Ocular allergies: an overview
All ocular allergic conditions are mediated in some part by the body’s inflammatory processes as an abnormal response to normally occurring antigens via both type I and type IV hypersensitivity reactions.3
Ocular allergy can range from allergic conjunctivitis, namely seasonal or perennial, to allergic dermatitis, to giant papillary conjunctivitis, to vernal keratoconjunctivitis or atopic keratoconjunctivitis (AKC), with the latter of the conditions involving both the conjunctiva, as well as the cornea. These conditions range from mild to severe, and management techniques should follow suit.2
For more mild forms of ocular allergy, environmental management may be adequate. This includes avoidance of the allergen, if possible, combined with palliative care, such as cool compresses and generous doses of refrigerated artificial tears, which can relieve symptoms and ease the allergic response.2 In-office saline eye wash treatments may also be effective to reduce symptoms of ocular allergies.4 In cases in which environmental control is either not possible or not effective, pharmacologic intervention, discussed in the main text, may be required.
With allergy season around the corner, patients and practitioners alike are plagued with the effects of ocular allergies. (See “Ocular Allergies: An Overview,” right.) This article serves as a reminder of the topical treatments at our disposal in our fight against allergic eye conditions.
Topical treatments
We have four categories of topical treatments available for ocular allergy:
• Mast cell stabilizers. These medications attempt to stabilize mast cells to prevent the future release of histamine. Active histamine is responsible for the symptoms of ocular allergy, such as ocular itch. Mast cell stabilizers have a delayed onset.1
• Antihistamines. Topical antihistamines are beneficial for the temporary reduction of ocular itch. Antihistamines alone are unable to stabilize mast cells and prevent future degranulation, however they are capable of arresting active histamine to reduce active symptoms of ocular itch.1 For this reason, these medications can be considered in cases of acute ocular allergy, however, should not be relied on for long-term therapy.
• Combination drugs. These medications act to both reduce active signs and symptoms, such as ocular itch, conjunctival injection, papillae, and chemosis, and prevent future allergic reactions.2 Active signs and symptoms are arrested, as the medications bind to active histamine and yield it inactive. These medications prevent future reactions by stabilizing the mast cells, which are responsible for the release of histamine. Due to their fast-acting effects and ability to prevent future reactions, combination drugs should be considered in any case of ocular allergies where both signs and symptoms are present, but no corneal involvement or severe disease process is active for which a steroid would be indicated.
• Corticosteroids. These medications reduce the signs of ocular allergy related to the inflammatory response, such as papillary reactions and chemosis, as they inhibit the inflammatory processes responsible for such signs. (See “Patient Access to Prescription Drugs,” below.) OM
References
1. Bielory L. Update on ocular allergy treatment. Expert Opin Pharmacother. 2002;3(5):541-53. doi: 10.1517/14656566.3.5.541.
2. Bielory L. Ocular allergy treatment. Immunol Allergy Clin North Am. 2008;28(1):189-224. doi: 10.1016/j.iac.2007.12.001.
3. Chigbu DG. The pathophysiology of ocular allergy. A Review. Cont Lens Anterior Eye. 2009;32(1):3-15; quiz 43-4. doi: 10.1016/j.clae.2008.07.003.
4. Yamamoto M, Mimura T, Mizota A, et. al. Usefulness of eyewash solution on allergic conjunctivitis. Invest Ophthalmol Vis Sci. 2019;60(9):6717.
Prescription topical ophthalmic drug companies
Alcon
Allergan (an AbbVie company)
Bausch + Lomb
Harrow
Johnson & Johnson (ACUVUE Theravision)
Patient access to prescription drugs
By Chris Wroten, OD
Regardless of a patient’s health insurance formulary, as with any condition it is a doctorof optometry’s duty to prescribe the medication(s) that will best treat the patient’s allergies. That said, should patient access to the most appropriate medications be an issue, here are some action steps to pave the way for the one or more prescription medications you deem most appropriate.
- Use samples/coupons. For OTC medications, some pharmaceutical representatives will provide samples and/or patient coupons for their products, but often these items must be requested from your pharmaceutical representative for your patients. Additionally, patients can be directed to the websites of topical allergy medication manufacturers, where they can often print coupons for use at the pharmacy (sometimes up to 25% off).
- Employ prescription drug discount programs. Programs, such as GoodRx, SingleCare, and WellRx, among others, are free to patients, offer real-time local pharmacy-pricing comparisons, and usually include OTC allergy products. Additionally, I have found that many offer deeper discounts when patients bring a coupon from the program’s app/website along with a doctor’s prescription for the medication (even though it’s an OTC drug).
- Consider listed alternatives. One advantage of most e-prescribing platforms is the ability to see patient medication costs, so do so if available, and if little-to-no coverage exists for your first choice, consider listed alternatives, keeping in mind any differences in ingredients that may need to be accounted for.
- Utilize patient assistance programs. When the cumulative cost of any medications to treat these recurring and chronic ocular symptoms are a significant barrier to treatment for patients, provide them with a manufacturer’s patient assistance program phone number/website.
Ultimately, our patients deserve our assistance in getting the most appropriate treatment. OM
