THERAPEUTIC FOCUS

How to Become a Hero

A new drop helps clinicians treat ocular and respiratory allergies.

Mel Friedman, O.D., Memphis, Tenn.

When managing patients who complain of problems commonly associated with contact lens wear, the primary eyecare physician must consider any allergy issues facing the patient. These issues are not limited to the eyes. Patients who have ocular allergies often face respiratory and other systemic allergy as well. Fortunately, as I will explain, we have found a therapy that can effectively treat symptoms of both ocular and respiratory allergies. With this drop, I have become a hero in the eyes of my contact lens patients.

Allergy on the rise

A management approach that accounts for allergy is necessary because the incidence of allergy has been steadily on the rise since the 1980s.¹ (Many allergy authorities attribute this fact to increased levels of industrialization and pollution.) Today, more than 20% of the U.S. population will exhibit some form of respiratory allergy with eye involvement.² In addition, more than 50% of contact lens wearers will experience ocular allergic episodes. One explanation for this large percentage is that allergens tend to stay in contact with the corneal surface longer for contact lens wearers because the allergens get trapped under the contact lens. To relieve the discomfort, allergy patients may temporarily discontinue wearing contact lenses, or quit wearing them altogether.

When a contact lens patient who has a history of allergies presents, it is critical to note the medications he/she is using. Allergy patients often take oral antihistamines, which may cause ocular dryness. One study reported that oral antihistamines will reduce tear flow by more than 30%.³

Relief beyond ocular itch

In our practice, we have found bepotastine besilate 1.5% (Bepreve, ISTA Pharmaceuticals) effectively treats the symptoms of seasonal allergic conjunctivitis, while minimizing the problem of dry eyes (muscarinic effect) and the discomfort associated with the use of oral antihistamines and other eye drops. (Bepotastine besilate was originally marketed in Japan as an oral antihistamine tablet.)

We have prescribed Bepreve to 150 contact lens patients who suffer from ocular allergies. In this group, the elimination of the ocular itch was not the only benefit Bepreve provided. It reduced and, in some cases, eliminated allergic rhinitis. Also, some patients reported relief with sinus congestion. As a result of the effects of Bepreve on nasal symptoms, many of these patients were able to discontinue their use of oral antihistamines. A significant benefit here is that by eliminating the oral antihistamines, we believe the tear flow returned to what was “normal,” thus enabling these patients to wear contact lenses longer and with a higher degree of comfort.

I must acknowledge that relief from allergic rhinitis is an off-label benefit, as Bepreve is only indicated for the treatment of ocular itching associated with allergic conjunctivitis. However, our use is supported by Bepreve clinical study results against a pre-specified secondary efficacy endpoint (nonocular composite symptom score).⁴

The off-label benefit has changed how we manage patients who wear contact lenses. For example, when a patient describes a stuffy and/or runny nose, we ask whether it is due to a cold or allergy. When the patient responds that it is allergy-related, we instill Bepreve in both eyes before the examination. This technique helps the practitioner differentiate between an allergic vs. viral problem. That is, after the installation of Bepreve, patients who have allergies typically not only experience relief of their itchy eyes, they say, “I can breathe.” In some cases, patients are so surprised at the clearing of their allergic rhinitis and ocular itch, they request a prescription.

Safety and efficacy

Bepreve's success is attributed to its mechanisms of action. A histamine H1 receptor antagonist, it has a low affinity for other receptors (specifically the muscarinic receptor associated with drowsiness, dryness of mouth and eyes). It is worth noting that the practitioner can feel comfortable using Bepreve with its record of safety and indication for children as young as age two. However, it must be noted that some patients (25% in clinical studies) have complained of having a mild after-taste upon using Bepreve. The positive side of this effect demonstrates that the lachrymal system is open.

In clinical trials, Bepreve has been demonstrated as safe and comfortable. In a six-week study, Bepreve was found associated with less ocular dryness than the placebo and was equally comfortable.

Potential to treat GPC

Giant papillary conjunctivitis is another serious problem in today's contact lens practice. We have investigated the potential use of Bepreve with a HEMA contact lens as the drug delivery system to treat this condition. This approach seems to have a profound effect on reducing the signs and symptoms of GPC. As a result of this off-label technique, the patient is able to wear contact lenses with few problems. Using a disposable contact lens and a medication that has a low concentration of B.A.K. (.005%) should reduce the concern of corneal toxicity and damage to the lens material. We believe this treatment approach warrants further study.

Making a difference

It is not often we find an anti-allergy agent that can change our approach to treatment and improve practice success. But when patients are referred to the practice because of our ability to treat ocular allergies in contact lens wearers, we conclude that this anti-allergy agent (Bepreve) has made the difference. OM

Dr. Friedman consults for Bausch + Lomb and ISTA Pharmaceuticals.

1. Platts-Mills TA, Erwin E, Heymann P, Woodfolk J. Is the hygiene hypothesis still a viable explanation for the increased prevalence of asthma? Allergy. 2005;60 Suppl 79: 25–31.
2. MedicineNet.com. Eye Allergy. www.medicinenet.com/%20eye_allergy/page2.htm. (Accessed 3/2012.)
3. Welch D, Ousler G, Nally L, et al. Ocular drying associated with oral antihistamines (loratadine) in the normal population — an evaluation of exaggerated dose effect. Adv Exp Med Biol. 2002;506(Pt B):1051-5.
4. Torkildsen GL, Williams JI, Gow JA, et al, for the Bepotastine Besilate Ophthalmic Solutions Clinical Study Group. Bepotastine besilate ophthalmic solution for the relief of nonocular symptoms provoked by conjunctival allergen challenge. Ann Allergy Asthma Immunol. 2010 Jul;105(1):57-64.