What is the treatment for allergic conjunctivitis?

Treatment of Allergic Conjunctivitis

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

First-Line Treatment Options

Non-Pharmacological Measures

• Environmental modifications:
  • Allergen avoidance and minimization of exposure 1
  • Humidify ambient air to prevent tear evaporation 1
  • Avoid direct air drafts to reduce eye irritation 1
• Symptomatic relief:
  • Cold compresses to reduce local pain and swelling 1
  • Preservative-free artificial tears (2-4 times daily) to dilute allergens and inflammatory mediators 2, 1

Pharmacological First-Line Therapy

• 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

For symptoms not adequately controlled with first-line therapy:

• Short-term topical corticosteroids (1-2 weeks):

  • Loteprednol etabonate 0.2% - preferred due to lower risk of IOP elevation 1, 3
  • Should only be used under ophthalmologist supervision 1
  • Monitor for increased intraocular pressure and cataract formation 2, 3

• Oral antihistamines:

  • Effective for concurrent allergic rhinitis 1
  • Caution: May induce or worsen dry eye syndrome 2, 1
  • Second-generation options preferred to avoid sedation 1

Treatment for Severe or Refractory Cases

• Topical immunomodulators:

  • Cyclosporine 0.05-0.1% for severe cases 2, 1
  • Tacrolimus 0.03-0.1% for severe cases 2, 1
  • Tacrolimus 0.03% for children 2-15 years; 0.03% or 0.1% for patients ≥16 years 2

• Additional options:

  • Leukotriene receptor antagonists (e.g., montelukast) - particularly useful with comorbid asthma 1
  • Immunotherapy for severe seasonal allergic conjunctivitis 2

Special Considerations for Specific Types

Vernal Keratoconjunctivitis (VKC)

• First-line: Mast cell stabilizers, antihistamines, cool compresses, ocular lubricants 2
• For acute exacerbations: Topical corticosteroids 2
• FDA-approved: Cyclosporine 0.1% for VKC in children and adults 2
• For severe sight-threatening cases: Supratarsal injection of corticosteroid 2

Atopic Keratoconjunctivitis

• Conservative strategies plus antihistamines and mast cell stabilizers 2
• Moderate disease: Topical corticosteroids and calcineurin inhibitors 2
• Eyelid involvement: Pimecrolimus cream 1% or tacrolimus ointment 2

Monitoring and Follow-up

• Regular follow-up based on disease severity and treatment 2
• For patients on corticosteroids:
  • Baseline and periodic measurement of intraocular pressure 2, 1
  • Pupillary dilation to evaluate for cataract 2
  • Follow-up within 1-2 weeks 1
• Monitor for keratoconus in allergic and atopic disease 2

Important Cautions

• Avoid prolonged use of ocular decongestants/vasoconstrictors (limit to 3 days) to prevent rebound hyperemia 1
• Contact lens wearers should remove lenses before instilling drops and wait at least 5 minutes before reinsertion 1
• Avoid tap water for irrigation if corneal abrasion is suspected 1
• Avoid punctal plugs as they prevent flushing of allergens 1
• Refer to ophthalmologist for visual loss, severe pain, corneal involvement, or lack of response to therapy 1