allergy

Top Five Mistakes in the Management of Allergy Patients

JOHN L. SCHACHET, O.D., Englewood, Colo.

Avoid these classic blunders in the care of ocular allergies.

Allergy is everywhere in our environment, no matter where you live. In fact, allergic disease affects more than 20% of the U.S. population, according to the American Academy of Allergy, Asthma and Immunology (AAAAI). In addition, those who suffer from allergies may encompass as much as 50% of the population, according to a 2003 to 2004 Gallup Poll. Moreover, the same poll estimates that 90% of these individuals experience ocular symptoms as well, and yet, ocular allergies have been traditionally under reported.¹

With all this in mind, it seems strange that most people with eye allergies seek "professional" help from their grocery and pharmacy store clerks. Eyecare practitioners of both the O.D. and M.D. variety certainly have more knowledge than those lay people, yet the over-the-counter (OTC) allergy market continues to thrive. People don't come to see us without first trying OTC drugs and, when they don't work, they ask their family practitioners, allergists, Ear, Nose and Throat (ENT) doctors and pediatricians, to name a few. Then, when they still don't get adequate relief, they ultimately come to see those of us in the eyecare field.

So, how can we ensure these patients see us first? By being aware of the most commonly-made O.D. mistakes surrounding ocular allergy, which we will address here.

1. LACK OF MARKETING

One reason patients don't seek our expertise first: poor marketing to both patients and other healthcare workers about our ability to treat allergy. Whether you use a newspaper ad, on-hold messages, practice newsletters or simply spread the word about your ability to treat allergy to your own patients, you need to do something if you expect this vital and lucrative part of your practice to expand to meet national trends and demands. The loss of productivity and lost workdays due to allergy costs the country at least $5 billion a year, according to a 2004 study about quality-of-life issues related to allergy.¹

Being proactive will ultimately help reverse this trend when we affect our patients positively upon the early onset of symptoms.

2. MISDIAGNOSIS

It's extremely important to differentiate the potential allergy sufferer from the patient who has dry eye or bacterial or viral conjunctivitis. While this last comparison seems rather easy, it isn't always so simple. Other naturally occurring signs, such as redness, blurred vision, mucous discharge, etc. can exacerbate or mask symptoms, complicated the differential diagnosis.

We all know that the hallmark of allergy is itching, but does every allergy sufferer complain of this symptom? Admittedly, most do, but not all. Remember: There is so such a thing as 100% in the healthcare field.

Considering the allergic cascade causes about 90% of the ocular-allergy cases we see, we need to understand that this cascade evolves into a specific and narrowly focused form of inflammatory disease. During allergic episodes, mast cells migrate to the superficial layers of tissue, where they are degranulated by immune or mechanical stimuli. Once degranulation occurs, histamine, the principal mediator of the allergic response, is released into the blood stream and causes vasodilation and erythema, increased vascular permeability (edema) and neural stimulation (itching). Preformed mediators are also released during this phase in the form of prostaglandins, leukotrienes, cytokines, etc. While all of these are important, the principal mediator is still histamine. We have learned that the human eye has some 50 million mast cells.²

So, inflammatory responses are very common during the release of all these mediators into the human body and into the eye, more specifically.

Dry eye also complicates this differential diagnosis. The caveat used to be: if the eye burns, it's dry eye, if it itches, it's allergy and if there is mucous discharge, it's considered a bacterial infection until proven otherwise. While this might work as a generalization, the differential diagnosis can be much more difficult than this simple saying.

Therefore, to determine a definitive diagnosis, conduct a complete battery of dry-eye tests. Begin with a biomicroscopic evaluation of the anterior segment with emphasis on the tear layer to analyze its composition (thickness, debris, meibomian gland oil and sebaceous secretions) as well as the tear meniscus for its apparent volume.

Next, obtain a tear break-up time to help assess the quality of the tears. Then, stain the conjunctiva and cornea with fluorescein dye, and use a Wratten filter for a complete evaluation. Look carefully at the conjunctiva for dry spots or dry areas. Lissamine green dye can be additionally helpful to examine the conjunctiva, and perform some type of fluid analysis to assess the quantity of tears present in the conjunctival sac.

