What are the treatment options for allergic conjunctivitis?

Treatment Options for Allergic Conjunctivitis

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

First-Line Treatment Options

Non-Pharmacological Approaches

• Cold compresses and irrigation with preservative-free artificial tears or saline solution to relieve mild symptoms 1
• Allergen avoidance by identifying and minimizing exposure to potential allergens 1
• Environmental modifications:
  • Humidify ambient air to prevent tear evaporation
  • Avoid direct air drafts (fans, air conditioning, heaters)
  • Follow the 20-20-20 rule for computer users (every 20 minutes, look at something 20 feet away for 20 seconds) 1

Pharmacological Approaches

1. Dual-action antihistamine/mast cell stabilizers (e.g., olopatadine, epinastine, ketotifen, azelastine)

   • Provide both immediate relief and prevention of symptoms
   • Most effective first-line therapy 1

2. Pure mast cell stabilizers (e.g., cromolyn sodium, lodoxamide, nedocromil)

   • Better for prevention than acute relief
   • Most effective when used before allergen exposure
   • Dosing: 1-2 drops in each eye 4-6 times daily at regular intervals 1, 2
   • Symptomatic response usually evident within days, but may require up to six weeks 2

3. Artificial tears

   • Help dilute allergens and inflammatory mediators on the ocular surface
   • Alleviate coexisting tear deficiency 3

Second-Line Treatment Options

1. Oral antihistamines

   • Second-generation (e.g., loratadine, cetirizine, fexofenadine) preferred due to less sedation
   • Effective for rhinorrhea, sneezing, itching, and allergic conjunctivitis
   • Limited effect on nasal congestion
   • May induce or worsen dry eye syndrome and impair tear film's protective barrier 3, 1

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

   • For severe symptoms unresponsive to first-line treatments
   • Loteprednol etabonate preferred due to reduced risk of intraocular pressure elevation
   • Requires ophthalmologist supervision due to risks of increased intraocular pressure and cataract formation 1
   • Baseline and periodic measurement of intraocular pressure should be performed 3, 1

Treatment for Severe/Refractory Cases

1. Topical cyclosporine

   • Effective for severe vernal/atopic conjunctivitis
   • Allows for reduced use of topical steroids
   • Shown to be effective in preventing seasonal recurrences 3, 1

2. Topical tacrolimus

   • Effective for severe cases of allergic conjunctivitis
   • For eyelid involvement: pimecrolimus cream 1% or tacrolimus ointment 0.03% (ages 2-15) or 0.03%/0.1% (ages 16+) 3, 1

3. Allergen-specific immunotherapy

   • Useful for hyposensitization in recurrent cases
   • May be limited by expense, long-term patient commitment, and risk of anaphylaxis 3, 1

4. Consultation with specialist

   • Consider referral to allergist or dermatologist for disease that cannot be adequately controlled with topical medications and oral antihistamines 3

Common Pitfalls to Avoid

• Avoid punctal plugs as they prevent flushing of allergens and inflammatory mediators from the ocular surface 3, 1
• Avoid prolonged use of topical ocular vasoconstrictors as they can cause rebound hyperemia ("conjunctivitis medicamentosa") 1
• Avoid topical ocular corticosteroids without ophthalmologist supervision due to risks of increased intraocular pressure and cataract formation 1
• Avoid first-generation antihistamines due to sedation and anticholinergic effects 1
• Contact lens wearers should remove lenses before instilling drops and wait at least 5 minutes before reinsertion 1

Follow-up Recommendations

• Schedule follow-up based on severity of disease, etiology, and treatment
• Consider timing visits during symptomatic periods
• Follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy
• If corticosteroids are used, monitor for glaucoma and cataract formation with baseline and periodic IOP measurements 3, 1
• Schedule follow-up within 1-2 weeks when initiating corticosteroid therapy 1