What are the treatment options for allergic conjunctivitis?

Treatment Options for Allergic Conjunctivitis

Dual-action agents combining antihistamine and mast cell stabilizing properties are the most effective first-line treatment for allergic conjunctivitis, providing both immediate symptom relief and prevention of future episodes. 1

First-Line Treatments

Non-Pharmacological Approaches

• Wear sunglasses as a barrier against airborne allergens 2, 3
• Apply cold compresses to reduce inflammation and provide symptomatic relief 2, 3, 1
• Use refrigerated artificial tears to dilute allergens and inflammatory mediators 2, 3
• Avoid eye rubbing as it can worsen symptoms and potentially lead to keratoconus 2, 3
• Implement allergen avoidance strategies (hypoallergenic bedding, frequent clothes washing, bathing before bedtime) 2, 3

Pharmacological Options

• Dual-action agents (olopatadine, ketotifen, epinastine, azelastine) are preferred as they provide both immediate relief and prevention 1, 4
• Over-the-counter topical antihistamine/vasoconstrictor agents for mild cases 2, 3
• Second-generation topical histamine H1-receptor antagonists are more effective than OTC options 2
• Refrigerate topical medications for additional cooling relief upon instillation 2

Second-Line Treatments

• Mast cell stabilizers (cromolyn, lodoxamide, nedocromil, pemirolast) for frequently recurrent or persistent cases 2, 1, 5
• Brief course (1-2 weeks) of topical corticosteroids with low side-effect profiles (like loteprednol etabonate) for inadequately controlled symptoms 2, 3, 1, 6
• Topical NSAIDs such as ketorolac for temporary relief of ocular itching 1, 7

Monitoring and Precautions

• When using corticosteroids, monitor for:
  • Increased intraocular pressure (baseline and periodic measurements) 2, 3
  • Cataract formation (pupillary dilation evaluation) 2, 3
  • Secondary infections 1
• Avoid prolonged use of vasoconstrictors due to risk of rebound hyperemia 2, 1
• Be cautious with oral antihistamines as they may worsen dry eye syndrome and impair the tear film's protective barrier 2, 3, 1
• Avoid punctal plugs as they prevent flushing of allergens and inflammatory mediators 2, 1

For Severe or Refractory Cases

• Topical cyclosporine or tacrolimus can be effective 2, 3, 5
• Allergen-specific immunotherapy (subcutaneous or sublingual) may be beneficial 2, 3
• Consultation with an allergist or dermatologist for difficult-to-control cases 2, 3

Special Considerations for Vernal/Atopic Conjunctivitis

• Follow similar stepwise approach as seasonal allergic conjunctivitis 2, 3
• Topical cyclosporine 0.05% has shown effectiveness and may reduce need for topical steroids 1, 5
• Loteprednol etabonate has demonstrated efficacy in reducing signs and symptoms of allergic conjunctivitis during peak pollen exposure 6
• Monitor closely for keratoconus, especially with persistent eye rubbing 2, 3

Treatment Algorithm

1. Start with non-pharmacological measures and refrigerated artificial tears
2. For mild symptoms: Use dual-action agents (preferred) or antihistamine/vasoconstrictor
3. For persistent symptoms: Add mast cell stabilizers
4. For inadequate control: Brief course of topical corticosteroids (with appropriate monitoring)
5. For severe/refractory cases: Consider cyclosporine/tacrolimus or specialist referral