What are the treatment options for allergic conjunctivitis?

Treatment Options for Allergic Conjunctivitis

Dual-action topical antihistamine/mast cell stabilizers are the first-line therapy for allergic conjunctivitis, providing both immediate symptom relief and prevention of symptoms. 1

First-Line Treatment Options

Topical Dual-Action Antihistamine/Mast Cell Stabilizers

• Most effective agents for treating signs and symptoms of allergic conjunctivitis 1, 2
• Specific options include:
  • 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

Preservative-Free Artificial Tears

• Dilute allergens and inflammatory mediators on the ocular surface 1
• Should be applied 2-4 times daily 1
• Can be used as adjunctive therapy with other medications

Second-Line and Adjunctive Treatments

Topical Corticosteroids

• Reserved for severe symptoms unresponsive to first-line treatments 1
• Loteprednol etabonate 0.2% is preferred due to better safety profile 1, 3
• Important cautions:
  • Use only under ophthalmologist supervision 1
  • Risk of intraocular pressure elevation 1, 3
  • Potential for cataract formation with prolonged use 1
  • Not recommended for long-term use 3
  • Less effective than prednisolone acetate 1% for uveitis 3

Immunomodulators for Severe/Refractory Cases

• Topical cyclosporine or tacrolimus for long-term management 1
• Consider for cases not responding to other treatments

Systemic Treatments

• Oral antihistamines (second-generation preferred)

  • Effective for both ocular and nasal symptoms 1, 4
  • Caution: May induce or worsen dry eye syndrome 1

• Intranasal corticosteroids

  • First-line for moderate-to-severe symptoms with nasal congestion 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 and Non-Pharmacological Approaches

• Cold compresses to reduce local pain and swelling 1
• Allergen identification and avoidance 1
• Humidify ambient air and avoid direct air drafts 1
• For computer users:
  • Take regular breaks from screen time 1
  • Position screens below eye level 1
  • Follow the 20-20-20 rule (every 20 minutes, look at something 20 feet away for 20 seconds) 1
  • Make conscious effort to blink fully and regularly 1

Special Considerations

Contact Lens Wearers

• Maintain proper lens hygiene 1
• Remove lenses before instilling drops 1
• Wait at least 5 minutes before reinsertion 1

Medications to Avoid or Use with Caution

• Ocular decongestants/vasoconstrictors: Limit to 3 days to prevent rebound hyperemia 1
• First-generation antihistamines: Avoid due to sedation and anticholinergic effects 1
• Punctal plugs: Avoid as they prevent flushing of allergens 1
• Tap water irrigation: Avoid if corneal abrasion or epithelial defect is suspected 1

Monitoring and Follow-Up

• Regular follow-up visits should include:

  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy 1

• For patients on topical corticosteroids:

  • Follow-up within 1-2 weeks 1
  • Baseline and periodic measurement of intraocular pressure 1, 3

Referral Criteria for Ophthalmologist

• 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

Recent research indicates that newer formulations of topical dual-action agents have longer duration of action, allowing for decreased frequency of use 2. High-concentration olopatadine 0.77% has shown longer duration of action and better efficacy for ocular itch compared to lower concentrations 2.