What is the treatment for allergic conjunctivitis?

Treatment of Allergic Conjunctivitis

Start with dual-action topical agents (olopatadine, ketotifen, epinastine, or azelastine) as first-line therapy, as these provide both rapid symptom relief and prevention of recurrent episodes. 1, 2

First-Line Treatment Approach

Non-Pharmacological Measures

• Implement allergen avoidance strategies including wearing sunglasses as a physical barrier against airborne allergens, using hypoallergenic bedding, frequent washing of clothes, and showering before bed 3, 1
• Apply cold compresses to reduce inflammation and provide immediate symptomatic relief 3, 1
• Use refrigerated preservative-free artificial tears four times daily to dilute allergens and inflammatory mediators on the ocular surface 3, 1
• Strictly avoid eye rubbing, as this worsens symptoms and can lead to keratoconus, particularly in atopic patients 3, 1

Pharmacological First-Line Treatment

• Prescribe dual-action agents (antihistamine + mast cell stabilizer) such as olopatadine, ketotifen, epinastine, or azelastine as the most effective first-line therapy 1, 2
• These agents provide rapid onset of action (treating acute symptoms) while simultaneously preventing future episodes through mast cell stabilization 1, 2
• Dual-action agents can be stored in the refrigerator for additional cooling relief upon instillation 2

Second-Line Treatment (If Inadequate Response After 48 Hours)

• Add a brief 1-2 week course of loteprednol etabonate (0.2% for seasonal allergic conjunctivitis) if symptoms do not improve within 48 hours on dual-action agents 1, 2, 4
• Loteprednol is the only FDA-approved ophthalmic corticosteroid specifically indicated for seasonal allergic conjunctivitis 4, 5
• Critical monitoring requirements when using any corticosteroid:
  • Obtain baseline intraocular pressure (IOP) measurement 3, 1
  • Perform periodic IOP monitoring throughout treatment 3, 1
  • Dilate pupils to evaluate for cataract formation 3, 1
  • Monitor for glaucoma, especially with prolonged use 3, 1

Third-Line Treatment (Severe or Refractory Cases)

• Consider topical cyclosporine 0.05% or tacrolimus for severe cases unresponsive to the above treatments 3, 1, 2
• Cyclosporine 0.1% is FDA-approved specifically for vernal keratoconjunctivitis in both children and adults 3
• Topical cyclosporine may allow for reduced use of topical steroids in chronic cases 2
• For vernal keratoconjunctivitis, use cyclosporine 0.05% at least four times daily to prevent seasonal recurrences 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 3, 1, 2
• Avoid oral antihistamines as primary therapy, as they worsen dry eye syndrome and impair the tear film's protective barrier 1, 2
• Limit vasoconstrictor use to less than 10 days, as chronic use leads to rebound hyperemia (conjunctivitis medicamentosa) 1, 2
• Avoid unnecessary topical antibiotics, as they cause toxicity and are not indicated for allergic conjunctivitis 1
• Strictly limit topical corticosteroids to 1-2 weeks maximum when used for acute exacerbations 3, 1, 2

Special Considerations for Severe Forms

Vernal/Atopic Keratoconjunctivitis

• Topical corticosteroids are usually necessary to control severe symptoms and signs 2
• For severe atopic keratoconjunctivitis unresponsive to topical therapy, consider supratarsal injection of corticosteroid 3
• For eyelid involvement in patients 2 years or older, use topical tacrolimus ointment (0.03% for ages 2-15 years; 0.03% or 0.1% for ages 16+) 2
• Be aware that tacrolimus or pimecrolimus may increase susceptibility to herpes simplex keratitis 2

When to Refer

• Consult an allergist or dermatologist for patients with disease inadequately controlled with topical medications and oral antihistamines 3, 1
• Consider allergen-specific immunotherapy (subcutaneous or sublingual) for achieving desensitization, though usage may be limited by expense, long-term patient commitment, and risk of anaphylaxis 3, 1
• Refer to ophthalmology if no improvement occurs to rule out vernal or atopic keratoconjunctivitis 1

Follow-Up Strategy

• Reassess within 48-72 hours to confirm symptom improvement 1
• Monitor for keratoconus in patients with allergic conjunctivitis and atopic disease, as adequate control of allergies and avoiding eye rubbing are crucial to decrease progression of ectasia 1, 2
• Frequency of follow-up visits depends on disease severity, etiology, and treatment response 1, 2