If that sounds familiar, you’re probably among the millions facing eye allergies, or allergic conjunctivitis. Unlike the nasal-centric and familiar allergic rhinitis, or “hay fever,” allergic conjunctivitis targets the transparent cell layer covering the white of the eye and lining the lids, the conjunctiva — although both allergies frequently coexist. About 50 million Americans face allergies, which are immune system overreactions to otherwise benign environmental triggers. The majority endure the worst symptoms when grasses, pollens, and mold are abundant, with the ailment often recurring each year. When allergies target the eyes, though, the condition can be infuriatingly confounding. People may treat allergic conjunctivitis as part of a nasal allergy, or they mistake it for more serious conditions, including infectious conjunctivitis (“pink eye”), dry eye disease (DED), blepharitis, herpes virus, or keratitis. Making these distinctions is critical to ensuring that you receive the proper treatment and quickly reduce not only symptoms but the risk of harm. The American College of Allergy, Asthma, and Immunology (ACAAI) warns, for example, that extended use of some nasal allergy medications can leave allergic eyes drier and more irritated than they were previously.
What Is an Eye Allergy?
Eye allergy occurs when the body, sensing an attacker, mobilizes the eye’s estimated 50 million white blood “mast” cells to release histamine and other substances to defeat outside irritants. The histamine stimulates the eye’s blood flow, encouraging swelling and redness as vessels dilate and leak. The histamine also stimulates the eye’s many nerve endings thus initiating the maddening allergic itch. Common allergens include pollen, dust mites, ragweed, mold, pet dander, perfumes, smoke, and some fragrance or cosmetic ingredients. But almost anything can provoke reactions in susceptible people.
Why Eye Allergies Have Gotten Worse
“You can have an eye allergy as a child, or suddenly develop it in your twenties, or after a viral infection,” says Feryal Hajee, MD, an allergist and immunologist with Metropolitan Asthma and Allergy in Little Silver, New Jersey. Some researchers blame the current allergy boom, however, on climate change. Purvi Parikh, MD, an allergist and immunologist with Allergy and Asthma Network of Murray Hill in New York City, points to a “longer and stronger” allergy season. An artlcle published in February 2021 in Environmental Sciences estimated that pollen season runs 20 days longer than its previous duration. Complicating this is a dependance on antibiotic drugs and antibacterial cleaners that can imbalance the delicate bacterial cocktail in our guts — the microbiome. “We’re exposed to more pollutants and diminished good bacteria, so our immune systems are less well-developed than they should be,” says Hajee. That leaves us comparatively ill-equipped to combat irritants.
So, Do You Have an Eye Allergy? If Yes, Which One?
“If you have itchy, watery eyes, it’s usually an allergy,” says Dr. Parikh. Intense itching, often with tearing and redness, is the thread that binds these common ocular allergies:
Seasonal Allergic Conjunctivitis
Accounting for most eye allergies in the United States, seasonal conjunctivitis predictably recurs in spring (pollen), summer (trees, grasses, mold), and fall (ragweed). Additional symptoms: allergic shiners (dark under-eye circles); light sensitivity; puffy eyelids.
Perennial Allergic Conjunctivitis
Perennial eye allergies endure year-round as they are commonly caused by household (or workplace) irritants, dust mites, mold, and pet dander. Additional symptoms: same as seasonal conjunctivitis, but less severe.
Vernal Keratoconjunctivitis
This condition, while year-round, can worsen during pollen seasons, and targets boys, young men, and people with asthma or eczema. Additional symptoms: feeling of something in your eye; light sensitivity.
Atopic Keratoconjunctivitis
Also year-round, atopic keratoconjunctivitis strikes older men who have allergic dermatitis (an immune reaction in their skin). Additional symptoms: burning; thick mucus that accumulates on eyelids overnight.
Contact Allergic Conjunctivitis
Direct contact with any number of potential allergens, such as eye drops with preservatives, can lead to this allergic reaction. Additional symptoms: discomfort wearing your lenses; mucus discharge.
Giant Papillary Conjunctivitis
A severe contact allergic conjunctivitis, this condition leads to fluid sacs (papules) forming in the upper eyelid lining. Doctors can see them by turning lids inside out. Additional symptoms: blurry vision from mucus discharge; foreign body sensation; discomfort wearing contacts; a sense that contacts are “moving”; puffy or droopy eyelids.
If Not an Eye Allergy, What Is It?
