Cases/Ophthalmology

Troublesome Allergic Conjunctivitis and Hay Fever — Free SCA Practice Case

Gardener with troublesome allergic conjunctivitis and hay fever

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Brenda Miller

Age

48 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"My eyes are incredibly itchy and swollen. I can't stop rubbing them. My usual tablets aren't working."

Medical Records

●PMH: Seasonal Allergic Rhinitis (Hay Fever) since childhood. Mild Asthma (last prescription 3 years ago).
●Medications: Cetirizine 10mg OD (bought OTC). Sodium Cromoglicate Eye Drops (bought OTC).
●Allergies: Grass Pollen (severe), Tree Pollen.
●Occupation: Landscape Gardener (Self-employed).

Recent Notes

●1 Year Ago: Telephone consult for hay fever. Advised to use Beclomethasone nasal spray.

Patient Script

For the friend playing the patient role

Character Overview: You are Brenda. You are miserable. Your eyes are streaming, red, and gritty. You are a landscape gardener, so you are surrounded by pollen all day. You cannot afford to take time off work. You are frustrated because you have "tried everything" from the chemist and nothing is touching it.

Opening Sentence: "Hi Doctor. I'm suffering. My eyes are on fire—they're so itchy and puffy I can barely see straight. I'm a gardener, so I'm out in it all day. I've taken the antihistamines and used the drops the chemist gave me, but it's getting worse, not better."

History if Asked (Data Gathering Phase)

●
The Symptoms:
- ●Eyes: "It feels like there's sand in them. They are red, watery, and the eyelids are puffed up."
- ●Nose: "My nose is constantly running and blocked. I'm sneezing 20 times a morning."
- ●Timing: "It started a month ago (Tree pollen) but has exploded this week (Grass pollen)."
●
Current Management (Compliance Check):
- ●Tablets: "I take a Cetirizine every morning. Sometimes I take two if it's bad."
- ●Drops: "I use the Optrex ones (Cromoglicate) maybe twice a day? But they sting, and I forget them when I'm working."
- ●Nasal Spray: "I tried that Beconase spray last year but it didn't work instantly, so I chucked it." (Common error).
●
Red Flags:
- ●Vision: "My vision is fine when I blink away the tears."
- ●Pain: "No deep pain, just grittiness and burning."
- ●Light Sensitivity: "A bit, but only because they are so sore."
- ●Contact Lenses: "No, I wear glasses."

ICE — Ideas, Concerns, Expectations

(Actor guidance: Do not volunteer any of this unprompted. Only surface when the candidate directly explores the patient's perspective.)

●Ideas: "I think it's just really bad hay fever — worse than I've ever had it. I'm wondering if being outside all day every day has made it build up over the years or something. I just don't know why the chemist stuff isn't working anymore."
●Concerns: "Honestly, I'm worried I'm going to lose customers. I've already had to redo one job because I couldn't see what I was doing properly. And it's not just the work — I look dreadful. My eyes are swollen shut in the mornings and I worry people think there's something wrong with me. I also just want to make sure it's nothing more serious — like, could it be an infection or something?"
●Expectations: "I need something stronger that actually works. I've tried everything from the chemist and I'm still suffering. I'm hoping you can prescribe me something proper — especially for the eyes — so I can get through the season and keep working."

If Asked — Medical History and Medications

(Actor guidance: Only provide this detail if the candidate asks specifically about past medical history, medications, or asthma.)

●Asthma: "I was told I had mild asthma years ago, but I haven't needed an inhaler in ages — probably three years since I last picked one up. I don't wheeze or get breathless really. It's never been a big issue for me."
●Cetirizine: "I buy it from the supermarket. I take one every morning, 10mg. Sometimes if I'm really struggling I'll double up, but I don't think it makes much difference. I've been taking it for years."
●Sodium Cromoglicate drops: "The pharmacist recommended them. I'm meant to use them four times a day but honestly I manage twice at best — they sting, and when I'm up to my elbows in soil I can't exactly stop and put drops in."
●Beclomethasone nasal spray: "The doctor suggested that last year over the phone. I did try it for a few days but it didn't seem to do anything, so I stopped. Nobody told me I had to keep using it."
●Allergies: "I know I'm allergic to grass pollen — that's the worst one. Tree pollen sets me off earlier in the year but it's not as bad. I had a blood test years ago that confirmed it."

Social History and Lifestyle Impact

(Actor guidance: This should come through naturally in conversation, not as a rehearsed block. Weave in when the candidate asks about work or daily life.)

●Occupation and daily life: Brenda is a self-employed landscape gardener. She works outdoors six days a week during peak season (April–August), typically 8–10 hour days. She works alone and drives a van between jobs. She has no employees and no sick pay — if she doesn't work, she earns nothing.
●Lifestyle impact of the condition: "I had to leave a job halfway through on Tuesday because I genuinely couldn't see — my eyes were streaming so badly I couldn't tell where I was strimming. I nearly took out a client's rose bed. I've started wearing ski goggles which helps a tiny bit but I look ridiculous and they steam up. Mornings are the worst — my eyes are practically glued shut and it takes me twenty minutes with a cold flannel before I can even open them properly. I'm behind on three gardens now and I've got a client threatening to go elsewhere."

