Best Criteria to Grade Severity of Allergic Conjunctivitis
The 5-5-5 exacerbation grading scale is the most validated and practical scoring system for grading allergic conjunctivitis severity, using a weighted point system that assigns 100 points to severe corneal/conjunctival findings, 10 points to moderate inflammatory signs, and 1 point to mild surface changes. 1
The 5-5-5 Exacerbation Grading Scale
This scoring system provides objective, quantifiable assessment across all types of allergic conjunctivitis disease (ACD) and has been validated to differentiate between disease subtypes 1:
100-Point Grade Group (Severe Findings)
Each observation scores 100 points 1:
- Active giant papillae
- Gelatinous infiltrates of the limbus
- Exfoliative epithelial keratopathy
- Shield ulcer
- Papillary proliferation at lower palpebral conjunctiva
10-Point Grade Group (Moderate Findings)
Each observation scores 10 points 1:
- Blepharitis
- Papillary proliferation with velvety appearance
- Horner-Trantas spots
- Edema of bulbar conjunctiva
- Superficial punctate keratopathy
1-Point Grade Group (Mild Findings)
Each observation scores 1 point 1:
- Papillae at upper palpebral conjunctiva
- Follicular lesion at lower palpebral conjunctiva
- Hyperemia of palpebral conjunctiva
- Hyperemia of bulbar conjunctiva
- Lacrimal effusion
Severity Classification Based on Total Score
The validated score ranges demonstrate clear differentiation between disease types 1:
- Vernal keratoconjunctivitis (VKC): Median score 243 (range 12-444) - typically severe
- Atopic keratoconjunctivitis (AKC): Median score 32.5 (range 11-344) - typically moderate
- Seasonal/Perennial allergic conjunctivitis (SAC/PAC): Median score 13 (range 2-33) - typically mild
These score ranges allow classification into mild, moderate, or severe categories, which directly guides treatment intensity. 1
Clinical Application
The weighted scoring system reflects the clinical significance of findings, where corneal involvement and severe conjunctival changes (100-point findings) indicate need for aggressive management including potential ophthalmology referral 2. The system accounts for the spectrum from simple SAC/PAC (predominantly 1-point findings) to chronic severe forms like VKC and AKC (multiple 100-point and 10-point findings) 3.
For moderate-to-severe cases, especially chronic VKC, AKC, and giant papillary conjunctivitis, comanagement with an ophthalmologist is recommended. 2
Important Caveats
The presence of any 100-point findings (particularly shield ulcer or exfoliative epithelial keratopathy) indicates severe disease requiring immediate ophthalmologic evaluation, regardless of total score 1. These findings represent sight-threatening complications that can lead to permanent ocular surface damage 3.