What are the best eye drops for allergic conjunctivitis?

Best Eye Drops for Allergic Conjunctivitis

Dual-action topical antihistamine/mast cell stabilizers are the best eye drops for allergic conjunctivitis, with olopatadine being the most effective option for symptom relief. 1

First-Line Treatment Options

Dual-action agents provide both immediate symptom relief and prevention of symptoms, making them superior to single-action medications. The recommended options include:

• Olopatadine: Applied twice daily (ages >3 years)

  • High-concentration formulations (0.77%) show longer duration of action and better efficacy for ocular itch compared to lower concentrations 1, 2
  • Considered superior to other agents for treating ocular itch with prolonged effect when used once-daily 2

• Ketotifen: Applied twice daily (ages >3 years)

  • Effective for reducing subjective symptoms within 10 days in 60-80% of patients 3
  • Onset of action within 20 minutes, duration of 8-13 hours 3

• Epinastine: Applied twice daily (ages >12 years)

  • Has shown superior efficacy to placebo and equal or greater effectiveness than olopatadine 0.1% for ocular itch and conjunctival hyperemia 1, 2

• Azelastine: Applied 2-4 times daily (ages >4 years)

  • Demonstrated effectiveness in multiple clinical trials 1, 2

For Severe or Refractory Cases

When first-line treatments are insufficient:

• Short-term topical corticosteroids (e.g., loteprednol etabonate 0.2%):

  • Indicated for temporary relief of signs and symptoms of seasonal allergic conjunctivitis 4
  • Should only be used under ophthalmologist supervision due to risk of intraocular pressure elevation 1
  • Clinical trials show superiority to placebo in treating signs and symptoms of seasonal allergic conjunctivitis when dosed four times daily 4
  • Provides reduction in bulbar conjunctival injection and itching beginning approximately 2 hours after first dose 4

• For long-term management of severe cases:

  • Topical cyclosporine or topical tacrolimus may be considered 1

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:

  • Humidify ambient air
  • Avoid direct air drafts
  • Take regular breaks from screen time 1

Important Precautions

• Avoid prolonged use of ocular decongestants/vasoconstrictors:

  • Can cause rebound hyperemia ("conjunctivitis medicamentosa") 1

• Avoid punctal plugs:

  • Prevent flushing of allergens and inflammatory mediators from the ocular surface 1

• Monitor for complications with corticosteroid use:

  • Baseline and periodic intraocular pressure measurement is recommended
  • Follow-up within 1-2 weeks for patients using topical corticosteroids 1, 4

• Avoid first-generation oral antihistamines:

  • Can cause sedation and anticholinergic effects
  • May induce or worsen dry eye syndrome 1

Clinical Decision Algorithm

1. Initial treatment: Start with dual-action antihistamine/mast cell stabilizer (preferably olopatadine)
2. If inadequate response: Try alternative dual-action agent (epinastine, ketotifen, or azelastine)
3. For severe symptoms: Consider short-term topical corticosteroids (loteprednol 0.2%) under ophthalmologist supervision
4. For chronic management: Consider topical cyclosporine or tacrolimus for severe/refractory cases
5. Always include: Supportive measures like artificial tears and cold compresses

The evidence strongly supports dual-action agents as the most effective treatment for allergic conjunctivitis, with olopatadine showing particular efficacy for ocular itch with longer duration of action in its higher concentration formulations 1, 2.