What is the best way to manage allergic conjunctivitis?

Management of Allergic Conjunctivitis

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

First-Line Treatment Options

1. Preservative-free artificial tears

   • Apply 2-4 times daily to dilute allergens and inflammatory mediators on the ocular surface 1
   • Helps flush allergens from the eye

2. Dual-action topical antihistamine/mast cell stabilizers

   • Olopatadine: twice daily for ages >3 years 1
   • Ketotifen: twice daily for ages >3 years 1, 2
   • Epinastine: twice daily for ages >12 years 1
   • Azelastine: 2-4 times daily for ages >4 years 1

Second-Line and Severe Case Management

1. Short-term topical corticosteroids

   • Loteprednol etabonate 0.2% is preferred for severe symptoms unresponsive to first-line treatments 1, 3
   • Must be used under ophthalmologist supervision due to risk of intraocular pressure elevation 1, 3
   • Corticosteroids inhibit inflammatory response by inducing phospholipase A2 inhibitory proteins (lipocortins) 3
   • Loteprednol etabonate has a better safety profile than traditional corticosteroids due to its rapid metabolism to inactive compounds 3, 4

2. Systemic medications

   • Second-generation oral antihistamines for concurrent rhinitis symptoms 1
   • Intranasal corticosteroids for moderate-to-severe symptoms or prominent congestion 1
   • Leukotriene receptor antagonists (e.g., montelukast) particularly useful with comorbid asthma 1

3. Refractory cases

   • Topical cyclosporine and tacrolimus for long-term management of severe cases 1, 5

Non-Pharmacological Interventions

1. Cold compresses

   • Apply for 5 minutes to reduce local pain and swelling 1, 6
   • Research shows cold compresses can enhance the effect of pharmacological treatments 6

2. Allergen avoidance

   • Identify and minimize exposure to potential allergens 1
   • Critical component of long-term management

3. Environmental modifications

   • Humidify ambient air to prevent tear evaporation 1
   • Avoid direct air drafts (fans, air conditioning, heaters) 1
   • Follow the 20-20-20 rule for computer users (every 20 minutes, look at something 20 feet away for 20 seconds) 1

Follow-Up and Monitoring

• Regular follow-up visits should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 1
• For patients using topical corticosteroids:
  • Schedule follow-up within 1-2 weeks 1
  • Monitor intraocular pressure regularly 1, 3
  • Watch for cataract formation with prolonged use 3

Important Cautions and Pitfalls

• Avoid prolonged use of ocular decongestants/vasoconstrictors due to risk of rebound hyperemia ("conjunctivitis medicamentosa") 1
• Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 1
• Avoid tap water for irrigation if you suspect a corneal abrasion or have a known corneal epithelial defect 1
• Contact lens wearers should remove lenses before instilling drops and wait at least 5 minutes before reinsertion 1
• Avoid punctal plugs as they prevent flushing of allergens and inflammatory mediators from the ocular surface 1

Special Considerations for Children

• 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, 5

Treatment Algorithm

1. Mild cases:

   • Preservative-free artificial tears + cold compresses
   • Add topical dual-action antihistamine/mast cell stabilizer if symptoms persist

2. Moderate cases:

   • Topical dual-action antihistamine/mast cell stabilizer
   • Consider adding oral antihistamine for concurrent rhinitis

3. Severe cases:

   • Short-term topical corticosteroid (preferably loteprednol etabonate) under ophthalmologist supervision
   • Consider topical cyclosporine or tacrolimus for long-term management

4. Refractory cases:

   • Ophthalmology referral
   • Consider immunotherapy for identified allergens 5, 7