What are the treatment guidelines for allergic conjunctivitis?

From the Guidelines

Treatment guidelines for allergic conjunctivitis should prioritize a stepwise approach, starting with non-pharmacological measures such as wearing sunglasses, cold compresses, and refrigerated artificial tears, as well as avoiding eye rubbing and allergens, as recommended by the most recent study 1.

Non-Pharmacological Measures

• Wearing sunglasses as a barrier to airborne allergens
• Cold compresses to reduce inflammation
• Refrigerated artificial tears to provide symptomatic relief
• Avoiding eye rubbing to prevent further irritation
• Avoiding allergens to reduce exposure

Pharmacological Measures

• For mild cases, antihistamine/vasoconstrictor agents or second-generation topical histamine H1-receptor antagonists can be used, such as olopatadine (0.1% or 0.2%) once or twice daily, ketotifen 0.025% twice daily, or epinastine 0.05% twice daily, as suggested by 1 and supported by 1.
• For moderate symptoms, topical corticosteroids such as loteprednol 0.2% or fluorometholone 0.1% can be used short-term (1-2 weeks) to control inflammation, but require monitoring for intraocular pressure elevation, as recommended by 1.
• Mast-cell stabilizers can be used for chronic or recurrent cases, and combination agents with antihistamine and mast-cell stabilizing properties can be used for either acute or chronic disease, as noted in 1.

Additional Considerations

• Environmental modifications, such as avoiding known allergens, keeping windows closed during high pollen seasons, using air purifiers, and washing hands and face after outdoor exposure, are crucial in managing allergic conjunctivitis, as emphasized by 1.
• Oral antihistamines like cetirizine 10mg daily or loratadine 10mg daily may help when multiple allergic conditions are present, but may induce or worsen dry eye syndrome, as cautioned by 1.
• Referral to an ophthalmologist is recommended if symptoms persist beyond 2-3 weeks of treatment or if vision becomes affected, as advised by the example answer.

From the FDA Drug Label

Loteprednol Etabonate Ophthalmic Suspension, 0.2% is indicated for the temporary relief of the signs and symptoms of seasonal allergic conjunctivitis. In two double-masked, placebo-controlled six-week environmental studies of 268 patients with seasonal allergic conjunctivitis, Loteprednol Etabonate Ophthalmic Suspension, 0. 2%, when dosed four times per day was superior to placebo in the treatment of the signs and symptoms of seasonal allergic conjunctivitis.

The treatment guidelines for allergic conjunctivitis include the use of Loteprednol Etabonate Ophthalmic Suspension, 0.2%, dosed four times per day, for the temporary relief of signs and symptoms of seasonal allergic conjunctivitis 2 2.

• The medication provides reduction in bulbar conjunctival injection and itching, beginning approximately 2 hours after instillation of the first dose and throughout the first 14 days of treatment.

From the Research

Treatment Guidelines for Allergic Conjunctivitis

• The primary approach for managing allergic conjunctivitis (AC) involves topical pharmacologic treatments, with dual-acting antihistamine-mast cell stabilizing agents considered first-line therapeutics 3.
• These dual-acting agents provide acute relief of signs and symptoms and block persistent inflammation to promote regression of AC 3.
• Recent studies have demonstrated the effectiveness of a newly-developed, higher-concentration formulation of a dual-acting antihistamine-mast cell stabilizer, which provides a 24-hour duration of action with once-daily dosing 3, 4.
• Topical antihistamines, such as alcaftadine, levocabastine, and azelastine, have been shown to be effective in treating AC symptoms in randomized controlled trials (RCTs) 4.
• Mast cell stabilizers, such as cromoglycate, are also used to treat AC, and can be used in combination with antihistamines 5, 6.
• Clinical guidelines recommend topical therapy with antihistamines, mast cell stabilizers, or dual-action agents as first-line treatment for seasonal and perennial allergic conjunctivitis (SAC and PAC) 7.
• The choice of treatment should take into account the potential for ocular surface damage and the presence of comorbidities, such as dry eye disease 7.

Treatment Options

• Dual-acting antihistamine-mast cell stabilizers: olopatadine, azelastine, ketotifen, and epinastine 3, 4.
• Topical antihistamines: alcaftadine, levocabastine, and azelastine 4.
• Mast cell stabilizers: cromoglycate, nedocromil sodium, and sodium cromoglycate 5, 6.
• Corticosteroids: may be used for short courses in severe cases or for chronic conjunctivitis 6.
• Immunotherapy: may be considered for severe cases or for patients with subcutaneous or sublingual immunotherapy 6.

Key Considerations

• The treatment of AC should aim to provide consistent suppression of conjunctival inflammation 3.
• The choice of treatment should be based on the severity of symptoms, the presence of comorbidities, and the potential for ocular surface damage 7.
• Topical treatments should be used with caution, as many medications contain compounds that may contribute to ocular surface damage 7.