ALLERGY 
Taking Allergy Treatment to the Next Level

Ever wonder how your colleagues go about treating ocular allergy patients? Whether you're missing out on an important step or consideration in treating this condition? This month, several experts give you their input on five allergy questions so you can compare your own methods and theories to theirs.
See how they approach treating this condition, how they select topical drugs, how they view the role of systemic antihistamines and other issues.

Q Is therapy for ocular allergy a step-by-step process or a one-size-fits-all approach?

I select medications by their ability to effectively inhibit disease mechanisms. Allergic disease is one of multiple mechanisms. For chronic disorders such as allergic disease, first grade the severity of the presentation, and base initial treatment on this finding. Initiate treatment, assess the patient and modify as needed.
Add additional drugs to the treatment regimen in a step fashion to emphasize efficacy and cost-effectiveness and minimize drug side effects.

Step 1: Use of artificial tears liberally p.r.n. is the first "step" for allergic conjunctivitis to debulk the antigen from the ocular surface and provide a soothing effect.
Step 2: Antihistamine/decongestant over-the-counter (OTC) medications are a cost-effective way to augment artificial tear therapy. These agents markedly reduce edema, redness and itching. Because they contain a sympathomimetic agent, avoid prescribing them for patients who have cardiovascular disease. Limit dosing to t.i.d. to avoid ocular irritation.
Step 3: Topical mast cell inhibitors are excellent prophylactic agents for the management of allergic conjunctivitis. Because they don't have antihistamine or anti-inflammatory activity, they won't provide relief in patients exhibiting acute disease. They're most effective when started prior to the individual's allergy season and before he becomes asymptomatic. For maximal effect, advise patients to use the drops daily on a regular dosage regimen, not p.r.n.
Step 4: Combination mast cell inhibiting/antihistamine agents are often convenient and effective in mild-to-moderate cases. They're expensive, but are cost-effective when other therapies fail.

Consider using oral medication only if topical therapy fails.

Bruce E. Onofrey, O.D., R.Ph., F.A.A.O., Albuquerque, N.Mex.

I think it's important to prescribe anti-allergy therapies based on the patient's needs and not "shotgun" his treatment. Use steroids wisely, but don't avoid using them in patients who have a severe case of the disease. Occasionally, you can use low-dose steroids for relatively long periods of time, and loteprednol etabonate 0.2% (Alrex) is particularly well-suited for such cases.

Jimmy D. Bartlett, O.D., F.A.A.O., Birmingham, Ala.

Clinical signs and patient demeanor guide the management process. Non-aggressive treatment can prolong symptoms and propel your patient to seek relief elsewhere. Patients who don't get better fast enough can present a practice management nightmare. You don't want to be asked for a referral to an ophthalmologist. So, my goal is a fast relief of symptoms. You need to walk that thin line between making the patient comfortable and excessive use of medication.

I don't hesitate to use topical steroids when indicated. Holding back the big guns can result in undertreatment, which unnecessarily draws out distress. Tears, decongestants and cool compresses can relieve symptoms in a cost-effective manner, but may not provide the immediate improvement needed to make the patient happy. Potent topical antihistamines or steroids shouldn't be relegated to a secondary treatment to be used only when less aggressive therapy fails. Judicious use of stronger anti-allergy therapies results in quick relief and happy patients.

Sheldon H. Kreda, O.D., F.A.A.O., Lauderhill, Fla.

Successful, long-term management of ocular allergy requires accurate diagnosis and initiation of the most appropriate medicine. "Shotgun" therapy using a "one-medicine-fits-all" approach frequently fails, can cloud the picture by eliminating signs that disable us from making the proper diagnosis and may make things worse -- for example, mistakenly treating herpes simplex infection as an allergic conjunctivitis using a topical steroid.

Plant pollen, house dust and animal dander, though harmless themselves, along with various household chemicals, when brought into contact with a sensitized individual, may trigger an acute contact allergy producing conjunctival chemosis, hyperemia, tearing and itching. The classic, immediate allergic reaction begins a short time after the tissue is exposed to the allergen.

Treatment includes removing the offending agent, applying topical artificial tear drops, prescribing oral OTC antihistamines and cold compresses. In more severe cases, include combinations of topical antihistamines, topical nonsteroidal anti-inflammatories (NSAIDs) and topical steroidal anti-inflammatory medications.

Andrew S. Gurwood, O.D., F.A.A.O., Philadelphia, Pa.

