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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 Although 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 Fast-acting drugs. 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 Treatment Trends
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 Preventive care. 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 Oral immunotherapy. For patients
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 Widely prescribed. 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 combined antihistamine/mast-cell 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- 2014;14(5):451-456. 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) Nonpharmacologic strategies. Last
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. 2014; 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-
Considering corticosteroids. In cas-
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.

Source: http://www.aao.org/assets/3f77632c-a639-4772-90f0-aab4bcb305e5/635601432657570000/march-2015-clinical-update-cornea-pdf