December 2018

COVER FEATURE

Good habits for healthy eyes
Customized approach to treating ocular allergies


by Michelle Stephenson EyeWorld Contributing Writer


A patient with seasonal allergic conjunctivitis (SAC). The image demonstrates a watery eye, bulbar conjunctival hyperemia and chemosis, and fine tarsal conjunctival papillary changes.
Source: Vincent de Luise, MD


“The obligation of the
ophthalmologist is to make the right diagnosis the first time because there are vastly different treatment strategies depending on the type of ocular allergy.”
—Vincent de Luise, MD



 

There are five categories of ocular allergies, and treatment depends on the category

Ocular allergies are very common, affecting up to a third of the population. They can be divided into five broad categories, and the treatment depends on the diagnosis.
“Therapy needs to be tailored to the diagnosis,” said Vincent de Luise, MD, Yale University, New Haven, Connecticut. “For example, if a patient has giant papillary conjunctivitis due to contact lens wear, treatment would begin with removing the contact lens.”
He noted that there are five categories of ocular allergy, and itch is present with all five.
• Seasonal allergic conjunctivitis, which is the most common
• Perennial allergic conjunctivitis
• Atopic keratoconjunctivitis
• Giant papillary conjunctivitis, which is usually due to contact lenses
• Vernal keratoconjunctivitis, which appears in children
“The obligation of the ophthalmologist is to make the right diagnosis the first time because there are vastly different treatment strategies depending on the type of ocular allergy,” Dr. de Luise said.
For example, many ophthalmologists avoid using steroids in patients with seasonal allergic conjunctivitis. “We do things like avoidance of the allergens, cold compresses, and non-preserved artificial tears, which are simple, palliative types of strategies for seasonal allergic conjunctivitis,” Dr. de Luise said. “In contrast, a patient with destructive corneal scarring from the atopic type of keratoconjunctivitis will often need topical steroids or perhaps even oral steroids to manage the condition.”

