What are the treatment options for allergic conjunctivitis?

Treatment Options for Allergic Conjunctivitis

For mild to moderate allergic conjunctivitis, topical antihistamine/mast cell stabilizer combinations are the most effective first-line treatment, followed by topical corticosteroids for refractory cases. 1

First-Line Treatments

Non-Pharmacological Measures

• Wear sunglasses to create a barrier against airborne allergens 1
• Apply cold compresses to reduce inflammation and provide symptomatic relief 1
• Use refrigerated artificial tears to dilute allergens and inflammatory mediators 1
• Avoid eye rubbing which can worsen symptoms and potentially lead to keratoconus 1
• Implement allergen avoidance strategies including hypoallergenic bedding, eyelid cleansers, frequent clothes washing, and bathing/showering before bedtime 1

Pharmacological Options

• Mild allergic conjunctivitis:

  • Over-the-counter topical antihistamine/vasoconstrictor agents 1
  • Second-generation topical histamine H1-receptor antagonists (more effective) 1
  • Note: Chronic use of vasoconstrictors can cause rebound vasodilation upon discontinuation 1

• Recurrent or persistent allergic conjunctivitis:

  • Mast cell stabilizers 1
  • Dual-action medications combining antihistamine activity with mast-cell stabilizing properties (most effective for both acute and chronic disease) 1
  • Refrigerating these medications can provide additional symptomatic relief 1

Second-Line Treatments

For Inadequately Controlled Symptoms

• Brief course (1-2 weeks) of topical corticosteroids with low side-effect profiles 1

  • Loteprednol etabonate is specifically indicated for allergic conjunctivitis with a better safety profile than traditional corticosteroids 2
  • Loteprednol etabonate undergoes predictable transformation to inactive metabolites, reducing risk of side effects 2, 3

• Important monitoring when using corticosteroids:

  • Baseline and periodic measurement of intraocular pressure (IOP) 1
  • Pupillary dilation to evaluate for cataract formation 1
  • Monitor for glaucoma, especially with prolonged use 1

Adjunctive Treatments

• Cooled preservative-free artificial tears to alleviate coexisting tear deficiency and dilute allergens 1
• Oral antihistamines may be used but can potentially worsen dry eye syndrome and impair the tear film's protective barrier 1
• Topical mast-cell inhibitors formulated as nasal sprays and aerosols can help alleviate associated allergic rhinitis symptoms 1

Severe or Refractory Cases

Advanced Therapies

• Topical cyclosporine or tacrolimus for severe cases 1

  • Cyclosporine 0.1% is FDA approved for vernal keratoconjunctivitis in children and adults 1
  • These immunomodulators may allow for reduced use of topical steroids 1

• Allergen-specific immunotherapy (subcutaneous or sublingual) for patients with inadequate control with topical medications 1, 4

  • Requires long-term commitment (minimum 3 years for long-term benefit) 4
  • May be limited by expense and risk of anaphylaxis 1

Special Considerations

Vernal/Atopic Conjunctivitis

• Treatment follows similar stepwise approach as seasonal allergic conjunctivitis 1
• For acute exacerbations, topical corticosteroids are usually necessary 1
• Supratarsal injection of corticosteroid may be considered for severe sight-threatening cases unresponsive to topical therapy 1

Important Cautions

• Avoid punctal plugs as they prevent flushing of allergens and inflammatory mediators 1
• Monitor for keratoconus in patients with allergic conjunctivitis, especially with persistent eye rubbing 1
• Consultation with an allergist or dermatologist may be beneficial for patients with difficult-to-control disease 1

Follow-up Recommendations

• Frequency based on disease severity, etiology, and treatment 1
• Consider timing visits during symptomatic periods 1
• Follow-up should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 1