Symptoms and Severity

Although some symptoms are similar in all forms (itching – which is typical of allergic conjunctivitis, distinguishing it from other forms of a red eye – redness, tearing and photophobia), the pathophysiology, disease associations, and clinical presentation can differ, for example, the giant papillae in VKC and CLC. The disease severity and management are different in these phenotypes of ocular allergy (Figure 2). While SAC and PAC (very often associated with rhinitis) impair a patient’s quality of life they are mild diseases and are easily controlled by adequate anti-allergic treatment. On the other hand, VKC (occurring alone or more frequently associated with asthma, particularly in young boys before puberty and in some geographical regions with intense natural light) and AKC (typically associated with atopic eczema) are rare but severe clinical entities, in which the involvement of the cornea (vernal and atopic keratoconjunctivitis) is difficult to treat and may eventually cause impairment of visual function.

The allergist has a central role in the diagnosis of allergic conjunctivitis. Patients with bilateral red itching eyes should always be referred to the allergist not only for skin testing and IgE determination, which may be negative, particularly in some cases of VKC and AKC, but also to evaluate general and ocular clinical symptoms. The allergist can also arrange for more sophisticated tests such as the detection of eosinophils in tears, which is typical of VKC and AKC, or of SAC and PAC during the acute phase. The age of the subject, the clinical association with asthma or eczema, the presence of ocular pain or of an intense photophobia, and a poor response to common anti-allergic treatments should prompt the allergist to consult an ophthalmologist to evaluate the presence of a possible corneal involvement.

Therapeutic Considerations

 An adequate treatment of rhinitis with topical steroids, immunotherapy when indicated, systemic and topical antihistamines (or more recent molecules with a dual antihistaminic and anti-inflammatory action) may easily control SAC and PAC. The corneal involvement in VKC and AKC often requires the use of steroids, with the potential for severe iatrogenic side effects of these drugs in the eye (glaucoma, ulcers).

Future Research Needs 

Research efforts in allergic conjunctivitis should mainly be devoted to the most severe forms of ocular allergy (SOA), in an attempt to clarify their pathophysiology better, to standardize diagnosis, and to suggest new forms of treatment. 

Rhinosinusitis

Key Statements 

• Rhinosinusitis (RS) is one of the most common and expensive medical conditions. 

• RS occurs in a number of forms, the most common of which are either acute or chronic. 

• Initial treatment of RS is usually by a primary care physician (PCP) and if unsuccessful, the PCP should refer either to a surgeon or to an allergist for specialized care. 

• In the vast majority of cases, RS is controlled by proper medical management without the need for surgery. 

• Surgery should be considered only in those patients who are properly managed but in whom a number of medical treatment programs fail. 

• The Allergist, who is trained in allergy, immunology, microbiology, internal medicine and/or pediatrics combined with an expert knowledge of nasal and sinus anatomy and appropriate pharmacology, is best suited to manage RS.