What is the management of allergic conjunctivitis?

Management of Allergic Conjunctivitis

Start with dual-action topical antihistamine/mast cell stabilizer eye drops (olopatadine, ketotifen, epinastine, or azelastine) as first-line therapy, as these provide both immediate symptom relief and ongoing protection with rapid onset of action within 30 minutes. 1, 2

First-Line Treatment Approach

Non-Pharmacological Measures

• Wear sunglasses outdoors to create a physical barrier against airborne allergens 1, 2
• Apply cold compresses to reduce inflammation and provide symptomatic relief 3, 1
• Use refrigerated preservative-free artificial tears 4 times daily to dilute allergens and inflammatory mediators on the ocular surface 1, 2
• Strictly avoid eye rubbing, which can worsen symptoms and potentially lead to keratoconus, especially in patients with atopic disease 1, 2
• Implement allergen avoidance strategies including hypoallergenic bedding, frequent clothes washing, and bathing/showering before bedtime 1, 2

Pharmacological First-Line Treatment

• Dual-action agents (olopatadine, ketotifen, epinastine, azelastine) are the most effective first-line topical treatment because they combine antihistamine and mast cell stabilizer properties, providing both acute symptom relief and prevention of future episodes 1, 2
• Olopatadine 0.1% has rapid onset within 30 minutes with 8-hour duration of action 4
• These agents can be refrigerated for additional cooling relief upon instillation 2
• For mild cases with coexisting allergic rhinitis, intranasal corticosteroids or oral antihistamines may provide additional relief of ocular symptoms 3

Second-Line Treatment for Inadequate Response

When to Escalate

• If symptoms do not improve within 48 hours on dual-action drops, add a brief 1-2 week course of topical corticosteroid 1, 2, 4

Corticosteroid Use

• Loteprednol etabonate is the preferred topical corticosteroid due to its low side-effect profile, specifically designed for allergic conjunctivitis with reduced risk of intraocular pressure elevation compared to traditional corticosteroids 1, 2, 5
• Loteprednol etabonate is FDA-approved for steroid-responsive inflammatory conditions including allergic conjunctivitis 5
• Critical monitoring requirements when using any corticosteroid: baseline and periodic intraocular pressure (IOP) measurement plus pupillary dilation to evaluate for glaucoma and cataract formation 1, 2
• Limit corticosteroid use to 1-2 weeks only for acute exacerbations 1, 2

Third-Line Treatment for Severe or Refractory Cases

Topical Immunomodulators

• For severe cases unresponsive to the above treatments, consider topical cyclosporine 0.05% or tacrolimus 1, 2
• Cyclosporine 0.1% is FDA-approved for vernal keratoconjunctivitis in children and adults 2
• Cyclosporine may allow for reduced use of topical steroids and has demonstrated reduction in signs and symptoms after two weeks in vernal keratoconjunctivitis 2

Special Considerations for Vernal/Atopic Keratoconjunctivitis

• Topical corticosteroids are usually necessary to control severe symptoms in vernal or atopic keratoconjunctivitis 2
• For severe atopic keratoconjunctivitis unresponsive to topical therapy, consider supratarsal injection of corticosteroid 1, 2
• For eyelid involvement in patients 2 years or older, use pimecrolimus cream 1% or topical tacrolimus ointment (0.03% for ages 2-15 years; 0.03% or 0.1% for ages 16+) 2
• Be aware that tacrolimus or pimecrolimus may increase susceptibility to herpes simplex keratitis 2

Critical Pitfalls to Avoid

What NOT to Do

• Never use punctal plugs in allergic conjunctivitis because they prevent flushing of allergens and inflammatory mediators from the ocular surface 1, 2
• Avoid relying on oral antihistamines alone as primary treatment, as they may worsen dry eye syndrome and impair the tear film's protective barrier 1, 2, 4
• Avoid chronic vasoconstrictor use beyond 10 days, as over-the-counter antihistamine/vasoconstrictor combinations can cause rebound hyperemia (conjunctivitis medicamentosa) with prolonged use 3, 2, 4
• Avoid indiscriminate antibiotic use, as topical antibiotics can induce toxicity and are not indicated for allergic conjunctivitis 2

Medications with Limited Role

• Mast cell stabilizers alone (cromolyn, lodoxamide, nedocromil, pemirolast) have slow onset of action requiring several days for optimal relief, making them more suitable for prophylactic use rather than acute symptom relief 3, 2
• Topical NSAIDs such as ketorolac provide only temporary relief of ocular itching and have limited efficacy 3, 2

When to Refer

Indications for Specialist Consultation

• Consult an allergist or dermatologist for patients with disease that cannot be adequately controlled with topical medications and oral antihistamines 2
• Allergen-specific immunotherapy (subcutaneous or sublingual) is useful for achieving hyposensitization in refractory cases, though usage may be limited by expense, long-term patient commitment, and risk of anaphylaxis 2
• Arrange face-to-face ophthalmology evaluation if no improvement is seen within 48-72 hours to rule out vernal or atopic keratoconjunctivitis 4
• Monitor for keratoconus in patients with allergic conjunctivitis and atopic disease, as adequate control of allergy and eye rubbing are important to decrease progression of ectasia 2

Follow-Up Strategy

• Reassess in 48-72 hours to confirm symptom improvement 4
• Frequency of follow-up visits is based on disease severity, etiology, and treatment 2