How Can I Manage Itchy Eyes

In recent years, we’ve seen Australia’s pollen season stretching further, now commonly extending into summer and even early autumn.1 This longer period of allergen exposure is becoming a real issue for patients dealing with ocular allergy. For many, it’s not just a seasonal inconvenience, it affects comfort, concentration, and quality of life. Shaina Zheng explains how optometrists can make the difference.

WRITER Shaina Zheng

Itchy, red, watery, sore, and swollen eyes are common complaints. Itching tends to be the most bothersome symptom, as highlighted by Mikhail et al.2 The problem is that itching often leads to eye rubbing. While it might bring momentary relief, rubbing causes more harm than good. It ramps up inflammation, aggravates the ocular surface, and in some cases, especially in younger patients, may contribute to corneal ectasia and induced astigmatism.

As optometrists, we’re in a unique position to recognise and manage ocular allergy early, ideally before symptoms escalate. Timely intervention can make a significant difference, both in relieving immediate discomfort and preventing longer term changes to the ocular surface and vision.

Understanding the way allergic conjunctivitis presents, and what drives it, allows us to tailor management, provide effective education, and reduce modifiable risk factors like allergen exposure and eye rubbing. As frontline providers, we need to be proactive in helping patients navigate the allergy season with minimal disruption to their lives.

WHY DO OCULAR ALLERGIES OCCUR?

Seasonal allergic conjunctivitis is easily the most common form of ocular allergy we encounter in practice. It tends to flare up in spring and early summer, usually triggered by airborne allergens, with grass and tree pollens being the main culprits.3 Patients typically present with itchy, red, watery eyes, often accompanied by mild eyelid swelling. It’s usually bilateral, and vision is rarely affected.

Most cases are mild and self-limiting, but symptoms can be incredibly disruptive, especially for children or contact lens wearers. Some patients tolerate it year after year without seeking help, until symptoms become more persistent or start affecting day-to-day comfort.

While many cases improve as pollen levels drop, repeated exposure can lead to ongoing ocular surface inflammation.4 That’s why early identification and appropriate treatment are so important and can make a big difference in controlling symptoms and preventing escalation.

WHAT SETS OCULAR ALLERGIES APART FROM OTHER CONDITIONS?

Ocular allergy usually presents bilaterally with itchy, red, watery eyes. Mild lid oedema is common, and patients frequently report rubbing their eyes, either out of habit or desperation for relief. In paediatrics, parents often describe behavioural changes like blinking, squinting, or irritability.

Slit lamp findings often include:

• Conjunctival hyperaemia,

• Chemosis,

• Papillae: most obvious on the inferior palpebral conjunctiva, though upper lid eversion may show more in vernal keratoconjunctivitis (VKC) cases, and

• Watery (not mucopurulent) discharge. It’s essential to rule out other causes of red eye:

Dry Eye Disease

Often mistaken for allergy, dry eye tends to cause burning, grittiness, and fluctuating vision rather than intense itch. Punctate staining and reduced tear break-up time help differentiate it. It’s also worth remembering that allergy and dry eye frequently co-exist.

Infectious Conjunctivitis

Infectious conjunctivitis usually starts unilaterally, particularly in bacterial cases. Look for mucopurulent discharge and a sticky or crusty lid margin on waking. Viral cases may include systemic symptoms or preauricular lymphadenopathy.

Blepharitis/Meibomian Gland Dysfunction

These patients often have lid margin inflammation, lash crusting, and telangiectasia but not the classic conjunctival findings or itch associated with allergy.

A focussed case history is key. Ask about itching, eye rubbing, seasonality, and co-existing conditions like hay fever, eczema, or asthma. These clues often help steer the diagnosis.

MANAGEMENT AND TREATMENT STRATEGIES

When is a Non-Pharmacological Approach Most Effective?

Sometimes the basics are the most effective place to start, especially in children or those with mild disease.

Allergen Avoidance

• Wrap-around sunglasses help shield the eyes from airborne allergens.

• Keeping windows closed on high pollen days can help.

• Dust mite control measures are useful at home, especially in bedrooms.

Cold Compresses and Preservative Free Artificial Tears

• Cold compresses offer immediate relief by reducing hyperaemia and itch.

• Preservative-free lubricants help wash allergens from the ocular surface and protect against environmental triggers.

Patient Education

• Eye rubbing is one of the most damaging habits and patients need to understand the risks.

• Hygiene tips like washing hands regularly and changing pillowcases frequently can go a long way.

• Eyelid hygiene – daily eyelid cleansing – is important to remove allergens.

• Encourage patients to avoid outdoor activity during peak pollen times.

When is a Pharmacological Treatment Most Appropriate?

Topical Antihistamines and Mast Cell Stabilisers

Dual action drops, such as olopatadine and ketotifen, remain our first-line treatment for seasonal allergies. They provide rapid relief from symptoms and suppress further mediator release. Twice daily dosing makes them easy to stick to, which supports better long-term control.

