With allergy season fast approaching, you’ll soon see a number of patients presenting with various types of ocular reactions ranging from seasonal allergic conjunctivitis (SAC) to perennial allergic conjunctivitis (PAC).
No matter the presentation, contact lens wear will be compromised for the duration of the reaction. Each individual patient will require a different management plan, so it’s important to step back and assess the various treatment options available for your allergic conjunctivitis patients.
Here, several experts share their insights on how to keep patients happy and comfortable during springtime’s annual assault on the ocular surface.
Treating Perennial vs. Seasonal Allergies
Before deciding on an appropriate treatment regimen, it’s first important to determine which type of allergic conjunctivitis you’re dealing with. Deciding whether your patient’s allergies are perennial or seasonal will impact how you approach managing the condition.
“The severity of the signs and symptoms of seasonal sufferers drives my prescribing model,” says Alissa Coyne, OD, who practices at The Eye Institute in Philadelphia. “This can include preservative-free artificial tears and cool compresses, an allergy prescription (such as an antihistamine or a combination agent), and/or a pulse steroid therapy.” In some severe cases, Dr. Coyne says, “all of the above” must be prescribed to hasten allergy relief.
Proper preparation is key when dealing with patients presenting with SAC. Rich Mangan, OD, who practices in Lexington, Ky., feels it is beneficial to preemptively treat the condition—before it becomes a more significant problem.
“With SAC, considerable time is spent explaining the allergic cascade and the importance of proactively treating, so as to avoid a full-blown allergic response,” says Dr. Mangan. “This often means starting a mast cell stabilizer or combination agent two to four weeks before allergy season is due to start.” Alert patients who have had bouts of SAC in years’ past of the need for a visit to begin prophylactic therapy.
While PAC symptoms are typically milder in nature than SAC, it’s just as important to get the jump on what is triggering the allergic response in your patients.
“For patients with suspected PAC, it is important to find out what allergen(s) the patient is sensitive to,” adds Dr. Mangan. “Allergy testing can help reduce exposure to the offending antigen(s). These patients are also more accepting of using mast cell stabilizers on a chronic basis.”
Prescription vs. OTC Medications
Once you’ve determined whether you’re dealing with SAC or PAC, the next step is deciding on an appropriate treatment regimen.
There are numerous allergy medications—both prescription and over-the-counter—to consider: mast cell stabilizers, antihistamines, antihistamine/mast cell stabilizer combination agents, steroids and non-steroidal anti-inflammatory drugs (NSAIDs). Which of these you prescribe will largely depend on the signs and symptoms of the presentation.
“If the condition is very mild, I like to start with preservative-free artificial tears to rinse away/dilute potential allergens,” says Julie A. Tyler, OD, a Module Chief of Primary Care at Nova Southeastern University’s The Eye Care Institute in Davie, Fla.
“If I do prescribe or recommend an over-the-counter medication, I generally opt for a medication that has more than a vasoconstrictor-antihistamine agent,” she says, preferring to choose one that also includes a mast cell stabilizer. “My first choice—and what I prescribe most often—are medications that have characteristics of both antihistamine and mast cell stabilization, such as Pataday (olopatadine 0.2%, Alcon) and Lastacaft (alcaftadine 0.25%, Allergan).”
While antihistamines will work in most cases, more severe presentations will require a different management plan.
“For more severe ocular symptoms I will start with a steroid drop,” says Denise Goodwin, OD, Professor of Optometry at Pacific University. “Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch + Lomb) works well, but occasionally a more potent steroid, such as Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb), is necessary to get the condition under control.”
Patients presenting with allergies who have underlying disease may require more specialized treatment to stabilize and reduce symptoms.
“In cases of severe allergic conjunctivitis associated with chronic systemic and concurrent atopic disease, immunomodulators such as cyclosporin-A may also be added to stabilize the patient’s overall condition,” says Dr. Tyler. “Oral antihistamines can be extremely useful in some cases, but keep in mind that they do dry the eyes. This can exacerbate the ocular allergy symptoms.”
Developing a Treatment Regimen
“I recommend topical medication when I am confident that we are dealing with either an acute, seasonal or perennial form of allergic conjunctivitis,” says Dr. Mangan. “If the signs and symptoms do not support a true allergy, but instead support dry eye disease, then refrigerated preservative-free artificial tears may be a better place to start.”
Reinforcing Dr. Mangan’s approach, Dr. Coyne agrees that it is important to thoroughly examine each patient to ensure you’re truly dealing with an allergic condition before recommending a topical medication.
“My therapeutic regimen differs based on the symptomology and severity of the response,” says Dr. Coyne. “It is important to note the symptoms of allergic conjunctivitis can closely relate to those of different types of dry eye or ocular surface disease. Therefore, careful slit-lamp examination assessing the lashes, meibomian glands (including expression) and tear film integrity is also pertinent in appropriate diagnosis and treatment.”
If a patient presents with no complaints but shows papillary findings upon examination, “I am most likely to recommend palliative therapy, including preservative-free artificial tears and cool compresses,” she explains. “I also provide the patient with the appropriate education, discussing the possibility of seasonal allergies and the different options available if they become symptomatic.” She also stresses the importance of follow-up exams during allergic episodes.
According to Dr. Tyler, not all patients initially presenting with allergic conjunctivitis will be candidates for topical medications.
