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Conjunctivitis - allergic - Management
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How do I manage someone with seasonal or perennial allergic conjunctivitis?

  • Before treating a person with a red eye for seasonal or perennial allergic conjunctivitis, you must exclude the serious causes of a red eye that can result in permanent visual impairment. For further information on this and how to diagnosis seasonal and perennial conjunctivitis, see Diagnosing allergic conjunctivitis.

What self care advice can I give a person with seasonal or perennial conjunctivitis?

  • Advise symptomatic people with seasonal or perennial allergic conjunctivitis to:
    • Remove contact lenses, if these are worn, until symptoms and signs resolve.
    • Avoid rubbing their eyes.
    • Avoid exposure to the allergen when practical.
    • Place cool compresses on the affected eyes to ease symptoms.
Clarification / Additional information
  • Exposure to pollen is reduced by staying indoors but is usually impractical and unnecessary if symptoms are well controlled with drug therapy. Practical measures to reduce pollen exposure include keeping windows in buildings and cars closed at times when pollen counts are high, using wrap around sunglasses and using a car fitted with a pollen filter.
  • Reducing exposure to house dust mites involves significant inconvenience and cost to the patient. There is a lack of any good quality evidence for its effectiveness but it is recommended by some experts. It should only be considered when drug treatment has failed to control symptoms and the responsible allergen has been confirmed by allergy testing. Measures recommended include:
    • Fitting mattresses with house dust mite impermeable covers; use synthetic pillows and acrylic duvets, and keep furry toys off the bed. Wash all bedding and furry toys at least once a week.
    • If possible, choosing, wooden or hard floor surfaces instead of carpets. Blinds that can be wiped clean should be fitted instead of curtains. Surfaces should be wiped regularly with a clean, damp cloth.
Basis for recommendation

What drug treatments should I prescribe for a person with seasonal or perennial conjunctivitis?

  • Before treating a person with seasonal or perennial allergic conjunctivitis, you must exclude the serious causes of a red eye that can result in permanent visual impairment. For further information, see Diagnosing allergic conjunctivitis.
    • When rapid relief of symptoms is required, prescribe an oral or topical ocular antihistamine, depending on the person's preference and previous response to treatment.
    • When prolonged control of symptoms is required, prescribe an oral antihistamine, topical ocular antihistamine, or a topical ocular mast cell stabilizer, depending on the person's preference and previous response to treatment. Explain that they will need to maintain treatment over the period of time that they are exposed to allergens to maintain control of symptoms.
    • When a topical ocular mast cell stabilizer is prescribed long term, also prescribe an oral antihistamine or topical ocular antihistamine, if:
      • Symptom control is needed in the first few weeks while waiting for the mast cell stabilizer to take effect.
      • Breakthrough symptoms occur.
    • When symptoms persist despite treatment with an antihistamine and a mast cell stabilizer:
      • Reassess the diagnosis.
      • Consider prescribing a different antihistamine or mast cell stabilizer.
      • Refer for specialist assessment, depending on clinical judgement.
    • When symptoms are severe and there is no doubt about the diagnosis, consider prescribing a 3–5 day course of an oral corticosteroid to gain rapid control of symptoms while continuing or initiating other treatment to control ongoing symptoms. Refer to an immunologist if oral corticosteroids are required more than very occasionally.
Clarification / Additional information
  • Factors affecting choice of oral or topical antihistamine for rapid control of symptoms:
    • Topical antihistamines have a more rapid onset of action than oral antihistamines and may be preferred for people with occasional symptoms who require treatment only intermittently.
    • Many people find that oral antihistamines are more convenient to use when an antihistamine is required regularly.
  • Factors affecting choice between antihistamines and mast cell stabilizers for long-term control of symptoms:
    • Oral antihistamines may help to control symptoms of allergic rhinitis, which is commonly associated with seasonal and perennial allergic conjunctivitis.
    • Oral antihistamines are available in once-daily preparations that have a long duration of action, making them convenient to use.
    • Oral antihistamines can cause systemic adverse effects, most commonly sedation.
    • Mast cell stabilizers may take several weeks or months to achieve their maximal effect [Suchecki et al, 2003; Khaw et al, 2004].
  • Oral corticosteroids for severe symptoms:
    • When symptoms and signs of eye redness are severe, a serious cause must be considered and the person referred for same-day assessment if there is any doubt about the diagnosis.
    • Consider the diagnosis of severe seasonal or perennial allergic conjunctivitis only when:
      • The person has a clear history of exposure to an allergen that has previously caused seasonal or perennial allergic conjunctivitis.
      • There are no signs of ciliary injection or loss of visual acuity.
Basis for recommendation
  • Antihistamines and mast cell stabilizers:
    • The recommendations for use of antihistamines are based on:
    • The recommendations for use of topical ocular mast cell stabilizers are based on evidence of their effectiveness in reducing symptoms of seasonal allergic conjunctivitis and is supported by expert opinion [American Academy of Ophthalmology, 2003; Khaw et al, 2004].
    • Good-quality trials are lacking that compare the efficacy of:
      • Different antihistamines against each other.
      • Different mast cell stabilizers against each other.
      • Topical antihistamines against oral antihistamines.
      • Combining mast cell stabilizers and antihistamines against use of a single treatment.
    • Despite the lack of evidence, combining antihistamines and mast cell stabilizers is widely recommended [American Academy of Ophthalmology, 2003; Yanoff and Duker, 2004].
    • The recommendation to consider switching to a different antihistamine if symptoms do not settle with the first-choice antihistamine is pragmatic advice based on:
      • The professional opinion of expert reviewers.
      • Extrapolation of the evidence of individual variability in the response to, and tolerability of, antihistamines in the treatment of urticaria and angioedema [Grattan et al, 2001; Zuberbier et al, 2006].
  • Oral corticosteroids:
    • CKS could find no trial evidence of oral corticosteroid use in managing severe symptoms of allergic conjunctivitis.
    • The recommendation to use oral corticosteroids is based on experience of their use in relieving symptom exacerbation in other conditions, for example, the consensus of an international group of experts concluded that a short course of oral corticosteroid can be helpful in rapidly relieving the symptoms of allergic rhinitis [ARIA, 2001]. Clinical experience confirms this consensus and there is no reason not to believe that they may also have a role in the management of severe symptoms of allergic conjunctivitis.

