of the disease in terms of lost work and school time, cost of medical visits, diagnostic testing, and medication is considerable.4Smith AF Waycaster C Estimate of the direct and indirect annual cost of bacterial conjunctivitis in the United States.BMC Ophthalmol. 2009; 9: 13Crossref PubMed Scopus (54) Google Scholar, 5Zegans ME Sanchez PA Likosky DS et al.Clinical features, outcomes, and costs of a conjunctivitis outbreak caused by the ST448 strain of Streptococcus pneumoniae.Cornea. 2009; 28: 503-509Crossref PubMed Scopus (12) Google Scholar The risk factors for developing conjunctivitis depend on the etiology. The associated and predisposing factors for the types of conjunctivitis that are most common or most important to treat are listed in Table 1. Symptoms may be exacerbated by the coexistence of blepharitis, dry eye, or other causes of ocular surface inflammation.TABLE 1Typical Clinical Signs of, Associated/Predisposing Factors for, and Natural History of ConjunctivitisType of ConjunctivitisClinical SignsAssociated/Predisposing FactorsNatural HistoryPotential SequelaeAllergic Seasonal/perennial•Bilateral. Eyelid edema, periorbital hyperpigmentation (allergic shiners), conjunctival injection, chemosis, watery discharge, mild mucous discharge•Environmental allergens (e.g., grasses, pollens)•Outdoor air pollution, secondary to fuel combustion, dust storms, truck traffic, mine dumps and industrial parks, pre- and postnatal exposure to environmental tobacco smoke13Jalbert I Golebiowski B Environmental aeroallergens and allergic rhino-conjunctivitis.Curr Opin Allergy Clin Immunol. 2015; 15: 476-481Crossref PubMed Scopus (8) Google Scholar, 14Nkosi V Wichmann J Voyi K Mine dumps, wheeze, asthma, and rhinoconjunctivitis among adolescents in South Africa: any association?.Int J Environ Health Res. 2015; 25: 583-600Crossref PubMed Scopus (12) Google Scholar, 15Al-Wahaibi A Zeka A Health impacts from living near a major industrial park in Oman.BMC Public Health. 2015; 15: 524Crossref PubMed Scopus (6) Google Scholar, 16Shirinde J Wichmann J Voyi K Allergic rhinitis, rhinoconjunctivitis and hayfever symptoms among children are associated with frequency of truck traffic near residences: a cross sectional study.Environ Health. 2015; 14: 84Crossref PubMed Scopus (10) Google Scholar•Exposure to dogs, cats, farm animals17Solis-Soto MT Patino A Nowak D Radon K Association between environmental factors and current asthma, rhinoconjunctivitis and eczema symptoms in school-aged children from Oropeza Province–Bolivia: a cross-sectional study.Environ Health. 2013; 12: 95Crossref PubMed Scopus (9) Google Scholar•Recurrent, often associated with allergic rhinitis, dry eye, meibomian gland dysfunction (MGD) with mucin hyperproduction18Arita R Validity of noninvasive meibography systems: noncontact meibography equipped with a slit-lamp and a mobile pen-shaped meibograph.Cornea. 2013; 32: S65-70Crossref PubMed Scopus (20) Google Scholar, 19Garcia-Posadas L Contreras-Ruiz L Soriano-Romani L Dartt DA Diebold Y Conjunctival goblet cell function: effect of contact lens wear and cytokines.Eye Contact Lens. 2016; 42: 83-90Crossref PubMed Scopus (9) Google Scholar•Minimal, local Vernal•Bilateral. Giant papillary hypertrophy of superior tarsal conjunctiva, bulbar conjunctival injection, conjunctival scarring, watery and stringy mucoid discharge, limbal Horner-Trantas dots, limbal “papillae,” corneal epithelial erosions, corneal neovascularization and scarring, corneal vernal plaque/shield ulcer•Hot, dry environments such as West Africa; parts of India, Mexico, Central, North, and South America; and the Mediterranean region•May be associated with deficiencies of growth hormone, sex-hormone binding globulin, and dihydrotestosterone, or high levels of estrone20Stagi S Pucci N di Grande L et al.Increased prevalence of growth hormone deficiency in patients with vernal keratoconjuntivitis; an interesting new association.Hormones (Athens). 