I tend to lean toward a conservative approach to anything I'm treating (except uveitis). In mild cases, an OTC antihistamine/decongestant q.i.d. will suffice. I also recommend in any presentation what I call "grandma's remedies" -- cold packs and artificial tears. I also recommend antihistamines OTC P.O. for these patients.

Moderate-to-severe allergic presentations require more aggressive therapy. I like to use levocabastine (Livostin) for ocular allergy, and I also like ketorolac tromethamine (Acular). I used to shy away from steroids in these cases, but I've found that loteprednol etabonate 0.2% (Alrex) is an excellent medication for moderate-to-severe cases of ocular allergy. Although loteprednol etabonate 0.2% is a steroid, it doesn't produce the intraocular pressure elevation usually associated with steroids and provides the patient with quick relief.

Severe ocular allergy reactions (referring to above, these are usually acute presentations) require an even more aggressive therapy with stronger steroids. And anytime I use steroids, I closely monitor the patient. So, I guess I use a step approach to treating ocular allergy.

Ernie Bowling, O.D., M.S., F.A.A.O., Summerville, Ga.

Several recommendations in allergy therapy are a one-size-fits-all approach. All patients suffering from ocular allergy should try to eliminate the offending allergen and complete a thorough history of their allergies and allergy medications. Cool compresses and avoidance of rubbing also fall within the one-size-fits-all approach, but choosing a medication is a step-by-step process that requires advanced clinical decision-making and in-depth knowledge of the allergic response and mast cell degranulation cascade of events.

Alan N. Glazier, O.D., F.A.A.O., Rockville, Md.

Q How do you choose a topical drug for ocular allergy?

I do a thorough history and determine the level and significance of both ocular and systemic symptoms. If mild, I choose a drug that provides biphasic control (mast cell control and antihistamine effect) and dose it b.i.d. for 4 weeks. I then have the patient go to q.d. and continue if the symptoms are controlled.

For moderate cases, I may initially add a steroid to stop symptoms quickly and discontinue it in 1 to 2 weeks but continue the biphasic agent b.i.d.

If severe, I start with both agents and discontinue only the steroid at 2 to 3 weeks. I monitor the clinical status of these patients more carefully and titrate the agents p.r.n.

In patients whose symptoms are severe enough to warrant oral therapy, I'll initiate treatment with topical and oral agents and then taper the topical component to fit the scenario.

Jim Thimons, O.D., F.A.A.O., Fairfield, Conn.

If the acute onset of allergic conjunctivitis is less severe, then many of the over-the-counter (OTC) antihistamine/vasoconstrictor combinations will provide adequate treatment. I don't use these long term because of their potential for causing ocular rebound.

My favorite drug for chronic allergic conjunctivitis is olopatadine (Patanol), despite its higher cost than nonprescription drugs of choice. This drug offers both antihistamine and mast cell stabilizing effects without concern for addiction secondary to rebound. I'll frequently start a patient on olopatadine and a steroid that has minimal intraocular penetration so it's less likely to cause side effects such as cataracts and increased intraocular pressure. These, of course, will only typically pose a problem with chronic use, but nonetheless, I like to minimize the patient's initial relief. This gives the patient confidence in my care and ensures that he'll follow instructions as I taper the steroid while continuing olopatadine therapy.

Philip M. Buscemi, O.D.,Greensboro, N.C.

My approach to treating ocular allergy depends on the severity of the condition and the patient's state of mind. Clinical findings and patient symptoms don't always correspond. I treat mild allergy with artificial tears and cool compresses. I've also found that topical antihistamines work quickly and effectively. When combination antihistamine/mast cell stabilizer drops, such as olopatadine, became available with twice-daily dosing, they supplanted other drugs with more frequent dosing.

An aggressive, short-term course of topical steroids is safe and often the only effective treatment for ocular allergy. New, soft steroids, such as loteprednol etabonate 0.2% (Alrex) or loteprednol etabonate 0.5% (Lotemax), have virtually eliminated the common side effects of steroids. If I have any question about the risk of infection, I'll prescribe dexamethasone and tobramycin (TobraDex) drops.

Sheldon H. Kreda, O.D., F.A.A.O., Lauderhill, Fla.

Q What role do systemic antihistamines play in your treatment of ocular allergy?

Many patients who have chronic allergies are already on systemic allergy meds, and they're seeing me to seek additional relief for itchy eyes. The systemic antihistamines I usually prescribe are loratadine (Claritin) and fexofenadine (Allegra) because they produce few side effects and help in many cases of chronic, itchy eyes and runny nose. They're not panaceas, but are helpful to many patients.

