How to identify and treat allergic eye disease

As optometry's scope of practice has increased, optometrists have embraced allergic eye disease. Ocular allergies have multiple effects to patients in our practice. But, if allergies are unidentified because symptoms may not be present during office visits, patients may treat themselves. This leads to patients taking advice from friends and family members on what they think they should be using to treat their symptoms or looking to over-the-counter (OTC) products.  

Some topical OTC agents contain vasoconstrictors which have the potential for abuse and rebound hyperemia. Plus, overusing these products can cause keratitis. Contact lens-wearing allergy sufferers present an additional logistical challenge to appropriate treatment. Often these individuals are using products that are not approved to be used with contact lens wear. This can even further exacerbate their symptoms.

With all of the potential sequalae with those who treat themselves with topical OTC products, it is critical to identify these individuals when they are in the office and guide them to appropriate treatment options. If they come into their appointments symptomatic, it is relatively easy to identify them as allergy sufferers. But, if they come in to see you in the winter and their allergy symptoms are present in the spring and fall, they may not seek your advice on appropriate treatment options when symptomatic.

Probe deeper for allergy symptoms

Identifying individuals who may be symptomatic for allergic eye disease requires uncovering symptoms that patients may have at other times throughout the year. Make sure that the medication list that you have for your patients is current. Probe for more details about medications that patients may take as needed. We ask patients if they take any medications throughout the year, even if they are non-prescription products.

Additionally, if no medications are recorded in the chart, I will often ask, “Do you ever use allergy medications at any time throughout the year?” Frequently, this question will elicit a positive response for OTC allergy medication. Then I will engage the patient to discuss ocular symptoms. Asking the question to prompt a discussion will allow you to appropriately educate the patient on how to proceed with managing his allergies by providing a therapeutic agent or advising a return visit to assess ocular tissues and symptoms during an allergy flare.

Next: Allergy mechanism of action

Allergy mechanism of action

Acute allergic eye disease that is caused by a type 1 hypersensitivity response usually manifests with significant signs and symptoms when the allergen is encountered. It is often referred to as the immediate hypersensitivity response and is a mast cell-driven response-mast cells in the susceptible individual are coated with IgE antibodies specific for a certain allergen. When the patient comes in contact with the allergen and the allergen binds to the IgE molecules on the mast cell, the cell creates a crosslinking of these molecules on its surface, forming a massive release of histamine. The histamine release and then binding to various tissues is what manifests in the typical signs and symptoms our patients experience: ocular hyperemia, itching, tissue swelling, and tearing.¹

This mechanism is involved in both seasonal and perennial allergic conjunctivitis. Perennial allergic conjunctivitis has a chronic, prolonged exposure to allergens, which can also cause more chronic inflammation. Together, these comprise over 95 percent of allergic eye disease that we encounter in our practices.² A number of topical medications will provide symptomatic relief by having both anti-histamine and mast cell stabilizing properties.

Table 1 lists current medications that have both mast cell stabilizing and anti-histaminic properties, including their active molecule, brand name, whether they are prescription or over the counter, and their dosing regimen.

All of these medications work well, but realize that some patients may respond better to certain agents then others. Keep in mind that topical corticosteroids may be concurrently used in these individuals to help reduce the inflammation more quickly. Alrex (loteprednol 0.2%, Bausch + Lomb) is the only corticosteroid approved for use for allergies.³ Although it works remarkably well and is favored because of its low concentration and thus lower side effect profile, consider higher concentration topical corticosteroids for more severe inflammatory cases, such as loteprednol 0.5% (Lotemax and Lotemax gel, Bausch + Lomb).

Do not discount non-medical therapies for allergic conjunctivitis, including removing the patient from the allergen or attempting to remove the allergen from the patient with topical lubricants. Cold compresses for ocular manifestations also work wonders. Additionally, for those patients who are most symptomatic in the morning, suggest the patient wash her hair in the evening instead of in the morning because allergens reside in hair-transferring allergens to her pillow and causing high exposure of allergens all night.⁴

Next: Giant papillary conjunctivitis

Giant papillary conjunctivitis

With the increasing utilization of more frequent replacement contact lenses, we aren’t seeing giant papillary conjunctivitis (GPC) as much as we used to with soft lenses that were kept for a year. But, there will still be instances, often associated with contact lens abuse, that we will see GPC.⁵ Early GPC identification is critical because it can cause significant irritation and visual blurring. Additionally, it can cause excessive movement of the contact lens on the eye because of the large papillae that will cause movement of the lens with the blink.

