Experts offer top allergy tips

Ophthalmology Times and Optometry Times help you manage your patients through allergy season with tips from the experts.

We asked industry experts for their top suggestions to colleagues on how to best manage allergy.

Click here to see expert tips

Leonard Bielory, MD

Springfield, NJ

1. Incorporate skin testing to confirm specific allergen sensitivity (perennial vs. seasonal) because that commonly differentiates type of allergy. Seasonal allergy patients are more severe than perennial.

2. Understand the overlap between allergies and tear film dysfunction (â€Å“dry eye patientsâ€Â) and the use of antihistamines that have anticholinergic activities (essentially all antihistamines have muscarinic and anticholinergic binding activities).

3. Patients on hormone therapy for various reasons (polycystic ovarian dysfunction, birth control pills, cancer treatment regimens, etc.) have alterations in their tear films that increases their tear osmolarity and ocular symptoms consistent with tear film dysfunction.

Up next: Milton M. Hom, OD, FAAO

Milton M. Hom, OD, FAAO

Azusa, CA

Optometry Times Editorial Advisory Board member

1. Watch the weather. We have found that high temperatures combined with high humidity and high pollen counts are allergy triggers. Keep watch on the weather forecast to predict the big allergy days.

2. Asthma is a red flag for allergy and allergic conjunctivitis. We know that the eye (allergic conjunctivitis) and nose (allergic rhinitis) are connected, but do we think about the other direction to the lungs? It’s all about the entire airway, not just one part.  If you see asthma, think of rhinitis and ocular allergy.

3. Look at the plant life around you. Most seasonal allergies are due to pollen, and pollen comes from plants. If allergies are bothering your patients, have them look around their environment for flowering plants or pollen anthers. A tree or plant can be perfectly quiet in terms of allergy when not flowering. But when the flowers appear, pollen Armageddon happens. Beware the anthers.

Up next: Marguerite McDonald, MD, FACS

Marguerite McDonald, MD, FACS

Lynbrook, NY

1. I like to arm patients before allergy season with a topical agent to use as needed. My current favorite is Bepreve (bepotastine besilate 1.5%, Bausch + Lomb). It̢۪s highly effective, fast in onset of action, and kind to dry eyes.

2. I have patients tested in our office for airborne allergens using the Doctor̢۪s Allergy Formula kit (Bausch + Lomb). This helps tremendously with avoidance therapy.

3. If patients experience systemic symptoms, I refer to an allergist. This referral is good for the patients, and I have made a new friend with whom I can trade referrals.

Up next: Len Koh, OD, PhD

Len Koh, OD, PhD

Spokane, WA

1. Avoid allergens.

̢ۢ Pollen: Pay attention to pollen counts; they are highest in mid-morning and early evening. Glasses or sunglasses can reduce pollen exposure to the eyes. Close windows to minimize pollen getting in.

̢ۢ Mold: Keep humidity low (30 to 50 percent) to prevent mold growth with dehumidifier use as needed. Clean high-humidity areas, basements, bathrooms, and kitchens regularly.

• Dust: Use allergen-reducing covers for bedding. Wash bedding frequently in hot water temperatures >130° F to kill dust mites. Use damp mop or rag instead of dry dust mop or broom to trap allergens.

̢ۢ Pets: Keep them outdoors as much as possible, and not in the bedroom. Use hardwood or tile flooring in the home. Wash hands and clothing often.

2. Suggest patients incorporate eye washes, such as a cool water wash with or without a washcloth or a cold compress with ice cube in plastic bag.

3. Treatment.

̢ۢ Recommend artificial tears as needed if Step 2 does not offer relief.

̢ۢ Suggest over-the-counter Zaditor (ketotifen fumarate, Alcon) bid if wash and artificial tears do not offer relief.

̢ۢ Prescribe Pataday (olopatadine hydrochloride 0.2%, Novartis), Pazeo (olopatadine hydrochloride 0.7%, Novartis),, Lastacaft (alcaftadine, Allergan) qd.

̢ۢ Prescribe Lotemax (loteprednol etabonate 0.5%, Bausch + Lomb) or Pred Forte (prednisolone acetate, Allergan) for vernal or atopic allergic conjunctivitis

Up next: Michael Raizman, MD

Michael Raizman, MD

Boston

1.Encourage your patients not to rub their eyes. Eye rubbing brings allergens from the hands to the face and eyes. Rubbing also mechanically degranulates mast cells in the lids and conjunctiva and contributes to ocular inflammation and swelling.

