Seasonal Ocular Allergy:
New Options for a Recurring Problem
by richard trubo, contributing writer
interviewing gregg j. berdy, md, terrence p. o'brien, md, and michael b. raizman, md
lthough there are no epide- tions is not worsening the others," said One in Five
miological studies looking
Michael B. Raizman, MD, of Ophthal-
specifically at the preva-
mic Consultants of Boston.
lence of ocular allergy in
In some cases, it can be difficult to
the United States, several
sort out the symptoms of the various
studies have determined that allergic
conditions and determine the exact
disease overall is on the rise and that
diagnosis and best therapy. Even so, if
allergic conjunctivitis now affects at
clinical symptoms and signs such as
least 20 percent of the U.S. population
ocular irritation or redness are careful-
(approximately 60 million Americans). ly elicited and observed, the diagnosis About 35 percent of patients referred
can still be made with a high degree of
to an ophthalmologist's office for red
confidence, said Terrence P. O'Brien,
eye receive the diagnosis of allergic
MD, at the Bascom Palmer Eye Insti-
conjunctivitis, and about 95 percent of
tute in Miami. If the clinical picture
Approximately 20 percent of the U.S.
the cases of ocular allergy are seasonal
is not completely clear, point-of-care
population suffers from allergic con-
or perennial in nature.1
testing can sometimes help in making
The good news: More treatment op-
an accurate diagnosis. (See below, un-
tions are available today than a decade
der "What About Skin Testing?")
and help reduce symptom severity,"
ago, and many of the newer drugs re-
Importance of optimal therapy.
said Gregg J. Berdy, MD, at Ophthal-
quire application only once a day, un-
Most patients with allergy have season-
mology Associates in St. Louis, Mo.
like the regimen of two or four times
al or perennial conjunctivitis, which
No matter what
daily with the older agents.
almost never causes serious ocular
ophthalmic drug is chosen, the newer
abnormalities. "But vernal and atopic
formulations tend to have a very fast
Making the Diagnosis
allergies are relatively rare and need to
onset of action (about three to five
Ocular allergy is usually a clinical
be treated aggressively by ophthalmol-
minutes), which can improve patient
diagnosis; in most cases, it is not hard
ogists, as scarring or even vision loss
comfort and compliance. During al-
to differentiate from other conditions.
can occur," said Dr. Raizman.
lergy season, said Dr. Berdy, when
Even so, it can sometimes be challeng-
patients wake up in the morning and
ing to make the diagnosis when other
before they go outside, they can in-
ocular surface diseases are also pres-
In recent years,
still a drop of a dual-action agent in
ent. For example, it is not unusual for
there has been an evolution toward us-
their eyes, which will help prevent the
patients to have concomitant blephari-
ing combination treatments for ocular
symptoms of itching and redness.
tis or dry eye. As a result, patients with
allergy. For example, the front-line tar-
symptoms such as redness, itching,
geted medications for seasonal allergic
tearing, and burning should undergo
conjunctivitis are dual-action topical
What about prophy-
an ophthalmic exam that includes ex-
antihistamines and mast-cell stabiliz-
lactic treatment, especially for patients
amination of the lid margins and eval-
ers. "Combination dual-action eyedrop with a history of allergy? In many
uation of tear breakup time. "Also, you
therapy is not only convenient for the
cases, the allergic response is already
need to be certain that the treatment
patient, but these medications also act
well under way by the time treatment
you're giving for one of these condi-
rapidly to block the histamine receptor
is started, and the condition can hit
like an explosive forest fire, said Dr.
lower concentration with a decreased
allergists for decades," said Dr. Raiz-
O'Brien. "Once the patient already has
likelihood of causing side effects, as it
man, who added that it can be admin-
the redness, itching, and swelling of
is a nonketone ester topical corticoste-
istered by a technician or a nurse. With
the allergy cascade, it is almost too late
roid. If a clinician prescribes lotepred-
the test results in hand, the ophthal-
for mast-cell stabilization to have an
nol along with one of the dual-action
mologist may change or fine-tune the
immediate effect, although the topical
agents, the combination can bring
treatment approach for a particular
antihistamine may help block the his-
symptoms under control rapidly and
patient. "Once the ophthalmologist
tamine receptors," he added.
maintain comfort, said Dr. O'Brien.
confirms that the patient has an al-
Nevertheless, in patients who are
More potent corticosteroids can be re-
lergy—and not a condition such as
known to have the propensity for
served for intractable cases.