2014; 13: 382-388PubMed Google Scholar, 21Sacchetti M Lambiase A Moretti C Mantelli F Bonini S Sex hormones in allergic conjunctivitis: altered levels of circulating androgens and estrogens in children and adolescents with vernal keratoconjunctivitis.J Immunol Res. 2015; 2015945317Crossref PubMed Scopus (10) Google Scholar•Environmental allergens for acute exacerbations•Associated with a higher incidence of keratoconus•Onset in childhood; chronic course with acute exacerbations during spring and summer. Gradual decrease in activity within 2 to 20 years.•Vernal keratoconjunctivitis (VKC)-like disease noted in young adults without history of childhood allergic disease22Leonardi A Lazzarini D Motterle L et al.Vernal keratoconjunctivitis-like disease in adults.Am J Ophthalmol. 2013; 155: 796-803Abstract Full Text Full Text PDF PubMed Google Scholar•Eyelid thickening; ptosis; conjunctival scarring (predominantly superior tarsal); corneal neovascularization, thinning, ulceration, infection; visual loss; limbal stem cell deficiency, corticosteroid-induced cataract and glaucoma23Saboo US Jain M Reddy JC Sangwan VS Demographic and clinical profile of vernal keratoconjunctivitis at a tertiary eye care center in India.Indian J Ophthalmol. 2013; 61: 486-489Crossref PubMed Scopus (18) Google Scholar•Adult VKC with diffuse subepithelial thickening of tarsal plate without giant papillae, lower rate of corneal shield ulcers (less common than in children) Atopic•Bilateral. Eczematoid blepharitis; eyelid thickening, scarring; lash loss; papillary hypertrophy of superior and inferior tarsal conjunctiva; conjunctival injection and scarring; watery and stringy mucoid discharge; boggy edema; corneal neovascularization, ulcers and scarring; punctate epithelial keratitis. Can be associated with keratoconus and/or subcapsular cataract•Genetic predisposition to atopy•Environmental allergens and irritants for acute exacerbations•Associated with a higher incidence of keratoconus•Later (than vernal) onset; chronic course with acute exacerbations•Eyelid thickening or tightening, loss of lashes; MGD; 24Ibrahim OM Matsumoto Y Dogru M et al.In vivo confocal microscopy evaluation of meibomian gland dysfunction in atopic-keratoconjunctivitis patients.Ophthalmology. 2012; 119: 1961-1968Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar conjunctival scarring/cicatrization (include inferior); corneal scarring, neovascularization, thinning, infection, ulceration; cataract; visual loss; increased risk of retinal detachment, herpes simplex keratitis,25Sy H Bielory L Atopic keratoconjunctivitis.Allergy Asthma Proc. 2013; 34: 33-41Crossref PubMed Scopus (16) Google Scholar limbal stem cell deficiencyMechanical/Irritative/Toxic Superior limbic keratoconjunctivitis (SLK)•Bilateral superior bulbar injection, laxity, edema, and keratinization. Superior corneal and conjunctival punctate epitheliopathy, corneal filaments•Frequently associated with dysthyroid states, female gender•Subacute onset of symptoms, usually bilateral. May wax and wane for years•Superior conjunctival keratinization, pannus, filamentary keratitis, chemosis Blepharoconjunctivitis•Chronic with exacerbations. Anterior blepharitis affects the eyelid skin, base of the eyelashes, and the eyelash follicles. Posterior blepharitis causes MGD, tear film instability, concomitant dry eye. Bilateral, can be asymmetric•(See Dry Eye PPP11American Academy of Ophthalmology Cornea/External Disease Panel Preferred Practice Pattern®. Dry Eye Syndrome. American Academy of Ophthalmology, San Francisco, CA2018www.aao.org/pppGoogle Scholar)•Anterior: staphylococcal, Demodex, seborrheic•P