What is the best treatment for allergic conjunctivitis?

Best Treatment for Allergic Conjunctivitis

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

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

These dual-action agents are superior to single-action medications, with high-concentration olopatadine showing longer duration of action and better efficacy for ocular itch compared to other agents 2.

Adjunctive Therapies

• Preservative-free artificial tears: Use 2-4 times daily to dilute allergens and inflammatory mediators 1
• Cold compresses: Apply to 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

Treatment for Severe or Refractory Cases

Short-term Topical Corticosteroids

• Loteprednol etabonate 0.2% is preferred for severe symptoms unresponsive to first-line treatments 1, 3
• Important caution: Use only under ophthalmologist supervision due to risk of:
  • Intraocular pressure elevation
  • Cataract formation
  • Masking of infection 1, 3
• Loteprednol has shown effectiveness in clinical trials for seasonal allergic conjunctivitis when dosed four times daily 3

Immunomodulatory Agents (for chronic/severe cases)

• Topical cyclosporine and topical tacrolimus can be considered for long-term management of severe or refractory cases 1, 4
• These agents are particularly useful for vernal keratoconjunctivitis and atopic keratoconjunctivitis 4

Monitoring and Follow-up

• Baseline and periodic intraocular pressure measurement for patients using topical corticosteroids 1
• Schedule follow-up within 1-2 weeks for patients using topical corticosteroids 1
• Regular follow-up visits should include:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy 1

Important Precautions and Contraindications

• Avoid punctal plugs as they prevent flushing of allergens 1
• Avoid first-generation antihistamines due to sedation and anticholinergic effects 1
• Use oral antihistamines cautiously as they may induce or worsen dry eye syndrome 1
• Avoid prolonged use of ocular decongestants/vasoconstrictors due to risk of rebound hyperemia ("conjunctivitis medicamentosa") 1

Referral to Ophthalmologist

Refer children with allergic conjunctivitis to an ophthalmologist in cases of:

• 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