What is the treatment for allergic conjunctivitis?

Treatment of 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. 1

First-Line Treatment Approach

Start with dual-action antihistamine/mast cell stabilizer eye drops as these agents work within 30 minutes and address both acute symptoms and prevention of future episodes. 1, 2

• Preferred agents include:

  • Olopatadine 0.1% (twice daily) or 0.77% (once daily) 1, 2
  • Ketotifen 1, 2
  • Epinastine 0.05% 1, 2
  • Azelastine 1, 2

• Store dual-action drops in the refrigerator for additional cooling relief upon instillation 1

• Add refrigerated preservative-free artificial tears four times daily to dilute allergens and inflammatory mediators on the ocular surface 1, 3

• Apply cold compresses for additional symptomatic relief in mild cases 1, 2

Non-Pharmacological Measures (Implement Immediately)

• Wear sunglasses outdoors as a physical barrier against airborne allergens 1, 3
• Avoid eye rubbing, which worsens symptoms and can lead to keratoconus, especially in atopic patients 1
• Implement allergen avoidance strategies including hypoallergenic bedding, frequent clothes washing, and bathing/showering before bedtime 1

Second-Line Options (If First-Line Insufficient)

If symptoms persist after 48 hours on dual-action drops, escalate treatment: 1, 3

• Add topical NSAIDs (ketorolac) for temporary relief of ocular itching caused by seasonal allergic conjunctivitis 1, 4

• Consider mast cell stabilizers alone (cromolyn, lodoxamide, nedocromil, pemirolast) for prophylactic or longer-term treatment, though these have slower onset (several days) compared to dual-action agents 1, 2

Third-Line Treatment (Severe Cases or Acute Exacerbations)

Add a brief 1-2 week course of loteprednol etabonate if symptoms remain inadequately controlled. 1, 2, 3

• Critical monitoring requirements:

  • Obtain baseline intraocular pressure (IOP) measurement 1, 3
  • Perform pupillary dilation to evaluate for glaucoma and cataract 1, 3
  • Repeat IOP measurements periodically during treatment 1, 2

• Never exceed 1-2 weeks of topical corticosteroid use due to risks of elevated IOP, cataract formation, and secondary infections 1, 2, 5

• Use corticosteroids only as adjunct to antihistamine therapy, not as monotherapy 3

Fourth-Line Treatment (Refractory Cases)

For severe cases unresponsive to the above treatments, consider topical calcineurin inhibitors: 1

• Cyclosporine 0.05% (FDA-approved for vernal keratoconjunctivitis; use at least four times daily) 1
• Tacrolimus (alternative option) 1
• These agents may allow for reduced use of topical steroids 1

Critical Pitfalls to Avoid

• Never use punctal plugs in allergic conjunctivitis as they prevent flushing of allergens and inflammatory mediators from the ocular surface 1

• Avoid oral antihistamines as primary treatment because they may worsen dry eye syndrome and impair the tear film's protective barrier 1, 2, 3

• Avoid chronic vasoconstrictor use (over-the-counter antihistamine/vasoconstrictor combinations) as prolonged use beyond 10 days causes rebound hyperemia (conjunctivitis medicamentosa) 1, 3

• Do not use topical antibiotics as they can induce toxicity and are not indicated for allergic conjunctivitis 1

Special Populations

For vernal keratoconjunctivitis or atopic keratoconjunctivitis: 1

• Topical corticosteroids are usually necessary to control severe symptoms 1
• Topical cyclosporine 0.05% or tacrolimus should be used to reduce corticosteroid dependence 1
• For eyelid involvement in patients ≥2 years old, use pimecrolimus cream 1% or tacrolimus ointment (0.03% for ages 2-15; 0.03% or 0.1% for ages 16+) 1
• Warning: Tacrolimus or pimecrolimus may increase susceptibility to herpes simplex keratitis 1

When to Refer

• Consult ophthalmology if no improvement within 48-72 hours on dual-action drops to rule out vernal or atopic keratoconjunctivitis 3

• Consult allergist or dermatologist for patients with disease that cannot be adequately controlled with topical medications and oral antihistamines 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

Follow-Up Strategy

• Reassess in 48-72 hours to confirm symptom improvement 3
• Frequency of follow-up visits should be based on disease severity, etiology, and treatment response 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