Eyeworld

45 EW FEATURE December 2018 • Good habits for healthy eyes was difficult to control and it was associated with ENT issues, I think that systemic therapy is reasonable," he said. According to Dr. Chan, it is important to get ocular allergy symptoms under control. "Ocular allergies cause inflammation, which causes damage to the ocular sur- face. Patients can develop contact lens intolerance and severe dry eye disease over time if untreated. Dry eye can delay healing after corneal procedures, superficial corneal stain- ing can alter measurements of the corneal surface, and symptoms can worsen after any corneal surgery, which makes for an unhappy pa- tient and an unhappy ophthalmolo- gist," she said. EW Editors' note: Dr. Chan has financial interests with Alcon, Allergan, Bausch + Lomb, Santen (Osaka, Japan), Shire (Lexington, Massachusetts), and Tear- Lab (San Diego). Dr. de Luise and Dr. Jeng have no financial interests related to their comments. Contact information Chan: clarachanmd@gmail.com de Luise: vdeluisemd@gmail.com Jeng: bjeng@som.umaryland.edu Dr. de Luise added that immu- notherapy shots are being used. "These are desensitization shots that doctors can give their patients in the office. A series of six to 12 shots, usually over a few months, desensitizes the patient's body to a certain allergen and makes him or her produce less immunoglobulin E," he said. Future According to Dr. Jeng, some re- searchers are suggesting that oral immunomodulatory therapy is effective for treating ocular allergies. "I'm not sure that I would use this to treat someone who has run-of- the-mill seasonal allergies, but if it doses using something like Lotemax once a day to keep their symptoms in check. "I also find that tacrolim- us can be used once daily on itchy, excoriated eyelids and off-label in the eye as well," she said. According to Dr. Jeng, vernal keratoconjunctivitis stereotypically occurs in young boys with more pig- mentation in their skin. "However, it can occur in anyone. It first pres- ents in children between the ages of 7 and 15. It generally burns out by the time they're in their late teens or early 20s, but it doesn't have to. It has characteristic findings of limbal follicles in some patients and has that classic shield ulcer of the cornea in others," he said. bacterial diseases, so steroids should not be used if a patient has viral or bacterial ocular disease. "However, we recommend a short course of mild steroids," Dr. de Luise said. "I have found over the years that Alrex is too weak, so the recommendation would be to go right to Lotemax. It is quite helpful, and it has a bet- ter safety profile than the ketone steroids. In rare cases, one could try Restasis [cyclosporine, Allergan], which is an immune modulator and has efficacy in allergy patients." Bennie Jeng, MD, University of Maryland School of Medicine, Baltimore, said that atopic kerato- conjunctivitis is the most difficult to control. "It affects the lids, then the conjunctiva, and it can ultimately affect the cornea," he said. "Nine- ty-five percent of people who have ocular findings have some form of systemic atopic disease, while 5% have atopic disease isolated to the eyelids only. Atopic keratoconjunc- tivitis causes a lot of inflammation of the conjunctiva and the lids. This chronic inflammation can hurt the stem cells, which then causes corneal problems and can result in corneal scarring. I consider this a systemic disease, so I work with the allergist to get the systemic disease under control." Clara Chan, MD, University of Toronto, Canada, said that some of the more severe atopic patients may still need topical steroid pulses during flare-ups or ongoing low " The obligation of the ophthalmologist is to make the right diagnosis the first time because there are vastly different treatment strategies depending on the type of ocular allergy. " —Vincent de Luise, MD Five categories of ocular allergy • Seasonal allergic conjunctivitis • Perennial allergic conjunctivitis • Atopic keratoconjunctivitis • Giant papillary conjunctivitis • Vernal keratoconjunctivitis

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