Desired Outcomes • Relief of current allergic symptoms

• Prevention of future allergic symptoms

• No adverse effects from treatment

Nonpharmacologic Therapy

The primary treatment for ocular allergy is removal and avoidance of the allergen.19 For conjunctivitis medicamentosa, discontinue the offending medication.11 Apply cold compresses three to four times daily to reduce redness and itching and to provide symptomatic relief.

Pharmacologic Therapy

® Use a step-care approach for the treatment of allergic conjunctivitis. The first step is a nonmedicated, artificial tears solution. The solution dilutes or removes the allergen, providing relief while lubricating the eye. Solutions are applied two to four times daily as needed. Ointments may be used in the evenings to further moisturize the surface of the eye.19 There are many products on the market. Try a preservative-free formulation if other products sting or burn. Unit-dose preservative-free products are more expensive. Some newer multidose products, such as sodium perborate (Purite), have rapidly dissociating preservatives and are more cost-effective.

Table 63-4 Mechanisms of Action of Ocular Allergy Drugs


Mll[ h a ni Mm i



H.-neoefHür anragcfUit

Available onty In nomtnnatlari wtifi naphajaline


Kli(i.lJWI OiiLdrKJi'OL rrusL stdtxliiir

M.iy l-ihillir iylOllilH.'K.'liaW.'

Cromolyn sodium

M«! cell stabilizer


Hi.xtf/üi ,T>ni jQCfir:,r; inlUbit^GQelnoptd ctemctixlE

Supenoi H^ritopncn binding .ltjilny


M ■ jrKi H;-ieau»i ¿ßwaonüL irusKeH iMbi^a. ooii-inrismmsfofy

Ki-1 orotic

Pr:i<,l.-ii|!.ii*liii rihibihir


H lect'ptor anUgorvst, mast cell stdbiliier, eosinophil inhibitor ptowtei-scriviitlng fact* inhibit*

May inhibit eonnoptriehemdaxis


H.-receptor antagonist

Dcwmegulates intranellulai adKi«ion moleculeiv JfXHMintJ inilirrtrnJPOi^ri^Hifly' iri^1 IX1 uv.1^ toi up1o i Wfhs


Mjii! idl iWbilifltr

Mj)f tn' yu It? 3



Only Q?Kj-approved for scuional jllergk oonjunctivitii


Misr »II ibUiz«,!: -receptor ainaqofiiir

Vi.iy nhibit eoilnophiK


AflpllJtMrtrili, rtiMI iill SliljiliBer


Mast cell stabiluer


Av.iil^hk'1 Only In ...1!. ihir-l-^iiliML'

From Refi. 1/-I5L

From Refi. 1/-I5L

Table 63-5 Adult Dosing and Common Side Effects of Ocular Allergy Drugs



Common Side EfFecU1


Yaiiei tjy numl.x tinr: .iru! produci

Oiulai siiiyjiriLj


1 drop n'i jrfw; h.tJ -L'yL-itJ twi« djil;

Otulji flinging, IWKJMhftbilW raste

Cromolyn sodium 4%

1 -2 drops in each eye 4-6 «mes daily

Ocular stinging

Epi nasi me 0.05%

1 drop in cach oye Iw-co daily

Ocular Jtinginrj cold tymptoms

Ketorolac^« Ü.Í*

1 drop 4 limes a day

Ocular slinging, irritalum

Ketotifen OJCPSfc

1 dnjfi iri ¿if« [|V1 ¿y-HIv twire daily

lledey« fcbnjunfival motion!, headafhi1'


1 drap i" iifflet tetJ frr-'iil 4 timei diily

Otulii slinking. Iicudacho


l-i m aflected eyeiO 4 tlnrw tfally

Oïulir Ringing, foreign body wnsartkai


i drepirflfiiCMdtii(5J4 nmt*. daily

1 l'V.iliïl."ilr.a:ul.u ik'i PVfilfdiVQUKj !■■■■ In■:l.

secondary ocJar Mettions, systerric side effects posstile

MedKPïfflll ffr

i -2 tmoi in eatn e^s- te daily

tKMiaiitiiyjirXi. Isttef


1-2 diops ma'lieitede^is) î times daily at


6- loâ-lvtxji innervai!