If Asked — Associated Symptoms

(Actor guidance: Only provide these responses if directly asked about each symptom. Do not volunteer.)

●If asked about throat symptoms: "It does feel scratchy at the back of my throat sometimes, and I get this annoying post-nasal drip — like something's trickling down."
●If asked about cough: "I do get a bit of a dry cough, especially in the evenings. But nothing major."
●If asked about wheeze or chest tightness: "No, nothing like that. My chest is fine."
●If asked about skin rash or eczema: "No, my skin is fine. No rashes or anything."
●If asked about ear symptoms: "My ears feel a bit blocked sometimes, like when you're on a plane, but they don't hurt."
●If asked about discharge from the eyes: "They're watery mostly — clear, not gunky. No yellow or green stuff."
●If asked about swelling of lips, tongue, or face (angioedema): "No, nothing like that — just the eyes puffing up."
●If asked about fever or feeling generally unwell: "No, I feel fine in myself. It's just the eyes and nose."
●If asked about recent eye injury or foreign body: "No, nothing like that."
●If asked about headache or sinus pain: "I do get a dull ache across here sometimes (gestures across forehead and cheeks), but it's not a proper headache."
●If asked about sleep: "It's rubbish. I can't breathe through my nose at night and the itching wakes me up. I'm shattered."
●If asked about food allergies or oral allergy syndrome: "No, I can eat anything. No problems with fruit or anything like that."
●If asked about impact on driving: "I can manage, but my eyes water so much sometimes I have to pull over and wipe them. It's not safe really."

Responses to Management (The Negotiation Phase)

●
If the Doctor prescribes Fexofenadine:
- ●Reaction: "Is that stronger than the supermarket ones? Will it make me drowsy? I drive a van for work."
●
If the Doctor suggests a different Eye Drop (Olopatadine):
- ●Reaction: "I can't be putting drops in four times a day with dirty gardening hands. Is there one that lasts longer?" (Olopatadine is BD).
●
If the Doctor discusses the Nasal Spray:
- ●Reaction: Skeptical. "But it's my eyes that are the problem, Doctor. Why do I need a nose spray?" (Needs explanation of the ocular reflex/naso-ocular reflex).
●
If the Doctor suggests taking time off:
- ●Reaction: "I can't. It's peak season. If I don't work, I don't get paid. I need a medical fix."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Clinical Learning Points

Distinguishing Allergic Conjunctivitis from Other Causes

●Seasonal allergic conjunctivitis (SAC) is characterised by bilateral itching (the cardinal symptom), watering, redness, and eyelid swelling (chemosis), closely associated with rhinitis and a clear seasonal or trigger-related pattern.
●Infective conjunctivitis should be suspected if there is purulent or mucopurulent discharge, crusting, or a unilateral onset — none of these features are present here.
●Red flags requiring same-day ophthalmology review: unilateral redness, deep eye pain (not surface grittiness), significant photophobia, reduced or blurred visual acuity, or a distorted/fixed pupil. These suggest serious pathology — uveitis, keratitis, or acute angle-closure glaucoma — and must not be missed.
●Periorbital swelling alone is not a red flag in the context of bilateral allergic conjunctivitis, but angioedema (rapidly spreading lid swelling, lip or tongue involvement) would require urgent assessment.

Why Current Treatment Has Failed — Compliance and Pharmacology

●Sodium cromoglicate is a pure mast cell stabiliser. It requires four-times-daily dosing and must be used consistently for several weeks before reaching full effect. Using it twice daily reactively is ineffective — the same principle applies to intranasal corticosteroids.
●Cetirizine is a first-generation-to-second-generation transitional antihistamine with mild sedating potential. At 10mg OD it is often insufficient for severe seasonal disease. Doubling the dose is not recommended and does not meaningfully improve efficacy.
●The nasal spray abandonment after a few days is one of the most common real-world adherence failures in allergic rhinitis management — and one of the most important to identify and correct.

Escalated Pharmacological Management

●Oral antihistamine: Switch to fexofenadine 120mg OD (licensed for rhinitis) or 180mg OD (for urticaria/severe disease). Fexofenadine is non-sedating with no significant CNS effect — safe for drivers and machine operators. It does not require dose doubling.
●Topical eye drops: Switch from cromoglicate to a dual-action antihistamine/mast cell stabiliser: olopatadine 0.1% (Opatanol) or ketotifen 0.025%. Both provide rapid symptom relief (onset within a few minutes) and are dosed twice daily — a clinically significant compliance advantage over QDS cromoglicate, particularly for a patient working outdoors with limited hand hygiene access.
●
Intranasal corticosteroid: Reintroduce mometasone furoate or fluticasone propionate nasal spray. Key prescribing education:
- ●Takes few hours to produce initial effect and 2 weeks for maximum efficacy — consistent daily use is essential from the outset of the pollen season, not just on symptomatic days.
- ●Technique matters: shake well, aim the nozzle laterally (away from the nasal septum), do not sniff hard after application.
- ●Frame this as a preventative treatment, not a rescue medication.
●Supportive measures: Cold compresses reduce eyelid oedema; preservative-free lubricant drops (single-use vials) wash allergens off the ocular surface and can be used with unwashed hands during the working day.