A note about patients who present for eye exams: When allergy, dry eye or infection present at a primary exam visit, it may be helpful to switch to a medical mode and take care of this problem before completing the vision exam. Any of these conditions may influence the outcome of the refraction depending upon the severity of the symptoms. You can do the refraction after you've resolved the medical issues.

3. LACK OF PATIENT EDUCATION

When allergy is the diagnosis, you need to adequately educate the patient on the treatment plan, including the necessary therapies, as well as the dos and don'ts of management at home.

For instance, when recommending prescription therapy, go over the instructions and talk about potential outcomes if the patient uses the drug properly. Whether you prescribe medication or some other therapy, recommend the treatment approach in a strong, dogmatic manner, with written and/or verbal instructions.

Invite patients to ask about your therapy recommendations.

Also, invite patients to ask questions about your therapy recommendations. The patient needs to understand the consequences of non-compliance and how this may further complicate his condition. I cannot over-emphasize this. It's critically important to the success of your treatment plan. By educating the patient on why you've prescribed the drug and what the drug will do when used correctly, you encourage compliance, which will lead to a good outcome and patient referrals.

4. LACK OF FOLLOW-UP

A follow-up appointment is necessary to determine whether the treatment plan is working effectively. When you follow-up, you're treating the patient with maximum care as opposed to the advice they get from the store or pharmacy clerk. These follow-up appointments can be in short slots, not taking up much time, but still enhancing revenue for the day of the appointment.

5. NOT CHARGING APPROPRIATE FEES

If you're one of those O.D.s who think there's no money in taking care of these types of patients, you might re-think your position after you experience firsthand how lucrative ocular allergy treatment is. You should not treat these patients for free because the patient will perceive the treatment isn't worth anything when it is done at no cost. Allergy visits are an integral part of any optometric primary-care practice and if they aren't done in your practice, they should be for all of the reasons stated above. Be persistent in treating these patients and the desired outcome will prevail. Once it does, the practice will still be able to complete the vision exam and earn additional revenue.

Further, when you recommend a prescription product, make certain, even if you give the patient a sample, that you also give him a written prescription for refill purposes immediately. Do not let the patient control your sampling habits by coming to see you for "refills" that are free samples from the pharmaceutical companies. As the saying goes, "Samples do not a doctor make."

It's important that we get credit as a profession for written prescriptions in order to keep the samples flowing from the pharmaceutical manufacturers. If all you do is sample and not prescribe, it's not fair to ask the pharmaceutical company representative to include your practice in their sampling territory with the same service as a high prescriber would receive.

With all the profits that we assume the pharmaceutical companies make, it can be said that if we want to share in the samples, we need to do our part to help profitability, and we can't accomplish this by giving away the store. I'm not saying you should over-prescribe, but if you're going to prescribe anyway, why not give the patient a written prescription to take to her favorite pharmacy?

It has been said more than once that treating ocular allergy is a "gateway to beginning a successful therapeutic practice." For those in our profession who do not know where to begin to promote the medical model of optometry within our practices, the easiest place to start is with the practice of ocular allergy treatment. We are blessed today with the very best ocular drugs for allergy in our profession's history. And the best part is that they work effectively and well, without any significant side effects. Where else in our profession does medical treatment work as well with little or no complicating factors?

If you're not currently in a therapeutic model practice, heed this advice to begin with allergy. You will never regret your decision, and your patients will be much relieved that they have a consultant to help them with this debilitating problem. A happy patient will send many referrals your way, and your practice will thrive in this relatively new world of medical optometry. The ultimate goal of any successful treatment regimen is to create happy patients, but what's wrong with building a successful, economically sound practice at the same time?

You must, however, keep your patients aware that your practice not only treats this condition, but many others as well. What was once the sole responsibility of medicine is now shared with other professions, and the optometric community will continue to move forward as long as we are willing to accept our responsibility for our patients' welfare as it relates to total medical eyecare. With this in mind, if you're not currently following the medical model, begin with allergy treatment. You won't be sorry you did. OM

Dr. Schachet is in private practice in Englewood, Colo. He lectures widely in the United States, New Zealand and Canada. E-mail him at jschachet@aol.com.