Eyeworld

54 | EYEWORLD | MAY 2019 C ORNEA PHARMACEUTICAL FOCUS Contact information de Luise: vdeluisemd@gmail.com Udell: ijudell@aol.com usually starts with this agent and moves to other prescription agents in the class. "I'll go to the olopatadines because they have three different concentrations that I can work with," Dr. Udell said. These include the original Patanol (olopa- tadine 0.1%, Novartis), Pataday (olopatadine 0.2%, Novartis), and Pazeo (olopatadine 0.7%, Alcon), with both Pataday and Pazeo labeled for once-a-day use and Patanol labeled for twice-a- day use. Other H1 selective antihistamine alone or with mast cell stabilizers include Bepreve (bepotastine besilate, Bausch + Lomb), Elestat (epinastine, Allergan), Lastacaft (alcaftadine, Allergan), Optivar (azelastine, Medpointe Phar- maceuticals), and Zerviate (cetirizine, Nicox), Dr. Udell said. Dosing can be an important difference among these agents, Dr. de Luise pointed out, adding that he tends to avoid Optivar, which needs to be taken three times a day. "We know from the glaucoma world that if we ask a pa- tient to use a drop twice a day, there's a 35% re- duction in compliance over once-a-day dosing," Dr. de Luise said. The next step would be to consider a short trial of pulsing topical steroids. Practitioners today have safer ester steroids to use here. These include Alrex (loteprednol etabonate 0.2%, Bausch + Lomb) and Lotemax (lotepre- dnol etabonate 0.5%, Bausch + Lomb). Ketone steroids are very powerful but have a higher risk of IOP rise and cataract formation than the ester steroids, he pointed out. These days, Dr. Udell may move rapidly to steroid use. "If I see a very severe allergic reaction, I may start with that first," he said. "If they tried Zaditor and haven't had much of a O cular allergies are the top concern for many in the spring. Approxi- mately one in six people worldwide has some kind of eye allergy, said Vincent de Luise, MD. Today prac- titioners prescribe everything from antihistamine mast cell-stabilizing agents to steroids, cyclosporine, and more. While many are most familiar with seasonal allergic conjunctivitis (SAC), other vexing forms include perennial allergic conjunctivitis (PAC), vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), and giant papillary conjunctivitis (GPC), Dr. de Luise noted. Considering pathophysiology Mast cells that release histamine and in turn attack certain receptors are at the heart of the problem. "In the conjunctiva, we have hista- mine H1 receptors that cause itching," Dr. de Luise said, adding that there are also H2 recep- tors associated with redness, and H3 and H4 receptors that mediate the itch response. There can be prostaglandin issues as well. "Perennial allergy is similar but not quite as intense," he said. Offending agents tend to include things such as household allergens, pet dander, and mites. In diagnosing a SAC ocular allergy patient, it's best to hear the word "itch" from them to make a diagnosis, he stressed. Otherwise, something else is likely going on, be it dry eye, conjunctivochalasis, filamentary disease, or superior limbic disease. At the slit lamp, practitioners should be on the lookout for a red, watery eye, with clear, not purulent, discharge, as well as swelling, Dr. de Luise said. Treatment options Fortunately, there are a panoply of agents that can help these patients. Ira Udell, MD, point- ed out that patients can get Zaditor (ketotifen fumarate, Alcon), an anti-histamine mast cell stabilizer, over the counter. This originally was a prescription agent that was approved to be used twice a day. "But if you take it once a day and it works, that's fine," he said, adding that he Dealing with allergy in the air Chemosis and redness associated with SAC Source: Vincent de Luise, MD by Maxine Lipner EyeWorld Senior Contributing Writer About the doctors Vincent de Luise, MD Assistant clinical professor of ophthalmology Yale University School of Medicine New Haven, Connecticut Ira Udell, MD Professor and chair Department of ophthalmology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead, New York Financial interests de Luise: None Udell: InFocus Capital Partners

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