Treatment strategies

According to Dr. de Luise, the first step in treating a patient with ocular allergy is making the correct diagnosis. “If I can’t elicit the symptom of itch and the patient doesn’t use the word ‘itching,’ I should question my diagnosis because it may not be allergic,” he said.
Dr. de Luise said that the Doctor’s Rx Allergy Formula diagnostic test (Bausch + Lomb, Bridgewater, New Jersey) is a way for allergists or ophthalmologists to test for dozens of potential allergens that might be the underlying cause of the ocular allergy. “It has been out for awhile now and is covered by most insurance companies. It’s a 3- or 4-minute test that has a panel of approximately 60 allergens that are region-specific,” he said.
If a patient has seasonal allergic conjunctivitis, Dr. de Luise said that he uses a stepwise approach, beginning with modifying the environment. He recommends keeping windows closed and cleaning air ducts. “This is important. Mold can build up in the air ducts in houses and apartments and in air conditioning and heating vents, so we are blowing mold into our living environments. I often recommend a cold mist humidifier for my dry eye patients, but after a year or so, those cold mist humidifiers will have mold build up. That’s a secret disaster because you can’t see this mold, and you’re blowing it into your face and making yourself worse. I also recommend cold compresses,” he said.
The next step in the treatment of seasonal allergic conjunctivitis is non-preserved artificial tears. “As a corneal specialist, I am inundated with people who present with preservative-related eye problems. Most eye drops in bottles have preservatives, benzalkonium chloride being the most common one, and they can cause an allergic type of response. I’m keen on making sure that patients are using non-preserved medications,” he said.
The next step is an antihistamine drop, a mast cell inhibitor drop, or both. “Most ophthalmologists these days are using an eye drop that has an antihistamine, which addresses the acute problem, and a mast cell inhibitor, which helps the long-term reduction of the recurrence of the symptoms,” Dr. de Luise said. “One of the choices would be Patanol [olopatadine 0.1%, Alcon, Fort Worth, Texas], which is older now. The better strategy would be Pataday [olopatadine 0.2%, Alcon], and the best strategy would be Pazeo [olopatadine 0.7%, Alcon], which is a once-a-day dose. Pataday is also once a day, but many users need to use it more than once a day. Alcon decided to increase the concentration of the active ingredient to allow more patients to use the medication once a day to increase compliance.”
Other choices in this combination category of antihistamine/mast cell inhibitor include Bepreve (bepotastine besilate 1.5%, Bausch + Lomb) and Lastacaft (alcaftadine 0.25%, Allergan, Dublin, Ireland).
Patients with vernal conjunctivitis or atopic keratoconjunctivitis often find that cold compresses, non-preserved artificial tears, humidification and closing windows, and the use of combination antihistamine/mast cell inhibitors are not enough. They need more powerful strategies. “In these cases, we need to start considering ophthalmic cortisone drops, ophthalmic corticosteroids, or in severe cases, oral steroids,” Dr. de Luise said. “The next choice is topical steroids. My view is that ester steroids, such as Alrex [loteprednol 0.2%, Bausch + Lomb] and Lotemax [loteprednol 0.5%, Bausch + Lomb], have good efficacy and a lower risk profile than the older ketone steroids. It is important to note that we always recommend short-term use of corticosteroid drops because of the risk of intraocular pressure rise, which is a common problem, especially in patients who are steroid responders, which is 20% of the population. Another risk with corticosteroid drops is cataract formation.”
Steroid drops can also lower a patient’s resistance to viral and bacterial diseases, so steroids should not be used if a patient has viral or bacterial ocular disease. “However, we recommend a short course of mild steroids,” Dr. de Luise said. “I have found over the years that Alrex is too weak, so the recommendation would be to go right to Lotemax. It is quite helpful, and it has a better safety profile than the ketone steroids. In rare cases, one could try Restasis [cyclosporine, Allergan], which is an immune modulator and has efficacy in allergy patients.”
Bennie Jeng, MD, University of Maryland School of Medicine, Baltimore, said that atopic keratoconjunctivitis is the most difficult to control. “It affects the lids, then the conjunctiva, and it can ultimately affect the cornea,” he said. “Ninety-five percent of people who have ocular findings have some form of systemic atopic disease, while 5% have atopic disease isolated to the eyelids only. Atopic keratoconjunctivitis causes a lot of inflammation of the conjunctiva and the lids. This chronic inflammation can hurt the stem cells, which then causes corneal problems and can result in corneal scarring. I consider this a systemic disease, so I work with the allergist to get the systemic disease under control.”
Clara Chan, MD, University of Toronto, Canada, said that some of the more severe atopic patients may still need topical steroid pulses during flare-ups or ongoing low doses using something like Lotemax once a day to keep their symptoms in check. “I also find that tacrolimus can be used once daily on itchy, excoriated eyelids and off-label in the eye as well,” she said.
According to Dr. Jeng, vernal keratoconjunctivitis stereotypically occurs in young boys with more pigmentation in their skin. “However, it can occur in anyone. It first presents in children between the ages of 7 and 15. It generally burns out by the time they’re in their late teens or early 20s, but it doesn’t have to. It has characteristic findings of limbal follicles in some patients and has that classic shield ulcer of the cornea in others,” he said.
Dr. de Luise added that immunotherapy shots are being used. “These are desensitization shots that doctors can give their patients in the office. A series of six to 12 shots, usually over a few months, desensitizes the patient’s body to a certain allergen and makes him or her produce less immunoglobulin E,” he said.

Future

According to Dr. Jeng, some researchers are suggesting that oral immunomodulatory therapy is effective for treating ocular allergies. “I’m not sure that I would use this to treat someone who has run-of-the-mill seasonal allergies, but if it was difficult to control and it was associated with ENT issues, I think that systemic therapy is reasonable,” he said.
According to Dr. Chan, it is important to get ocular allergy symptoms under control. “Ocular allergies cause inflammation, which causes damage to the ocular surface. Patients can develop contact lens intolerance and severe dry eye disease over time if untreated. Dry eye can delay healing after corneal procedures, superficial corneal staining can alter measurements of the corneal surface, and symptoms can worsen after any corneal surgery, which makes for an unhappy patient and an unhappy ophthalmologist,” she said.

Editors’ note: Dr. Chan has financial interests with Alcon, Allergan, Bausch + Lomb, Santen (Osaka, Japan), Shire (Lexington, Massachusetts), and TearLab (San Diego). Dr. de Luise and Dr. Jeng have no financial interests related to their comments.

Contact information

Chan
: clarachanmd@gmail.com
de Luise: vdeluisemd@gmail.com
Jeng: bjeng@som.umaryland.edu

Five categories of ocular allergy


• Seasonal allergic conjunctivitis
• Perennial allergic conjunctivitis
• Atopic keratoconjunctivitis
• Giant papillary conjunctivitis
• Vernal keratoconjunctivitis

Customized approach to treating ocular allergies Customized approach to treating ocular allergies
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