Safe Allergy Medications for Patients with Glaucoma
Patients with glaucoma should use second-generation oral antihistamines or topical dual-action antihistamine/mast cell stabilizers for allergy relief, while strictly avoiding first-generation antihistamines and decongestants due to their risk of triggering angle-closure glaucoma. 1
Understanding the Risks
Patients with glaucoma must be careful when selecting allergy medications because certain classes can significantly increase intraocular pressure (IOP) and potentially worsen glaucomatous damage. The primary concern is with medications that have anticholinergic properties, which can precipitate angle-closure glaucoma in susceptible individuals.
Medications to Avoid
- First-generation antihistamines (such as diphenhydramine, chlorpheniramine)
- Tricyclic antidepressants
- Anticholinergic or sympathomimetic decongestants
- Antispasmodics
These medications can cause mydriasis (pupil dilation) that may trigger angle-closure glaucoma in predisposed patients 2, 3.
Safe Medication Options
Topical Ocular Options (First-Line)
- Dual-action antihistamine/mast cell stabilizers:
- Olopatadine
- Epinastine
- Ketotifen
- Azelastine
These are preferred first-line therapies as they provide both immediate symptom relief and prevention of allergic conjunctivitis symptoms 1.
Oral Options (Second-Line)
- Second-generation antihistamines:
- Loratadine
- Cetirizine
- Fexofenadine
These have minimal anticholinergic effects and are generally safe for glaucoma patients 1.
Non-Pharmacological Interventions
- Cold compresses
- Refrigerated artificial tears
- Environmental controls:
- Hypoallergenic bedding
- Regular eyelid cleansing
- Frequent clothes washing
- Bathing/showering before bedtime
- Wearing sunglasses as a barrier to airborne allergens 1
Special Considerations
Corticosteroids
For severe allergic symptoms not controlled with first-line treatments, a brief course (1-2 weeks) of topical corticosteroids may be considered, with loteprednol etabonate being preferred due to its reduced risk of IOP elevation 1. However, baseline and periodic IOP measurements should be performed when using any corticosteroid.
Contact Lens Wearers
Contact lens wearers with glaucoma can use olopatadine 0.2%, but should remove lenses before instilling drops and wait at least 5 minutes before reinsertion 1.
Treatment Algorithm
- First-line: Topical dual-action antihistamine/mast cell stabilizers
- Second-line: Second-generation oral antihistamines
- For severe symptoms: Short-term topical corticosteroids (preferably loteprednol etabonate)
- Always incorporate: Non-pharmacological interventions
Important Warnings
- Never use oral decongestants or first-generation antihistamines if you have glaucoma
- Avoid eye drops containing vasoconstrictors (redness relievers) as chronic use can lead to rebound vasodilation 1
- Be cautious with any new medication and consult your ophthalmologist before starting allergy treatments
By following these guidelines, patients with glaucoma can safely manage their allergy symptoms while minimizing the risk of worsening their glaucoma condition.