What are the recommended eye drops for allergic rhinitis?

Recommended Eye Drops for Allergic Rhinitis

For patients with allergic rhinitis experiencing ocular symptoms, dual-action agents that combine antihistamine and mast cell stabilizing properties (such as olopatadine or ketotifen) are the most effective first-line eye drop treatments due to their rapid onset of action and superior efficacy in relieving ocular itching and other allergic eye symptoms. 1

First-Line Eye Drop Options

• Dual-action agents (antihistamine + mast cell stabilizer) are the most effective for both acute and longer-term treatment of allergic conjunctivitis symptoms with onset of action within 30 minutes 1:

  • Olopatadine (Pataday, Patanol) - for adults and children ≥2 years: 1 drop in affected eye(s) once daily 2
  • Ketotifen (Alaway, Zaditor) - for adults and children ≥3 years: 1 drop in affected eye(s) twice daily, every 8-12 hours 3
  • Azelastine (Optivar), Epinastine (Elestat) - generally used twice daily 1

• Antihistamine eye drops provide rapid relief of acute symptoms but may need to be combined with other agents for optimal relief 1:

  • Emedastine (Emadine)
  • Levocabastine (Livostin)

• Mast cell stabilizers are more suitable for prophylactic or longer-term treatment as they require several days to achieve optimal effect 1:

  • Cromolyn sodium (Opticrom, Crolom) - 1-2 drops 4-6 times daily at regular intervals 4
  • Lodoxamide (Alomide)
  • Nedocromil (Alocril)
  • Pemirolast (Alamast)

Treatment Algorithm Based on Symptom Severity

For Mild Symptoms:

• Start with cold compresses and saline solution or artificial tears 1
• If insufficient, add OTC ketotifen eye drops twice daily 3, 5

For Moderate to Severe Symptoms:

• Begin with a dual-action agent like olopatadine or ketotifen 1, 5
• For persistent symptoms despite treatment, consider adding an intranasal corticosteroid, as fluticasone furoate nasal spray has been shown to significantly reduce ocular symptoms associated with seasonal allergic rhinitis 1

For Severe or Refractory Symptoms:

• Consider prescription-strength dual-action agents 1
• For severe symptoms unresponsive to other treatments, modified steroid eye drops like loteprednol etabonate (Alrex) may be considered for short-term use 1

Important Considerations and Precautions

• Vasoconstrictors (e.g., naphazoline, tetrahydrozoline) should be used cautiously and only for short periods (≤10 days) to avoid rebound hyperemia or conjunctivitis medicamentosa 1, 6

• Corticosteroid eye drops should be reserved for severe symptoms and used with caution due to potential vision-threatening side effects including cataract formation, elevated intraocular pressure, and secondary infections 1

• Studies have shown that ketotifen eye drops can improve not only ocular symptoms but also nasal symptoms in patients with allergic rhinitis 7

• Topical ophthalmic agents are generally more effective than oral antihistamines for ocular allergy symptoms and have a faster onset of action 1

• Combination therapy with an intranasal corticosteroid and an intranasal antihistamine may provide greater symptomatic relief for patients with moderate to severe allergic rhinitis with ocular symptoms 1

Comparative Efficacy

• Dual-action ophthalmic agents have been demonstrated to be more effective in preventing or treating ocular itching than other ocular agents in environmental challenge chambers or acute ocular allergen challenges 1

• Oral antihistamines are generally less effective for ocular allergy symptoms than topical ophthalmic agents and may cause excessive drying of the tear film 1

• Ketotifen eye drops have been shown to significantly decrease both ocular and nasal allergic symptoms, and when added to oral antihistamine regimens, can improve overall antiallergic efficacy 5