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An optometrist is part therapist, part detective, part physician, and always a caregiver. This fusion of roles is most evident when dealing with patients with ocular allergies. The allergy sufferer is often a chameleon of sorts, masquerading as a routine examination or a pink eye, and the challenge of diagnosing these patients is made more difficult by the fact that allergies affect patients across the age spectrum. The hallmark rubbing and itching of the eye, which can decrease the quality of a patient’s life, start him or her on a downward spiral, a fact that is often overlooked. Part of the reason for this oversight may relate to the way optometrists are trained: We are not taught to be proactive and think preventively. Yet, in the case of the allergy patient, this is what is needed.
FROM THEN TO NOW
Marc Bloomenstein, OD, discussed how ODs can tackle ocular allergery in AOC’s March/April 2012 issue. His call for leadership in this field still applies to today’s practice dynamics.
Around 30% of the US population has ocular and/or nasal symptoms multiple times per year,1 and so the question is, why are we not taking more of an active role in helping our patients? This is not an ephemeral problem, in fact, statistics show that the prevalence of allergies is on the rise.2 With the impact of climate change, industrialization, pollution, mobilization from different regions, new toxins, car exhaust, and cigarette smoke, we can expect to have more patients with allergic conjunctivitis in the near future. The problem is also exacerbated by the decreased immunity that we are perpetuating among children with the constant use of antibacterial wipes and gels, as well as antibiotics that are used in food—the phenomenon that has come to be known as the hygiene hypothesis.3
Optometry is a symptom-based profession, and optometrists routinely underestimate the impact that ocular surface disease can have on patients’ lives. Allergies are like family members coming for a visit: We think we know when they will arrive, and yet they tend to come early and stay longer than expected, and most often, we wish we could just make them go away. Unlike family members who overstay their welcomes, however, chronic allergies can make patients’ eyes more vulnerable to stronger and more severe symptoms like rhinitis. Research has shown that with sustained allergic responses, the conjunctival epithelium loses the tight gap junctions, thereby reducing the integrity of the conjunctiva.4 The epithelium becomes more permeable to allergens even when it is not allergy season.
Optometrists are uniquely positioned to help patients halt—or at least slow down—the cycle of an allergen initiating an immunoglobulin E hypersensitivity reaction leading to a chronic inflamed state. What does it say when Ben Stein and his Clear Eyes commercials have more sway over patients’ ocular health than an eye care specialist? As a profession, we need to stop letting patients succumb to the treatment du jour and take control of them when he or she is sitting in the examination chair.
The treatment of allergic conjunctivitis can be broken down into a combination of avoidance and prevention. Patients generally have a good idea of what triggers their allergic response. Many patients, however, are either unwilling or unable to avoid those triggers even though limiting exposure to those allergens—staying inside on high-pollution days, avoiding exercising in the middle of the day when the pollen count is high or when it is windy, and staying away from animals that may initiate the response—is a necessary part of the management plan.
Treatment most often begins with the use of artificial tears. The first line of defense the eye has is its thin layer of tear film, which can be damaged by inflammation secondary to allergic conjunctivitis. An artificial tear that balances the lipid layer and provides an increase in the aqueous portion will also be mildly retardant to allergens. Systane Balance (propylene glycol 0.6%; Alcon) is a good emulsion to provide that protection, although it has a high concentration of oil that may cause blurry vision. Refresh Optive Advance (carboxymethylcellulose sodium, glycerin, and polysorbate 80; Allergan) is a new tear formulation with less oil than Systane Balance, and it still provides the proper layer of tear coverage. Because the comorbidity of allergy and dry eye disease is often indefinable, an allergy patient may already be using a tear because of concomitant keratoconjunctivits sicca. For this reason, I prescribe Restasis (cyclosporine; Allergan) sooner rather than later among these patients to increase their aqueous production and to decrease the inflammatory load associated with keratoconjunctivitis sicca that exacerbates the allergic response.
Histamine is the villain in this drama. Histamine receptors are differentiated and cause myriad allergic symptoms.5,6 For example, the H1 receptor is the principal activator of the itch response, whereas H4 receptors increase eosinophil chemotaxis.7,8 Competitively antagonizing H1 receptors will relieve itching and competitively antagonizing H4 will work to reduce the inflammatory nature of the disease. Stopping the release of any mast cell components is important, because when left unchecked, they can exacerbate the inflammatory cascade.