How do I manage a person with giant papillary conjunctivitis?

  • Before treating a person with a red eye for giant papillary conjunctivitis, you must exclude the serious causes of a red eye that can result in permanent visual impairment. For further information, see Diagnosing allergic conjunctivitis.
  • Advise people with giant papillary conjunctivitis to:
    • Avoid rubbing their eyes.
    • Place cool compresses on the affected eyes to ease symptoms.
    • Remove contact lenses, if these are worn, and see an optician for further management.
    • Refer people with giant papillary conjunctivitis following eye surgery to an ophthalmologist.
Clarification / Additional information
  • The symptoms of conjunctival injection and mucoid discharge resolve quickly after contact lens use is discontinued, but papillae persist for some time [Suchecki et al, 2003].
  • Management of giant papillary conjunctivitis by an optician includes:
    • Changing the type of contact lens.
    • Advising about hygiene measures.
    • Reviewing and assessing the need for a mast cell stabilizer to prevent recurrence of symptoms.
Basis for recommendation

How should I manage someone with contact dermatoconjunctivitis?

  • Before treating a person with a red eye for contact dermatoconjunctivitis, you must exclude the serious causes of a red eye that can result in permanent visual impairment. For further information, see Diagnosing allergic conjunctivitis.
    • Advise people to:
      • Remove contact lenses, if they are worn, until symptoms and signs resolve.
      • Avoid rubbing their eyes.
      • Place cool compresses on the affected eyes to ease symptoms.
      • Avoid exposure to the identified allergen. When caused by cosmetics, symptoms should be allowed to resolve completely before trying an alternative product.
    • When contact dermatoconjunctivitis is due to eye drops, seek specialist advice as to an appropriate alternative, when continued treatment is necessary.
    • When contact dermatoconjunctivitis is severe, refer for same-day assessment and further management by a specialist.
Clarification / Additional information
  • Referral for people with severe contact dermatoconjunctivitis is recommended for confirmation of the diagnosis and further management with topical corticosteroids. Preservative-free eye drops may be recommended where appropriate.
Basis for recommendation
  • Antihistamines and mast cell stabilizers are not recommended for the treatment of contact dermatoconjunctivitis because they have no effect in controlling inflammation in type IV hypersensitivity reactions [Yanoff and Duker, 2004].

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