Steroids Are NOT Required for SAC and PAC
Steroids are not required for seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC), but should be reserved for moderate-to-severe cases and used cautiously and only temporarily when needed. 1, 2, 3
Treatment Algorithm Based on Severity
Mild Cases (First-Line Therapy)
- Artificial tears serve as the foundation for mild SAC and PAC 2, 3
- Topical antihistamines provide rapid relief from acute symptoms and itching 2, 3
- Mast cell stabilizers offer long-term control and are appropriate for extended use 4, 2, 3
- Dual-action agents (combining antihistamines and mast cell stabilizers) improve compliance through reduced application frequency 2, 3
Moderate-to-Severe Cases (When Steroids May Be Considered)
- Topical corticosteroids provide the most effective relief for severe, acute exacerbations 5
- However, steroids should be used cautiously and only temporarily 2, 3
- For prolonged treatment needs, unpreserved anti-allergic eye drops are preferred over continued steroid use 2, 3
Key Clinical Considerations
Why Steroids Are Not First-Line
The evidence consistently emphasizes that SAC and PAC have a milder course compared to chronic forms of allergic conjunctivitis 2, 3. This milder disease pattern means most patients achieve adequate symptom control without steroids.
When Steroids Become Necessary
A multifaceted treatment regimen may require corticosteroids for moderate-to-severe cases 1. The decision to use steroids should be based on:
- Severity of signs and symptoms 1
- Failure of first-line agents (antihistamines, mast cell stabilizers) 1, 4
- Presence of severe acute exacerbations 5
Safety Profile of Newer Steroid Options
If steroids are needed, loteprednol etabonate (a C-20 ester corticosteroid) offers similar efficacy to traditional steroids with:
- Greatly improved safety profile 5
- Less likelihood of elevating intraocular pressure 5
- Reduced risk of cataract formation 5
Critical Pitfalls to Avoid
- Do not use steroids as first-line therapy for routine SAC/PAC 2, 3
- Avoid prolonged steroid use due to risks of elevated intraocular pressure and cataract formation 5
- Recognize that SAC and PAC account for >90% of allergic conjunctivitis cases and typically respond to non-steroidal therapy 2, 3
- Reserve ophthalmology co-management for chronic severe forms (vernal keratoconjunctivitis, atopic keratoconjunctivitis, giant papillary conjunctivitis), not routine SAC/PAC 1