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Allergic eye disease

Seasonal, perennial, vernal, atopic

The following information provides a guide for GPs on how to manage or make a referral for presentation of Allergic eye disease (seasonal, perennial, vernal, atopic) in children.

 

  • Low risk pathology

    • No previous eye clinic diagnosis of allergic eye disease AND mild to moderate symptoms (itching, redness, watering) 
    • Mild to moderate flare-up of known vernal or atopic keratoconjunctivitis – exception: no improvement after two weeks of GP-prescribed treatment   

     

    Do not refer (See GP management & self care below)

  • Potential serious pathology

    • Severe symptoms and marked redness and pain, or any involvement of the cornea in any situation
    • No previous eye clinic diagnosis of allergic eye disease AND no improvement after one month of GP prescribed treatment
    • Previous diagnosis of vernal or atopic keratoconjunctivitis AND no improvement after two weeks of GP treatment
    • No previous eye clinic diagnosis of allergic eye disease AND no improvement after one month of G olopatadine or G ketotifen twice daily
    • Previous diagnosis of vernal or atopic keratoconjunctivitis AND no improvement after one month of combination treatment with
      • G olopatadine or G ketotifen twice daily plus
      • G ciclosporine A 1mg/ml four times a day 

     

    Urgent referral BY PHONE to Children's Eye Clinic

GP Management

Start medication – after self-care OTC preparations have failed.

If poor adherence or insufficient control of inflammation:

  • Olopatadine or Ketotifen eyedrops twice daily. These only require twice-daily administration throughout pollen season +/- rest of year as maintenance whilst condition persists. They have a faster onset of action; both can safely be used in children under the age of 3 years, although not licensed for this age group.
  • Sodium Cromoglycate 2% four times daily is an alternative but less effective/more frequent use needed.
  • Ciclosporin eyedrops 1mg/ml (Verkazia, licensed in children) ( refer to NCL JFC Ciclosporin factsheet [1]) - If previously prescribed by hospital for vernal/atopic eye disease and child has flare up again within 12 months can be restarted by primary care.
    • Dosage: four times a day initially and twice to four times daily for maintenance. If not improving within 2 weeks then refer to urgent eye clinic.
    • If a flare up happens more than 12 months after last seen then refer to urgent eye clinic.
    • Long term: can try to reduce and stop during the winter months

Artificial tears (carbomer, sodium hyaluronate,carboxymethycellulse/ glycerin, for example Hycosan, HyloForte, Viscotears, Optive, as necessary up to four times a day can provide a degree of extra symptom relief for mild disease.

For associated blepharitis: Please add treatment from blepharitis pathway.

Treat associated lid eczema with emollients +/- short course 0.5- 1% hydrocortisone skin cream/ointment or short-longer term tacrolimus ointment 0.03% twice a day.

Self-care & advice

  • Cold compresses
  • Over-the-counter anti-histamine eyedrops in mild disease (but no point if using opatanol)
  • Reduce exposure (wear sunglasses, sunhat)
  • If runny nose as well as itchy eyes: oral antihistamines, nasal sprays
  • If lid eczema: emollient cream
  • If blepharitis: warm lid compresses and lid margin cleaning
  • Children usually get better / condition disappears once older but may recur and need treatment especially during spring / summer for some years

Referral information

Always include:

  • Child’s date of birth
  • Address
  • NHS Number
  • Child’s social worker details (including Borough), if any
  • Parent/carer contact phone number and email, if available

Further Assistance

This pathway has been produced by the Moorfields hospital to help clinicians manage the healthcare of Children and Young People. However, if you need to contact a Paediatric clinician, please see below for contact details:

Moorfields Eye Hospital Paediatric helpline: 0207 2533411 extn 4569, Mon- Fri 10:00am-13:00pm then 14:00pm-16:00pm

video transcript
To clean the eyelids the first step is to do a warm compress which softens the debris on the eyelids making it easy to clean off.
Place a clean face cloth under a hot tap, nice and hot but not hot enough to burn or be uncomfortable. Wring it out and hold the hot compress on top of the closed eyes for one or two minutes.
If the cloth becomes cool, warm under the tap again, wring and replace it on the closed lids.
Next we perform the cleaning for older children we use a moistened cotton pad. This can be moistened in warm tap water or by using a weak solution of baby shampoo or bicarbonate of soda.
Squeeze out any excess moisture.
First you clean the back edge of the eyelid. Pull down the lower lid and run the bud firmly but gently along the thin line of skin behind the lashes four or five times.
 Do the same for the top lid putting it up and away from the eye. Then we clean the lashes. For the top lid, close the eyes firmly and scrub vigorously at the base of the lashes doing a small part of the lid at a time and moving gradually along the width of the lid to do all the lashes.
In the same movement to use for brushing your teeth. Then open the eye, look up and repeat with the bottom lid lashes, again moving gradually along the lid to ensure all the lashes are clean.
Ideally older children should be taught to do this themselves.
For younger children we start again with a warm compress.  Then use a face cloth to clean the lid edges moistened in warm tap water or with a weak solution of baby shampoo or bicarbonate of soda.
After moistening wring out the cloth wrapped the cloth tightly around the index finger so it covers the length of the finger holding the rest of the cloth in the hand.
With the child's eyes gently closed lay the finger with the length of the cloth along the lashes apply gentle pressure towards the eye and wipe up in a sweeping motion two to three times to clean the upper lid.
The gentle pressure towards the eyes will allow the eyelids to turn out a little so that the back edge of the eyelids are cleaned. Then wipe down two or three times in the same way to clean the lower lid.
To clean the base of the lashes; with your child's eyes tightly closed use the length of the the finger covered by the cloth to rub quite vigorously along where the lashes come out at the skin moving along the eyelids so that all areas are cleaned.

Review date: March 2026