What is the treatment for allergic conjunctivitis?

Treatment of Allergic Conjunctivitis

For allergic conjunctivitis, dual-action agents (antihistamine + mast cell stabilizer) are the most effective first-line pharmacological treatment due to their rapid onset of action and ability to both treat acute symptoms and prevent future episodes. 1

First-Line Treatment Options

Non-Pharmacological Interventions

• Cold compresses and irrigation with saline solution or artificial tears for mild symptoms 1, 2
• Allergen avoidance and wearing sunglasses as a barrier to airborne allergens 2
• Refrigerated preservative-free artificial tears to dilute allergens and inflammatory mediators 1

Pharmacological Options (Topical)

• Dual-action agents (antihistamine + mast cell stabilizer):

  • Olopatadine (Pataday, Patanol) 1, 3
  • Ketotifen (Alaway, Zaditor) 1, 3
  • Epinastine (Elestat) 1, 3
  • Azelastine (Optivar) 1
  • These agents have onset within 30 minutes and are suitable for both acute and longer-term treatment 1

• Antihistamines (H1-receptor antagonists):

  • Emedastine (Emadine) 1
  • Levocabastine (Livostin) 1
  • Effective for acute relief of ocular allergy symptoms 1

• Combination antihistamine/vasoconstrictor:

  • Antazoline (Vasocon-A) 1
  • Pheniramine (Visine-A, Naphcon-A, Opcon-A) 1
  • Note: These combinations work better than either agent alone but should be limited to 10 days to avoid rebound hyperemia 1, 2

Second-Line Treatment Options

• Mast cell stabilizers:

  • Cromolyn (Opticrom, Crolom) 1
  • Lodoxamide (Alomide) 1
  • Nedocromil (Alocril) 1
  • Pemirolast (Alamast) 1
  • Better for prophylactic or longer-term treatment due to slow onset of action (several days) 1, 4

• Topical NSAIDs:

  • Ketorolac (Acular) 1
  • Indicated for temporary relief of ocular itching caused by seasonal allergic conjunctivitis 1
  • Less effective than antihistamines and dual-action agents 5

Third-Line Treatment (For Severe Cases)

• Topical corticosteroids (for short-term use only):

  • Loteprednol etabonate (Alrex) - preferred due to lower risk of increasing IOP 1, 6
  • Should be reserved for severe symptoms and limited to 1-2 weeks 1, 2
  • Monitoring for increased IOP and cataract formation is necessary 1

• For refractory cases:

  • Topical cyclosporine or tacrolimus can be considered 1, 7

Treatment Algorithm Based on Severity

Mild Allergic Conjunctivitis

1. Non-pharmacological measures (cold compresses, artificial tears) 1, 2
2. Topical antihistamine or dual-action agent 1

Moderate Allergic Conjunctivitis

1. Dual-action agents (antihistamine + mast cell stabilizer) 1, 3
2. Add mast cell stabilizers for recurrent episodes 1

Severe Allergic Conjunctivitis

1. Dual-action agents plus short course (1-2 weeks) of topical corticosteroids 1
2. Consider cyclosporine for steroid-dependent cases 1, 7

Important Considerations and Pitfalls

• Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 1, 2
• Prolonged use of vasoconstrictors can lead to rebound hyperemia (conjunctivitis medicamentosa) 1, 2
• Topical corticosteroids carry risks of cataract formation, elevated IOP, and secondary infections 1, 6
• Environmental challenge chamber studies have shown dual-action agents are more effective than other ocular agents for preventing or treating ocular itching 1
• Loteprednol etabonate has a reduced risk of causing increased IOP compared to other ocular corticosteroids, making it safer for short-term use 1, 6