What is the first-line treatment for allergic conjunctivitis?

From the Guidelines

The first-line treatment for allergic conjunctivitis is topical antihistamine-mast cell stabilizer combination eye drops, such as olopatadine (Patanol) 0.1% or 0.2%, ketotifen (Zaditor) 0.025%, or azelastine 0.05%, typically administered 1-2 drops in the affected eye(s) twice daily. These medications work quickly to relieve symptoms while also preventing further allergic reactions 1. For mild cases, artificial tears used 4-6 times daily can help dilute allergens and provide symptomatic relief. Cold compresses applied to closed eyelids for 5-10 minutes several times daily can reduce itching and swelling. Patients should also practice allergen avoidance by identifying and minimizing exposure to triggers, keeping windows closed during high pollen seasons, washing hands after petting animals, and avoiding eye rubbing.

Key Considerations

• Topical antihistamine-mast cell stabilizer combination eye drops are preferred as first-line therapy because they provide both immediate relief of symptoms through antihistamine action and longer-term prevention through mast cell stabilization, addressing both the immediate symptoms and underlying allergic mechanisms 1.
• Artificial tears and cold compresses can be used as adjunctive therapies to provide symptomatic relief.
• Allergen avoidance is crucial in managing allergic conjunctivitis, and patients should be educated on ways to minimize exposure to triggers.

Treatment Options

• Topical antihistamine-mast cell stabilizer combination eye drops: olopatadine (Patanol) 0.1% or 0.2%, ketotifen (Zaditor) 0.025%, or azelastine 0.05% 1.
• Artificial tears: used 4-6 times daily to dilute allergens and provide symptomatic relief.
• Cold compresses: applied to closed eyelids for 5-10 minutes several times daily to reduce itching and swelling.

Important Notes

• Vasoconstrictors can be used for short-term relief of ocular redness, but prolonged use can lead to rebound hyperemia or conjunctivitis medicamentosa 1.
• Mast cell stabilizers can be used for prophylactic or longer-term treatment of chronic ocular allergies, but may require several days of treatment before optimal symptom relief is achieved 1.
• Ocular corticosteroids should be reserved for more severe symptoms of allergic conjunctivitis, as they can have vision-threatening side effects 1.

From the FDA Drug Label

Loteprednol Etabonate Ophthalmic Suspension, 0.2% is indicated for the temporary relief of the signs and symptoms of seasonal allergic conjunctivitis. In two double-masked, placebo-controlled six-week environmental studies of 268 patients with seasonal allergic conjunctivitis, Loteprednol Etabonate Ophthalmic Suspension, 0. 2%, when dosed four times per day was superior to placebo in the treatment of the signs and symptoms of seasonal allergic conjunctivitis.

The firstline treatment for allergic conjunctivitis is Loteprednol Etabonate Ophthalmic Suspension, 0.2% 2, which is indicated for the temporary relief of the signs and symptoms of seasonal allergic conjunctivitis 2.

• The recommended dosage is four times per day.
• It provides reduction in bulbar conjunctival injection and itching, beginning approximately 2 hours after instillation of the first dose and throughout the first 14 days of treatment.

From the Research

First-Line Treatment for Allergic Conjunctivitis

• The first-line treatment for allergic conjunctivitis includes dual-acting antihistamine-mast cell stabilizing agents, which provide acute relief of signs and symptoms and block persistent inflammation to promote regression of the condition 3.
• Topical antihistamines and mast cell stabilisers are also considered effective for treating seasonal and perennial allergic conjunctivitis, with some evidence suggesting they reduce symptoms and signs of the condition when compared with placebo 4.
• Dual-action antihistamines/MCS, such as olopatadine, azelastine, ketotifen, and epinastine, are commonly used for mild subtypes of allergic conjunctivitis and have been shown to be effective in reducing ocular itch and conjunctival hyperemia 5.

Treatment Options

• Antihistamines, cromoglycate, and short courses of corticosteroids are used to treat seasonal atopic conjunctivitis, while chronic conjunctivitis requires year-round treatment with mast cell stabilizers, antihistamines, or topical corticosteroids 6.
• Mast cell stabilizers and corticosteroid eye drops are used as first-line therapy for vernal conjunctivitis, and treatment of non-allergic eosinophilic conjunctivitis involves mast cell stabilizers, corticosteroid, and cyclosporine eye drops if necessary 6.
• Loteprednol etabonate, a novel corticosteroid, has been shown to be effective in preventing or treating the signs and symptoms of seasonal allergic conjunctivitis with a greatly improved safety profile compared to traditional corticosteroids 7.

Key Findings

• Dual-acting antihistamine-mast cell stabilizing agents are considered first-line therapeutics for allergic conjunctivitis due to their ability to provide acute relief and block persistent inflammation 3.
• High-concentration olopatadine has been shown to have a longer duration of action and better efficacy on ocular itch compared to low-concentration olopatadine 5.
• Topical antihistamines and mast cell stabilisers are well-tolerated and appear to be safe for short-term use, but long-term data on their efficacy is limited 4.