Many practitioners’ first-line of defense against ocular allergies has become an antihistamine/mast-cell stabilizer, and doctors are even trying some of the over-the-counter versions as they become available, according to several optometrists who spoke to Primary Care Optometry News.
They are also prescribing cold compresses, low-grade steroids, nasal inhalers, oral antihistamines and good old-fashioned common sense for allergy sufferers.
The patients and their symptoms are varied, as are the treatments to prescribe. More than 50 million people are experiencing allergies in the United States, according to the American Academy of Allergy, Asthma and Immunology. Allergic conjunctivitis is characterized by itchy, puffy, red eyes and sometimes blurred vision. Chemosis, edematous eyelids and papillae in the conjunctiva are all clinical signs of the disease
“Indeed there’s enough variability that there needs to be more than one approach,” John P. Herman, OD, FAAO, who practices in Pittsfield, Mass., told PCON in an interview. “There can’t be a cookbook approach.”
The first line of defense in treating ocular allergies has become a combination mast-cell stabilizer/antihistamine drop, according to private practitioner Glenn. S. Corbin, OD.
“I think the gold standard is the combination dual mechanism drug,” Dr. Corbin said in an interview. “I prescribe Pataday (olopatadine HCl 0.2%, Alcon) because I feel it’s the best combination drug on the market and because its once-a-day dosing is more convenient for patients and makes them more compliant.”
Dr. Herman said he uses a mast-cell stabilizer/antihistamine combination as a first-line therapy as well.
“If it’s going to be a long-term problem, you want to use something once or twice a day,” he said. “I prescribe Zaditor (ketotifen fumarate ophthalmic solution, Novartis) or Alaway (ketotifen fumarate ophthalmic solution, Bausch & Lomb). If it’s severe enough, I have them use Pataday twice a day. Short-term is a different issue. Then I use a low-grade steroid right away.”
Milton M. Hom, OD, FAAO, a PCON Editorial Board member who practices in Azusa, Calif., said he prefers Elestat (epinastine HCl ophthalmic solution 0.05%, Inspire) over any others. “It has a longer duration of action,” he told PCON. “If that doesn’t do the trick, then we move onto Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch & Lomb).”
Counsel the patient
Classic reaction: This shows a classic example of the ocular allergic reaction with a characteristic “glassy” appearance accompanied by redness.
Image: ORA Clinical
Dr. Hom said he first likes to counsel his patients. “Sometimes one of the treatments would be for them to avoid situations that give them an allergy in the first place,” he said. “If there’s something in their environment that’s irritating them or causing the allergy, if it’s possible to remove themselves from it or remove it from their environment, that’s generally my first choice. I like to give them tips about how to avoid pollens.”
Dr. Hom tells his patients to close the doors and windows to their dwellings, especially during a heavy pollen count. Seasonal allergic conjunctivitis is common and is a reaction to pollens and other environmental allergens.
“It’s more difficult when they’re indoor irritants such as cat allergies, which is an allergy to cat saliva. The protein fel-1 that’s in the saliva remains airborne for 9 to 12 hours,” he said.
In those cases, it is difficult to tell a patient to give away the family pet.
“I’d move to the mast-cell stabilizers then,” Dr. Hom said.
Dr. Hom added that he prescribes inhalers for allergy sufferers. “I love using inhalers,” he said. “Those work really well. They’re really good for rhinitis or runny nose.”
Often, his best efforts to counsel the patient about avoiding allergens are not successful, Dr. Hom admits. “What happens is that the patient has kids, they have to go to work, they have to go to school, they have to drive around, they have to go grocery shopping and they can’t avoid all the allergens out there because they have to actually go out to live. That’s where pharmaceutical treatments come in. Generally the mast-cell stabilizers are good as a first-line treatment.”
Ask patients about symptoms
Dr. Corbin also talks to his patients about ocular allergies, even out of season. He queries all patients to see if they experience any allergy symptoms during any part of the year. If they do, he sends them home with a prescription for Pataday.
“It’s called proactive prescribing,” Dr. Corbin said. “Then, when they do have symptoms they will have the prescription in hand.”
Dr. Corbin said nine out of 10 allergy patients will self-diagnose and self-prescribe. Many come in already having tried over-the-counter antihistamines and vasoconstrictors. It’s important to find this out, he said. “That defines opportunity for us for prescribing a better and safer drug,” Dr. Corbin said.
Rinse, cool the eye
Dr. Herman suggested rinsing the allergic eyes with cold saline, or using cold packs or washcloths as cool compresses.
“Cold shrinks blood vessels and can help with itching,” he said. “If it’s a real problem, I say to put ice in the washcloth. Rinse out the eye with cold saline. Go buy a few bottles of saline and put them in the refrigerator.”
Dr. Herman said if he had to suggest an over-the-counter medication for his patients, he would choose Zaditor. “As far as I can see, it is no different than when it was prescription,” he said.
A variety of artificial tears are available over-the-counter as well, and allergy sufferers sometimes try them before seeking medical help. “The problem with tears is that they just rinse eyes out,” Dr. Herman said. “If the patient expects that they’re going to cure something, they’re not.”
He also said the artificial tears marketed to allergy sufferers may cause rebound hyperemia.
If the symptoms do not lessen after 10 days of using the mast-cell stabilizer/antihistamine, Dr. Herman moves on to a topical steroid.
“After that you might even have to go up to Pred Forte (prednisolone acetate 1%, Allergan),” he said. “That will get them through a crisis. That presumes, by the way, that you’ve looked at the eye and there’s nothing going on with the cornea. If there’s not, proceed with the Pred Forte to start with.
“There’s a difference between palliative and medical treatment,” Dr. Herman continued. “What you’d love to be able to do is quiet all the follicles in the eye. Once that is accomplished you can backtrack and try some of the other things. The fear of steroids is an old one.”
Dr. Herman said he asks patients to come in for a follow-up visit in 4 to 10 days to check their IOP.
Dr. Corbin, however, said he limits his use of steroids on his allergy patients. “I’m not a believer in long-term use of steroids for allergies, especially when we have alternatives,” he said. “I typically use Lotemax four times a day for 2 weeks, with a maximum of 3 weeks, in addition to the Pataday.”
For more information:
- John P. Herman, OD, FAAO, can be reached at Pittsfield Vision Associates, 217 South St., Pittsfield, MA 01201; (413) 499-3797; fax: (413) 499-3834; e-mail: firstname.lastname@example.org. Dr. Herman has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Glenn S. Corbin, OD, is a member of the adjunct faculty at the Pennsylvania College of Optometry. He can be reached at Wyomissing Optometric Center Inc., 50 Berkshire Ct., Wyomissing, PA 19610; (610) 374-3134; fax: (610) 374-0484; e-mail: email@example.com. Dr. Corbin is a paid consultant for Alcon.
- Milton M. Hom, OD, FAAO, can be reached at 1131 East Alosta Ave., Azusa, CA 91702-2740; (626) 334-1585. Dr. Hom is a paid consultant for Inspire Pharmaceuticals.