What are good eye drops for allergic conjunctivitis?

Best Eye Drops for Allergic Conjunctivitis

Dual-action topical antihistamine/mast cell stabilizers (e.g., olopatadine, ketotifen, epinastine, 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

Dual-Action Antihistamine/Mast Cell Stabilizers

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

These medications work by both blocking histamine receptors and preventing mast cell degranulation, making them more effective than single-action drugs 4. Among these options, high-concentration olopatadine has demonstrated superior efficacy for ocular itch with a longer duration of action compared to other agents 4.

Supportive Measures

• Preservative-free artificial tears (2-4 times daily): Help dilute allergens and inflammatory mediators 1
• Cold compresses: Reduce local pain and swelling 1
• Environmental modifications: Humidifying ambient air, avoiding direct air drafts 1

For Severe or Refractory Cases

Short-term Topical Corticosteroids

For severe symptoms unresponsive to first-line treatments, short-term topical corticosteroids may be considered:

• Loteprednol etabonate 0.2% is preferred due to its improved safety profile 1, 5
  • It undergoes predictable transformation to inactive metabolites, minimizing adverse effects 6
  • Only 1% of patients experience clinically significant increases in intraocular pressure (≥10 mmHg) compared to 6% with prednisolone acetate 1% 6

Important: Topical corticosteroids should only be used under ophthalmologist supervision due to risks of increased intraocular pressure and cataract formation 1.

Other Options for Severe Cases

• Topical cyclosporine and tacrolimus: Can be considered for long-term management of severe or refractory cases 1
• Eyelid involvement: May be treated with pimecrolimus cream 1% or tacrolimus ointment 1

Treatment Algorithm Based on Severity

1. Mild disease: Conservative strategies plus antihistamines and mast cell stabilizers
2. Moderate disease: May require addition of topical corticosteroids and calcineurin inhibitors
3. Severe sight-threatening cases: May require supratarsal injection of corticosteroid 1

Important Cautions

• Avoid prolonged use of ocular decongestants/vasoconstrictors: Can cause rebound hyperemia ("conjunctivitis medicamentosa") 1
• Oral antihistamines: May induce or worsen dry eye syndrome 1
• Topical corticosteroids: Require ophthalmologist supervision to monitor for increased intraocular pressure, cataract formation, and masked infection 1
• First-generation oral antihistamines: Should be avoided due to sedation and anticholinergic effects 1

Monitoring and Follow-up

• Regular follow-up based on disease severity
• Schedule follow-up within 1-2 weeks for patients using topical corticosteroids 1
• Monitor for complications including corneal neovascularization, scarring, ulceration, and vision loss 1

Dual-action antihistamine/mast cell stabilizers have demonstrated superior efficacy and safety compared to other treatment options, with evidence showing they effectively reduce both symptoms and signs of allergic conjunctivitis while maintaining a favorable safety profile 7, 8.