Allergic Conjunctivitis and VKC: Types, Grading and Steroid-Sparing Treatment
Last updated: November 2026
Itching is the hallmark of allergic eye disease. Mild seasonal allergy needs only drops, but vernal and atopic keratoconjunctivitis threaten the cornea, and their long-term steroid use is a common cause of glaucoma and cataract in young people.
Types
| Type | Who | Key signs |
|---|---|---|
| Seasonal and perennial allergic conjunctivitis | Any age, with hay fever | Itch, watering, chemosis, mild papillae |
| Vernal keratoconjunctivitis (VKC) | Boys aged 5–15 in warm climates, usually remits after puberty | Giant cobblestone papillae on the upper tarsus, limbal Horner-Trantas dots, ropy discharge, shield ulcer |
| Atopic keratoconjunctivitis (AKC) | Adults with atopic dermatitis | Lid eczema, scarring, keratitis, keratoconus, cataract (anterior subcapsular) |
| Giant papillary conjunctivitis | Contact lens wearers, exposed sutures, prostheses | Giant papillae, mucus, lens intolerance |
Treatment ladder
| Step | Treatment |
|---|---|
| 1 | Avoid allergens, cold compresses, preservative-free lubricants |
| 2 | Dual-action antihistamine and mast cell stabiliser drops (olopatadine, ketotifen, bepotastine); mast cell stabilisers for prevention |
| 3 (VKC, AKC) | Topical ciclosporin (0.1% cationic emulsion is licensed for severe VKC in children) or tacrolimus 0.03–0.1% to spare steroids |
| 4 (flare) | Short pulse of topical steroid (loteprednol or fluorometholone preferred), with IOP checks |
| 5 | Supratarsal steroid injection, systemic therapy for refractory AKC |
Shield ulcer
A sterile, oval epithelial defect in the upper cornea in VKC, with a plaque of mucus and debris. Treat with intensive steroid plus antibiotic cover; debride the plaque if it does not heal, as it stops re-epithelialisation.
Long-term care
- Check IOP at every visit in children on steroids: steroid-induced glaucoma is silent and often severe.
- Discourage eye rubbing: VKC and AKC are linked to keratoconus.
- Watch for amblyopia from corneal scarring in children.
Where residents slip
- Long-term steroids without IOP monitoring in a child with VKC.
- Missing keratoconus in an eye-rubbing atopic patient.
- Using vasoconstrictor drops long-term (rebound redness).
Test yourself: flip cards
Related: Keratoconus: Signs, Indices, Staging, Progression and Treatment, Red Eye, Eye Steroids and Infection Regimens: Potency, Tapers and Antiviral Doses.
Key sources
- Leonardi A, et al. Management of ocular allergy. Allergy. 2019;74:1611-1630
- Leonardi A, et al. Efficacy and safety of 0.1% ciclosporin cationic emulsion in severe VKC (VEKTIS). Ophthalmology. 2019;126:671-681
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