dry eye, blepharitis, meibomian gland
seasonal ocular allergy, medications
dysfunction, or a problem related to
may be prescribed in advance of the
who are sensitive to grass pollens,
contact lens wear—then he or she can
time when symptoms are most likely
Oralair, the first approved sublingual
focus on a multimodal antiallergy
to erupt. Some patients prefer to start
allergen extract, made its debut on the
therapy," Dr. Berdy said.
a couple of weeks before the onset of
market last spring. This medication,
In-office testing makes sense for
allergy season and then stay on the
which is classified as an oral immuno-
patients who have chronic recurrent
medication throughout the month
therapy agent, is given in a once-daily
disease that has not followed a typical
(or months) in which they are usually
tablet that dissolves under the tongue,
pattern of seasonal allergic conjunc-
affected. This strategy provides some
and it can be started four months be-
tivitis and has not responded well to
protection and reduces the amount
fore the onset of grass pollen season.
therapy. "Allergists may balk at the
of allergic mediators that are released
Patients typically take the first dose in
thought of an ophthalmologist doing
from conjunctival mast cells.
the doctor's office and are monitored
skin testing," said Dr. Raizman, "but
The current crop for at least 30 minutes to make sure
these are patients who, most of the
of ocular allergy drugs includes olopa-
that no side effects occur. Thereafter,
time, are not going to see an allergist.
tadine 0.2 percent (Pataday), which
the drug can be taken at home.
By doing skin testing, you can encour-
is a dual-action drug. It was the first
In studies of about 2,500 patients in
age them to see an allergist." n
the United States and Europe, patients
stabilizer ophthalmic drug approved
taking Oralair showed a 16 to 30 per-
1 Gomes PJ. Curr Opin Allerg Clin Immunol.
in the United States and is typically
cent decline in allergy symptoms com-
prescribed for once-a-day administra-
pared with those taking placebo.2
2 U.S. Food and Drug Administration. April
tion. Olopatadine 0.7 percent (Pazeo)
2, 2014. www.fda.gov/NewsEvents/News
is expected on the market soon.
but not least, clinicians should not
Alcaftadine (Lastacaft) is a broad-
ignore the nonpharmacologic thera-
htm. Accessed Nov. 20, 2014.
spectrum antihistamine that is ap-
pies that can be used by patients with
3 Bilkhu PS et al. Ophthalmology.
proved for the prevention of itching
ocular allergy.3 For example, simple
associated with allergic conjunctivitis.
cool compresses are helpful for most
Yet another widely prescribed, topi-
patients. In addition, preservative-free
Dr. Berdy practices at Ophthalmology Associ-
cally administered drug for ophthal-
chilled artificial tears can provide
ates in St. Louis, Mo., and is assistant profes-
mic use is bepotastine (Bepreve). This
some symptomatic relief, and they can
sor of clinical ophthalmology at Washington
potent dual-action drug can be ad-
flush allergens (such as pollen) out of
University School of Medicine. Financial dis-
ministered twice a day and has shown
the eye. And simply shampooing one's
closure: Has interests in Alcon, Allergan, and
efficacy in reducing allergy symptoms
hair before going to sleep can reduce
Bausch + Lomb.
such as itching or watery eyes.
the allergen load on the pillow.
Dr. O'Brien is professor of ophthalmology
Other combination agents include
at Bascom Palmer Eye Institute in Miami.
epinastine eyedrops (Elestat) and
What About Skin Testing?
Financial disclosure: Has interests in Alcon,
azelastine (Astelin), which is adminis-
A relatively new skin test known as
Allergan, and Bausch + Lomb.
tered as a nasal spray.
Doctor's Allergy Formula is available
Dr. Raizman practices at Ophthalmic Consul-
for ophthalmologists to use in their of-
tants of Boston and is director of the Cornea
es where the allergy process is already
fices. "Because allergy is so common,
and Cataract Service at the New England Eye
well under way by the time patients
and screening panels may not be as
Center in Boston. Financial disclosure: Has
seek treatment, newer and safer topi-
helpful as you would like, options like
interests in Alcon, Allergan, and Bausch +
cal corticosteroids can help suppress
in-office skin tests can be useful in
some of the acute-phase (as well as
some cases," said Dr. O'Brien.
the late-phase) reactions. This cat-
"A number of ophthalmologists are
MORE ONLINE. For a chart of sug-
egory includes loteprednol etabonate
using this test, which is similar to the
gested treatment paradigms, see the
(Lotemax), which can be given in a
skin testing that has been available to
online version of this story at www.eyenet.org.
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