Recommended Eye Drops for Allergic Rhinitis and Conjunctivitis
Start with dual-action antihistamine/mast cell stabilizer eye drops (olopatadine, ketotifen, epinastine, or azelastine) as first-line therapy—these provide both immediate relief within 30 minutes and ongoing protection when used twice daily. 1
First-Line Treatment Algorithm
Dual-Action Agents (Preferred)
- Olopatadine 0.1%, ketotifen 0.025%, epinastine, or azelastine are the most effective first-line options recommended by the American Academy of Allergy, Asthma, and Immunology 1
- These agents work rapidly (onset within 30 minutes) and address both acute symptoms and prevention of future episodes 1, 2
- Dosing: Apply twice daily, every 8-12 hours 3
- Can be refrigerated before instillation for additional cooling relief 1
- No maximum treatment duration—safe for extended use unlike corticosteroids 2
Adjunctive Non-Pharmacological Measures
- Use refrigerated preservative-free artificial tears to dilute allergens and inflammatory mediators 1
- Apply cold compresses for symptomatic relief 1
- Implement allergen avoidance (sunglasses, hypoallergenic bedding, frequent clothes washing) 1
Second-Line Options for Inadequate Response
Mast Cell Stabilizers
- Cromolyn, lodoxamide, nedocromil, or pemirolast if dual-action agents are insufficient 1
- Better for prophylactic/longer-term treatment but have slower onset (several days) 1, 2
- Less ideal than dual-action agents due to delayed effect 2
Topical NSAIDs
- Ketorolac provides temporary relief of ocular itching in seasonal allergic conjunctivitis 1
- Consider as adjunct for breakthrough itching 1
Third-Line Treatment for Severe Cases
Short-Course Topical Corticosteroids
- Loteprednol etabonate 0.2% is FDA-approved for temporary relief of seasonal allergic conjunctivitis signs and symptoms 4
- Strictly limit to 1-2 weeks maximum for acute exacerbations or inadequately controlled symptoms 1, 2
- Requires baseline and periodic intraocular pressure (IOP) measurement plus pupillary dilation to monitor for glaucoma and cataract formation 1
- Use only as brief adjunct to antihistamine therapy, never as monotherapy 1
Topical Calcineurin Inhibitors (Refractory Cases)
- Cyclosporine 0.05% or tacrolimus for severe cases unresponsive to above treatments 1
- Particularly effective in vernal keratoconjunctivitis or atopic conjunctivitis 1
- May allow reduced corticosteroid use 1
Critical Pitfalls to Avoid
What NOT to Do
- Avoid punctal plugs—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 hyperemia (conjunctivitis medicamentosa) with prolonged use 1
- Avoid oral antihistamines as primary ocular treatment—they may worsen dry eye syndrome and impair the tear film's protective barrier 1, 2
- Avoid indiscriminate topical antibiotics—they can induce toxicity and are not indicated for allergic conjunctivitis 1
Corticosteroid Safety Monitoring
- If corticosteroids are necessary, perform baseline IOP and dilated fundus exam before starting 1
- Repeat IOP checks periodically during treatment 1
- Warn patients about risks of elevated IOP, cataract formation, and secondary infections 1, 2
Special Considerations
Pediatric Patients
- Ketotifen is approved for children 3 years and older 3
- Use preservative-free artificial tears in children under 5, especially with frequent application (>4 times daily) 5
Eyelid Involvement
- For allergic dermatitis of eyelids in patients ≥2 years: tacrolimus ointment 0.03% (ages 2-15) or 0.03-0.1% (ages 16+) 1, 5
- Be aware tacrolimus may increase susceptibility to herpes simplex keratitis 1
Evidence Supporting Ketotifen
- Research demonstrates ketotifen significantly reduces both ocular and nasal symptoms of allergic rhinoconjunctivitis 6, 7
- Ketotifen 0.025% is more effective and better tolerated than 0.05% concentration 8
- Superior to levocabastine and placebo in environmental studies 9