Eyeworld

EW FEATURE 44 Good habits for healthy eyes • December 2018 AT A GLANCE • Ocular allergies are common, affect- ing up to a third of the population. • The first step in treating a patient with ocular allergy is making the correct diagnosis. • It's important to get ocular allergy symptoms under control, otherwise post-procedure healing can be delayed, and symptoms can worsen after corneal surgery. by Michelle Stephenson EyeWorld Contributing Writer mast cell inhibitor include Bepreve (bepotastine besilate 1.5%, Bausch + Lomb) and Lastacaft (alcaftadine 0.25%, Allergan, Dublin, Ireland). Patients with vernal conjuncti- vitis or atopic keratoconjunctivitis often find that cold compresses, non-preserved artificial tears, hu- midification and closing windows, and the use of combination antihis- tamine/mast cell inhibitors are not enough. They need more powerful strategies. "In these cases, we need to start considering ophthalmic cortisone drops, ophthalmic cortico- steroids, or in severe cases, oral ste- roids," Dr. de Luise said. "The next choice is topical steroids. My view is that ester steroids, such as Alrex [loteprednol 0.2%, Bausch + Lomb] and Lotemax [loteprednol 0.5%, Bausch + Lomb], have good efficacy and a lower risk profile than the older ketone steroids. It is important to note that we always recommend short-term use of corticosteroid drops because of the risk of intraoc- ular pressure rise, which is a com- mon problem, especially in patients who are steroid responders, which is 20% of the population. Another risk with corticosteroid drops is cataract formation." Steroid drops can also lower a patient's resistance to viral and ed with people who present with preservative-related eye problems. Most eye drops in bottles have pre- servatives, benzalkonium chloride being the most common one, and they can cause an allergic type of response. I'm keen on making sure that patients are using non-pre- served medications," he said. The next step is an antihista- mine drop, a mast cell inhibitor drop, or both. "Most ophthalmol- ogists these days are using an eye drop that has an antihistamine, which addresses the acute problem, and a mast cell inhibitor, which helps the long-term reduction of the recurrence of the symptoms," Dr. de Luise said. "One of the choic- es would be Patanol [olopatadine 0.1%, Alcon, Fort Worth, Texas], which is older now. The better strat- egy would be Pataday [olopatadine 0.2%, Alcon], and the best strategy would be Pazeo [olopatadine 0.7%, Alcon], which is a once-a-day dose. Pataday is also once a day, but many users need to use it more than once a day. Alcon decided to increase the concentration of the active ingredient to allow more patients to use the medication once a day to increase compliance." Other choices in this combi- nation category of antihistamine/ of the allergens, cold compresses, and non-preserved artificial tears, which are simple, palliative types of strategies for seasonal allergic conjunctivitis," Dr. de Luise said. "In contrast, a patient with destruc- tive corneal scarring from the atopic type of keratoconjunctivitis will of- ten need topical steroids or perhaps even oral steroids to manage the condition." Treatment strategies According to Dr. de Luise, the first step in treating a patient with ocular allergy is making the correct diag- nosis. "If I can't elicit the symptom of itch and the patient doesn't use the word 'itching,' I should question my diagnosis because it may not be allergic," he said. Dr. de Luise said that the Doc- tor's Rx Allergy Formula diagnostic test (Bausch + Lomb, Bridgewater, New Jersey) is a way for allergists or ophthalmologists to test for dozens of potential allergens that might be the underlying cause of the ocular allergy. "It has been out for awhile now and is covered by most insurance companies. It's a 3- or 4-minute test that has a panel of approximately 60 allergens that are region-specific," he said. If a patient has seasonal allergic conjunctivitis, Dr. de Luise said that he uses a stepwise approach, beginning with modifying the envi- ronment. He recommends keeping windows closed and cleaning air ducts. "This is important. Mold can build up in the air ducts in houses and apartments and in air condi- tioning and heating vents, so we are blowing mold into our living environments. I often recommend a cold mist humidifier for my dry eye patients, but after a year or so, those cold mist humidifiers will have mold build up. That's a secret disas- ter because you can't see this mold, and you're blowing it into your face and making yourself worse. I also recommend cold compresses," he said. The next step in the treatment of seasonal allergic conjunctivitis is non-preserved artificial tears. "As a corneal specialist, I am inundat- There are five categories of ocular allergies, and treatment depends on the category O cular allergies are very common, affecting up to a third of the population. They can be divided into five broad categories, and the treatment depends on the diagnosis. "Therapy needs to be tailored to the diagnosis," said Vincent de Luise, MD, Yale University, New Haven, Connecticut. "For example, if a patient has giant papillary con- junctivitis due to contact lens wear, treatment would begin with remov- ing the contact lens." He noted that there are five categories of ocular allergy, and itch is present with all five. • Seasonal allergic conjunctivitis, which is the most common • Perennial allergic conjunctivitis • Atopic keratoconjunctivitis • Giant papillary conjunctivitis, which is usually due to contact lenses • Vernal keratoconjunctivitis, which appears in children "The obligation of the oph- thalmologist is to make the right diagnosis the first time because there are vastly different treatment strate- gies depending on the type of ocular allergy," Dr. de Luise said. For example, many ophthal- mologists avoid using steroids in pa- tients with seasonal allergic conjunc- tivitis. "We do things like avoidance Customized approach to treating ocular allergies A patient with seasonal allergic conjunctivitis (SAC). The image demonstrates a watery eye, bulbar conjunctival hyperemia and chemosis, and fine tarsal conjunctival papillary changes. Source: Vincent de Luise, MD

• Blank Page
• Blank Page (1)