ocular allergy
Getting a Handle on Ocular Allergy
O.D.s are uniquely suited to dealing with the problem, and doing so brings benefits to your practice.
BY RENé LUTHE, Senior Associate Editor

Allergy is everywhere — according to the American Academy of Allergy, Asthma and Immunology, allergic diseases affect more than 20% of the U.S. population. Many O.D.s have learned to turn this unfortunate fact of life to their advantage, helping patients find relief and accruing profits and prestige in return. With a proactive attitude and a nose for clues, they say that other optometrists can do the same.

History lessons

A careful patient history remains the first place to look for allergy clues. While hay fever sufferers may already know their triggers, pin-pointing the cause of an allergic reaction can still be tricky. Experts agree that a careful study of a patient's environment and lifestyle are essential. "Usually," says Steven J. Gradowski, O.D., F.A.A.O., Omaha, Neb., "patients don't make the connection between environmental, nutritional and other triggers to their ocular allergies."

What's more, when patients present for their annual exam — typically the only time you'll see them — they may not be experiencing allergies, particularly if their problem is seasonal. Because of this, Glenn Corbin, O.D., of Reading, Pa., recommends a proactive approach. "I make the assumption that everyone potentially has allergy," he says. He questions "every single patient" about ocular redness, itching, etc.

In addition to questions about pets in patients' homes and medications, experts recommend you ask about common household items. William Townsend, O.D., of Amarillo, Texas, says it's crucial to ask about the flooring material in the home. "We encourage patients to get rid of carpet, if possible," he says. "This has been shown to reduce the severity and duration of allergy." Also ask patients about the chemicals they use around the house, such as detergents or air fresheners. Bobby Christensen, O.D., of Midwest City, Okla., points out that fabric softeners have been linked to allergies; even the patient's car and pillow are suspects. "You need to find out where they're having the most reaction, and when it's most severe," he says.

Addressing lifestyle

There are plenty of options short of medication that can help patients achieve allergy relief. With pets often linked to allergies, you can advise getting rid of the animal, although for some patients this is an extreme solution. Experts agree that keeping the pet off of the bed, and preferably out of the bedroom, is crucial, as is more frequent grooming. Dr. Christensen advises looking for fragrance-free pet shampoos to avoid another potential irritant.

When it comes to personal grooming, Dr. Townsend advises patients bathe before bed. "You come in the house with pollen and other allergens in your hair," he explains. "If you put your head on the pillow, you deposit these, which are then in contact with your face and ocular adnexa all night."

Around the house, emphasize cleaning air ducts and furniture more frequently, as well as shampooing carpets if patients can't remove them altogether. Air filters designed to remove allergens also help. For contact lens wearers, Dr. Gradowski suggests cleaning with a hydrogen peroxide system with non-preserved saline rinsing solution.

Drug options

When a patient comes to the end of options for avoidance, it's time for medications. Most patients come to you because their chosen over-the-counter (OTC) products haven't worked, so they're ready to accept this. However, some patient education goes a long way in getting them to fill your prescription. "Patients assume that taking oral OTC medication should address all their allergy symptoms," Dr. Corbin says. "But it doesn't address ocular ones."

He tells patients that topical medications are the best way to treat ocular symptoms. It's also important to inform patients that prescription medications require much less frequent dosing than OTCs, providing convenience as well as greater efficacy. "The duration of action for these [OTC] antihistamine/decongestant products is about two hours, yet the recommended dosage is four times a day," Ernie Bowling, O.D., M.S., F.A.A.O., of Summerville, Ga., points out. "So what the patient winds up doing is using the medication more than recommended, which can produce a number of problems, such as a rebound conjunctival hyperemia or a chemical keratitis." However, the antihistamic effects of the combination antihistamine/mast cell stabilizers that allergy experts recommend last for approximately 12 hours.

Dr. Townsend informs patients that BAK, found in most OTC drops, can further dry out the ocular surface. Most prescription products, he says, cause minimal drying comparatively.

Keep them in contact lenses

Prescription mast cell stabilizers/antihistamine drops, experts say, not only treat both seasonal and perennial allergies effectively, they also help prevent that dreaded side effect of ocular irritation — discontinuation of contact lens wear. Dr. Bowling gives his patients a prescription for a combination mast cell stabilizers/antihistamine before allergy season begins, for "pre-loading." Dr. Christensen instructs his patients to instill a drop of Patanol (olopatadine hydrochloride, Alcon) in each eye first thing in the morning and at least five minutes before inserting their lenses; he tells them to instill the second dose in the evening after they've removed their lenses. A trial run of two weeks at this schedule may be necessary because resolution may take more than one week, Dr. Christensen says.

Other tips include a change in wearing schedules. Dr. Bowling acknowledges that while few patients will likely decrease their wear time, they may be amen-able to a more frequent replacement schedule. "If they replace lenses every two weeks, try changing them weekly," he says. "And instruct patients to clean their lenses every day. Or change to a daily replacement lens during allergy season."

Getting the message out

Treating ocular allergy requires little investment for marketing or staff training. Dr. Christensen has trained his staff to give patients tips on what they can do to address allergy symptoms until their appointment. Dr. Bowling has an "allergy questionnaire" posted on the walls of his reception area, optical department and each of the exam rooms. "It's just three questions that at least get patients to think about what they may be experiencing," he says.

Dr. Townsend asks patients if other family members have the same symptoms. "Since this condition is genetically driven, they often do. We ask them to refer family members as well, and that is a very effective and inexpensive form of marketing."

Scot Morris, O.D., of Conifer, Colo., pursues a more aggressive marketing strategy, sending out fliers to his community and posting ads in local newspapers to reach new patients. While it may be more expensive, "If I can get the patient in for allergies, I can keep him in for all his other eyecare needs," he reasons.

Assert your authority

Treating ocular allergy is profitable in two ways, say practitioners. First, patients suffering from seasonal allergies typically require one to two visits, while those with perennial allergies may need to come in as often as every six weeks, according to Dr. Morris. "Many docs overlook this," he says. "Other O.D.s won't see these patients enough and so they end up going somewhere else."

The other, equally valuable benefit is the assertion of prescription authority and full-scope eye care practice. (See "How to Maximize Prescription Authority," on page 36.) "Every time you have a patient who presents a prescribing opportunity, issue one to show the patient that you treat eye disease," Dr. Corbin says. "Treating ocular allergy is easy and sets a precedent."

Will patients visit an O.D. for treatment instead of their primary care physician? Dr. Gradowski believes so. "Although many allergists will prescribe the same eye drops we might," he says, "they usually do not have a slit lamp to evaluate the lids, conjunctiva and tarsal plates to see just how the allergic response affects these tissues. With the tools optometrists have at our disposal, we can reduce the number of visits patients need to just one or two. You can really make a believer out of someone who's suffered for years with ocular allergies and they become a great referral source."