What are the recommended eyedrops for allergic conjunctivitis?

Recommended Eyedrops for Allergic Conjunctivitis

For allergic conjunctivitis, dual-action antihistamine/mast cell stabilizer eyedrops such as ketotifen 0.025% or olopatadine are the most effective first-line treatments, offering rapid onset (within 15 minutes) and extended duration of action (up to 8 hours). 1

First-Line Treatment Options

Dual-Action Agents (Antihistamine + Mast Cell Stabilizer)

These medications are preferred due to their superior efficacy and convenience:

• Ketotifen fumarate 0.025% (Alaway, Zaditor)

  • Dosing: 1 drop in affected eye(s) twice daily, every 8-12 hours 2
  • Benefits: Rapid onset (15 minutes), extended duration (8 hours), effective for both acute and chronic symptoms 3
  • Suitable for adults and children ≥3 years 2

• Olopatadine (Pataday, Patanol)

  • Dosing: 1 drop in affected eye(s) twice daily, every 6-8 hours 4
  • Suitable for adults and children ≥2 years 4

• Other options: Azelastine (Optivar), Epinastine (Elestat) 1

Second-Line Treatment Options

Single-Action Agents

For patients who don't respond adequately to dual-action agents:

Antihistamines

• Emedastine (Emadine)
• Levocabastine (Livostin) 1

Mast Cell Stabilizers

• Cromolyn sodium (Opticrom, Crolom)
• Lodoxamide (Alomide)
• Nedocromil (Alocril)
• Pemirolast (Alamast) 1
  • Note: These have slower onset of action and require several days of treatment before optimal relief 1

For Moderate to Severe Cases

Short-Term Corticosteroids (for inadequate response to above treatments)

• Loteprednol etabonate 0.2% (Alrex)
  • Limited to brief courses (1-2 weeks) 1
  • Caution: Monitor for increased intraocular pressure and cataract formation 5

For Severe/Refractory Cases

• Topical cyclosporine 0.05% or tacrolimus may be considered 1

Supportive Measures

• Refrigerated artificial tears to dilute allergens and provide symptomatic relief 1
• Cold compresses to reduce inflammation and provide comfort 1
• Allergen avoidance strategies:
  • Wearing sunglasses outdoors
  • Hypoallergenic bedding
  • Eyelid cleansers to remove allergens
  • Frequent clothes washing
  • Bathing/showering before bedtime 1

Important Considerations

• Avoid prolonged use of vasoconstrictors (like tetrahydrozoline or naphazoline) as they can cause rebound hyperemia 1
• Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 1
• Avoid punctal plugs in allergic conjunctivitis as they prevent flushing of allergens from the ocular surface 1
• If using multiple ophthalmic products, wait at least 5 minutes between applications 4

Treatment Algorithm

1. Start with dual-action agent (ketotifen 0.025% or olopatadine)
2. Add refrigerated artificial tears and implement supportive measures
3. If inadequate response after 1 week: Consider short-term topical corticosteroid (1-2 weeks)
4. For severe/refractory cases: Consider topical cyclosporine or tacrolimus
5. For cases with significant systemic allergic symptoms: Consider consultation with allergist for possible immunotherapy 1

Monitoring

If corticosteroids are used, monitor intraocular pressure and examine for cataract formation. For patients with chronic allergic conjunctivitis, monitor for development of keratoconus, especially if eye rubbing is present 1.