Often, systemic antihistamines and decongestants aggravate the problem by causing dryness, so it's sometimes necessary to add topical allergy drops and institute dry eye therapy. I refer patients who have chronic allergies and are getting little relief from oral antihistamines to an allergist for complete antigen sensitivity testing.

Bobby Christensen, O.D., F.A.A.O., Midwest City, Okla.

Oral medications such as loratadine (Claritin) and fexofenadine (Allegra) have been helpful for ocular symptoms in patients suffering from seasonal allergies. But these medications also have a tendency to dry out mucous membranes and create dry eye symptoms. Also, some of these medications, including generic Claritin D, contain huge dosages of pseudoephedrine, which can raise pulse, blood pressure and induce insomnia.

Brian DenBeste, O.D., F.A.A.O., Winter Park, Fla.

Q Does punctal occlusion play a role in the treatment of ocular allergy?

Only as an adjunct to conventional treatments. The tear film plays a role in eliminating potential allergens. So it's important to allow the tear film to function as normally as possible.

In a severe dry eye, the tears won't function to eliminate potential allergens, which can allow a potentially more severe allergic reaction. In such a case, punctal occlusion may play a role in allowing for a more normal tear film function, and I may suggest it as an adjunct to conventional treatment for allergic eye disease.

In milder dry eye, punctal occlusion plays less of a role in my practice. I wouldn't recommend punctal occlusion solely as an adjunct treatment for allergic eye disease because I worry about causing a stasis of tear flow and interfering with the tear film's ability to clear allergens. This might worsen allergic eye disease.

James E. Grove, O.D., F.A.A.O., Boiling Springs, Pa.

Upon first exposure to an allergen, the body recognizes the allergen and activates processed B-cells to produce allergen-specific immunoglobulin type E (IgE) antibodies. The mast cell is primed by the binding of the IgE antibody. On second exposure to an allergen, the binding of the allergen to its IgE antibody activates the mast cell. Once activated, the mast cell releases preformed and newly formed mediators.

Punctal occlusion can assist by:

•  creating a barrier with the increased tear film to the allergen exposure to the conjunctival and ocular surface
•  diluting the allergen concentration in existing tears
•  assisting in "washing" out the allergen from the ocular surface before it aggressively stimulates the allergic response.

Unfortunately, this approach is less than fully successful in most patients because the allergic response is rapid and significantly symptomatic. Also, it may be argued that plugging the puncta will reduce tear exchange and hinder the allergen from draining from the ocular surface.

Robert E. Prouty, O.D., F.A.A.O., Buena Vista, Colo.

Q Do you treat chronic ocular allergy differently than you treat acute ocular allergy?

Absolutely. With an acute case of ocular allergy, we're treating the symptoms and the cause at the same time. I typically treat acute allergy with a soft steroid or antihistamine drops (depending on the situation) not only to provide relief, but also to interrupt the inflammatory cycle.

With more of a chronic presentation of ocular allergy, I'll prescribe a short-term antihistamine for 3 to 4 weeks, but I'll also start the patient on a mast cell stabilizer at the same time. I do this because the mast cell stabilizer won't kick in for about 3 to 4 weeks. So we use the antihistamine to control the situation now and the mast cell stabilizer to take care of the long term.

It's equally important for patients who suffer from acute and chronic cases of ocular allergy to frequently use artificial tears or lubricants to wash out allergens. I also recommend using cold compresses for both cases.

Scot Morris, O.D., F.A.A.O., Leawood, Kans.

Acute ocular allergy normally causes sudden conjunctival edema, redness and stringy matter. I prescribe cold compresses, the decongestant/ antihistamine combination naphazoline HCl and pheniramine (Naphcon-A), saline rinses and diphenhydramine (Benadryl).

If the antigen (animal, food or chemical) has been eliminated, this treatment will usually resolve most of the symptoms within 8 to 24 hours. If the patient has to drive, I might substitute chlorpheniramine (Chlor-Trimeton) for the diphenhydramine to reduce drowsiness.

Bobby Christensen, O.D., F.A.A.O., Midwest City, Okla.

Treat severe acute allergic conjunctivitis as you would vernal conjunctivitis -- with steroids to "put the fire out." Then taper these medications and use one of the safer mast cell stabilizers, nonsteroidal anti-inflammatory drugs (NSAIDs) or antihistamines.

For run-of-the-mill seasonal allergies, a host of medications can safely treat the patient without requiring long-term or staged therapy.

Brian DenBeste, O.D., F.A.A.O., Winter Park, Fla