What is the treatment for allergic conjunctivitis?

Treatment for Allergic Conjunctivitis

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

First-Line Treatment Options

Pharmacological Interventions

1. Dual-action antihistamine/mast cell stabilizers

   • Medications: olopatadine, epinastine, ketotifen, azelastine
   • Benefits: Provide both immediate relief and prevention of symptoms
   • Mechanism: Block histamine receptors and prevent mast cell degranulation
   • High-concentration olopatadine 0.77% has shown longer duration of action and better efficacy for ocular itch compared to lower concentrations 2

2. Pure mast cell stabilizers

   • Medications: lodoxamide, nedocromil, pemirolast, cromolyn
   • Best used: Preventively, before allergen exposure
   • Note: Less effective for acute symptom relief 1

3. Short-term topical corticosteroids (for severe cases)

   • Recommended: Loteprednol etabonate 0.2%
   • Duration: Limited to 1-2 weeks
   • FDA-approved specifically for seasonal allergic conjunctivitis 3
   • Advantage: Reduced risk of intraocular pressure elevation compared to other corticosteroids 1, 4
   • Mechanism: Inhibits inflammatory response by inducing phospholipase A2 inhibitory proteins 3

Non-Pharmacological Interventions

• Cold compresses to reduce inflammation and provide symptomatic relief
• Refrigerated artificial tears to dilute allergens and provide cooling relief
• Environmental controls:
  • Wearing sunglasses outdoors
  • Using hypoallergenic bedding
  • Regular eyelid cleaning
  • Frequent clothes washing
  • Bathing/showering before bedtime
• Avoiding eye rubbing (important to prevent keratoconus progression) 1

Treatment Algorithm

1. Mild symptoms:

   • Start with non-pharmacological measures
   • Add dual-action antihistamine/mast cell stabilizer if symptoms persist

2. Moderate symptoms:

   • Dual-action antihistamine/mast cell stabilizer as primary therapy
   • Consider oral antihistamines if concurrent nasal symptoms exist (caution: may worsen dry eye)

3. Severe symptoms or acute exacerbations:

   • Short-term topical corticosteroid (loteprednol etabonate 0.2%) for 1-2 weeks
   • Continue dual-action antihistamine/mast cell stabilizer

Monitoring and Follow-up

• For patients on corticosteroids: Baseline and periodic measurement of intraocular pressure
• Follow-up visits should include:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy 1

Important Considerations and Pitfalls

• Contact lens wearers: Remove lenses before instilling drops and wait at least 5 minutes before reinsertion 1

• Avoid long-term corticosteroid use: Despite loteprednol's improved safety profile, prolonged use still carries risks of glaucoma and cataract formation 4

• Avoid vasoconstrictors for chronic use: Can cause rebound vasodilation with prolonged use 1, 5

• Oral antihistamines caution: May induce or worsen dry eye syndrome 1

• Avoid punctal plugs: These prevent flushing of allergens and inflammatory mediators from the ocular surface 1

• Monitor for keratoconus: Allergic conjunctivitis and eye rubbing are associated with keratoconus development 1