What is the treatment for allergic conjunctivitis?

Treatment of Allergic Conjunctivitis

Dual-action topical agents (antihistamine + mast cell stabilizer) such as olopatadine, ketotifen, epinastine, or azelastine are the most effective first-line pharmacological treatment for allergic conjunctivitis. 1, 2

Stepwise Treatment Algorithm

First-Line: Non-Pharmacological Measures + Dual-Action Agents

Non-pharmacological interventions should be implemented immediately:

• Wear sunglasses as a physical barrier against airborne allergens 3, 4
• Apply cold compresses to reduce inflammation 1, 2
• Use refrigerated preservative-free artificial tears to dilute allergens and inflammatory mediators on the ocular surface 3, 1
• Avoid eye rubbing, which can worsen symptoms and potentially lead to keratoconus, especially in atopic patients 3, 4
• Implement allergen avoidance: hypoallergenic bedding, eyelid cleansers to remove allergens, frequent clothes washing, and bathing/showering before bedtime 3, 4

Pharmacological first-line treatment:

• Dual-action agents are superior to single-action agents because they provide rapid onset (within 30 minutes) for acute symptom relief while also preventing future episodes through mast cell stabilization 1, 2
• Olopatadine 0.1%: 1 drop in affected eye(s) twice daily, every 6-8 hours (FDA-approved for ages 2+) 5
• Ketotifen: 1 drop in affected eye(s) twice daily, every 8-12 hours (FDA-approved for ages 3+) 6
• Epinastine and azelastine are equally effective alternatives 1, 2
• These agents can be stored in the refrigerator for additional cooling relief upon instillation 3

Second-Line: Mast Cell Stabilizers Alone

For prophylactic or longer-term treatment when dual-action agents are insufficient:

• Mast cell stabilizers (cromolyn, lodoxamide, nedocromil, pemirolast) have slower onset of action (several days) but are effective for chronic prevention 1, 2
• Cromolyn sodium is specifically FDA-approved for vernal keratoconjunctivitis 7

Alternative second-line option:

• Topical NSAIDs (ketorolac) provide temporary relief of ocular itching in seasonal allergic conjunctivitis 1, 2

Third-Line: Short-Course Topical Corticosteroids

For inadequately controlled symptoms or severe cases:

• Brief course (1-2 weeks only) of low side-effect profile topical corticosteroids such as loteprednol etabonate 3, 1, 2
• Critical monitoring requirements: Baseline and periodic intraocular pressure (IOP) measurement and pupillary dilation to evaluate for glaucoma and cataract formation 3, 4
• Avoid indiscriminate use: Corticosteroids can prolong adenoviral infections and worsen HSV infections 3

Fourth-Line: Immunomodulators for Severe/Refractory Cases

For severe cases unresponsive to above treatments:

• Topical cyclosporine 0.05% or tacrolimus can be considered 3, 1, 4
• Cyclosporine 0.1% is FDA-approved for vernal keratoconjunctivitis in children and adults 1
• These agents may allow for reduced use of topical steroids 1

Critical Pitfalls to Avoid

Avoid chronic vasoconstrictor use:

• Over-the-counter antihistamine/vasoconstrictor combinations can cause rebound vasodilation (conjunctivitis medicamentosa) with prolonged use 3, 1, 2

Avoid oral antihistamines as primary treatment:

• Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier 3, 1, 2

Avoid punctal plugs:

• Punctal plugs prevent flushing of allergens and inflammatory mediators from the ocular surface and should not be used in allergic conjunctivitis 1, 4

Avoid indiscriminate antibiotic use:

• Topical antibiotics can induce toxicity and are not indicated for allergic conjunctivitis 3

Special Considerations

For vernal or atopic keratoconjunctivitis:

• Follow the same stepwise approach but with lower threshold for specialist referral 4
• Supratarsal corticosteroid injection may be considered for severe sight-threatening cases unresponsive to topical therapy 4

Consultation with allergist or ophthalmologist is beneficial for difficult-to-control disease or when considering allergen-specific immunotherapy 4