GPC is caused by an ensuing irritation to the upper tarsal plate. Although a number of things can cause this, it is usually secondary to a contact lens deposits. Because of the chronic inflammation that is visible in patients exhibiting GPC, in addition to mast cell stabilizer/antihistamine combinations, these patients will often require temporary discontinuation of contact lens wear along with treatment with a topical corticosteroid.⁶

Contact lens wear is typically not resumed until the presence of GPC has subsided. We attempt to refit these patients into a daily disposable lens.⁷ Because a fresh, clean lens is placed on the eye every day, there isn’t the opportunity for deposits to accumulate on the lens, and there is less of a likelihood of reactivation of GPC.

If daily disposables aren’t an option, consider prescribing a hydrogen peroxide solution to clean and care for the lenses. This seems to provide those individuals comfort and the cleaning mechanism provides a clean surface that mitigates the superior tarsal plate interaction with chemicals typically found in multipurpose solutions. Table 2 shows three one-step peroxide systems.

Next: Other chronic allergic disease

Other chronic allergic disease

Other forms of chronic ocular allergic disease include atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC).

AKC is typically seen in adults with an associated atopic dermatitis. Although itching and redness are seen in this condition, it can involve the cornea because of the inflammatory cells that invade it. These patients will have significant mucous discharge. Additionally, they may have a concurrent blepharitis concurrently seen in atopic disease.^8,9

VKC will often be seen in younger males, usually below age 20, although not exclusive to this patient type. These patients will have a classic cobblestone papillae which can cause ptosis due to the size of the papillae. These patients will also have significant mucous discharge. Additionally, the limbal corneal region can manifest trantas dot-small, white elevations in the limbal region of the cornea that represent inflammatory cell infiltration into the region. They may be very obvious or very subtle.^10,11

For both AKC and VKC, in addition to the mast cell stabilizer/anti-histamine agents, these conditions frequently require a short-term pulse therapy of a topical corticosteroid to subside the underlying inflammatory response. Whenever utilizing topical corticosteroids, be sure to rule out infectious etiology and monitor intraocular pressures (IOPs) to make sure they do not become elevated. Immunomodulator therapy, such as topical cyclosporine A 0.05% (Restasis, Allergan), has shown effectiveness in each of these disease states and has the benefit of not having the side effect profile of corticosteroids.^12,13

Be sure to accurately identify and appropriately treat this highly symptomatic condition in your patients. Considering these strategies can optimize both the identification and treatment strategies.

Dr. Brujic received honoraria in the past two years for speaking, writing, participating in an advisory capacity or research from: Alcon, Allergan, Bausch + Lomb, Beaver Visitec, Bio-Tissue, Optovue, Paragon, RPS, Shire, Specialeyes, TelScreen, Topcon, Valley Contax, VMax Vision, VSP and ZeaVision.

References

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3. Bausch + Lomb. Alrex Package Insert. Available at: http://www.bausch.com/Portals/107/-/m/BL/United%20States/USFiles/Package%20Inserts/Pharma/alrex-package-insert.pdf. Accessed 5/9/16.

4.Bielory L, Meltzer EO, Nichols KK, Melton R, Thomas RK, Bartlett JD. An algorithim for the management of allergic conjunctivitis. Allergy Asthma Proc. 2013 Sep-Oct;34(5):408-20.

5. Tagliaferri A, Love TE, Szczotka-Flynn LB. Risk factors for contact lens-induced papillary conjunctivitis associated with silicone hydrogel contact lens wear. Eye Contact Lens. 2014 May;40(3):117-22.

6. Comstock TL, Decory HH. Advances in corticosteroid therapy for ocular inflammation: loteprednol etabonate. Int J Inflam. 2012;2012:789623. doi: 10.1155/2012/789623

7. Donshik PC, Porazinski AD. Giant papillary conjunctivitis in frequent-replacement contact lens wearers: a retrospective study. Trans Am Ophthalmol Soc. 1999;97:205-16.

8. Chen JJ, Applebaum DS, Sun GS, Pflugfelder SC. Atopic keratoconjunctivitis: A review. J Am Acad Dermatol. 2014 Mar;70(3):569-75.

9. Sy H, Bielory L. Atopic keratoconjunctivitis. Allergy Asthma Proc. 2013 Jan-Feb;34(1):33-41.

10. Pattnaik L, Acharya L. A comprehensive review on vernal keratoconjunctivitis with emphasis on proteomics. Life Sci. 2015 May 1;128:47-54.

11. Solomon A. Corneal complications of vernal keratoconjunctivitis. Curr Opin Allergy Clin Immunol. 2015 Oct;15(5):489-94.

12. Yücel OE, Ulus ND. Efficacy and safety of topical cyclosporine A 0.05% in vernal keratoconjunctivitis. Singapore Med J. 2015 Nov 13. doi: 10.11622/smedj.2015161.

13. Erdinest N, Solomon A. Topical immunomodulators in the management of allergic eye diseases. Curr Opin Allergy Clin Immunol. 2014 Oct;14(5):457-63.