What are the treatment options for itching eyes after a concussion?

Treatment of Itching Eyes After Concussion

Itching eyes after concussion is not a typical post-concussive symptom and should be evaluated as a separate allergic or inflammatory condition, treated with standard ophthalmic therapies while simultaneously addressing the underlying concussion through visual/oculomotor rehabilitation.

Understanding the Clinical Context

Post-concussion ocular symptoms typically manifest as blurred vision, double vision, ocular pain, convergence insufficiency, accommodative dysfunction, and photophobia—not itching 1, 2, 3. Itching suggests an allergic or inflammatory process unrelated to the concussion mechanism itself 4.

Immediate Management of Eye Itching

First-Line Topical Treatment

• Dual-action ophthalmic agents (antihistamine + mast cell stabilizer) provide the most effective relief for ocular itching, with onset of action within 30 minutes 4
• Ketotifen (Alaway, Zaditor) is FDA-approved for temporary relief of itchy eyes, dosed as 1 drop in affected eyes twice daily (every 8-12 hours) for patients ≥3 years old 5
• Alternative dual-action agents include olopatadine (Pataday, Patanol), azelastine (Optivar), and epinastine (Elestat) 4

Alternative Topical Options

• Topical antihistamines alone (emedastine, levocabastine) provide relief but are less effective than dual-action agents 4
• Mast cell stabilizers (cromolyn, lodoxamide, nedocromil) require several days for optimal effect and are better for prophylaxis than acute relief 4
• Topical NSAIDs (ketorolac) reduce prostaglandin-mediated ocular itching in seasonal allergic conjunctivitis 4
• Avoid prolonged use of vasoconstrictors (>10 days) as they can cause rebound hyperemia without addressing the allergic response 4

When Oral Antihistamines Are Insufficient

• Oral antihistamines are generally less effective than topical agents for ocular symptoms, have slower onset, and may cause excessive tear film drying 4
• Reserve oral agents for patients with concurrent nasal/systemic allergic symptoms 4

Concurrent Post-Concussion Visual Management

Essential Visual/Oculomotor Assessment

All concussion patients with persistent visual symptoms require formal oculomotor evaluation to screen for vergence, accommodative, or eye movement dysfunction 6, 7. This assessment is critical because:

• Up to 69% of concussion patients have ocular dysfunction including convergence insufficiency, accommodative deficits, and saccadic abnormalities 3
• These deficits cause headache, visual symptoms, and concentration difficulties that overlap with but are distinct from allergic itching 6

Oculomotor Vision Treatment Protocol

• Implement vergence training, accommodative training, and eye movement exercises for patients with documented visual dysfunction 6, 7
• Treatment should be administered at least once weekly for a minimum of 4 weeks 7
• Clinical experience demonstrates improvements in visual symptoms, headache, and fatigue 6

Integrated Rehabilitation Approach

• Initiate sub-symptom threshold aerobic exercise with gradual increases in intensity, which improves overall symptom burden, physical functioning, and quality of life 6, 7
• Coordinate interdisciplinary treatment from at least two healthcare disciplines (e.g., optometry/ophthalmology + physical therapy) if symptoms persist beyond 4 weeks 6, 7
• Provide systematic patient education about symptom management and expected recovery course 6, 7

Critical Pitfalls to Avoid

• Do not attribute all post-concussion ocular symptoms to the brain injury itself—allergic conjunctivitis requires separate treatment 4
• Do not use topical corticosteroids for simple allergic itching without ophthalmologic supervision, as they carry risks of elevated intraocular pressure, cataracts, and secondary infections 4
• Do not delay formal visual assessment if symptoms persist beyond 2 weeks—early intervention prevents progression to persistent post-concussion syndrome 7
• Avoid complete rest beyond 48 hours as prolonged inactivity may impair concussion recovery 7

When to Refer to Ophthalmology

• Immediate referral if corneal involvement, severe inflammation, or vision changes are present 4
• Routine referral for persistent ocular symptoms beyond 2-4 weeks despite appropriate topical therapy 3
• Urgent evaluation if using topical corticosteroids—requires baseline and periodic IOP measurement and cataract screening 4