May 2018


Navigating the red eye
Guide to treating seasonal allergic conjunctivitis

by Vanessa Caceres EyeWorld Contributing Writer

Papillary vernal conjunctivitis

Seasonal allergic conjunctivitis
Source: Vincent de Luise, MD

These often-miserable patients can find relief with a stepwise approach

Some ophthalmologists may think of seasonal allergic conjunctivitis (SAC) as less exciting than surgical treatment, said John Sheppard, MD, president, Virginia Eye Consultants, Norfolk, Virginia. Yet he thinks SAC doesn’t deserve a bad rap.
“As a doctor, you get your full fee, it’s a quick visit, and you’ll have [medication] samples in the office. You’ve made patients happy, and they’ll love you forever,” he said.
Ocular allergy may seem like just an annoyance, but it has a real impact on quality of life. In fact, SAC symptoms can potentially be worse than nasal symptoms, said Leonard Bielory, MD, professor of medicine, Seton Hall University School of Medicine, and adjunct professor, Rutgers University Center for Environmental Prediction, New Brunswick, New Jersey.1 This leads him to describe some presentations of SAC as conjunctivorhinitis instead of the traditional rhinoconjunctivitis name.
As SAC patients enter your office more frequently—Dr. Bielory and others have shown in various studies that allergy seasons around the globe are getting longer and more intense—you’ll want a strategy to maximize their treatment. Here are several pearls.

Pearl 1: Determine what kind of allergy the patient has
Redness and itching are the hallmark signs of SAC. If the patient presents with these symptoms during key times of the year associated with the allergy season, that’s another strong clue to indicate SAC. Tearing, lack of discharge, swelling, papillary tarsal conjunctival reaction, and chemosis also are signs of SAC, said Vincent de Luise, MD, assistant clinical professor of ophthalmology, Yale University School of Medicine, New Haven, Connecticut. The patient also likely has other systemic symptoms, such as a runny nose.
During your exam with these patients, it’s important to check for any potentially serious findings associated with other types of allergy, such as vernal keratoconjunctivitis, Dr. Sheppard said.

Pearl 2: Encourage avoidance of allergens
Although there are plenty of medications patients can use, avoidance is usually far more effective, Dr. Sheppard said. However, he realizes this can be hard if not impossible to do with certain allergic triggers, including pollens, dust, fungus, and mold. Still, Dr. Sheppard’s office will give patients a handout with tips on avoiding triggers and minimizing the allergic effect. Suggestions include eliminating dust from the home, chilling any drops that are used, and not rubbing the eyes. Other advice can include wearing protective eyewear, washing clothes frequently, and keeping windows closed, said Christopher Starr, MD, associate professor of ophthalmology, Weill Cornell Medical Center, New York-Presbyterian Hospital, New York.
Also in the realm of non-drug solutions, Dr. de Luise encourages the use of cold compresses to reduce histamine release and non-preserved artificial tears to help flush out allergens.

Pearl 3: Start with a topical antihistamine/mast cell stabilizer
“The advantage is rapid action from the antihistamine and the long-term benefits of mast cell stabilization,” Dr. de Luise said. Using just one of these agents on its own is not as effective as the dual action, said Bennie Jeng, MD, professor and chair, Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore.
The once-daily Pataday (olopatadine, Alcon, Fort Worth, Texas) and the once-daily Lastacaft (alcaftadine ophthalmic solution, Allergan, Dublin, Ireland) are more convenient and improve compliance, Dr. de Luise said. Other combination agents are effective and available, but they require twice-daily dosing.

Pearl 4: Consider a short dose of pulse steroids if the topical antihistamine/mast cell stabilizer is not effective enough
This is similar to what an allergist might use to treat an asthmatic patient, Dr. Bielory said. “You do a short burst without a high penetrating value,” he said.
Dr. de Luise recommends the use of an ester steroid such as loteprednol 0.2% (Alrex, Bausch + Lomb, Bridgewater, New Jersey) or loteprednol 0.5% (Lotemax, Bausch + Lomb) as they are associated with a lower risk of IOP pressure rise and cataracts than ketone steroids. Dr. Starr also will occasionally consider oral steroids such as the methylprednisolone dose pack. “The eyelids often require steroid or tacrolimus ointment as well,” he said. Oral steroids may come into play if severe cutaneous disease is involved, and nebulized steroids have a role if there is severe pulmonary disease, Dr. Sheppard said.

