What is the recommended management for a patient with allergic conjunctivitis?

Management of Allergic Conjunctivitis

Start with dual-action topical agents (olopatadine, ketotifen, epinastine, or azelastine) as first-line pharmacological treatment, as these provide both immediate symptom relief and ongoing protection through combined antihistamine and mast cell stabilizer effects. 1

First-Line Treatment Approach

Non-Pharmacological Measures (Implement for All Patients)

• Apply cold compresses for immediate symptomatic relief 1
• Use refrigerated preservative-free artificial tears 4 times daily to dilute allergens and inflammatory mediators on the ocular surface 1
• Wear sunglasses as a physical barrier against airborne allergens 1
• Implement allergen avoidance strategies including hypoallergenic bedding, eyelid cleansers to remove allergens, frequent clothes washing, and showering/bathing before bedtime 1
• Counsel patients to avoid eye rubbing, which can worsen symptoms and potentially lead to keratoconus, especially in atopic patients 1

Pharmacological First-Line Treatment

• Prescribe dual-action agents (olopatadine, ketotifen, epinastine, or azelastine) as the most effective first-line option due to their rapid onset of action within 30 minutes and ability to both treat acute symptoms and prevent future episodes 1, 2
• Store eye drops in the refrigerator for additional cooling relief upon instillation 1
• These agents can be used continuously for both seasonal and perennial allergic conjunctivitis as long as allergen exposure persists, with no specified maximum treatment duration 2

Second-Line Treatment (For Prophylaxis or Longer-Term Management)

• Consider mast cell stabilizers alone (cromolyn, lodoxamide, nedocromil, or pemirolast) for prophylactic or longer-term treatment, though these require several days to achieve optimal symptom relief due to slow onset of action 1, 2
• Topical NSAIDs such as ketorolac can provide temporary relief of ocular itching caused by seasonal allergic conjunctivitis 1

Third-Line Treatment (For Inadequate Response or Severe Symptoms)

If symptoms do not improve within 48 hours on dual-action drops, add a brief 1-2 week course of loteprednol etabonate 1

Critical Monitoring Requirements for Topical Corticosteroids

• Perform baseline intraocular pressure (IOP) measurement and pupillary dilation to evaluate for glaucoma and cataract formation before initiating corticosteroids 1
• Continue periodic IOP monitoring throughout corticosteroid use 1
• Strictly limit topical corticosteroids to 1-2 weeks maximum 1, 2
• Loteprednol etabonate is preferred due to its low side-effect profile compared to traditional corticosteroids 1, 3

Fourth-Line Treatment (For Severe or Refractory Cases)

Vernal Keratoconjunctivitis or Atopic Conjunctivitis

• Consider topical cyclosporine 0.05% at least 4 times daily for severe cases unresponsive to dual-action agents and corticosteroids 1
• Cyclosporine demonstrates reduction in signs and symptoms after 2 weeks and may allow for reduced use of topical steroids 1
• Topical tacrolimus 0.03% or 0.1% can be used as an alternative to cyclosporine 1

For Eyelid Involvement

• Use pimecrolimus cream 1% or topical tacrolimus ointment (0.03% for ages 2-15 years; 0.03% or 0.1% for ages 16+) for patients 2 years or older 1
• Be aware that tacrolimus or pimecrolimus may increase susceptibility to herpes simplex keratitis 1

For Sight-Threatening Disease

• Consider supratarsal corticosteroid injection for severe atopic keratoconjunctivitis not responsive to topical therapy 1
• Systemic immunosuppression (montelukast, interferons, oral cyclosporine or tacrolimus) is rarely warranted but may be considered in consultation with an allergist or dermatologist 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 1
• Avoid chronic use of over-the-counter antihistamine/vasoconstrictor combinations (such as naphazoline/pheniramine), as prolonged vasoconstrictor use beyond 10 days can cause rebound vasodilation (conjunctivitis medicamentosa) 1
• Avoid oral antihistamines as primary treatment, as they may worsen dry eye syndrome and impair the tear film's protective barrier 1, 2
• Avoid indiscriminate use of topical antibiotics, as they provide no benefit for allergic disease, induce toxicity, and contribute to antibiotic resistance 1

Follow-Up Strategy

• Base the frequency of follow-up visits on disease severity, etiology, and treatment response, with visits timed during symptomatic periods 1
• Monitor patients with atopic disease for keratoconus, as adequate allergy control and preventing eye rubbing can decrease ectasia progression 1
• For perennial allergic conjunctivitis, reassess the need for dual-action agents at regular follow-up visits based on symptom control 1

When to Refer

• Consult an allergist or dermatologist for patients with disease that cannot be adequately controlled with topical medications and oral antihistamines 1
• Consider allergen-specific immunotherapy (subcutaneous or sublingual) for achieving hyposensitization in persistent severe cases, though usage may be limited by expense, long-term patient commitment, and risk of anaphylaxis 1

Pediatric Considerations

• Sodium cromoglycate is the safest option for very young children, including infants, due to its lack of age restriction and can be used four times daily 1
• Monitor for eye rubbing in children, which can lead to keratoconus in atopic patients 1