Different eye conditions can share symptoms, but there are some important differentiators. “Pain in the eye or diminished vision are serious symptoms not typical for allergies,” says Hajee. Dry Eye Disease (DED) Allergy and DED are confoundingly similar. As noted in an article in the July 2020 issue of Ocular Immunology and Inflammation, they “share ocular (eye) surface inflammation,” and can both coexist and clinically overlap in ways that facilitate or worsen each other. A close examination of the lids and the eye’s surface, and a thorough medical history can tease out the correct diagnosis. “The most important question is whether problems occur at the same time each year, which suggests seasonal allergies,” says Mina Massaro-Giordano, MD, co-director of the Penn Dry Eye and Ocular Surface Center of the Penn University Medical Center in Philadelphia. In mild cases, using preservative-free lubricating drops can help flush allergens from the eyes and increase comfort. But when allergy is suspected, Dr. Massaro-Giordano says that she may prescribe mast cell inhibitors immediately before allergy season. “These can keep the mast cells from opening and releasing all the histamines,” she says. Viral or Bacterial Conjunctivitis (Pink Eye) Weepy, red, painful eyes indicate infection or inflammation of the conjunctiva. These forms of pink eye are highly contagious, may initially appear in one eye, and generate a sticky secretion that coats the lashes. A swollen lymph node near the ear may also appear. Blepharitis Pollen-clogged tear glands can resemble blepharitis, a disorder of the eyelid’s oil-producing glands. But true blepharitis is most often infectious. Marked by irritation, redness, flaky eyelid skin, and crusted lashes, it can actually follow an allergic reaction to cosmetics or contact lenses. Eyelid scrubs and warm compresses are recommended. Keratitis An inflammation of the cornea, the dome-shaped tissue covering the iris, keratitis comes with redness, pain, watering, and blurry or decreased vision, but rarely with itching. It can be infectious (bacteria, fungi, parasites, viruses) or brought on by contact lenses, a mild injury, or a foreign object in the eye. Quick treatment prevents complications and damage. Herpes Eye Disease A herpes virus of the cornea (herpes keratitis) leads to pain, tearing, redness, light sensitivity, and a skin rash or sore near the eye. Direct observation or special blood tests can confirm its presence. Other ‘Itchy’ Conditions Contact dermatitis, atopic eczema, and psoriasis are all characterized by itching on the eyelid or “periorbital” skin around the eye.
How Will Your Doctor Diagnose an Ocular Allergy?
Any or all of these steps inform an allergy diagnosis: Personal History Timing is key to seasonal allergies, so it’s critical to take a personal and family medical history to reveal previous allergies, eczema, psoriasis, hives, and other reactions. Perennial allergic conjunctivitis is trickier as doctors must narrow down possible irritants, such as dust, to find the culprit. Slit-Lamp Exam Using a special magnified lamp enables the doctor to view surface damage particular to infection, dryness, or injury. Swollen blood vessels, though, can point to allergy. Diagnostic Dyes Orange fluorescein and lissamine green eye drops highlight damage from DED, infection, or abrasions. “The dye can reveal an allergic pattern of small ‘cobblestone’ bumps on the eye,” says Massaro-Giordano. Schirmer Test A thin “Schirmer” paper that collects tear samples can help determine whether tears are defective in their composition or deficient in their amount, common causes of DED. Researchers are exploring new tests that may eventually deliver far more detailed findings. Direct Observation The appearance of dark circles under the eye (“allergic shiners”), skin rashes, secretions, and bumps often point to particular nonallergic conditions. “If there’s eczema or the skin looks scaly and dry, or you see red, thickened patches, it can suggest a more severe and chronic allergy, atopic dermatitis, treatable by steroid creams,” says Massaro-Giordano. Skin Tests Skin prick, puncture, or scratch tests help pinpoint the right irritant from among about 50 substances. The tests probe for contact, seasonal, or perennial irritants, with a positive result indicated by raised, red bumps on the skin. Serum Immunoglobulin E (IgE) Blood Tests Using these allergen-specific IgE blood tests doctors have a better chance of identifying the culprits involved in food allergies, quantifying the amount of white blood cells, or eosinophils, being generated to battle allergens. Adenovirus Testing To differentiate a highly contagious viral eye infection, often occurring suddenly, from an allergic condition, doctors may use one of several stool, blood, or mucus tests.
How to Prevent Eye Allergies or Relieve Their Symptoms
Prevention is powerful and there is much that people can do themselves:
Avoid a known allergen as much as possible.Protect eyes with sunglasses, visored hats, and swimming goggles.Wash hands when coming indoors (especially after handling animals).Wash your face to eliminate allergens.Use cold compresses to soothe eyes.Try preservative-free tear substitutes.Consider mite-proof bedding.Wash sheets and blankets in hot water weekly.Check for and eliminate mold by regularly cleaning the areas of your home where moisture may accumulate, including these often-neglected spots: the base of the toilet, closets and mudrooms, HVAC filters, water filters, windowsills, and gutters.Use air-conditioning at home and in the car.Remove shoes at the door.
Products and Practices to Avoid
Eye drops infused with herbal extractsEye products using preservativesWindow fans that draw in allergensIndoor humidity exceeding 30 to 50 percent (to discourage mold)Dry-dusting or sweeping floors (which spreads allergens)Over-wearing contact lensesRubbing eyes
Available Treatments for Eye Allergies
For many, short-term use of an over-the counter (OTC) therapy can help resolve eye allergy symptoms. It’s important to remember, however, that while eye allergies can be uncomfortable, even debilitating, they aren’t painful. People experiencing eye pain should see a doctor. Besides offering a wider range of options if OTC treatments aren’t helpful, ophthalmologists, allergists, and immunologists can ensure that you don’t have another kind of problem.