The Naso-Ocular Reflex — Why the Nasal Spray Helps the Eyes

●The naso-ocular reflex is a well-established physiological pathway: afferent signals from trigeminal nerve fibres in the nasal mucosa trigger efferent lacrimation and conjunctival vasodilation via parasympathetic pathways. Nasal pollen exposure directly drives ocular symptoms.
●This is why treating nasal inflammation with an intranasal corticosteroid produces measurable improvement in eye symptoms — even without additional topical ocular treatment.
●When a patient challenges the nasal spray recommendation ("but it's my eyes that are the problem"), this reflex is the explanation. A clear, patient-friendly framing: "The nerves in your nose and eyes are closely connected. When pollen inflames your nose, it sends signals that make your eyes water and itch. Calming the nose with the spray will genuinely help your eyes."

Allergen Reduction — Practical Advice for Outdoor Workers

●
Complete allergen avoidance is not achievable for a landscape gardener. Harm reduction strategies are the goal:
- ●Wraparound sunglasses or close-fitting safety goggles while working — significantly reduces direct ocular pollen exposure.
- ●Apply a thin layer of Vaseline (petroleum jelly) around the nostrils to trap pollen particles before they are inhaled.
- ●Shower and change clothes immediately after work — pollen accumulates on hair, skin, and clothing throughout the day.
- ●Keep van windows closed; use recirculated (not fresh) air on the air conditioning while driving.
- ●Monitor pollen forecasts (Met Office or Pollen UK) and schedule the most intensive outdoor tasks on lower-count days where possible.
- ●These measures are evidence-based supportive recommendations endorsed by BSACI guidelines for allergic rhinoconjunctivitis management.

Steroid Eye Drops — Do Not Prescribe in Primary Care

●Topical corticosteroid eye drops (e.g., dexamethasone, prednisolone acetate) should not be prescribed in primary care without specialist involvement.
●Risks include: raised intraocular pressure and steroid-induced glaucoma, posterior subcapsular cataracts with prolonged use, and reactivation of herpes simplex keratitis.
●If maximal primary care treatment (dual-action topical drops, oral fexofenadine, intranasal steroid) is insufficient, refer rather than escalate to topical steroids.

United Airways — Asthma Awareness

●Allergic rhinitis and asthma share a common underlying inflammatory mechanism (united airways disease). Poorly controlled rhinitis is an independent risk factor for worsening asthma control.
●Brenda has a background of mild asthma and reports an evening dry cough during a severe allergic flare. This warrants clinical attention: ask about wheeze, chest tightness, and nocturnal symptoms, and consider whether asthma reassessment is needed.
●Intranasal corticosteroids used for rhinitis have been shown to improve lower airway outcomes in patients with co-existent asthma — another reason to ensure consistent use.
●If asthma reassessment is indicated, this can be deferred to the follow-up appointment to avoid overloading this consultation.

Referral Criteria

●Refer to ophthalmology if: diagnosis is uncertain, visual acuity is reduced, or symptoms fail to respond to maximal first-line treatment (oral fexofenadine + dual-action topical drops + intranasal steroid).
●Consider referral to an allergy specialist for consideration of allergen immunotherapy (sublingual or subcutaneous grass pollen immunotherapy) if severe seasonal disease recurs despite optimal pharmacological management. Immunotherapy is the only disease-modifying treatment available and can significantly reduce symptom burden over subsequent seasons.

Safety Netting and Follow-Up

●Arrange review in 2–4 weeks to assess response to the escalated regimen, check nasal spray technique, and confirm compliance.
●Advise the patient to return urgently (same-day) if she develops: reduced or blurred vision, deep eye pain, significant photophobia, or unilateral redness — any of which would require same-day ophthalmology assessment.
●Non-urgent return if: new symptoms develop, the escalated plan produces no improvement within 2–4 weeks, or she develops any respiratory symptoms suggesting asthma deterioration.

Common Candidate Mistakes in This Case

●Prescribing a sedating antihistamine (e.g., chlorphenamine) to a patient who drives a van professionally — this is a prescribing safety failure. Always confirm driving and occupational status before choosing an antihistamine.
●Reintroducing the nasal spray without addressing why it failed — the patient abandoned it after a few days because no one explained the 2-week lag. Simply re-prescribing it without this conversation virtually guarantees the same outcome.
●Treating eyes and nose as separate problems — candidates who do not explain the naso-ocular reflex lose the opportunity to convert a sceptical patient and often face a standoff over the nasal spray.
●Prescribing QDS eye drops to a patient who has already disclosed she cannot manage QDS dosing while working outdoors — olopatadine or ketotifen's twice-daily regimen is clinically superior here for adherence, not just convenience.
●Omitting occupational and allergen-reduction advice — telling a landscape gardener to "avoid pollen" without practical strategies reflects a failure to engage with the patient's actual circumstances.

Mapped to the RCGP curriculum topic: Ophthalmology.

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