What are the recommended medications for treating allergic conjunctivitis?

Medications for Allergic Conjunctivitis

First-Line Treatment: Dual-Action Topical Agents

Dual-action agents combining antihistamine and mast cell stabilizer properties—specifically olopatadine, ketotifen, epinastine, and azelastine—are the most effective first-line pharmacological treatment for allergic conjunctivitis. 1

These agents provide:

• Rapid symptom relief within 30 minutes due to antihistamine effects 2
• Ongoing protection through mast cell stabilization 1
• Ability to treat both acute symptoms and prevent future episodes, making them suitable for continuous use during allergen exposure 1, 2
• No maximum treatment duration restrictions, unlike corticosteroids, supporting extended use for perennial allergic conjunctivitis 2

Adjunctive Non-Pharmacological Measures

• Refrigerated preservative-free artificial tears dilute allergens and inflammatory mediators on the ocular surface 1
• Cold compresses and saline irrigation provide relief for mild symptoms 1
• Allergen avoidance strategies including sunglasses as physical barriers, hypoallergenic bedding, and showering before bedtime 1

Second-Line Options for Specific Scenarios

Pure Mast Cell Stabilizers

Cromolyn, lodoxamide, nedocromil, and pemirolast are better suited for prophylactic or longer-term prevention when symptoms are predictable, though they have slower onset (several days) compared to dual-action agents 1, 2

Topical NSAIDs

Ketorolac provides temporary relief of ocular itching in seasonal allergic conjunctivitis but lacks the comprehensive efficacy of dual-action agents 1

Third-Line Treatment: Short-Course Topical Corticosteroids

For severe symptoms or acute exacerbations inadequately controlled by dual-action agents, add loteprednol etabonate for a strictly limited 1-2 week course. 1, 3

Critical Monitoring Requirements

• Baseline and periodic intraocular pressure (IOP) measurement 1
• Pupillary dilation to evaluate for glaucoma and cataract formation 1
• Never use corticosteroids as monotherapy—only as brief adjunct to antihistamine therapy 1

Corticosteroid Risks

Topical corticosteroids carry significant risks including:

• Elevated intraocular pressure 1, 3
• Cataract formation 1, 3
• Secondary infections 1

Fourth-Line Treatment: Immunomodulators for Refractory Cases

For severe cases unresponsive to the above treatments, particularly vernal or atopic keratoconjunctivitis, topical cyclosporine 0.05% or tacrolimus should be considered. 1

• Cyclosporine 0.1% is FDA-approved for vernal keratoconjunctivitis in children and adults 1
• Cyclosporine allows for reduced corticosteroid use and is effective with at least four times daily dosing 1
• For eyelid involvement in patients ≥2 years, 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

Critical Pitfalls to Avoid

Never Use Punctal Plugs

Punctal plugs are contraindicated in allergic conjunctivitis because they prevent flushing of allergens and inflammatory mediators from the ocular surface 1

Avoid Oral Antihistamines as Primary Treatment

Oral antihistamines may worsen dry eye syndrome and impair the tear film's protective barrier, making them suboptimal for ocular allergy management 1, 2

Avoid Chronic Vasoconstrictor Use

Over-the-counter antihistamine/vasoconstrictor combinations cause rebound vasodilation (conjunctivitis medicamentosa) with prolonged use 1, 2

Avoid Indiscriminate Antibiotic Use

Topical antibiotics are not indicated for allergic conjunctivitis and can induce toxicity 1

Escalation Algorithm

1. Start with dual-action topical agents (olopatadine, ketotifen, epinastine, or azelastine) plus artificial tears 1
2. If inadequate response within 48 hours, add loteprednol etabonate for 1-2 weeks maximum with IOP monitoring 1
3. If symptoms remain uncontrolled, consider topical cyclosporine or tacrolimus for long-term management 1
4. For disease uncontrolled with topical medications, consult allergist for consideration of allergen-specific immunotherapy (subcutaneous or sublingual) 1

Special Populations

Vernal/Atopic Keratoconjunctivitis

• Topical corticosteroids are usually necessary to control severe symptoms 1
• Long-term topical calcineurin inhibitors (cyclosporine or tacrolimus) may be required 1
• For severe atopic keratoconjunctivitis unresponsive to topical therapy, consider supratarsal corticosteroid injection 1
• Monitor for keratoconus, as adequate allergy control and avoiding eye rubbing decrease ectasia progression 1