What is the treatment for an allergic reaction causing eye swelling?

Treatment of Allergic Eye Swelling

For allergic eye swelling (periorbital angioedema), start with dual-action topical antihistamine/mast cell stabilizer eye drops (olopatadine, ketotifen, epinastine, or azelastine) combined with cold compresses and oral antihistamines; if symptoms are severe or involve systemic signs, administer intramuscular epinephrine immediately. 1, 2

Immediate Assessment: Rule Out Anaphylaxis

• Check for systemic symptoms immediately: difficulty breathing, tongue/throat swelling, lightheadedness, vomiting, or disseminated hives indicate anaphylaxis requiring epinephrine 0.3-0.5 mg IM in the anterolateral thigh. 3
• Fatal allergic reactions are associated with delayed epinephrine administration, so err on the side of early treatment if any respiratory or circulatory symptoms are present. 3
• If only localized eye swelling without systemic symptoms, proceed with topical and oral treatment below. 3

First-Line Treatment for Isolated Eye Swelling

Topical Ophthalmic Therapy

• Prescribe dual-action antihistamine/mast cell stabilizer eye drops (olopatadine 0.1%, ketotifen, epinastine, or azelastine) as first-line treatment—these provide rapid onset within 30 minutes and work for both acute relief and prevention. 1, 2
• These agents are superior to single-action antihistamines or mast cell stabilizers alone because they address both immediate histamine-mediated symptoms and prevent future mast cell degranulation. 1, 2
• Refrigerate the eye drops for additional cooling relief upon instillation. 1

Non-Pharmacological Measures

• Apply cold compresses to reduce swelling and provide symptomatic relief. 3, 1, 4
• Use refrigerated preservative-free artificial tears to dilute allergens and inflammatory mediators on the ocular surface. 1, 2
• Instruct patients to avoid eye rubbing, which worsens symptoms and can lead to keratoconus in atopic patients. 1

Oral Antihistamines

• Add oral antihistamines (loratadine, cetirizine, or fexofenadine) for additional systemic control, particularly if nasal symptoms coexist. 3, 5
• Important caveat: Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier, so topical therapy remains primary for ocular symptoms. 1, 2

Escalation for Severe or Refractory Swelling

Short-Course Topical Corticosteroids

• If symptoms remain inadequately controlled after 48 hours on dual-action drops, add a brief 1-2 week course of low side-effect profile topical corticosteroid such as loteprednol etabonate. 1, 2
• Perform baseline and periodic intraocular pressure (IOP) measurement plus pupillary dilation to evaluate for glaucoma and cataract formation when using any corticosteroid. 1
• Never exceed 1-2 weeks of topical corticosteroid use due to risks of elevated IOP, cataract formation, and secondary infections. 1, 2

Oral Corticosteroids for Large Local Reactions

• For extensive periorbital swelling (large local allergic reaction), consider a short course of oral corticosteroids (prednisone) to limit inflammatory swelling. 3, 6
• This swelling is caused by allergic inflammation, not infection, and does not require antibiotic therapy. 3

Critical Pitfalls to Avoid

• Never use punctal plugs in allergic conjunctivitis—they prevent flushing of allergens and inflammatory mediators from the ocular surface. 1
• Avoid chronic vasoconstrictor use: Over-the-counter antihistamine/vasoconstrictor combinations cause rebound vasodilation (conjunctivitis medicamentosa) with prolonged use beyond 10 days. 1, 5
• Do not prescribe antibiotics for allergic eye swelling—this is an allergic condition, not an infection. 5
• Avoid oral antihistamines as sole treatment for ocular symptoms—topical therapy is more effective and faster-acting. 1, 5

When to Refer or Escalate

• Immediate emergency transport if any signs of anaphylaxis develop (respiratory symptoms, hypotension, or widespread urticaria). 3
• Consider ophthalmology referral if symptoms persist despite 2 weeks of appropriate topical therapy or if corticosteroids are needed beyond the initial short course. 1
• Refer to allergist for consideration of allergen-specific immunotherapy in severe recurrent cases refractory to conventional treatment. 1, 5

Special Considerations

• For stinging insect-related reactions: Remove any retained stinger immediately by scraping (not pinching) to prevent additional venom injection. 3
• Prescribe epinephrine autoinjector for patients with history of systemic reactions to insect stings, as risk of future anaphylaxis ranges from 25-70%. 3
• Implement allergen avoidance strategies including hypoallergenic bedding, frequent clothes washing, and showering before bedtime. 1