Fortunately, we have some truly effective pharmacologic choices to prescribe—agents that move our patients out of the grocery store aisle and toward the pharmacy. The use of an H1 antagonist with mast cell-stabilizing properties should be the treatment of choice in mild to moderate cases of allergy. One such option is Bepreve (bepotastine besilate ophthalmic solution 1.5%; Ista), which is indicated for twice-daily use for the treatment of ocular itching associated with allergic conjunctivitis. Bepreve comes in a 10-mL bottle and allows patients to dose when their allergic response is at its greatest. Bepreve has shown a strong affinity to the H1 receptor and in clinical trials has demonstrated the ability to rapidly reduce the itch response.9,10
For some patients, twice-a-day dosing may not be the optimal choice, especially because no drop is indicated for use with contact lenses. There are two mast cell-stabilizing antihistamines that are approved by the Food and Drug Administration for once-daily dosing. Pataday (olopatadine; Alcon) is a higher concentration of the company’s Patanol formulation, which is indicated for twice-daily use. Pataday has been proven to be comfortable and formidable in the use of mild allergic conjunctivitis.11-13 The 2.5-mL bottle, if used properly once a day, should last 1 month. The other once-daily formulation is Lastacaft (alcaftadine; Allergan). In a trial of conjunctival allergens, Lastacaft, delivered in a convenient 3-mL bottle, was associated with minimal itching at 16 hours, making it a nice option for single dosing. Lastacaft is the only allergy drop with an indication for the prevention of itching associated with allergic conjunctivitis. Lastacaft is also unique in that it carries a pregnancy category B approval, thus making it a safe choice for women thinking about pregnancy or who currently are pregnant. Allergies often occur in younger patients who may only present with ocular symptoms. Knowing that a medication is approved for use in pediatric patients as young as 2 years old should offer peace of mind, especially if one product must be prescribed for an entire family of allergy patients.
The allergy cascade is not just limited to the histamine response, and thus, the mediators that induce inflammation may need to be treated topically. The concomitant use of a steroid like Alrex (loteprednol etabonate 0.2%; Bausch + Lomb), which is indicated for the temporary relief of the signs and symptoms of seasonal allergic conjunctivitis, is a great adjunctive therapy for chronic allergy patients. The agent has been shown to be safe and effective in limiting the inflammatory portion of the chronic allergic state without inducing any long-term steroid-associated complications.14
Ask about your patients’ systemic medications, know what drops they are putting in their eyes, and ask that simplest of all questions: ”Do your eyes ever itch?” Prevention is worth a pound of smiles and happy patients, and ultimately, this will mean a robust waiting room.
1. Nathan RA, Meltzr EO, Selner JC, Storms W. Prevalence of allergic rhinitis in the United States. J Allergy Clin Immunol. 1997;99:S808-S814.
2. Nathan RA. The burden of allergic rhinitis. Allergy Asthma Proc. 2007;28:3-9.
3. Strachan DP. Hay fever, hygiene, and household size. BMJ. 1989;299(6710):1259-1260.
4. Ono SJ, Lane K. Comparison of effects of alcaftadine and olopatadine on conjunctival epithelium and eosinophil recruitment in a murine model of allergic conjunctivitis. Drug Des Devel Ther. 2011;5:77-84.
5. Schwartz LB, Austen KF. Structure and function of the chemical mediators of mast cells. Prog Allergy. 1984;34:271-321.
6. Snyder SH, Axelrod J. Tissue metabolism of histamine -C14 in vivo. Fed Proc. 1965;24:774-776.
7. Owen DA, Poy E, Woodward DF. Evaluation of the role of histamine H1- and H2-receptors in cutaneous inflammation in the guinea-pig produced by histamine and mast cell degranulation. Br J Pharmacol. 1980;69:615-623.
8. Robertson I, Greaves MW: Responses of human skin blood vessels to synthetic histamine analogues. Br J Clin Pharmacol. 1978;5:319.
9. Abelson AB, Torkildsen GL, Williams JI, et al. Time to onset and duration of action of the antihistamine bepotastine besilate ophthalmic solutions 1.0% and 1.5% in allergic conjunctivitis: a phase III, single-center, prospective, randomized, double-masked, placebo-controlled, conjunctival allergen challenge assessment in adults and children. Clin Ther. 2009;31:1908-1921.
10. Macejko TT, McLaurin EB, Kurata FK, et al. Bepotastine besilate ophthalmic solution 1.5% reduces ocular itching following dosing in the conjunctival allergen challenge (CAC) model of acute allergic conjunctivitis. Invest Ophthalmol Vis Sci. 2009:50, E-Abstract 6328.
11. Pataday [package insert]. Fort Worth, TX; Alcon, Inc.; 2006.
12. Abelson MB, Gomes PJ, Pasquine T, et al. Efficacy of olopatadine ophthalmic solution 0.2% in reducing signs and symptoms of allergic conjunctivitis. Allergy Asthma Proc. 2007;28(4):427-433.
13. Epstein AB, Van Hoven PT, Kaufman A, et al. Management of allergic conjunctivitis: an evaluation of the perceived comfort and therapeutic efficacy of olopatadine 0.2% and azelastine 0.05% from two prospective studies. Clin Ophthalmol. 2009;3:329-336.
14. Pavesio CE, Decory HH. Treatment of ocular inflammatory conditions with loteprednol etabonate. Br J Ophthalmol. 2008;92(4):455-459.
Marc Bloomenstein, OD
• Director, optometric services, Schwartz Laser Eye Center, Scottsdale, Ariz.
• Financial disclosure at time of article: consultant and member of speakers’ bureau, Alcon, Allergan, Ista Pharmaceutics, Bausch + Lomb