Managing Ocular Allergy Patients

Find out how these experts handle classic cases, including children.

Dr. Karpecki: The typical contact lens patient who has allergic eye disease usually is diagnosed with some component of dry eye as well. Patients may have a few papillae on the upper tarsal plate, suggesting a mild case of giant papillary conjunctivitis (GPC).¹ What's your typical protocol for managing this type of patient?

Staged approach

Dr. Devries: I'd start the patient on an antihistamine/mast cell stabilizer, such as epinastine HCl ophthalmic solution 0.05% (Elestat, Inspire Pharmaceuticals). I'd consider reducing the patient's lens wearing time or discontinuing lens wear, and adding a corticosteroid, depending on the severity of symptoms.

Dr. Nichols: In addition to using a topical antihistamine/mast cell stabilizer, I'd add a lubricant before and after the patient wears his contact lenses. This can help wash allergens from the ocular surface as well as reestablish a stable tear film.

Dr. Karpecki: When do you prescribe a corticosteroid?

Dr. Gaddie: I prescribe a corticosteroid in the case of a bulbous conjunctiva — when there's an edematous, glassy-eyed appearance — or when the tarsal conjunctiva is red and inflamed. Corticosteroid treatment, which I prescribe for no more than 2 or 3 weeks, enhances the effects of the antihistamine/mast cell stabilizer.

Giant papillary conjunctivitis is characterized by papillae on the upper tarsal plate.

Corticosteroids plus artificial tears

Dr. Devries: In addition to using a corticosteroid for severe cases of ocular allergy, I use preservative-free, artificial tears to wash allergens out of the eye and treat dryness.

Dr. Karpecki: That's a good plan of action. Palliative measures, including cool compresses, are very effective.

Dr. Nichols: Imagine that one of your patients with a history of dry eye is using cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan). She experiences a flare-up of allergy symptoms. There are several options — what would you do?

Dr. Karpecki: If the patient's eye has a chemotic or glassy appearance, and if she's complaining about itching, the antihistamine/mast cell stabilizer combination is sufficient. You can use one of the newer treatments, such as epinastine, that don't dry out the eyes. In moderate to severe cases, however, adding a corticosteroid may be warranted, especially if the patient has had allergies for a long time, successfully has used corticosteroids, has tried over-the-counter topical medications with no success or has symptoms that are significantly affecting their lifestyle or work.

Dr. Gaddie: I stop patients from wearing contact lenses when they're using corticosteroids. I want to eliminate the inflammation before I return them to lenses. Then, hopefully, I can maintain the patients on an antihistamine/mast cell stabilizer.²

Prescription meds are best

Dr. Karpecki: How do you decide which antihistamine/mast cell stabilizer is best for your patients? Ketotifen fumarate, marketed under the brand names Zaditor (Novartis Ophthalmics), and Alaway (Bausch & Lomb), are available over the counter. But I believe we're better off prescribing a drug instead of sending patients to the pharmacy to choose from the plethora of antiallergy medications. If we don't prescribe a medication for them, we minimize the importance of medical management.

Dr. Devries: I agree. I try to educate my patients about over-the-counter (OTC) brands. I don't want to leave it up to them to choose what's best. A patient can end up self-medicating with an OTC vasoconstrictor. So I see tremendous value in writing prescriptions for allergy medications.

"If a patient's eye has a chemotic or glassy appearance, and if she's complaining about itching, [an] antihistamine/mast cell stabilizer combination is sufficient." — Paul M. Karpecki, O.D.

Managing allergies and dry eye

Dr. Karpecki: Previously, we discussed the steps you'd take to diagnose year-round allergy and dry eye symptoms in a golf pro (See "Recognizing Ocular Allergies"). Now let's say the same patient has systemic exacerbations, including red eyes, sinus congestion and rhinitis, which affect his game. What would you recommend?

Dr. Devries: I would prescribe an antihistamine/mast cell stabilizer, such as epinastine, because it helps with congestion.

Dr. Gaddie: Many patients have allergic rhinitis that masquerades as ocular allergy symptoms. I like working with a patient's primary care physician or prescribing some type of antihistamine inhaler and/or a corticosteroid inhaler. Of course, it's important to monitor IOP in patients using topical corticosteroids or corticosteroid inhalers. You don't have to use an oral medication that will cause ocular dryness.

Pediatric care

Dr. Karpecki: Let's discuss allergies in children. Pediatric cases are important because 40% of all children suffer from allergies.³ Many visit our offices before they see a pediatrician. Sometimes, they're referred for treatment of ocular symptoms.

Let's say you have a 12-year-old female asthma patient with year-round allergies, who's being treated with nebulizers. She's referred to you when symptoms flare up in the spring and the fall. What are the typical causes of allergies in children and what can we do to eliminate them?

Controlling the environment

Dr. Devries: I'd look for ways to control the patient's environment. I'd discuss triggers such as dust mites, pet dander and old pillows, linens or carpets with parents. The house may need a thorough, professional cleaning to eliminate the allergens.

Dr. Nichols: Modern houses are designed to lock in air for energy conservation, creating a potential allergen-rich environment. So I'd recommend that the child's parents investigate the air quality in the home. Are the ceiling fan blades covered with dust? Do the furnace and air filters need to be replaced?

Dr. Karpecki: Indoor allergies definitely play a big part. I'd ask if the child spends most of his time indoors or playing outside. If she's mostly indoors, this could affect her immunity to outdoor allergens. Genetics are also a factor because more parents have allergies than in past generations.⁴

Dr. Karpecki: What is the best way to manage a patient like this if she's already seeing a pediatrician? Would you treat her only if her symptoms exacerbate twice a year? Would educating the patient and her parents help? What about palliative treatment? What would be your next step?

Dr. Gaddie: A 12-year-old child's immune system typically is well established when it comes to environmental allergies, suggesting that she could have allergies for the rest of her life. I'd prescribe a continual course of topical therapy with an antihistamine/mast cell stabilizer, which may prevent her from experiencing breakthrough symptoms.

Dr. Nichols: If you manage her symptoms effectively with the antihistamine/mast cell stabilizer, you may be able to discontinue the oral agent she's taking. Topical therapy and the reduction of environmental allergens might be sufficient to control symptoms.

Comanaging in two directions

Dr. Karpecki: Our success as clinicians also depends on how we comanage our patient's overall care with another physician. We see a large number of children who present with ocular symptoms and need to be referred to a pediatrician or allergist to manage systemic allergies, including asthma. As a result, we often comanage in various directions.

Dr. Nichols: That's often the case. But comanagement should be reciprocal. We have to be mindful of the high association between asthma and allergy in younger children, especially if they haven't outgrown their allergies by age 10. We need to monitor those who take corticosteroid agents by performing routine dilated eye exams and looking for signs of cataract and glaucoma development over the course of their lifetime.

Dr. Karpecki: These are great suggestions we all need to remember as we treat the pediatric population. In the next article, we'll discuss strategies to manage allergy patients who wear contact lenses, a unique challenge in optometric practice. OM