What is the appropriate management for itchy irritated eyes?

Management of Itchy Irritated Eyes

For itchy irritated eyes, first-line treatment should be preservative-free artificial tears to dilute allergens and inflammatory mediators, followed by dual-action topical antihistamine/mast cell stabilizers such as olopatadine or ketotifen if symptoms persist. 1

Initial Assessment and Treatment Algorithm

First-Line Treatment:

• Preservative-free ocular lubricants/artificial tears
  • Apply 2-4 times daily 2, 1
  • Formulations with higher hyaluronate percentage offer greater efficacy for more severe symptoms 1
  • Helps dilute allergens and inflammatory mediators on the ocular surface 1

Second-Line Treatment (if lubricants alone are ineffective):

• Topical antihistamine/mast cell stabilizer eyedrops 2, 1
  • Options include:
    • Olopatadine: Apply twice daily (for ages >3 years) 2, 3
    • Ketotifen: Apply twice daily (for ages >3 years) 2, 4
    • Epinastine: Apply twice daily (for ages >12 years) 2
    • Azelastine: Apply 2-4 times daily (for ages >4 years) 2

Non-Pharmacological Interventions

• Apply cold compresses to reduce local pain and swelling 1
• Identify and avoid potential allergens 1
• Follow the 20-20-20 rule for computer users (every 20 minutes, look at something 20 feet away for 20 seconds) 1
• Humidify ambient air and avoid direct air drafts 1
• Make conscious effort to blink fully and regularly 1

Important Precautions

• For contact lens wearers:
  • Remove lenses before instilling drops 1, 4
  • Wait at least 10 minutes before reinserting lenses 4
• Avoid tap water for irrigation if corneal abrasion is suspected 1
• Do not touch tip of container to any surface to avoid contamination 4
• Replace cap after each use 4

When to Refer to Ophthalmology

• Moderate to severe pain
• Visual loss
• Severe purulent discharge
• Corneal involvement
• Lack of response to therapy after 72 hours 1, 4
• Recurrent episodes 1

Special Considerations

• Avoid prolonged use of ocular decongestants/vasoconstrictors as they can cause rebound hyperemia ("conjunctivitis medicamentosa") 1
• Oral antihistamines may worsen dry eye syndrome 1
• Topical corticosteroids should only be used under ophthalmologist supervision for severe symptoms unresponsive to other treatments 1

Evidence Quality

Research shows that both ketotifen and olopatadine effectively reduce symptoms of allergic conjunctivitis compared to placebo, with studies demonstrating they diminish the expression of inflammatory markers on conjunctival surface cells 5. A Cochrane review found that topical antihistamines and mast cell stabilizers are effective in reducing symptoms of seasonal allergic conjunctivitis in the short term 6. The American Academy of Ophthalmology and the American Academy of Allergy, Asthma, and Immunology recommend dual-action topical antihistamine/mast cell stabilizers as effective first-line therapy 1.