What are the treatments for red itchy eyes?

Treatment of Red Itchy Eyes

For red itchy eyes, start with dual-action topical antihistamine/mast cell stabilizers (olopatadine, ketotifen, epinastine, or azelastine) as first-line therapy, as these provide both immediate relief and ongoing protection against allergic conjunctivitis, which is the most likely diagnosis when itching is the predominant symptom. 1

Initial Assessment: Determine the Cause

When evaluating red itchy eyes, itching is the most consistent and distinguishing feature of allergic conjunctivitis, differentiating it from infectious causes 2. Key clinical features to assess:

• Allergic conjunctivitis: Bilateral presentation, watery discharge, itching as predominant symptom, no matted eyelids, often seasonal or perennial pattern 2
• Viral conjunctivitis: Watery discharge, follicular reaction on inferior tarsal conjunctiva, preauricular lymphadenopathy, often starts unilateral then becomes bilateral 2
• Bacterial conjunctivitis: Mucopurulent discharge with matted eyelids, papillary (not follicular) reaction 2

First-Line Treatment for Allergic Conjunctivitis

Dual-action agents (olopatadine, ketotifen, epinastine, azelastine) are recommended as the most effective first-line treatment due to their rapid onset of action and ability to both treat acute symptoms and prevent future episodes 1. These agents can be dosed 1-2 times daily and may be refrigerated for additional cooling relief upon instillation 1.

Non-Pharmacological Measures (Use Concurrently)

• Wear sunglasses as a physical barrier against airborne allergens 3, 1
• Apply cold compresses for symptomatic relief 3, 1
• Use refrigerated preservative-free artificial tears to dilute allergens and inflammatory mediators 3, 1
• Avoid eye rubbing, which can worsen symptoms and potentially lead to keratoconus in atopic patients 1
• Implement allergen avoidance: hypoallergenic bedding, eyelid cleansers, frequent clothes washing, bathing/showering before bedtime 3, 1

Second-Line Options

If dual-action agents are insufficient after 48 hours:

• Mast cell stabilizers alone (cromolyn sodium, lodoxamide, nedocromil, pemirolast) are better for prophylactic or longer-term treatment but have slower onset of action 1. Cromolyn sodium is dosed 1-2 drops 4-6 times daily and may take several days to weeks for full effect 4
• Topical NSAIDs (ketorolac) provide temporary relief of ocular itching 1

Third-Line: Short-Term Corticosteroids (Use With Caution)

For severe cases or inadequately controlled symptoms, add a brief 1-2 week course (maximum) of low side-effect profile topical corticosteroids such as loteprednol etabonate 1.

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 or for prolonged periods due to risks of elevated IOP, cataract formation, and secondary infections 1

Fourth-Line: Severe or Refractory Cases

For cases unresponsive to the above treatments:

• Topical cyclosporine 0.05% (at least 4 times daily) or tacrolimus can be considered 1
• Cyclosporine may allow for reduced use of topical steroids and is particularly effective for vernal or atopic keratoconjunctivitis 1

Critical Pitfalls to Avoid

• Avoid chronic vasoconstrictor use: Over-the-counter antihistamine/vasoconstrictor combinations cause rebound vasodilation (conjunctivitis medicamentosa) with prolonged use 1
• Avoid oral antihistamines as primary treatment: They may worsen dry eye syndrome and impair the tear film's protective barrier, potentially worsening allergic conjunctivitis 3, 1
• Never use punctal plugs in allergic conjunctivitis: They prevent flushing of allergens and inflammatory mediators from the ocular surface 3, 1
• Avoid indiscriminate antibiotic use: Topical antibiotics provide no benefit for allergic conjunctivitis and can induce toxicity 3, 1

Red Flags Requiring Urgent Ophthalmology Referral

Refer immediately if any of the following are present:

• Visual loss or decreased visual acuity 5
• Moderate to severe ocular pain 5
• Corneal involvement or opacity 5
• Severe purulent discharge 5
• History of herpes simplex virus eye disease 5
• Immunocompromised state 5
• Lack of response to therapy after 3-4 days 5

Special Considerations for Viral Conjunctivitis

If viral conjunctivitis is suspected (watery discharge, follicular reaction, preauricular lymphadenopathy):

• Treatment is supportive only—antibiotics provide no benefit and may cause harm 2, 5
• Use preservative-free artificial tears 4 times daily 5
• Patient education about high contagiousness: minimize contact with others for 10-14 days from symptom onset 2
• Most cases are self-limited, resolving within 5-14 days 2