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Up to 40% of the US population experiences allergic rhinitis.1 Not only is the prevalence of allergy greater than we once thought, but approximately three out of four of those allergy sufferers have ocular symptoms.2 The timing of symptoms, although most common in the spring across much of the United States, can actually be very unpredictable. Climate change has extended the growing season of common sources of seasonal allergies, including ragweed, birch, and oak,3,4 and many patients are susceptible to perennial allergens like dust or pet dander that affect them throughout the year.
These trends should matter a great deal to contact lens practitioners. Based on approximately 37 million US contact lens wearers5 and the allergy prevalence discussed, there are about 11 million US contact lens wearers with ocular allergies. More than 40% of lens wearers with allergies say they get through peak allergy times by temporarily switching to spectacles.6 Assuming that one in five of those patients decides their contact lenses are too much hassle and they do not mind wearing glasses after all (a conservative estimate) and a per-patient revenue of $177 to $326 annually,7 this could potentially translate into 900,000 patients dropping out of contact lenses due to allergy and up to $290 million in lost revenue for optometry.
Contact lens dropout is compounded (for the profession and our patients) by the significant overlap between allergic conjunctivitis and dry eye disease (DED). Hom et al found a comorbidity rate of 78%.8 Allergic conjunctivitis has a negative effect on the lipid layer, which can lead to tear film instability and evaporation.9 A dry ocular surface in turn intensifies allergic reactions,10 in part because the tears are insufficient to wash away allergens. Finally, allergy sufferers may be taking systemic antihistamines, some of which reduce tear volume by as much as 34% after just a few days of use.11
There are steps we can take to treat ocular allergy and proactively help our contact lens wearers avoid discomfort and successfully remain in their lenses.
Perhaps the most effective and proactive step we can take for patients who are wearing reusable contact lenses is to switch them to a daily disposable lens (eg, 1-Day Acuvue Moist Brand Contact Lenses; Johnson & Johnson Vision Care). Research has shown that when worn on a daily disposable basis, this brand may provide improved comfort for many patients suffering from mild discomfort and/or itching associated with allergies during contact lens wear compared to lenses replaced at intervals of greater than 2 weeks.12,13
The buildup of lipids, proteins, and allergens on a contact lens keeps the allergen in contact with the ocular surface and can also cause mechanical friction and irritation, particularly in an eye that may already have some papillae and/or tear film changes. With a daily disposable modality, the patient can discard the allergen-coated lens and replace it with a fresh lens every day. This regimen also limits exposure to cleaning solution chemicals and preservatives.
In choosing contact lenses for patients with ocular allergies, we want to minimize any interaction between the lid and the lens surface. So, in addition to daily replacement, it is helpful to choose materials with a lower modulus, good wettability, and the lowest possible coefficient of friction. These attributes increase the chance of keeping patients comfortable in their lenses (see A Typical Case).
Most patients who are struggling with allergy-related discomfort will welcome the opportunity to switch to a daily disposable lens despite the additional cost. In fact, 65% to 70% of patients are willing to pay more for a more comfortable lens.14 Optometrists can also present daily wear lenses as an opportunity to temporarily rehabilitate patients’ eyes and explain that they can switch back to reusable lenses when allergy season is over. Once they experience the comfort and convenience of daily disposable lenses, most patients will choose not to switch back.
TREAT THE ALLERGY
Palliative measures such as artificial tears and cool compresses can be helpful in washing away allergens and reducing edema. Patients with significant symptoms will benefit from a topical combination antihistamine-mast cell stabilizer. These agents can rapidly relieve itching associated with ocular allergies. Allergy drops should be used before or after contact lens wear, but not during.
If there are significant clinical signs such as conjunctival edema, chemosis, or severe hyperemia, the patient may need a topical corticosteroid in addition to allergy medication. A low-dose steroid will have the added benefit of targeting inflammatory DED that often compounds the allergic symptoms. Topical steroids can be initiated before and after lens wear, but in many cases, we recommend stopping lens wear for 1 to 2 weeks so the steroid can be used four times a day to thoroughly treat the inflammation before resuming lens wear.
It is best to avoid systemic antihistamines whenever possible because of their drying effects on the eye.
DIAGNOSING THE RED EYE
When a new patient presents complaining of contact lens discomfort, perhaps with some redness and itching, a thorough history is the first step in determining whether the culprit is noncompliance, DED, ocular allergy, or some combination. It is also important to rule out more serious infectious causes and sight-threatening forms of allergy, including atopic keratoconjunctivitis, vernal keratocon-junctivitis in children, and giant papillary conjunctivitis.