Over the Counter
Artificial Tears
Like real tears, artificial tears help flush allergens and nonallergic irritants from the eye. They can be used as needed for dry, gritty, or irritated eyes. Alert: Look for preservative-free artificial tears, since you could be allergic to a preservative.
Ophthalmic Vasoconstrictors or Ophthalmic Decongestant Eye Drops
Eye drops advertising that they “get the red out,” including those that contain oxymetazoline, tetrahydrozoline, or naphazoline, work quickly to reduce redness and some inflammatory itching by constricting blood vessels in the eye. Decongestant eye drops work in much the same way. Alert: The benefits of these treatments may be limited. Of greater concern is that relying on these drops longer than two weeks can lead to a “rebound effect” in which symptoms may come roaring back. (If eye redness increases after you stop using these kinds of drops, this may be what you’re experiencing.)
Nonsedating Oral Antihistamines
These treatments stop eye itching by temporarily blocking histamine receptors body-wide (including, for example, in your skin and nose). Available products include loratadine (some brands: Alavert, Children’s Claritin, Children’s Clear-Atadine, Children’s Dimetapp ND Allergy, Claritin, Claritin RediTabs, Clearatadine, Loradamed, Triaminic Allerchews) and fexofenadine (some brands: Allegra, Allegra Allergy 12 Hour, Allegra Allergy 24 Hour, Children’s Allegra Allergy, Mucinex Allergy). Alert: Nonsedating oral antihistamines can be used on an as-needed basis — daily if necessary. Eric M. Macy, MD, an allergist and immunologist in the allergy department at Kaiser Permanente in San Diego, says that for most people, nonsedating antihistamines don’t cause drying or drowsiness, unlike “old-style” sedating antihistamines, such as diphenhydramine (Benadryl), which should be avoided. Dr. Hajee points out that some people report becoming very drowsy even with this nonsedating variety. In these cases, she says, you should rely more heavily on targeted eye drops.
Topical Combination Antihistamine–Mast Cell Stabilizer Eye Drops
These blends help stop itching caused by allergies by both blocking histamine receptors and reducing the amount of histamine released by mast cells. Products include ketotifen (some brands: Zaditor, Alaway, Zyrtec Itchy Eye) and olopatadine (brand: Pataday). Alert: Common side effects include burning and stinging upon administration. To combat this, Hajee suggests keeping the drops cool in the refrigerator. Because antihistamines — oral and topical — can reduce the quantity of tears produced, use of these OTCs may unmask or exacerbate existing dry eye disease. If you’re not benefiting after two weeks you should seek professional help. For those who use several eye drops — one for glaucoma, for example, and another for itchy eyes — Hajee and other medical experts advise taking a three- to five-minute break between instilling each in your eyes. “Using them quickly one after the other,” she says, “will result in you washing away one with the other, and you won’t enjoy the full benefits of either.”
By Prescription
Prescription Antihistamines and Antihistamine–Mast Cell Stabilizer Blends
These drugs offer single or combined ingredients to diminish itchy, watery eyes: epinastine ophthalmic (Elestat), bepotastine besilate ophthalmic solution (Bepreve), emedastine difumarate (Emadine), alcaftadine ophthalmic (Lastacaft), and cetirizine ophthalmic (Zerviate). The U.S. Food and Drug Administration has also approved contact lenses that deliver antihistamines directly to the eye. Alert: Like their OTC counterparts, these drops can burn and sting when instilled in the eye. To ease that initial discomfort, keep the drops cool in the refrigerator.
Mast Cell Inhibitors
By interrupting the mast cell release of histamines, these products begin work before allergy cascade starts: lodoxamide tromethamine (Alomide), ketotifen (Zaditor, Alaway, Thera Tears Allergy, Claritin Eye, Zyrtec Itchy Eye), olopatadine (Patanol, Pataday, Pazeo), and nedocromil ophthalmic (Alocril). Alert: To be effective these drugs work best when used before exposure to allergens or when allergy season starts.
Ophthalmic Corticosteroids
Loteprednol etabonate drugs (Lotemax, Alrex, Inveltys, Eysuvis) and other ophthalmic corticosteroids treat inflammation but must be used under a doctor’s supervision. Alert: Depending on the dose and length of use, steroid drugs can cause or worsen cataracts and pose a glaucoma threat. They may also promote new eye infections or possibly exacerbate existing ones. Keep in mind, too, that topical agents are systemically absorbed. The eye is a mucous membrane. Instill drops in your eye and you expose your entire body to that medication.
Immunotherapy
A holistic approach to treatment, immunotherapy involves a series of shots that gradually introduce greater amounts of an allergen or irritant to help the body become immune, or desensitized, to it. People who have repeated episodes of severe eye allergy throughout the year or annually can be excellent immunotherapy candidates, Hajee says. Alert: Consistency and compliance are all important as this therapy consists of weekly injections for several months followed by once a month for at least three years. The benefit, however, is that you’re preventing and possibly curing — as against treating — your eye allergy.
The Bottom Line
With the vast array of drugs and treatments available, just about everyone can find the right mix of medication and treatment to defeat allergic eye itch — without having to scratch. Says Hajee, “Most often, allergic conjunctivitis is more annoying than dangerous.”