1 2 dioti :n afïeilÉd eycis) 4 times daily

Headache, coSd symptoms


Varies hy manufacturer and rroduci

Ocular stirring

Table 63-6 Pediatric Dosing of Ocular Allergy Drugs



Antaicdlne V.irifi liy manufaciuiei ,ind prodift

Ani'ijiti ¡r.? OiPiit CNHivn ^yrotof ao? orowet; i diopiniitaii^i^iH^f«^^^

Oomolyn sodium Children 4 ycmsoi age or ddf.r 1 2 diuoi m cach eye 4 -i> limes daily

Fmedasi me Qjftifa Children i years of age or older: 1 dropm affected eye up 1o-fl Tirret da y lliin.r.iinr HflfV*) £hMl*fl Or dUtr; 1 drop ifii«IHythiioei!iily tor mi H flWceti totoiolic 0.5% Children J years Of ago or oifcr: ! drap in alfectixd eycHs) 4 tim« odjy fetolifen0UG3516 Children iyeaisof age or oMer: \ drop-n aifetted eyeis) twee daily lcw>tiitwH»K.LO.OS% Children 12 yey»s(?fi>gcor older; I drtipm affected ryrti) 4 rim« cljily

LodoKdrnKie O.L9t Children 2 vest of age or older: 1-2 dicps in affected eye£) 4 times daily

Mflikjfioirnl C hildren J yean of age or older: 1-3 diops in Mfh eye twice daily

Oloi)#i*iini? Q.L% Children 3 y*HH of age (ir oKVr; in ¿ifwifti fyefs) 2 rin>eiiJailyar fi- en a- inrnffvalt

Pemfolaii 0.1% Children 3 years oi age or oWer: 1-2 drops in ailKied eyefc) 4 times daily

Chenirarrilne VSiiestiyiivinufatiurer and product

If artificial tears are insufficient, the second treatment step is a topical antihistamine or antihistamine/decongestant combination. The antihistamine/decongestant combination is more effective than either agent alone. Decongestants are vasoconstrictors that reduce redness and seem to have a small synergistic effect with the antihistamine. The only topical decongestant used in combination products is naphazoline. Topical decongestants burn and sting on instillation and commonly cause mydriasis, especially in patients with lightercolored eyes. Long-term use leads to rebound congestion. Topical decongestant use should be limited to less than 10 days.19

There is still debate whether oral antihistamines control ocular allergy as well as topical antihistamines. Topical antihistamines are recommended before oral agents in step therapy because of the increased risk of systemic side effects with oral drugs. Ad ditionally, topical antihistamines provide faster relief of ocular symptoms. Consider

oral antihistamines when systemic symptoms are present.

If insufficient relief is obtained from these products, either a mast cell stabilizer

or a multiple-action agent is appropriate. Use mast cell stabilizers prophylactically throughout the allergy season. Full response may take 4 to 6 weeks.

If mast cell stabilizers or multiple-action agents are not successful, a trial of a topical NSAID is appropriate. Ketorolac is the only approved topical agent for ocular itching. NSAIDs do not mask ocular infections, affect wound healing, increase intraocular pressure, or contribute to cataract formation like the topical corticosteroids.

However, in clinical trials, for allergic conjunctivitis topical ketorolac was not as ef-

fective as olopatadine or emedastine. Full efficacy of ketorolac may take up to 2 weeks.19

If all these avenues are ineffective, short-term topical corticosteroids and immuno-

therapy are the third-line treatments for ocular allergy. Outcome Evaluation

Monitor patients for relief of symptoms. Ensure an adequate trial of the agent. If no improvement is seen, follow a stepped-care approach to treatment. Refer severe cases that do not respond to an ophthalmologist for short-term topical corticosteroids.

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