Review Question - QID 102610

This patient is presenting with allergic conjunctivitis given his itchy, red, and edematous eyes with symptoms that improve with showers (removal of the allergen). The most appropriate initial treatment for this patient is topical olopatadine (in particular since he works as a truck driver where sedating medications should be avoided).

Allergic conjunctivitis presents with itchy, red, watery eyes that tends to be worse seasonally. The most appropriate initial step in management for all patients is allergen avoidance; however, this is not always plausible. Other appropriate initial measures include topical olopatadine drops which are topical antihistamine drops that have minimal/absent systemic effects. If these drops do not work, third-generation antihistamines (such as cetirizine or loratadine) can be tried next as they cause very minimal sedation.

Figure A demonstrates red, watery, edematous eyes which are classic for allergic conjunctivitis.

Incorrect Answers:
Answer 1: Cetirizine is a third-generation antihistamine with minimal sedative properties. It would be appropriate to start this drug after allergen avoidance and topical olopatadine drops have failed. There are some studies that suggest sedation could occur with the use of cetirizine which should not be considered in this patient who works as a truck driver.

Answer 2: Diphenhydramine is a first-generation antihistamine that can cause sedation by blocking excitatory H1 histamine receptors in the cerebral cortex. This medication may be dangerous in a truck driver. Diphenhydramine could be used to control allergies at night/before bed or in allergic reactions (such as urticaria and anaphylaxis).

Answer 4: Reassurance may be appropriate if there was a suspected viral conjunctivitis which would present similarly to an allergic conjunctivitis with itchy, red, and watery eyes. This patient's symptoms which seem to be chronic and improve with irrigation suggest against this diagnosis; however, antihistamines can still be used in viral conjunctivitis for symptom control.

Answer 5: Topical erythromycin would be indicated to treat a bacterial conjunctivitis which presents with a thick purulent discharge from the eyes.

Bullet Summary:
The most appropriate initial steps in the management of allergic conjunctivitis include allergen avoidance, topical olopatadine, and third-generation antihistamines.