HOW TO SUCCESSFULLY IDENTIFY AND TREAT IN CLINICAL PRACTICE .
Oftentimes we are presented with the acute symptomatic patient who comes in complaining about red, itchy, irritated eyes. It is incumbent to accurately identify ocular allergies and differentiate them from other conditions that may present similarly, such as dry eye, blepharitis, viral conjunctivitis, bacterial conjunctivitis and infiltrative keratitis.
There are several factors that can help identify allergic conjunctivitis from these other entities. Frequently, the presentation is an acute onset and symptoms are associated with seasonal changes and the presence of allergens in the environment. This is not an absolute rule as some individuals may have chronic ocular allergies that are present year-round and the symptoms simply spike with seasonal changes.
The most common accompanying symptom that these patients will have is itching. With acute allergic conjunctivitis, this symptom may be more prevalent in the inner canthal region. This occurs because the natural blink mechanism moves the tears to the inner canthal region where they drain through the puncta on the superior and inferior eyelid. This can cause accumulation of allergens and histamine. Histamine causes much of the signs and symptoms associated with allergic conjunctivitis. Other signs that accompany allergic conjunctivitis include conjunctival hyperemia, conjunctival swelling, eyelid swelling and epiphora.
Just as important as identifying the acute presentation of allergic conjunctivitis is identifying those individuals who may have allergic presentation outside of the time of their eye exam. As an example, if you see a patient during the winter months for their exam, it is important to question them about ocular symptoms that they may have or medications that they may take at other times of the year. Patients with seasonal allergic conjunctivitis may not think to make us aware of ocular symptoms that are not present at the time of their visit. Identifying patients that may take oral antihistamines at other times of the year is critical in order to determine the presence of ocular symptoms. If they do have ocular symptoms it’s incumbent upon us to offer appropriate treatment options for when their symptoms manifest.
For the contact lens wearer, oftentimes the best solution is to make sure that the patient is wearing daily disposable lenses. Since they are disposed of on a daily basis, any allergens that have accumulated on the lens during the day are disposed of. When a new lens is placed on the eye each day it minimizes the chances of the lens causing additional ocular comfort issues and can help reduce symptoms of allergic conjunctivitis.
If a patient’s prescription is not available as a daily disposable lens, hydrogen peroxide cleaning systems, such as CLEAR CARE and CLEAR CARE PLUS (Alcon Laboratories), work remarkably well to sufficiently clean the lenses. These two peroxide systems are also approved for gas permeable (GP) lenses, so be sure to keep them in mind for those allergy sufferers wearing GP lenses.
Patients can try removing themselves from the allergen or if that isn’t possible, removing the allergen from themselves. This is typically done with artificial tears but only usually provides temporary relief. Cold compresses help with inflammation of the lids but will not get to the root of the problem which is histamine being released from mast cells. Mast cells release histamine when allergens bind to immunoglobulin E (IgE) receptors on the mast cells. This causes what is referred to as mast cell degranulation, releasing massive amounts of histamine, which causes itching, hyperemia and edema.
Fortunately, several therapeutic options exist to help patients with seasonal allergies. There are several antihistamines that are available. Olopatadine, a mast cell stabilizer, is available in three concentrations from Novartis: 0.1% (Patanol), 0.2% (Pataday) and 0.7% (Pazeo). Patanol is approved as a twice-a-day dosing regimen and Pataday and Pazeo as a once-a-day drop. Both 0.1% and 0.2% concentrations of olopatadine are available as generic drops.
Lastacaft (Allergan) is 0.25% alcaftadine and is approved as a once-daily dosing regimen. Two other prescription options that are available are epinastine 0.05% (Elestat from Allergan) and azelastine 0.05% (available as a generic). These are both approved as a twice-a-day dosing regimen. There is also an over-the-counter option that is available for the treatment of allergic conjunctivitis. Ketotifen 0.025% is approved as a twice-a-day dosing regimen and is available under several brands including SYSTANE Zaditor (Alcon), Alaway (Bausch + Lomb) and Equate Eye Allergy Relief Drops from Walmart.
A new antihistamine drop will be available in the U.S. in 2019. It is Zerviate (Eyevance Pharmaceuticals), which is the first topical ocular formulation of cetirizine. It is formulated at a concentration of 0.24%. Cetirizine is an antihistamine that competitively binds to histamine receptors to reduce the signs and symptoms of allergic conjunctivitis. Cetirizine is currently commercially available as an oral medication, Zyrtec (Johnson & Johnson Consumer, Inc.).
There are times when a patient with active allergic conjunctivitis requires a topical corticosteroid to control the signs and symptoms initially and before managing with a topical antihistamine. Although you need to make sure that you are assessing the intraocular pressure when a topical corticosteroid is used, they are usually used for only a short period of time to sequester the inflammatory response caused by the allergen. There are several topical corticosteroids available.
Loteprednol is available in two concentrations: 0.2% and 0.5%. The 0.2% is available as Alrex (Bausch + Lomb). Alrex is approved as a four-times-a-day dosing regimen for allergic conjunctivitis. The higher concentration of 0.5% is commercially available as loteprednol gel. Although not specifically approved for allergic conjunctivitis, many use it to sequester the initial symptoms of the disease.
Fluoromethalone acetate 0.1% is a topical corticosteroid available as Flarex (Novartis). Although not specifically approved for allergic conjunctivitis, it is approved for the treatment of steroid responsive inflammatory conditions of the palpebral and bulbar conjunctiva, cornea and anterior segment of the eye. The acetate formulation has shown significant improvement in efficacy over the alcohol formulation of fluoromethalone.
Managing allergic conjunctivitis is becoming an increasingly important component to our practices. Understanding appropriate identification and treatment strategies is critical to effectively managing these patients. A proactive approach is the best way to help these patients manage their
Mile Brujic, OD, FAAO, is a partner of Premier Vision Group, a three-location practice in northwest Ohio. He has authored more than 250 articles for publication and given more than 1,300 lectures.
WHERE TO FIND IT
800.451.3937 | Alcon.com
800.347.4500 | Allergan.com
Bausch + Lomb
800.828.9030 | Bausch.com
817.677.6120 | Eyevance.com
Johnson & Johnson Consumer, Inc.
800.343.7805 | Zyrtec.com
862.778.2100 | Novartis.com