Appropriate Ocular Allergy Treatment Depends on an Accurate Differential Diagnosis

Appropriate Ocular Allergy Treatment Depends on an Accurate Differential Diagnosis

i-bottleJust before allergy season begins each spring, articles start cropping up about allergic rhinitis. These typically cover how to distinguish it from the common cold and tips on how to help patients choose OTC products. But you don’t hear much about ocular allergies, how they differ from allergic rhinitis and the appropriate treatment. Since many patients with eye symptoms assume they have typical seasonal allergies—and subsequently self-treat with over-the-counter products—pharmacists who intervene can quickly assess for potential ocular allergies and help patients avoid unnecessary systemic medication by recommending the best ocular allergy treatment.

Accurate Differential Diagnosis of Ocular Allergy Symptoms

The most interesting aspect of ocular allergies is that they have one pathognomonic symptom—itching, noted Mark B. Abelson, MD in Ophthalmology Times.1 Dr. Abelson calls it an old-fashioned diagnosis, one that doesn’t usually require high-powered kits, tear samplings or biomarkers because itching must be present to confirm allergic conjunctivitis. By comparison, allergic rhinitis is marked by sneezing, a runny nose and nasal congestion, with or without irritated, watering eyes. The breakdown of eye symptoms in ocular allergies versus other conditions looks like this:

  • Eye redness in ocular allergy: Vasoactive amine activity causes a diffuse, hazy, mild pink discoloration with no scleral vessel involvement.
  • Eyelid swelling plus chemosis: More typical of allergic conjunctivitis than allergic rhinitis.
  • Burning, tearing and mucous discharge: May be present with ocular allergies but also symptomatic of dry eyes and allergic rhinitis.
  • Eye redness in other eye conditions: Follows more specific patterns. For example, ocular hyperemia in dry eye usually appears as fine, horizontal vessel dilation in the interpalpebral fissure.2
  • Crusting and purulent discharge: Indicates bacterial infection.
  • Profuse tearing with violet red hyperemia: Probably a viral infection.

The two major subtypes of ocular allergies are seasonal and perennial. Ragweed blooming in late summer is the most common cause of seasonal ocular allergies, but they’re also triggered by trees in the spring and grasses or weeds throughout summer. If there doesn’t seem to be a seasonal connection, mold, mites, cockroaches, dust, the family pet and any number of common allergens may trigger allergic conjunctivitis at any time of the year.

In addition to making a distinction between ocular allergies versus allergic rhinitis and viral or bacterial conjunctivitis, a differential diagnosis must also consider:

  • Giant papillary conjunctivitis: Common complication from wearing contact lens. Symptoms include itchy eyes, mucous discharge and blurred vision.
  • Contact dermatoconjunctivitis: Ask patients whether they’re recently used eye drops or products around their eyes, such as skin creams and cosmetics, as they may be sensitive to active or inactive ingredients. Most toxic reactions appear as redness in the lower half of the eye.
  • Vernal conjunctivitis: An uncommon allergic condition that primarily occurs in children and adolescents, especially boys, living in hot, dry climates. It causes intense itching with thick discharge.
  • Atopic conjunctivitis: While it’s rare, atopic conjunctivitis can cause blindness. It affects adults 30 to 50 years old, concurrent with atopic dermatitis, eczema and allergic asthma. Symptoms include chronic inflammation of the conjunctiva, pain, watery discharge, photophobia and blurred vision.

A Pharmacist’s Role in Ocular Allergy Treatments

An estimated 43 percent of patients with ocular allergies self-treat with over-the-counter decongestants. They aren’t aware that decongestants won’t relieve the itching or that prolonged use may result in rebound hyperemia, creating an ongoing cycle of self-treatment with meds that don’t help. At least 27 percent choose oral antihistamines, which are less effective for eye symptoms and can exacerbate ocular allergies. These patients need guidance from compounding pharmacists, who can follow this 3-step treatment approach:3

  • Step 1: Avoid allergens, don’t rub eyes, use artificial tears, limit contact lens use and apply cold compresses.
  • Step 2: Continue step 1 but add OTC eye drops—combination antihistamine and mast-cell stabilizer—and intranasal corticosteroids if the patient also has allergic rhinitis.
  • Step 3: Consider referral for prescription eye drops and intranasal corticosteroids, consider allergen immunotherapy, and consider a short course of oral corticosteroids if symptoms are severe or persistent.

When you reach out to patients purchasing OTC products, whether they’re eye drops or systemic medications that target the symptoms of allergic rhinitis, perform a quick assessment for ocular allergies and recommend the most appropriate treatment. In the process, consider the following:

History of eye drop use: Patients with ocular allergies are more likely to be sensitive to preservatives, additive and drugs in eye products, so find out if they’ve used any ophthalmic compounds. It takes several days to weeks for sensitization to develop, so they may not connect product use with their itchy eyes. Refer to a doctor if necessary to nail down the allergen. In the meantime, talk about compounded ophthalmic medications that eliminate irritating preservatives and other substances.

Adherence: Ask patients if they have trouble using eye drops; give tips if needed. Then review the dosage with them to encourage compliance. If they struggle to use eye drops, they may not use them two to four times daily as recommended. On the other hand, if symptoms remain, some patients may be tempted to overuse OTC drops. If eye drops sting, keeping them in the refrigerator may alleviate the problem.

OTC medications: The gold standard for ocular allergies combines topical antihistamines with mast-cell stabilizers. The current OTC options for allergic conjunctivitis include cromolyn and ketotifen 0.025 percent.

Topical NSAIDs: Moderate to severe symptoms that aren’t relieved with antihistamines and mast-cell stabilizers may require short-term treatment with topical NSAIDs, such as ketorolac, diclofenac, flurbiprofen and indomethacin.

Prescription medications: Most prescription meds have the disadvantage of being more expensive than OTC products, but they have the benefit of just once or twice daily administration:

  • Emedastine difumarate
  • Lodoxamide tromethamine
  • Nedocromil sodium
  • Pemirolast
  • Alcaftadine
  • Azelastine 0.05 percent
  • Bepostastine besilate
  • Epinastine HCl
  • Olopatadine HCl 1 percent or 2 percent

Compounded Options Improve Management of Ocular Allergies

The experts recommend ocular allergy treatment based on a case-by-case approach that tailors the therapy to the patient’s symptoms, allergen profile and personal preferences. You couldn’t describe the benefits of compounding better than that. Compounding pharmacists have the opportunity to raise patient awareness of ocular allergies, suggest the best treatment, and improve outcomes with individualized compounded options, whether based on OTC or prescription pharmaceuticals.

Pharmaceutica North America provides high-quality bulk APIs along with a commitment to innovative research and evidence-based solutions for your patients. Contact us today to learn about our products and how we can meet your pharmaceutical needs.

Show 3 footnotes

  1. “What Clinicians Should Know About Ocular Allergies,” March 2016,,0
  2. “Code Red: The Key Features of Hyperemia,” April 2010,
  3. “Does Allergic Conjunctivitis Always Require Prescription Eyedrops?” December 2015,

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