Dual-acting antihistamine/mast-cell stabilizers such as Pataday and Patanol (Alcon), and Lastacaft (Allergan) have convenient dosing schedules that make them the medications of choice.
Alrex (B+L) is a good option for the treatment of SAC because of its low side-effect profile,while in severe cases Pred Forte (Allergan) and Lotemax (B+L) are also used.

Take this quiz to find out how up-to-date you are on diagnosing, managing, and treating ocular allergy.

Symptoms of ocular allergy are often one of the reasons patients visit our office, and while in some parts of the country the weather may seem like anything but allergy season, now is the time to prepare your practice for the parade of allergy sufferers that warmer weather brings.

Do you recall the pathophysiology of the allergic cascade? Can you accurately distinguish between SAC, VKC, and AKC? Do you know the proper non-pharmacologic and pharmacologic treatments of ocular allergy? Let’s find out.

Q: According to the CDC, how many people were diagnosed with hay fever in the past 12 months (2012 data), and what is the number of physician office visits that had a primary diagnosis of allergic rhinitis?

a.  5.2 million, 5.5 million
b. 10.1 million, 15.6 million
c. 17.6 million, 11.1 million
d. 23.5 million, 27.3 million

The correct answer is C. According the American Academy of Allergy, Asthma and Immunology, allergic diseases affect more than 20% of the U.S. population, and are the sixth leading cause of chronic disease in the country. The estimated overall costs of allergic rhinitis totaled more than $6 billion in 2012.

Q: Seasonal allergic conjunctivitis (SAC) is a ___ hypersensitivity, ______ mediated reaction.

a. type-1, IgE
b. type-1, IgG
c. type-2, IgE
d. type-2, IgA

The correct answer is A. SAC is type-1 hypersensitivity, IgE-mediated reaction. A patient will experience sensitization to environmental allergens, and in this stage, the IgE molecule binds to receptors on sensitized mast cells and basophils, preparing them to future allergen exposure. After another exposure to the allergen, mast cells degranulate, leading to a release of inflammatory mediators, including histamine, prostaglandins, leukotrienes, and cytokines. In the late phase, eosinophils, neutrophils, basophils, and T-lymphocytes infiltrate the conjunctival mucosa, also releasing mediators, leading to a recurrence and prolongation of symptoms.

Q: Which is not an important sign of vernal keratoconjunctivitis (VKC)?

a. Horner-Trantas dots
b. SPK
c. swollen pre-auricular nodes
d. shield ulcers
e. large conjunctival papillae on the back of the superior tarsus.

The answer is C, swollen pre-auricular nodes. These are found in a viral infection. All of the other choices are signs of VKC.

Q: Which demographic is most likely to present with atopic keratoconjunctivitis (AKC)?

a. females age 10 and under
b. males age 30 to 50
c. females and males age 65 or older
d. males age 3 to 20

The answer is B. AKC is a perennial disorder, frequently occurring in men ages 30 to 50. They usually demonstrate a history of atopic dermatitis or eczema that has been present since childhood. AKC patients usually present with intense bilateral itching of the lid skin, periorbital area, and conjunctiva, as well as tearing, burning, photophobia, blurred vision, and a stringy, rope-like mucous discharge. Males age 3 to 20 are most likely to present with VKC.

Q: What are some effective non-pharmacologic ways to manage allergic conjunctivitis?

a. limiting time spent outdoors when allergen levels are high
b. showering and washing hair before bed
c. wearing sunglasses
d. using hypoallergenic bedding and changing sheets frequently
e. keeping windows and doors closed at home
f. all of the above

The correct answer is F, all of the above. These steps, including removing shoes and outerwear at the door, removing carpets, using a high quality HEPA air filter, and washing sheets in hot water are all strategies to reduce indoor allergens.

Q: Which is not true regarding topical ocular decongestants?

a. intensive use causes down-regulation of conjunctival alpha-1 receptors, resulting in “rebound hyperemia” once medication is stopped
b. they are recommended as a first line of treatment of allergic conjunctivitis
c. they do not affect the conjunctival response to the antigen, and have little effect on itching
d. they are contraindicated

The correct answer is B. Topical ocular decongestants reduce chemosis and conjunctival hyperemia by using an alpha-agonist mechanism. This stimulates alpha receptors in the blood vessels, resulting in vasoconstriction and decreased conjunctival edema. These drops usually work within minutes and last about two hours. Examples of topical ocular decongestants include Visine (tetrahydrozoline HCl 0.05%), Refresh Redness Relief (phenylephrine HCl 0.12%), Visine L.R. (oxymetazoline HCL 0.25%), and Clear Eyes (naphazoline HCl 0.12%).

Q: Which of the following is dual-acting antihistamine/mast-cell stabilizer?

a. Alaway (Bausch + Lomb)
b. Pataday (Alcon)
c. Naphcon-A (Alcon)
d. Alocril (Allergan)
e. Alrex (B+L)

The correct answer is B, Pataday. Dual-acting antihistamine/mast-cell stabilizer medications can prevent the onset of the allergic response, as well as provide ongoing relief to patients. Besides Pataday (olopatadine HCl, 0.2%), they include Patanol (olopatadine HCl 0.1%, Alcon), Bepreve (bepotastine besilate 1.5%, B+L), Lastacaft (alcaftadine 0.25%, Allergan), Optivar (azelastine 0.05%, Meda Pharmaceuticals; also available in generic), and Elestat (epinastine HCl, Allergan; also available in generic).Their fast-acting properties, as well as their safety profile and convenient dosing schedules of once or twice a day, tend to make these the medications of choice for many ODs.

Q. Corticosteroids help control allergic reaction by _______.

a. suppressing mast cell proliferation
b. inhibiting the production of inflammatory mediators
c. reducing the influx of inflammatory cells
d. causing the constriction of ocular blood vessels
e. all of the above
f. A, B, and C

The correct answer is F. Corticosteroids act on both the early and late phases of the allergic reaction, and can be used for managing severe ocular allergy, VKC, and AKC. Corticosteroids can also be useful for managing dry eye disease, which may occur along with ocular allergy. Alrex (loteprednol etabonate 0.2%, B+L) is an ester-based steroid, which has a lower risk of steroid-induced side effects. Due to its efficacy and safety, it is a good choice for the treatment of SAC. In severe cases, steroids such as Pred Forte (prednisolone, Allergan) and Lotemax (loteprednol 0.5%, B+L) are also used. As always, you should monitor IOP at all follow-up visits while treating with a topical corticosteroid.

Treating ocular allergy patients will help grow the medical side of your practice, provide patients with immediate and long term relief of their symptoms, and help drive referrals as satisfied, happy patients who have found relief send fellow allergy sufferers your way.

Jennifer L. Stewart is in private practice at Norwalk Eye Care in Norwalk, CT.


Alcon Laboratories, Inc. •800-451-3937 •alcon.com

Allergan •800-347-4500 •allergan.com

Bausch + Lomb •800-828-9030 •bausch.com

Meda Pharmaceuticals, Inc. •800-526-3840 •optivar.com


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