DECA Criteria for Allergic Conjunctivitis
The DECA criteria are validated patient-reported tools from the Spanish consensus document that classify allergic conjunctivitis severity (mild, moderate, or severe) and control status (controlled vs. non-controlled), providing a practical framework for diagnosis and treatment decisions. 1
Severity Classification
The DECA criteria stratify allergic conjunctivitis into three severity levels based on symptom intensity and impact 1:
- Mild: Minimal ocular symptoms that do not significantly interfere with daily activities 1
- Moderate: Noticeable ocular symptoms causing some functional impairment 1
- Severe: Substantial ocular symptoms with marked impact on quality of life and daily functioning 1
The criteria demonstrated strong discriminant validity, effectively differentiating between these three severity categories in validation studies 1.
Control Assessment
Allergic conjunctivitis is considered controlled when all three of the following criteria are met 2:
- Ocular symptoms are not uncomfortable or present on at most 2 days per week 2
- Visual analog scale (VAS) score for ocular symptoms is below 5 2
- Conjunctival hyperemia is graded 0 or 1 on the Efron scale 2
Patients not meeting these criteria are classified as non-controlled and require treatment escalation 1, 2.
Diagnostic Approach
The DECA framework emphasizes that ocular symptoms should be assessed independently from rhinitis symptoms, even though allergic conjunctivitis commonly coexists with allergic rhinitis 1:
- Evaluate ocular-specific symptoms including itching, hyperemia, lacrimation, and foreign body sensation 3
- Confirm Type I allergic diathesis through appropriate testing 3
- Document both subjective symptoms and objective findings (conjunctival hyperemia, swelling, folliculosis, papillae) 3
- Use the reflective total ocular symptom score (rTOSS) and conjunctival hyperemia scales as complementary assessments 1
Management Algorithm Based on DECA Classification
For Mild to Moderate Severity:
- First-line: Antiallergic eye drops (mast cell stabilizers with antihistaminic action), preferably single-dose or preservative-free formulations 4
- Non-pharmacological measures: lacrimal substitutes, allergen avoidance, ocular surface protection 4
For Severe or Non-Controlled Cases:
- Second-line: Short-course topical corticosteroids to control acute flare-ups 4, 3
- Third-line: Cyclosporine eye drops for disease-modifying treatment in refractory cases 4
- Specialized ophthalmologic follow-up is mandatory for severe forms 4
Clinical Validation and Utility
The DECA criteria showed strong correlation with established instruments including the modified ARIA criteria, RCAT, and ESPRINT-15 questionnaires 1:
- Demonstrated satisfactory longitudinal validity and responsiveness to treatment changes 1
- Particularly useful for monitoring therapy effectiveness over time 1
- Can be used as a patient-reported outcome measure in both clinical practice and research settings 1
Important Caveats
Refer to ophthalmology when 4:
- Conjunctivitis occurs without rhinitis
- Suspicion of vernal keratoconjunctivitis, atopic keratoconjunctivitis, or perennial allergic conjunctivitis
- Vision-threatening features are present 2
- IgE-mediated testing fails to establish diagnosis (consider conjunctival allergen provocation testing) 4
The DECA criteria specifically address IgE-mediated allergic conjunctivitis and should not be applied to non-IgE-mediated conditions like chronic blepharoconjunctivitis 4.