Selecting Initial Therapy for Treating Ocular Allergies

When working with patients who have ocular allergies, it is important to start with the basics.

By Gina Wesley, OD, MS, and Kelly Kerksick, OD

Allergies are the most common diagnosis in both of our practices, which happen to be in the heart of the Midwest. We frequently tell patients that there is no such thing as an allergy season here anymore. During the past 30 years, the prevalence of allergic disease has increased across all allergic spectrums.1 It seems that many of our patients can be just as affected by allergies in any season, and children can be just as affected as adults. This translates to a wealth of opportunity for managing allergic patients in our practices. Although the actual estimate in numbers varies widely, at least 20% of the population suffers from allergic conjunctivitis at some point during the year.2

PATIENTS DON’T KNOW WHAT THEY DON’T KNOW

Although it sounds like a cliché, patients truly “don’t know what they don’t know.” It has been our experience that quite often an allergy sufferer will attribute symptoms such as itchiness, grittiness, or redness as being a variation of normal, particularly if they wear contact lenses. So often, these patients assume that their symptoms are normal and to be expected with contact lens wear and do not associate their contact lens discomfort with allergies. Similarly, even patients who do not wear contact lenses will consider their symptoms “normal” for the climate they live in. This makes it very important to ask patients about such symptoms and then take the time to educate them as to the fact that such symptoms are often due to ocular allergies. This may have a big impact on one’s practice, as we have found that contact lens dropout has decreased significantly since we started treating allergies more aggressively and our being more diligent about educating patients regarding allergies and their affect on patients’ ocular health and comfort. Additionally, many of our asthenopic patients have found added relief by targeting this eye disease.

When thinking about ocular allergies, it is important to start with the basics: understand the chronic nature of the condition, learn how it affects the eyes (Figure), explain to patients that they are not alone in this problem, and discuss strategies to best treat their condition. Let us first discuss one of our most common patient sufferers of ocular allergies, the contact lens patient.

CONTACT LENS PATIENTS

Contact lens patients are some of our most motivated patients. These individuals generally want convenience, but they also place high value on the comfort of their lenses throughout the course of the day. Most contact lens wearers love the flexibility and vision that they gain from their contacts, and dropout is usually not a desired end point. As a result, when contact lens dropout is a last resort for this particular population, it may occur when allergy problems are making them miserable.

Allergy sufferers who wear contact lenses can be a challenge, but there are some ways to manage these individuals that we have found can really help to improve their end-of-day lens comfort and vision even at the peak of their allergies. Keep in mind that patients may have already tried many over-the-counter options before coming to see an eye care specialist, and it is our job to now solve their issues quickly, completely, and with long-lasting results.3

A daily disposable modality generally works best for those who have allergy problems. The big advantage of dailies is the elimination of continued buildup of proteins and lipids (that serve as allergens, the culprit of allergic reaction) on the surface of the contact lens. We have also found that a clean contact lens surface will make all the difference for patients who have issues with end of day dryness or discomfort. As a result, we frequently have the dailies conversation with patients who present with allergy problems in our practices. Research shows that patients who suffer from ocular allergies can experience a significant increase in ocular comfort by being fit with daily disposable contact lenses.4

Unfortunately, not all eyes are candidates for dailies lenses, but most of the time, the limitations of dailies lie in the prescription parameters. If we have patients who have high amounts of astigmatism or need a multifocal design, dailies lenses offer limited availability in these parameters. In such cases, when it is necessary to use a longer-wearing modality, it is important to educate patients on the importance of digitally rubbing lenses when cleaning their contact lenses and/or introduce the hydrogen peroxide solution options. We like to describe this as the difference between taking your car through an automatic car wash versus washing the car by hand. In both cases, the cars appear to be clean; however, if you wipe dry the car taken through the automatic car wash, you will notice more dirt and grime on the chamois. The same scenario is true for contact lens surfaces.

PHARMACEUTICAL INTERVENTION

There are a number of pharmaceuticals that can provide relief for allergy sufferers. Because allergies can be so frustrating for patients, we tend to treat the symptoms first so that the patient notices improvement and gets relief. We also, however, want to treat the underlying cause of the reaction. To do this, we will prescribe a combination mast cell stabilizer/antihistamine as a first line of treatment. These medications provide relief from itching by their antihistaminic activity, as well as protect against future allergen encounters by reducing mast cell degranulation. One of the advantages of using one of the modern mast cell stabilizer/antihistamine combinations is that they are very safe with minimal side effects, which makes them an excellent choice for children as well as adults. Another benefit is the fact that these combination drugs offer once-a-day dosing, which is more convenient to the patient and helps to reinforce compliance.

If the patient’s allergies are more advanced, prescribing a steroid should also be considered, especially if the condition is severe enough to cause underlying inflammation to the conjunctiva. This method of treatment is well documented to show additional resolution of both signs and symptoms.5 If inflammation is present, patients can be very uncomfortable and may present with symptoms similar to patients with dry eye disease, vocalizing complaints of grittiness and redness. When this is the case, we like to dose the steroid q.i.d. for the first 2 weeks and taper to b.i.d. for 2 more weeks.

We find that the fastest route to recovery for the patient is to use the steroid in conjunction with a mast cell stabilizer/antihistamine combination because this combination provides treatment for the best of both worlds. The steroid will work to eliminate the root of the inflammation, and the mast cell stabilizer/antihistamine combination helps get rid of patients’ symptoms very quickly as well as adds long-lasting resolution. Both drugs play a very important role in the healing process: without the use of the steroid, much of the inflammation will linger, and without the use of the mast cell stabilizer/antihistamine combination, patients remain symptomatic and uncomfortable.

CONCLUSION

Treating allergies can be very lucrative for a practice. We have only just begun in describing considerations of what type of patients and what type of treatments can bring relief. Not only can a practice increase their revenues by capturing these patients for additional followup care and treatment throughout the course of a year, this is also a great way to improve a patient’s quality of life and be the eye care practitioner who makes the difference.

Kelly Kersick, OD, is the founder of Midwest Vision Care in Columbia, Illinois, and senior director of professional services at Vision Source. Dr. Kerksick may be reached at kerksickod@ yahoo.com.

Gina Wesley, OD, MS, FAAO, is the founder of Complete Eye Care of Medina in Medina Minnesota. Dr. Wesley may be reached at drwesley@cecofmedina.com.

  1. Asthma and Allergy Foundation of America. www.aafa.org. Accessed March 11, 2013.
  2. Bielory L, Katelaris CH, Lightman S, et al. Treating the ocular component of allergic rhinoconjunctivitis and related eye disorders. Med Gen Med. 2007;9(3):35.
  3. Bruijic M, Miller J. Ocular allergies: treat it and fit it! Review of Cornea and Contact Lens. http://www.reviewofcontactlenses.com/content/d/allergy/c/33087. Accessed March 11, 2013.
  4. Stiegemeier M, Thomas S. Seasonal allergy relief with daily disposable lenses. Contact Lens Spectrum. 2001;16(4):24-28.
  5. Dimov V. Ocular allergy: Allergic conjunctivitis and related conditions, brief review. Updated Feb. 2, 2012. http://allergycases.org/2005/02/ocular-allergy-allergic-conjunctivitis.html. Accessed March 11, 2013.