What is the treatment for allergic conjunctivitis?

Treatment for Allergic Conjunctivitis

Dual-action topical agents (olopatadine, ketotifen, epinastine, or azelastine) are the most effective first-line treatment for allergic conjunctivitis, providing both immediate symptom relief and ongoing protection through combined antihistamine and mast cell stabilizer activity. 1

First-Line Treatment Approach

Non-Pharmacological Measures

• Implement allergen avoidance strategies including wearing sunglasses as a physical barrier against airborne allergens, using hypoallergenic bedding, washing clothes frequently, and bathing/showering before bedtime 1
• Apply cold compresses to reduce inflammation and provide symptomatic relief 1, 2
• Use refrigerated preservative-free artificial tears 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, 3

Pharmacological First-Line Treatment

• Prescribe dual-action topical agents (olopatadine, ketotifen, epinastine, or azelastine) as first-line pharmacological therapy due to their rapid onset of action (within 30 minutes) and ability to both treat acute symptoms and prevent future episodes 1, 2
• These agents can be stored in the refrigerator for additional cooling relief upon instillation 1
• Olopatadine 0.1% provides efficacy for at least 8 hours, supporting twice-daily dosing, and is suitable for both acute and long-term prophylactic treatment 2
• Unlike corticosteroids, dual-action agents have no specified maximum treatment duration and can be used continuously as long as allergen exposure persists 1, 2

Second-Line Treatment Options

When First-Line Therapy is Insufficient

• Mast cell stabilizers alone (cromolyn, lodoxamide, nedocromil, pemirolast) are better for prophylactic or longer-term treatment but have a slow onset of action (several days), making them less suitable for acute symptom relief 1, 2
• Topical NSAIDs such as ketorolac can provide temporary relief of ocular itching caused by seasonal allergic conjunctivitis, though they are inferior to dual-action agents 1, 4

Third-Line Treatment for Severe Cases

Short-Term Corticosteroid Use

• For inadequately controlled symptoms or acute exacerbations, add a brief course (strictly limited to 1-2 weeks maximum) of topical corticosteroids with a low side-effect profile, such as loteprednol etabonate 1, 2, 5
• Loteprednol etabonate is FDA-approved for steroid-responsive inflammatory conditions including allergic conjunctivitis and has a lower risk profile than prednisolone acetate 1% 5
• Critical monitoring requirements: Perform baseline and periodic intraocular pressure (IOP) measurement plus pupillary dilation to evaluate for glaucoma and cataract formation when using any corticosteroid 1, 3
• Use corticosteroids only as a brief adjunct to antihistamine therapy, not as monotherapy, due to risks of elevated IOP, cataract formation, and secondary infections 1, 2

Fourth-Line Treatment for Refractory Cases

Topical Immunomodulators

• For severe cases unresponsive to the above treatments, consider topical cyclosporine 0.05% or tacrolimus 1, 3
• Cyclosporine 0.1% is FDA-approved for vernal keratoconjunctivitis in children and adults and may allow for reduced use of topical steroids 1
• For vernal keratoconjunctivitis, use topical cyclosporine 0.05% at least four times daily to prevent seasonal recurrences 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

Treatments That Can Worsen Outcomes

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

Escalation Strategy

When to Intensify Treatment

• If symptoms do not improve within 48 hours on dual-action drops, add a brief 1-2 week course of loteprednol etabonate with appropriate IOP monitoring 1
• For severe atopic keratoconjunctivitis unresponsive to topical therapy, consider supratarsal injection of corticosteroid 1, 3
• Systemic immunosuppression is rarely warranted but options include montelukast, interferons, and oral T-cell inhibitors such as cyclosporine and tacrolimus 1

When to Refer

Consultation Indications

• Consult an allergist or dermatologist for patients with disease that cannot be adequately controlled with topical medications and oral antihistamines 1, 3
• 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, 3
• Consult an ophthalmologist when conjunctivitis occurs alone without rhinitis, or if vernal keratoconjunctivitis or atopic keratoconjunctivitis is suspected 6

Follow-Up and Monitoring

Surveillance Strategy

• Frequency of follow-up visits should be based on disease severity, etiology, and treatment response, with timing of visits during symptomatic periods considered 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
• For perennial allergic conjunctivitis, reassess the need for dual-action agents at regular follow-up visits based on symptom control 1