Pearl 5: Make a plan to treat dry eye disease
It’s common for patients with SAC to also have dry eye, said Dr. Bielory, who has co-authored several studies on the topic. “One has to appreciate that there may be an overlap, and what may sound good for one condition may exacerbate the other,” Dr. Bielory said.
Case in point: Treating SAC with oral antihistamines may help allergy symptoms, but they also can lead the patient to experience dry eye, Dr. Jeng said. Plus, older age and the use of contact lenses heighten the chance of dry eye.
“If they have bad symptoms, it’s reasonable to use the oral antihistamines if they can control dry eye with artificial tears,” Dr. Jeng said. “But if there’s still a problem, I recommend they don’t use the drying antihistamines.”
Dr. Jeng does not use Restasis (cyclosporine, Allergan) or Xiidra (lifitegrast, Shire Pharmaceuticals, Lexington, Massachusetts) in SAC patients with dry eye. He prefers, if necessary, to offer a short course of steroids. However, other ophthalmologists will give the more potent dry eye medications a try. When allergy symptoms go beyond the eyes, Dr. Sheppard recommends use of an oral antihistamine along with Singulair (montelukast sodium, Merck, Kenilworth, New Jersey), which is not an antihistamine and does not have a drying effect.

Pearl 6: Involve allergists and allergy testing when necessary
If allergy control is still a problem after the use of topical drops or steroids or if the allergic problems go beyond just the eyes, get your local allergist involved. Another time to involve an allergist is if a person has been using an oral antihistamine for seasonal allergies for a couple of years but still has not gotten enough relief.
One option that allergists may offer is testing and subcutaneous injections, or allergy shots. “Sometimes patients can have shots. It’s commonly done if testing can identify what the trigger is,” Dr. Jeng said. Subcutaneous injections can be a nuisance, he said, but they also are effective.
Dr. Sheppard’s office is able to do allergy testing with exposure to 59 different stimulants. This is offered to patients who do not have an allergist, and patients find the testing convenient as they do not have to seek out another physician for their care, he said. “Once you have results, you can make strict recommendations for lifestyle changes. If the patient is still miserable or sensitive, we’ll refer to an allergist for skin hyposensitization therapy,” Dr. Sheppard said.
Dr. Bielory, who frequently studies the link between rhinitis and SAC, continually encourages collaboration among ophthalmologists and allergists.
Allergists also are a potentially useful contact if a patient may one day want to try sublingual immunotherapy, or SLIT. This newer treatment option involves oral tablets or drops under the tongue to create progressive desensitization to generate immunological tolerance. It can be used on its own or in tandem with allergy shots, Dr. Bielory said. Sublingual immunotherapy typically targets one allergen at a time.
“If sublingual immunotherapy is shown to be effective for the eyes, more ophthalmologists may recommend it,” Dr. Jeng said.
Subcutaneous immunotherapy, when properly formulated, can assist a patient in being exposed to 10 to 100 times more pollen before having the severe clinical symptoms, Dr. Bielory said.

Pearl 7: Preach about persistence
Patients with SAC sometimes need to be seen frequently throughout allergy season until both physician and patient find the right treatment mix. “There’s no magic bullet,” Dr. Jeng said. “I tell my patients this so they know if we try one over-the-counter or prescription medication, it doesn’t mean we’re done. It’s trial and error,” he said.

Pearl 8: Have patients return early before allergy season starts
Dr. Starr likes to start patients on treatment a week or two before allergy season kicks in to mute or potentially avoid the acute allergic response. He reminds SAC patients to keep a diary or calendar entry regarding when their symptoms start each year so they will know when to see him or when to prophylactically begin their medications. EW


1. Bielory L, et al. Ocular and nasal allergy symptom burden in America: the Allergies, Immunotherapy, and RhinoconjunctivitiS (AIRS) surveys. Allergy Asthma Proc. 2014;35:211–8.

Editors’ note: Dr. Sheppard has financial interests with Alcon, Allergan, Bausch + Lomb, and other ophthalmic companies. Dr. Starr has financial interests with Alcon, Allergan, Bausch + Lomb, Shire, and other ophthalmic companies The other physicians have no financial interests related to their comments.

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Guide to treating seasonal allergic conjunctivitis Guide to treating seasonal allergic conjunctivitis
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