“In presentations where the patient has already self-medicated, at times I will delay adding extra topical agents to the mix—as long as the patient’s vision and cornea do not look to be significantly compromised,” says Dr. Tyler. “This will allow for a wash out of the medications and potentially eliminate additional allergens—and maybe even avoid the need for medications at all.”
It is also important to ensure that any patient potentially receiving a topical medication is in good health overall. “Although low-dose steroids for allergies are fairly safe, I may avoid using them in those with a decreased immune system or a current ocular infection,” cautions Dr. Goodwin.
Contact Lens Wearers and Allergy
Allergic conjunctivitis is uncomfortable enough on its own, and the addition of contact lenses tends to further exacerbate the problem. Most of your contact lens wearers will hate the idea of switching back to their glasses for allergy season, so consider some alternatives to making the switch from contacts to glasses.
“In an ideal world, it would be great to have every one of our symptomatic contact lens wearers with a history of seasonal or perennial allergies switch to single-use daily disposable contact lenses or accept reverting back to glasses,” says Dr. Mangan. “In most cases, this is not practical, nor is it necessary.” Studies show that instilling antihistamine/mast cell stabilizers prior to lens insertion can improve ocular comfort and increase contact lens wearing time—“without inducing ocular surface drying,” he says. “The same cannot be said for oral antihistamine use.”
Discuss with your patients who want to remain in their contact lenses how simple it is to instill these drops during allergy season. Adding these extra steps to their care routine may seem like a hassle, but it will ensure they may still wear their lenses—even at the peak of allergy season.
“I tell the patients to instill the drops in the morning, wait about five minutes, and then put the contact lenses in,” explains Dr. Goodwin. “Then, I instruct them to put another drop in the eyes when they take the lenses out at night.”
Of course, this will not work with all contact lens wearers. Patients presenting with more severe conditions will likely need to suspend lens wear and switch to glasses. If your patients are adamant about remaining in their contact lenses, consider persuading them to make the switch to daily disposables.
“For the worst sufferers, I encourage the discontinuation of contact lenses or the move to daily wear—even if it is just for the peak times of allergy season,” says Dr. Coyne, citing a study by Wolffsohn and Emberlin showing that daily disposable lenses play a vital role as a non-pharmacological treatment modality.1 “The release of unbound polyvinyl alcohol—a polymer that is part of the make-up of certain contact lenses and used for its lubricating properties—can stabilize the tear film, lubricate the ocular surface and provide relief from allergic expression by diluting and flushing out allergens and other mediators that contact the ocular surface.”
Before deciding on treatment plans involving either prescription or OTC medications, consider educating your patients on some simple changes they can make to their daily routine to limit exposure to allergens and the duration of allergic episodes when they do occur. Determine what the patient’s allergic triggers are, and make recommendations based upon your findings.
“First and foremost, I try to question the patient to help identify their individual triggers,” says Dr. Tyler. “Secondly, I encourage the use of artificial tears, cool compresses and palliative measures to decrease inflammation prior to initiating prescription medications.”
An Allergen-free Home Makeover
Avoiding allergens altogether will help to prevent allergic conditions in patients. Here's a list of a few things patients can do in their homes to reduce the impact of allergens.
Remove pets from the home--at least from the bedroom--even if only temporarily.
Replace down pillows with hypoallergenic ones.
Replace any makeup or detergent products with hypoallergenic options.
Replace carpeting with hard-wood floors.
Vacuum and dust regularly.
Simple behavioral changes can dramatically decrease the impact of symptoms in patients as well. “My biggest recommendation is to avoid rubbing the eyes—this exacerbates the signs and symptoms,” says Dr. Goodwin. Studies have shown that just rubbing one’s eyes can exacerbate allergy symptoms. She also encourages patients to start using antihistamine/mast cell stabilizer drops two weeks prior to the time the symptoms usually start.
Of course, it is possible to reduce—and in some cases avoid altogether—ocular allergic symptoms without need for medications.
“Avoiding the offending agent is the first line of treatment in allergy management,” says Dr. Coyne. “Lifestyle modifications can include staying indoors—especially when the pollen count is high and when there is freshly cut grass. Also, a dehumidifier can be placed in damp areas to decrease the likelihood of mold and mold spores.” Bathrooms and kitchens should remain clean and dry to diminish mold growth, she adds.
Educating your patients is one of the best methods of avoiding allergic conditions. Once you understand a patient’s individual triggers, stress the importance of avoiding these catalysts in order to limit the severity of the allergic reaction. To determine what each patient’s triggers are, consider having them tested for allergies—you’ll both be thankful you did when you’re devising a treatment plan.
“For PAC patients especially, allergy testing is a critical first step in determining precisely what is causing your patient's allergic reaction,” says Dr. Mangan. “Narrowing the list of potentially offending allergens through skin-prick or blood testing allows for more targeted avoidance techniques and treatments, including immunization therapy.”
He also suggests that SAC patients should pay attention to local weather and pollen counts on a daily basis and stay in air conditioned environments during times of high pollen counts.
While allergy season can be difficult for many patients, proper preparation and patient education can simplify your treatment plan—and their lives. Remember that allergy treatment regimens are not a one-size-fits-all solution; every patient will have their own individual needs, and oftentimes, the trigger will determine the solution.
1. Wolffsohn JS, Emberlin JC. Role of contact lenses in relieving ocular allergy. Cont Lens Anterior Eye. 2011; 34(4):169-72