What is the treatment for allergic conjunctivitis in children?

Treatment of Allergic Conjunctivitis in Children

Dual-action topical antihistamine/mast cell stabilizers are the first-line treatment for allergic conjunctivitis in children, with olopatadine being FDA-approved for children as young as 2 years of age. 1, 2

Step-wise Treatment Approach

First-line Treatment

• Topical dual-action antihistamine/mast cell stabilizers:
  • Olopatadine 0.1-0.2% (FDA approved for children ≥2 years): One drop in affected eye(s) once daily 1, 2
  • Other options: epinastine, ketotifen, azelastine 1, 3
  • These medications provide both immediate symptom relief and prevention of symptoms with onset within 30 minutes 1
  • More effective than single-action medications and have better local tolerability in children 4, 3

Non-pharmacological Interventions (Use alongside medications)

• Allergen avoidance: Identify and minimize exposure to potential allergens 1
• Cold compresses: Reduce local pain and swelling 1
• Preservative-free artificial tears: Dilute allergens and inflammatory mediators on the ocular surface 5, 1
• Environmental modifications:
  • Humidify ambient air to prevent tear evaporation
  • Avoid direct air drafts (fans, air conditioning) 1

Second-line Treatment (For moderate to severe symptoms)

• Short-term topical corticosteroids (1-2 weeks):
  • Loteprednol etabonate 0.2% is preferred due to reduced risk of intraocular pressure elevation 5, 1, 6, 7
  • Only use under ophthalmologist supervision due to risks of increased intraocular pressure and cataract formation 1
  • Baseline and periodic measurement of intraocular pressure should be performed 5

Third-line Treatment (For severe or refractory cases)

• Topical cyclosporine: For long-term management of severe cases 5, 1, 8
• Topical tacrolimus: Effective for severe allergic conjunctivitis 5, 1

Special Considerations for Children

• Age restrictions: Olopatadine is FDA approved for children 2 years and older; consult a doctor for children under 2 years 2
• Follow-up: Schedule follow-up within 1-2 weeks when initiating corticosteroid therapy 1
• Contact lens wearers: Remove lenses before instilling drops and wait at least 5 minutes before reinsertion 1
• Monitoring: Regular follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 5

When to Refer to an Ophthalmologist

Refer children with allergic conjunctivitis to an ophthalmologist in the following circumstances:

• Visual loss
• Moderate or severe pain
• Severe purulent discharge
• Corneal involvement
• Lack of response to therapy
• Recurrent episodes
• Suspected vernal keratoconjunctivitis or atopic keratoconjunctivitis 5, 1, 8

Cautions and Pitfalls

• Avoid prolonged use of ocular decongestants/vasoconstrictors (>10 days) as they can cause rebound hyperemia ("conjunctivitis medicamentosa") 1
• Oral antihistamines may induce or worsen dry eye syndrome and impair the tear film's protective barrier 5, 1
• Avoid punctal plugs as they prevent flushing of allergens and inflammatory mediators from the ocular surface 1
• Do not use steroid eye drops without ophthalmologist supervision 1
• Avoid tap water for irrigation if you suspect a corneal abrasion 1

Ketotifen fumarate 0.025% has been specifically studied in pediatric populations (ages 8-16) and shown to be effective and safe with no drug-related systemic adverse events reported 9, making it another good option for children with allergic conjunctivitis.