At this time of year, patients are quick to point to allergies as the culprit for their itchy, watery, burning eyes. But symptoms of dry eye disease overlap significantly with allergies, so it takes some detective work to tease out what’s really bothering the patients and, therefore, recommend the appropriate treatment plan.

A combination of detailed questioning and leaning on your clinical instincts is the best way to determine whether it’s dry eye or allergies — or both — that are making your patients suffer.

PINPOINT THE SOURCE OF ITCHING

“Differentiate between whether it is the eye that itches or the lids,” says Scott Hauswirth, OD, FAAO, of the UCHealth Sue Anschutz-Rodgers Eye Center, in Aurora, Colo. “Patients often lump these together, so it’s up to you to find out whether they’re talking about the globe, which would tend to indicate probable allergies, or are they talking about the lid,” he explains. Also, “make sure they’re not describing a foreign body sensation. Try to get a feel for whether the symptoms are something they’re feeling intermittently as opposed to chronically.”

ASK ABOUT ALLERGIES — AND ALLERGY MEDICATIONS

“I ask my patients regularly whether they have seasonal allergies, and if so, when do their allergies normally flare up and what their usual symptoms are,” says Cecelia Koetting, OD, FAAO, Optometric Management’s “Dry Eye” columnist, who practices in Denver. “Just because they have seasonal allergies, doesn’t mean that they have eye allergies,” she points out. “Or maybe they don’t have the typical runny nose, but they do have eye allergies.”

“Ask allergic patients what they take for their allergies, because OTC pills can cause dryness and exacerbate dry eye disease,” says Dr. Koetting. “Ask the patient whether they are taking any medication with a ‘D,’ like Claritin-D or Zyrtec-D. Those contain a decongestant, which can add dryness.”

LOOK FOR THIS UNMISTAKABLE SIGN

“When examining the conjunctiva, make sure that you invert the lid a little bit and take a look for papillae, which are usually present at least in mild amounts with allergic types of reactions,” says Dr. Hauswirth.

“The biggest differentiator is going to be papillae — those we know are going to be very specific to allergies,” adds Dr. Koetting. “That tells us that we need to treat the front surface, and we need to be moving into a topical antihistamine, a mast cell stabilizer, or a pill, along with a topical drug in some cases.”

CONSIDER TREATING IN TANDEM

“Allergies and dry eye are not mutually exclusive — a lot of the time, patients have both, and allergies are going to contribute to dry eye,” says Dr. Koetting. Dry eye will exacerbate allergies, notes Dr. Hauswirth. “It reduces the eyes’ ability to dilute the antigens, so there’s a higher concentration of antigens triggering receptors on the surface,” he explains.

“We treat dryness and allergies at the same time,” notes Dr, Koetting. “We calm the allergy first, then look at the glands to determine whether further treatment is needed or there is another underlying cause for dryness.” OM