Make your examination lane a “guilt-free zone” by asking open-ended, nonjudgmental questions about lens wear and care: “How many hours per day do you wear your contact lenses? Do you prefer to shower with them? How often do you throw them away?” It is important to know when symptoms began and what time of day they are most bothersome.
We think of itching as a hallmark of allergic conjunctivitis, but it is also associated with other conditions, therefore it is helpful to know the location of the itching. In allergic conjunctivitis, patients most commonly experience itching in the nasal canthal or conjunctival regions, and an itchy eyelid margin may point to blepharitis. Less specific itching combined with dryness or grittiness is likely DED alone or in combination with allergy.
We evert the lids in every contact lens patient. This is a simple test that quickly provides the information needed to make treatment decisions. The upper tarsal plate is an immunologically active area and hyperemia or papillae in that area are signs that the contact lens is contributing to the problem. Corneal and conjunctival staining, evaluation of the meibomian glands and tear meniscus height, and osmolarity testing are additional steps that aid in diagnosis.
Contact lens wearers with allergic conjunctivitis are exactly the type of patients we need to capture in our practices. We have the diagnostic tests and topical treatments to provide excellent care for these patients. Not only can we relieve their allergic signs and symptoms, but in doing so, we can help them be more comfortable and successful in their contact lenses.
Johnson & Johnson Vision Care provided editorial assistance with this article.
Paul Karpecki, OD, is clinical director at Koffler Vision Group in Lexington, Kentucky. He is a consultant to Bausch + Lomb and Johnson & Johnson Vision Care Inc. Dr. Karpecki may be reached at (859) 402-2814; firstname.lastname@example.org.
Arti S. Shah, OD, is in private practice at Elander Eye Care in Santa Monica, California. She is a professional affairs consultant for Johnson & Johnson Vision Care. Dr. Shah may be reached at (310) 393-0634; email@example.com.
- Rosario N, Bielory L. Epidemiology of allergic conjunctivitis. Curr Opin Allergy Clin Immunol. 2011;11(5):471-476.
- Abelson MB, McLaughlin JT, Gomes PJ. Antihistamines in ocular allergy: are they all created equal? Curr Allergy Asthma Rep. 2011;11(3):205-211.
- Zhang Y, Bielory L, Georgopoulos PG. Climate change effect on Betula (birch) and Quercus (oak) pollen seasons in the United States [published online ahead of print June 21, 2013]. Int J Biometeorol. doi: 10.1007/s00484- 013-0674-7.
- Ziska L, Knowlton K, Rogers C, et al. Recent warming by latitude associated with increased length of ragweed pollen season in central North America. Proc Natl Acad Sci USA. 2011;108(10):4248-4251.
- Nichols JJ. Contact Lenses 2013. Contact Lens Spectrum. January 1, 2014.
- Eye on Allergies consumer survey, conducted June 6-9, 2006, by Market Tool on behalf of Vistakon, Division of Johnson & Johnson Vision Care, Inc.
- Rumpakis J. New data on contact lens dropouts: An international perspective. January 15, 2010. Review of Optometry. http://www.revoptom.com/content/d/contact_lenses_and_solutions/c/18929/. Accessed April 15, 2014.
- Hom MM, Nguyen AL, Bielory L. Allergic conjunctivitis and dry eye syndrome. Ann Allergy Asthma Immunol. 2012;108(3):163-166.
- Suzuki S, Goto E, Dogru M, et al. Tear film lipid layer alterations in allergic conjunctivitis. Cornea. 2006;25(3):277-280.
- Gomez PJ, Ousler GW, Welch DL, et al. Exacerbation of signs and symptoms of allergic conjunctivitis by a controlled adverse environment challenge in subjects with a history of dry eye and ocular allergy. Clin Ophthalmol. 2013;7:157-165.
- Ousler GW 3rd, Workman DA, Torkildsen GL. An open-label, investigator-masked, crossover study of the ocular drying effects of two antihistamines, topical einastine and systemic loratadine, in adult volunteers with seasonal allergic conjunctivitis. Clin Ther. 2007;29(4):611-616.
- Solomon OD, Freeman MI, Boshnick EL, et al. A 3-year prospective study of the clinical performance of daily disposable contact lenses compared with frequent replacement and conventional daily wear contact lenses. CLAO J. 1996;22:250-257.
- Hayes VY, Schnider CM, Veys J. An evaluation of 1-day disposable contact lens wear in a population of allergy sufferers. Cont Lens and Anterior Eye. 2003;26:85-93.
- Frangie J, Schiller S, Hill L. Understanding lens performance from wearers of monthly replacement contact lenses. Optom Today. 2008;48(12):39-42.