What is the management and treatment of allergic conjunctivitis?

Management and Treatment of Allergic Conjunctivitis

The management of allergic conjunctivitis should follow a stepwise approach, starting with allergen avoidance and lacrimal substitutes, progressing to dual-action antihistamine/mast cell stabilizer eye drops for mild to moderate cases, and reserving short-term topical corticosteroids for severe or refractory cases. 1, 2

Diagnosis

• Allergic conjunctivitis is typically diagnosed clinically based on:
  • Characteristic symptoms: ocular pruritus (hallmark symptom), epiphora, and hyperemia
  • History of seasonal or perennial allergic triggers
  • Associated allergic conditions (e.g., allergic rhinitis)
• Diagnostic tests are rarely necessary for typical presentations 2
• Ophthalmology referral is indicated when:
  • Conjunctivitis occurs without rhinitis
  • More severe forms are suspected (vernal keratoconjunctivitis or atopic keratoconjunctivitis)
  • Symptoms are refractory to standard treatment 1

Treatment Algorithm

First-Line: Non-Pharmacological Approaches

• Environmental modification and allergen avoidance:
  • Reduce exposure to identified allergens (pollen, dust mites, pet dander)
  • Use air conditioning or air purifiers
  • Wash bedding frequently in hot water
• Proper eye care:
  • Cold compresses to reduce inflammation and provide symptomatic relief
  • Artificial tears/lacrimal substitutes (preferably preservative-free) to dilute and flush allergens 1, 2

Second-Line: Pharmacological Treatment for Mild-Moderate Cases

• Topical ophthalmic medications (preferred over systemic):
  • Dual-action agents (combined antihistamine/mast cell stabilizers) are most effective:
    • Provide immediate relief (antihistamine effect) and prevent future reactions (mast cell stabilization)
    • Examples include olopatadine, ketotifen, epinastine
  • Single-dose formulations or preservative-free options are preferred 1
  • For mild cases, decongestant/antihistamine combinations may provide short-term relief 2

Third-Line: Treatment for Moderate-Severe or Refractory Cases

• Oral antihistamines may be added for concurrent allergic rhinitis 2
• Topical ophthalmic corticosteroids:
  • Reserved for severe flare-ups or refractory cases
  • Short-term use only (1-2 weeks) due to potential side effects
  • Ester-based corticosteroids (e.g., loteprednol etabonate) have improved safety profiles with lower risk of IOP elevation and cataract formation compared to ketone-based steroids 3
  • Require ophthalmology monitoring if used beyond short-term 1
• Topical cyclosporine:
  • Disease-modifying treatment for severe forms
  • Well-tolerated and effective for chronic cases 1

Fourth-Line: Advanced Therapies

• Immunotherapy:
  • Consider for patients with identified allergens and inadequate response to conventional treatments
  • Can modify the underlying allergic response 2, 4

Special Considerations

Different Forms of Allergic Conjunctivitis

• Seasonal allergic conjunctivitis (SAC):
  • Typically associated with specific pollen seasons
  • Often co-exists with allergic rhinitis
• Perennial allergic conjunctivitis (PAC):
  • Year-round symptoms related to indoor allergens
  • May require longer-term management strategies 2
• Vernal keratoconjunctivitis and atopic keratoconjunctivitis:
  • More severe forms requiring specialized ophthalmology care
  • May need more aggressive treatment with topical steroids or cyclosporine 1

Pitfalls to Avoid

• Prolonged use of vasoconstrictors/decongestants can lead to rebound hyperemia
• Extended corticosteroid use without ophthalmology supervision risks serious complications (glaucoma, cataracts)
• Misdiagnosis of bacterial conjunctivitis (which presents with morning crusting rather than itching) 5
• Overlooking dry eye disease, which can coexist with or mimic allergic conjunctivitis 1

By following this stepwise approach and recognizing when to escalate therapy or refer to specialists, most cases of allergic conjunctivitis can be effectively managed with good outcomes for patient comfort and quality of life.