CLINICAL

  ANTERIOR

BE ALLERGY AWARE

OR MISS THE OPPORTUNITY TO HELP PATIENTS AND YOUR PRACTICE

JOSH JOHNSTON, O.D., F.A.A.O.

A 21-YEAR-OLD spectacle-wearing female presented for her annual exam. Results revealed a mild nearsighted prescription with normal medical tests. After I completed the exam, I took one last look at her medical record and noticed a history of systemic allergies and oral antihistamine use. As a result, I asked, “Do your eyes ever itch, water or bother you during allergy season?” The patient’s eyes widened with recognition. “Yes! They do bother me! They usually itch in the spring and early fall, and I get drops at the pharmacy to treat them,” she replied.

Her reply gave me the “in” to provide education about the adverse effects of OTC drops and how I have the ability to prescribe her safer and more effective medications to alleviate that bothersome itch. Do you do the same when an asymptomatic allergy sufferer presents for an eye exam? If you answered, “no,” you are missing out on an enormous opportunity to better these patients’ quality of life, which creates loyalty to your practice, appointments for other medical eye issues, such as dry eye disease (DED), and referrals.

Here’s a primer on ocular allergy to inspire you to start questioning asymptomatic patients and provide the best treatments. (See chart for common codes used when treating allergies.)

OVERVIEW

The most common types of allergic conjunctivitis we, as optometrists, see and treat are seasonal allergic conjunctivitis (SAC) and perennial allergic conjunctivitis (PAC). SAC is more acute and worse, and PAC is less severe and chronic. Both are Type 1 or combined IgE-dependent hypersensitivity inflammatory reactions.

Specifically, allergen exposure triggers the inflammatory cascade with mast cell degranulation and the release of inflammatory mediators, such as histamine, which causes symptoms. These symptoms (discussed below) are unpleasant for our patients, and they have an even greater effect on those who wear contact lenses or have concomitant DED. For contact lens wearers, allergens can be deposited and build up on their lenses, decreasing wear time and comfort. With regard to DED patients, because dry eye and allergic conjunctivitis are both caused by inflammation, these two separate inflammatory conditions can make each other worse, increasing symptoms.

SYMPTOMS

• Burning

• Excessive tearing

• Itching

• Mucous discharge

CLINICAL SIGNS

• Chemosis

• Conjunctival hyperemia

• Conjunctival injection

• Eyelid edema

• Papillae

MANAGEMENT OPTIONS

Seven non-OTC drop choices are available to alleviate the symptoms and signs of SAC and PAC:

• Eye wash/artificial tears. Prescribe these to clear allergens from the tear film. This is a particularly good treatment for DED patients, as they have less tear production with less allergens being “washed out,” which can worsen DED.

• Cool compresses. This works to decrease irritation and the discomfort from itching.

• Prescription anti-histamines/mast cell stabilizers. These block H1 and H2 receptors, decreasing the amount of allergens that bind to mast cells.

• Nasal allergy sprays. Combination anti-histamine and steroid nasal sprays are available OTC and have secondary efficacy against allergic conjunctivitis.

• Topical steroids. These are ideal for patients who have intense symptoms, such as severe itching, chemosis and decreased contact lens wear.

• Daily disposable contact lenses. These prevent allergen build up on the lens in allergic patients.

• Peroxide-based contact lens solution. This is ideal for patients who have a history of systemic allergies, atopy or SAC and PAC and do not want to wear daily disposable lenses. The solution reduces the likelihood of severe allergy symptoms because it contains less preservatives than other solutions.

THAT PATIENT

I prescribed the aforementioned patient with a new combination allergy drop and educated her to start using this q.d. OU, two weeks before her normal allergy symptoms start. I discussed how doing so will allow time for the mast cell stabilizer to take effect and prevent the allergic cascade from occurring. She was excited about a new and better treatment option, rather than suffering like in years past.

The next time you have an asymptomatic patient with a known history of allergies, ask him or her about SAC and PAC. Even if the patient is not currently experiencing symptoms, prescribe the latest treatment options. OM

DR. JOHNSTON practices at Georgia Eye Partners. He focuses on ocular surface disease and has extensive experience in co-managing cataract and refractive surgery patients. Email him at drj@gaeyepartners.com, or visit tinyurl.com/OMcomment to comment.