When prescribing, consider the formulation. For patients with underlying dry eye or ocular surface inflammation, a preservative-free option is usually the better choice. Preservatives like benzalkonium chloride (BAK) can aggravate the very surface we’re trying to protect.

Corticosteroids

Short courses of topical steroids may be necessary in moderate to severe cases or where there’s corneal involvement. We need to be cautious with these; checking for intraocular pressure (IOP) and prescribing for short-term use only. If VKC or atopic keratoconjunctivitis (AKC) is suspected, referral to ophthalmology may be appropriate if there are no improvements with topical steroid treatment.

Systemic Antihistamines

Systemic options can be helpful, especially when there is co-existing rhinitis or dermatitis. But we do need to be cautious; they can exacerbate dry eye, particularly in older patients or contact lens wearers.

CASE STUDY: MANAGING OCULAR ALLERGY IN A YOUNG CHILD

A five-year-old boy was referred for an eye exam after a school vision screening picked up astigmatism. Mum mentioned that his eyes had been red for about a month. He was rubbing them often and complained of itchiness and sensitivity to light. She’d also noticed he was getting headaches after school.

Refraction revealed moderate hyperopic astigmatism. Slit lamp examination showed grade two papillae on the inferior palpebral conjunctiva and mild hyperaemia. Based on clinical signs and history, the diagnosis was seasonal allergic conjunctivitis.

We initiated treatment with:

• Olopatadine 0.1% (Patanol), twice daily, and

• Lid hygiene with a gentle eyelid cleanser, also twice daily.

At his four-week review, things had improved significantly:

• Less redness,

• Papillae were reduced,

• No more rubbing, and

• Headaches had also eased, likely due to less visual and ocular stress.

This case is a good reminder that allergy can present subtly in kids and may be misattributed to refractive error or behavioural issues.

Identifying and treating ocular allergy early can improve not just comfort, but also visual development during those critical early years.

HOW DO I MANAGE ONGOING CARE?

Optometrists are often the first, and sometimes the only, clinicians that patients turn to when eye allergies flare up. We’re in a prime position to offer diagnosis, treatment, and ongoing support.

Spring and early summer are ideal times for allergy reviews, particularly in children, contact lens wearers, and those with known atopic disease. A brief conversation about symptoms can save weeks of discomfort later.

When prescribing or co-managing patients on topical steroids, regular monitoring is essential. Check IOP, assess for early signs of cataract, and keep an eye on surface changes.

SHOULD OCULAR ALLERGIES BE REFERRED FOR COLLABORATIVE CARE?

Escalate care to an ophthalmologist or allergy specialist when:

• There’s corneal involvement (e.g., shield ulcers in VKC),

• Symptoms persist despite treatment, or

• The patient may benefit from allergy testing or immunotherapy.

Working with GPs, allergists, and ophthalmologists ensures a holistic approach, particularly for children, chronic cases, or when systemic allergy needs managing alongside ocular symptoms.

WHAT DIFFERENCE WILL I MAKE?

Ocular allergy is common, and we’re seeing it more often and for longer due to extended pollen seasons. The impact on our patients can be significant, but with the right approach, we can reduce symptoms, protect the ocular surface, and improve quality of life.

Simple strategies, like identifying symptoms early, recommending dual action drops, promoting allergen avoidance, and discouraging rubbing, can make a big difference. We also need to be mindful of formulation choices, especially for patients with underlying dry eye or surface disease.

This is a space where optometrists can lead with confidence. We see these patients first. We understand the ocular surface. And we’re well placed to ensure allergy season doesn’t mean months of unnecessary discomfort.

Shaina Zheng BOptom MBA GAICD is a co-owner optometrist at Eyecare Plus Mermaid Beach in Queensland. She currently serves as the Vice President of the Dry Eye Society, where she drives professional education, clinical best practice initiatives, and industry collaboration. She is also the founder of Dry Eye Impact, an organisation dedicated to advancing patient-focussed dry eye care through innovation, compassion, and collaborative professional networks across Australia.

References

1. Baab S, Le PH, Gurnani B, Kinzer EE. Allergic conjunctivitis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan 26. Available at: statpearls. com/pharmacist/ce/activity/107871 [accessed July 2025].
2. Mikhail E, Azizoglu S, Gokhale M, Suphioglu C. Questionnaires assessing the quality of life of ocular allergy patients. J Allergy Clin Immunol Pract. 2020;8(9):2945–52. doi: 10.1016/j.jaip.2020.04.023.
3. Dhankhar A, Darssan D, Osborne NJ, et al. Influence of ENSO, droughts, and temperature rise on pollen and pollen seasons in Australia. Sci Total Environ. 2025;975:179326. doi: 10.1016/j.scitotenv.2025.179326.
4. Ueta M, Kinoshita S. Ocular surface inflammation is regulated by innate immunity. Prog Retin Eye Res. 2012;31(6):551–575. doi: 10.1016/j.preteyeres.2012.05.003.