From the Guidelines
For itchy eyes that are not responding to topical and oral antihistamines, I recommend trying a topical mast cell stabilizer such as cromolyn sodium 4% eye drops (4-6 times daily) or a combination antihistamine/mast cell stabilizer like olopatadine 0.1% (twice daily) or ketotifen 0.025% (twice daily) as the first line of treatment. These options are supported by the most recent evidence from 1, which suggests that topical medications can be effective in managing seasonal allergic conjunctivitis.
Key Considerations
- Topical corticosteroids, such as loteprednol 0.5% eye drops, can be considered for a short course (1-2 weeks) under medical supervision if the symptoms persist, as they have a low side effect profile and can provide relief for severe symptoms 1.
- Preservative-free artificial tears used frequently can help flush allergens and provide relief, and concomitant use of cooled preservative-free artificial tears may alleviate coexisting tear deficiency and dilute allergens and inflammatory mediators on the ocular surface 1.
- Identifying and avoiding triggers is crucial, and common culprits include pollen, pet dander, dust mites, and makeup.
- If symptoms persist despite these measures, it is essential to see an ophthalmologist or allergist as you may have a condition beyond allergic conjunctivitis, such as dry eye syndrome, contact lens-related issues, or ocular rosacea.
Additional Treatment Options
- Topical cyclosporine or tacrolimus can be considered in severe cases, as they have been shown to be effective in reducing signs and symptoms of vernal keratoconjunctivitis 1.
- Cold compresses applied for 5-10 minutes several times daily can reduce inflammation and itching.
- Refractory itchy eyes often indicate that the underlying inflammation has become self-perpetuating, requiring anti-inflammatory treatment rather than just antihistamines, which primarily block histamine receptors but don't address ongoing inflammatory cascades.
From the Research
Treatment Options for Itchy Eyes Refractory to Topical and Oral Antihistamine
- For patients with itchy eyes that are refractory to topical and oral antihistamine, treatment with topical corticosteroids may be considered, although long-term use can have significant side-effects 2.
- Topical immunomodulatory agents, such as cyclosporine A and tacrolimus, can be used to inhibit T-cell activation and have shown encouraging results in patients with severe allergic eye conditions 2, 3.
- In cases of severe allergic conjunctivitis, treatment with topical cyclosporin A 0.05% has been shown to decrease the severity of symptoms and clinical signs, and can reduce the need for steroids 3.
- For chronic conjunctivitis, treatment with mast cell stabilizers, antihistamines, or topical corticosteroids may be required, while atopic keratoconjunctivitis may require treatment with corticosteroid and cyclosporine eye drops 4.
- A multifaceted treatment regimen comprising patient education, lifestyle modification, and topical medications (such as antihistamines and/or mast cell stabilizers and corticosteroids) may be required to manage ocular allergies effectively 5.
Specific Treatment Agents
- Topical dual-action antihistamines/mast cell stabilizers, such as olopatadine, azelastine, ketotifen, and epinastine, are commonly used to treat mild subtypes of allergic conjunctivitis 6.
- High-concentration olopatadine 0.77% has been shown to have a longer duration of action and better efficacy on ocular itch compared to low-concentration olopatadine 0.2% 6.
- Alcaftadine has been shown to have H4 receptor inverse agonism, anti-inflammatory, and mast cell stabilizing activities, making it a potential treatment option for allergic conjunctivitis 6.