What is the treatment for allergic conjunctivitis?

Treatment of Allergic Conjunctivitis

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

First-Line Treatment Options

• Specific medication options include:

  • Olopatadine: applied twice daily (ages >3 years)
  • Ketotifen: applied twice daily (ages >3 years)
  • Epinastine: applied twice daily (ages >12 years)
  • Azelastine: applied 2-4 times daily (ages >4 years) 1

• These dual-action agents are superior to placebo and are the most effective agents for treating signs and symptoms of allergic conjunctivitis 2

• High-concentration olopatadine 0.77% has demonstrated longer duration of action and better efficacy for ocular itching compared to lower concentrations 2

Treatment Algorithm

1. Initial treatment: Start with dual-action topical antihistamine/mast cell stabilizers
2. Adjunctive therapy: Add preservative-free artificial tears (2-4 times daily) and cold compresses
3. For severe or refractory cases: Consider short-term topical corticosteroids (e.g., loteprednol etabonate 0.2%) under ophthalmologist supervision
4. For long-term management of severe cases: Consider topical cyclosporine or tacrolimus

Corticosteroid Therapy for Severe Cases

• Loteprednol etabonate 0.2% is FDA-approved for temporary relief of signs and symptoms of seasonal allergic conjunctivitis 3
• Corticosteroids work by inhibiting inflammatory response through induction of phospholipase A2 inhibitory proteins (lipocortins) 3
• Loteprednol etabonate is a "soft" corticosteroid designed to be rapidly converted to inactive metabolites, minimizing adverse effects 4, 5
• Important safety consideration: Topical corticosteroids should only be used under ophthalmologist supervision due to risks of:
  • Intraocular pressure elevation
  • Cataract formation
  • Masking of infection 1

Adjunctive Measures

• Preservative-free artificial tears: Dilute allergens and inflammatory mediators (2-4 times daily) 1
• Cold compresses: Reduce local pain and swelling 1
• Environmental modifications:
  • Humidify ambient air
  • Avoid direct air drafts
  • Take regular breaks from screen time (follow 20-20-20 rule)
  • Position computer screens below eye level 1

Monitoring and Follow-up

• Baseline and periodic intraocular pressure measurement for patients using topical corticosteroids
• Follow-up within 1-2 weeks for patients using topical corticosteroids
• Regular assessment of treatment efficacy and potential adverse effects 1

Important Precautions and Contraindications

• Avoid punctal plugs: They prevent flushing of allergens and inflammatory mediators
• Avoid first-generation antihistamines: Can cause sedation and anticholinergic effects
• Use oral antihistamines with caution: May induce or worsen dry eye syndrome
• Avoid prolonged use of ocular decongestants/vasoconstrictors: Can cause rebound hyperemia ("conjunctivitis medicamentosa") 1
• Topical corticosteroids require ophthalmologist supervision: Risk of increased intraocular pressure, cataract formation, and masking of infection 1

Special Considerations for Children

• Refer children with allergic conjunctivitis to an ophthalmologist if they experience:
  • 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