What is the treatment for allergic conjunctivitis?

Treatment for Allergic Conjunctivitis

Start with dual-action topical agents (olopatadine, ketotifen, epinastine, or azelastine) as first-line therapy, as they provide both immediate symptom relief and ongoing protection through combined antihistamine and mast cell stabilizer effects. 1

First-Line Treatment Approach

Non-Pharmacological Measures

• Apply cold compresses and use refrigerated preservative-free artificial tears to dilute allergens and inflammatory mediators on the ocular surface 1
• Implement strict allergen avoidance: wear sunglasses as a physical barrier against airborne allergens, use hypoallergenic bedding, wash clothes frequently, and shower before bedtime 1
• Counsel patients to avoid eye rubbing, which can worsen symptoms and potentially lead to keratoconus, especially in atopic patients 1

Pharmacological First-Line Treatment

• Prescribe dual-action agents (olopatadine, ketotifen, epinastine, or azelastine) as the most effective first-line pharmacological treatment 1, 2
• These agents have rapid onset within 30 minutes and maintain efficacy for at least 8 hours, making them suitable for both acute relief and prophylactic treatment 2
• Unlike mast cell stabilizers alone, dual-action agents can treat acute symptoms immediately while preventing future episodes 1
• Store dual-action agents in the refrigerator for additional cooling relief upon instillation 1

Second-Line Treatment Options

When First-Line Therapy Is Insufficient

• Consider pure mast cell stabilizers (cromolyn, lodoxamide, nedocromil, pemirolast) for prophylactic or longer-term treatment, though they have slower onset of action requiring several days 1, 2
• Topical NSAIDs such as ketorolac provide temporary relief of ocular itching but are inferior to dual-action agents 1, 3

Third-Line Treatment for Severe Cases

Short-Term Corticosteroid Use

• For severe symptoms or acute exacerbations unresponsive to dual-action agents within 48 hours, add a brief 1-2 week course of loteprednol etabonate 1, 4
• Loteprednol etabonate is FDA-approved for temporary relief of seasonal allergic conjunctivitis and has a low side-effect profile compared to other corticosteroids 4
• Obtain baseline intraocular pressure (IOP) measurement and perform pupillary dilation to evaluate for glaucoma and cataract formation before initiating corticosteroids 1
• Monitor IOP periodically during corticosteroid use due to risks of increased IOP, cataract formation, and secondary infections 1, 2

Fourth-Line Treatment for Refractory Cases

Immunomodulators for Severe Disease

• For vernal keratoconjunctivitis or atopic conjunctivitis unresponsive to the above treatments, prescribe topical cyclosporine 0.05% or tacrolimus 1, 5
• Cyclosporine 0.1% is FDA-approved for vernal keratoconjunctivitis in children and adults and may allow for reduced corticosteroid use 1
• For severe atopic keratoconjunctivitis unresponsive to topical therapy, consider supratarsal injection of corticosteroid 1
• 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+) 1
• Be aware that tacrolimus or pimecrolimus may increase susceptibility to herpes simplex keratitis 1

Critical Pitfalls to Avoid

Medications That Worsen Outcomes

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

When to Refer

• Consult an allergist or ophthalmologist for patients with disease that cannot be adequately controlled with topical medications 1
• Consider allergen-specific immunotherapy (subcutaneous or sublingual) for achieving hyposensitization, though usage may be limited by expense, long-term patient commitment, and risk of anaphylaxis 1
• 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 1