Milton Hom, O.D., F.A.A.O.: Will dry eye and allergy medications someday be available without a prescription by an eye doctor? I was at the American College of Allergy Asthma and Immunology 2012 meeting, and the FDA’s new paradigm was discussed. In the past year, the FDA has been proposing a new drug class, some call “behind-the-counter” (BTC) drugs. A pharmacist can sell BTC drugs without a prescription. Of course, the main advantage is cutting costs. Among the guidelines, drugs must be classified as “safe use” for common chronic conditions, such as cholesterol or diabetes medications. Elements of BTC drugs are already being implemented by managed care plans in some states.

From our perspective, topical allergy and dry eye medications may fall under this classification.

Ben Gaddie, O.D., F.A.A.O.: We are already starting to see this with the product FreshKote (Focus Laboratories). It was recently reclassified as BTC, which really caused confusion among patients and pharmacists. Some patients had to work hard to get FreshKote, as pharmacists were directing patients to generic over-the-counter lubricants unless they were pressed for FreshKote. I suspect one strategy for companies seeking BTC classification with the FDA will be to outsource the BTC trade to mail-order pharmacies to avoid the cost of doing business in retail pharmacies.

M.H.: I’ve been prescribing a lot for allergies lately, and about 70% of ocular allergy patients have rhinitis. Before, I would recommend the Neti Pot for a nasal rinse. The lavage clears out the pollen and rinses the nose.

Now, NeilMed has a new variation on the Neti Pot called the Sinus Rinse, available as OTC. Instead of awkwardly pouring the saline into one nostril, you can squeeze the saline in, allowing the pressure to be easily selfcontrolled. It’s not as messy, and it’s much easier to use. Patients love it.

B.G.: Nasal rinses are a hit-or-miss fad with patients: Either people love them or hate them. I tend to represent the latter; however, I do have many patients who swear by it. I like prescribing a nasal-inhaled steroid/antihistamine in addition to the nasal rinses. In addition, don’t forget that many of the topical antihistamine/mast cell stabilizers also have some effect downstream (no pun intended) as the drop drains via the nasolacrimal system. My favorite, if the patient can tolerate the taste, is Bepreve (Bausch + Lomb).

M.H.: I also like nasal sprays. Ideally, I found the best way to use them is to first rinse with Neti Pot or Sinus Rinse, then spray. This clears the mucus and makes the spray more effective.

B.G.: With the iCare tonometer, we can effectively screen IOP during all of our comprehensive eye examinations. No anesthesia is needed, and the patient will not feel the applanation. Better yet, my experiences show excellent correlation to Goldmann tonometry. While I’m not yet ready to declare that the device is ready for full-time glaucoma management, there are many patients who have prominent brows or deep-set globes on whom I simply can’t get reliable Goldmann readings. Add to that patients who have deepening of the eyelid sulcus as a side effect from prostaglandin analogues used for the treatment of glaucoma.

M.H.: The hand-held feature and no messy Fluress makes a huge difference vs. a slit lamp-based Goldmann. We’ve come a long way since Shiotz. OM