What is the treatment for allergic conjunctivitis?

Treatment of Allergic Conjunctivitis

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

First-Line Treatment Options

Non-Pharmacological Approaches

• Preservative-free artificial tears (2-4 times daily)
  • Dilutes allergens and inflammatory mediators on the ocular surface 1
  • Provides symptomatic relief

Pharmacological Approaches

• Dual-action topical antihistamine/mast cell stabilizers
  • Olopatadine: twice daily for ages >3 years 1
  • Ketotifen: twice daily for ages >3 years 1
  • Epinastine: twice daily for ages >12 years 1
  • Azelastine: 2-4 times daily for ages >4 years 1

Second-Line Treatment Options

For Severe or Refractory Symptoms

• Short-term topical corticosteroids (e.g., loteprednol etabonate 0.2%)

  • Indicated for temporary relief of signs and symptoms of seasonal allergic conjunctivitis 2
  • Should only be used under ophthalmologist supervision due to risk of intraocular pressure elevation 1
  • Inhibits inflammatory response by inducing phospholipase A2 inhibitory proteins 2
  • Clinical trials have shown effectiveness in reducing bulbar conjunctival injection and itching, beginning approximately 2 hours after first dose 2

• Topical cyclosporine and tacrolimus

  • Consider for long-term management of severe or refractory cases 1

Systemic Options

• Oral antihistamines (preferably second-generation)

  • Effective for allergic conjunctivitis with concurrent rhinitis 1, 3
  • Caution: May induce or worsen dry eye syndrome 1

• Intranasal corticosteroids

  • First-line for moderate-to-severe symptoms or when congestion is prominent 1
  • More effective when combined with antihistamines 1

• Leukotriene receptor antagonists (e.g., montelukast)

  • Similar efficacy to antihistamines 1
  • Particularly useful with comorbid asthma 1

Lifestyle Modifications

• Apply cold compresses to reduce local pain and swelling 1
• Identify and avoid allergen triggers 1
• Humidify ambient air and avoid direct air drafts 1
• For computer users:
  • Follow the 20-20-20 rule (every 20 minutes, look at something 20 feet away for 20 seconds) 1
  • Position screens below eye level 1
  • Take regular breaks and blink fully and regularly 1

Monitoring and Follow-Up

• Regular follow-up visits should include:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy 1
• For patients using topical corticosteroids:
  • Schedule follow-up within 1-2 weeks 1
  • Monitor intraocular pressure 1, 2

Special Considerations

For Contact Lens Wearers

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

Pediatric Considerations

• Refer children to an ophthalmologist in cases of:
  • Visual loss
  • Moderate or severe pain
  • Severe purulent discharge
  • Corneal involvement
  • Lack of response to therapy
  • Recurrent episodes
  • Suspected vernal keratoconjunctivitis or atopic keratoconjunctivitis 1, 4

Potential Pitfalls and Cautions

• Avoid prolonged use of ocular decongestants/vasoconstrictors - can cause rebound hyperemia ("conjunctivitis medicamentosa") 1
• Avoid tap water irrigation if corneal abrasion or epithelial defect is suspected 1
• Avoid punctal plugs as they prevent flushing of allergens and inflammatory mediators 1
• Limit topical decongestant use to 3 days to prevent rhinitis medicamentosa 1
• Monitor blood pressure in hypertensive patients taking oral decongestants 1
• Avoid first-generation antihistamines due to sedation and anticholinergic effects 1
• Use corticosteroids with caution - can increase intraocular pressure, cause cataract formation, and mask infection 1, 2, 5