2. Remind patients when they come in from outdoors on a day with high pollen counts to wash their faces and hands, brush or comb their hair, and change their clothes.

3. Artificial tears that are chilled in the refrigerator feel especially good when applied to an itchy, irritated eye. Cooling the ocular surface may reduce inflammation and discomfort as well.

Up next: Michael Cooper, OD

Michael Cooper, OD

Willimantic, CT

Optometry Times Editorial Advisory Board member

1.Never forget that the allergy season is year round. As part of our battery of questions, we always ask patients if their allergies are spring, fall, a combination, or perennial.

In the New England area, some homes date back to pre-Colonial America (mid to late 1600s), so I ask how much mold is present in their houses to gauge whether this may have an impact on allergy status.

2. Make sure your patients are armed with coupon/saving cards. Although we try to keep the cards present in the office, sometimes we run out at the height of the spring and fall seasons. Remember that most companies have dedicated websites for their products which allow patients to download the coupon directly to their tablet/phone/computer.

3. Don̢۪t be afraid to lean on your local pharmaceutical representatives for samples and formulary details. They can be your life preserver when insurance plan coverage goes sideways.

4. If a patient presents with acute symptoms, a great way to manage these cases is to utilize a topical steroid (i.e., Pred Forte, Lotemax Gel [loteprednol etabonate 5%, Bausch + Lomb], Durezol [difluprednate, Novartis]) to quell both the symptoms and signs. Although it is the brute force method, your patients will thank you for the added rapid relief.

These medications can be used as a monotherapy pulse or in combination with your choice of antihistamine/mast cell stabilizer.

Finally, I always send a letter to encourage a patient to heed our recommendation to see an allergist in order to better manage the systemic pathology.

Up next: Bill Townsend, OD, FAAO

Bill Townsend, OD, FAAO

Canyon, TX

Optometry Times Editorial Advisory Board member

1. An ideal topical therapeutic agent for treatment of allergic eye disease should:

̢ۢ Possess anti-inflammatory properties

• Exert H1-blocking antihistaminic effects and stabilize mast cell membranes 

Look for these properties in topical agents.

2. If possible, prescribe agents that need to be instilled only one time per day.

3. In patients with severe allergic conjunctivitis, especially those with a significant atopic profile, evert lids for early signs of atopic and vernal keratoconjunctivitis. These conditions, although rare, do occur in at-risk individuals and have the potential to damage the cornea and in some cases impair vision.

Up next: Robert J. Weinstock, MD

Robert J. Weinstock, MD

Tampa, FL

1. Add allergy signs and symptoms questions to your patient intake form to help identify patients.

2. Ask technicians review the questions in the exam room to ensure the information is entered into the electronic health record (EHR).

3. Incorporate allergy testing and allergy treatment into your routine and consider making it part of the dry eye/ocular disease clinic services.

Up next: Mile Brujic, OD, FAAO

Mile Brujic, OD, FAAO

Bowling Green, OH

Optometry Times Editorial Advisory Board member

1. Make sure you identify patients with allergies—even if patients come in without active symptoms, question about allergies any time throughout the year.

2. Don't be afraid of steroids—when warranted, use them for these patients. 

3. Daily disposable contact lenses are often ideal for allergy suffers.

Up next: Art Epstein, OD, FAAO

Art Epstein, OD, FAAO

Phoenix

1. Don̢۪t underestimate the number of patients who have ocular allergy signs and symptoms but don̢۪t realize that you can treat them more effectively with modern topical medications. Always ask.

2. Tailor therapy for the patient. Some patients prefer the convenience of a once-a-day medication, while others prefer the dosing control of a twice-a-day medication.

3. Topical allergy medications are most frequently used as needed for rescue in the middle of an acute allergy attack. Most patients won̢۪t tell you that unless you ask them. Prescribe accordingly.

4. Allergy and dry eye are often comorbid because decreased dilutional reserve in both aqueous deficient and evaporative dry eye increase the relative concentration of allergens on the ocular surface. Allergy also increases surface inflammation. This can worsen the misery of dry eye. Treating both at the same time can be prudent.

Get more content from our Ocular Allergy Resource Center here