What is the treatment for allergic conjunctivitis?

Treatment of Allergic Conjunctivitis

Dual-action topical antihistamine/mast cell stabilizers (e.g., olopatadine, ketotifen, epinastine, azelastine) are the first-line therapy for allergic conjunctivitis, providing both immediate symptom relief and prevention of symptoms. 1

First-Line Treatment Options

Topical Antihistamine/Mast Cell Stabilizers

• Specific options include:
  • Olopatadine: twice daily for ages >3 years
  • Ketotifen: twice daily for ages >3 years
  • Epinastine: twice daily for ages >12 years
  • Azelastine: 2-4 times daily for ages >4 years 1

Supportive Measures

• Preservative-free artificial tears (2-4 times daily) to dilute allergens and inflammatory mediators 1
• Cold compresses to reduce local pain and swelling 1
• Environmental modifications:
  • Humidifying ambient air
  • Avoiding direct air drafts
  • Taking regular breaks from screen time (following the 20-20-20 rule) 1

Second-Line Treatment

Topical Corticosteroids

• For severe symptoms unresponsive to first-line treatments
• Loteprednol etabonate 0.2% is FDA-approved for temporary relief of signs and symptoms of seasonal allergic conjunctivitis 2
• Important precautions with corticosteroids:
  • Should only be used under ophthalmologist supervision
  • Short-term use only
  • Risk of intraocular pressure elevation, cataract formation, and masking infection 1, 2
  • Requires baseline and periodic intraocular pressure measurement 1
  • Follow-up within 1-2 weeks for patients using topical corticosteroids 1

Third-Line Treatment for Severe/Refractory Cases

• Topical cyclosporine or tacrolimus for long-term management 1, 3

Treatments to Avoid

• Punctal plugs (prevent flushing of allergens) 1
• First-generation oral antihistamines (cause sedation and anticholinergic effects) 1
• Prolonged use of ocular decongestants/vasoconstrictors (can cause rebound hyperemia) 1
• Oral antihistamines may induce or worsen dry eye syndrome 1

Monitoring and Follow-up

• Regular follow-up based on disease severity and treatment
• Assessment should include:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy 1

When to Refer to an 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

Complications to Watch For

• Corneal neovascularization
• Scarring
• Ulceration
• Vision loss
• Dry eye syndrome
• Meibomian gland dysfunction 1

The treatment approach should be guided by symptom severity, with dual-action topical antihistamine/mast cell stabilizers forming the cornerstone of therapy for most patients with allergic conjunctivitis, and corticosteroids reserved for severe or refractory cases under appropriate supervision.