What is the treatment for allergic conjunctivitis?

Treatment of Allergic Conjunctivitis

Dual-action antihistamine/mast cell stabilizers (e.g., olopatadine, epinastine, ketotifen, azelastine) are the preferred first-line therapy for allergic conjunctivitis, providing both immediate symptom relief and prevention of symptoms. 1

First-Line Treatment Approach

1. Non-pharmacological interventions:

   • Cold compresses to reduce inflammation and provide symptomatic relief 2, 1
   • Refrigerated artificial tears to dilute allergens and provide cooling relief 2, 1
   • Environmental controls:
     • Wearing sunglasses as a barrier to airborne allergens 2, 1
     • Using hypoallergenic bedding 2, 1
     • Cleaning eyelids to remove allergens 2, 1
     • Frequent clothes washing 2, 1
     • Bathing/showering before bedtime 2, 1
   • Avoiding eye rubbing (important to prevent keratoconus progression) 2, 1

2. Pharmacological interventions:

   • First-line: Dual-action antihistamine/mast cell stabilizers 1
     • Examples: Olopatadine, Epinastine, Ketotifen, Azelastine
     • Benefits: Provide both immediate relief and prevention
     • Many can be refrigerated for additional cooling relief 2

Second-Line Treatment Options

For cases not adequately controlled with first-line therapy:

1. Pure antihistamines:

   • Examples: Emedastine, Levocabastine 1
   • Useful for acute symptom relief

2. Pure mast cell stabilizers:

   • Examples: Lodoxamide, Nedocromil, Pemirolast, Cromolyn 1
   • Better for prevention than acute relief
   • Most effective when used before allergen exposure 2

3. Short-term topical corticosteroids (1-2 weeks):

   • For severe symptoms unresponsive to other treatments 2, 1
   • Loteprednol etabonate is preferred due to reduced risk of IOP elevation 1, 3
   • FDA-approved specifically for seasonal allergic conjunctivitis 3
   • Caution: Monitor for glaucoma and cataract with regular use 2

4. Oral antihistamines:

   • Can be considered for concurrent nasal symptoms 4
   • Caution: May induce or worsen dry eye syndrome 2, 1

Monitoring and Follow-up

• Follow-up visits should include:

  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy 2, 1

• If corticosteroids are used:

  • Baseline and periodic measurement of intraocular pressure
  • Pupillary dilation to evaluate for cataract 2, 1

Special Considerations

• Contact lens wearers:

  • Remove lenses before instilling drops
  • Wait at least 5 minutes before reinsertion 1

• Keratoconus risk:

  • Allergic conjunctivitis and eye rubbing are associated with keratoconus
  • Adequate control of allergy symptoms is important to prevent progression 2, 1

• Rebound effects:

  • Avoid chronic use of vasoconstrictor agents as they can cause rebound vasodilation 2, 1

• Severe/refractory cases:

  • Consider topical cyclosporine or tacrolimus 2
  • Allergen-specific immunotherapy for long-term management 1

Treatment Algorithm

1. Start with non-pharmacological measures + dual-action antihistamine/mast cell stabilizer
2. If inadequate control after 1-2 weeks, add pure antihistamine or pure mast cell stabilizer
3. For severe symptoms or acute exacerbations, add short-term (1-2 weeks) topical corticosteroid (preferably loteprednol)
4. Consider oral antihistamines only if concurrent nasal symptoms are present
5. For refractory cases, consider referral to specialist for immunotherapy or other advanced options

The evidence consistently shows that topical antihistamines and mast cell stabilizers effectively reduce symptoms of allergic conjunctivitis compared to placebo 5, with dual-action agents providing the most comprehensive relief 1. While corticosteroids are highly effective for inflammation, their use should be limited to short courses due to potential side effects 6.