Eyeworld

64 | EYEWORLD | DECEMBER 2023 C ORNEA LESSONS LEARNED by Liz Hillman Editorial Co-Director About the physicians Esen Akpek, MD Bendann Family Professor of Ophthalmology Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore, Maryland Leonard Bielory, MD Professor of Medicine, Allergy, Immunology and Ophthalmology Hackensack Meridian School of Medicine Springfield, New Jersey Perspectives on ocular allergy and allergic conjunctivitis T he topic of ocular allergy and associ- ated conjunctivitis is broad, ranging from seasonal to perennial, acute/ episodic to chronic. EyeWorld asked ophthalmologist and ocular surface specialist Esen Akpek, MD, and ocular allergist/ immunologist Leonard Bielory, MD, to provide an overview on the topic. Dr. Bielory said the area of ocular allergy is multidisciplinary. He also said it's important to realize that "for something to be clinically relevant, we all have different tolerances." He explained that patients have different thresholds where they think an allergy is impacting their quality of life. "When it comes to symptoms, we all have the propensity to develop allergies; 40% complain of them," he said. "It reaches a level where it breaks through what I call their level of tolerance." Once that level is reached, that's when the patient seeks professional medical help. Ocular symptoms for most allergies, Dr. Bielory said, are red, itchy, and/or tearing eyes. Depending on what their symptoms are seems to determine what type of medical profession- al the patient seeks help from first. Dr. Bielory pointed to the Allergies, Immunotherapy, and RhinoconjunctivitiS (AIRS) surveys published in 2014, which found that patients who had itchy eyes were seeking medical treatment from pe- diatricians, ophthalmologists/optometrists, and nurse practitioners/physician assistants, while nasal congestion as a symptom had patients vis- iting otolaryngologists, allergist/immunologists, and family medicine physicians. 1 While ophthalmologists will see patients who experience ocular allergy, Dr. Bielory said he thinks ophthalmologists will try a few strate- gies and if those don't work, refer to an aller- gist. The chances of allergic symptoms being only in the eyes occurs in 5–10% of cases, Dr. Bielory said. If physicians see and treat only the eyes, they're not dealing with the whole patient. "The patient might not be satisfied just tak- ing eye drops when they have sneezing, nasal congestion, and a variety of other conditions. The allergist acts like a medical ophthalmologist because ophthalmologists are primarily sur- geons, but they treat symptoms that they see— tear film dysfunction as well as ocular allergy and more severe forms," he said. With more severe ocular allergy cases, such as atopic keratoconjunctivitis, vernal conjunc- tivitis, and giant papillary conjunctivitis, Dr. Bielory said an allergist who might see the patient first needs to work in concert with an ophthalmologist. "The international consensus of treatment on ocular allergy … shows there should be cross fertilization," he said. In the ICON paper, 2 which explored the diagnosis and management of allergic conjunc- tivitis, the authors described a "predominance of self-management [that] increases the risk of suboptimal therapy that leads to recurrent exacerbations and the potential development of more chronic conditions that can lead to corneal complications and interference with the visual axis." The authors wrote that "successful management includes overcoming the challeng- es of underdiagnosis and even misdiagnosis by Slit lamp images of micro-giant papillary conjunctivitis in a patient with perennial allergic conjunctivitis (left) and vernal keratoconjunctivitis (right) Source: Esen Akpek, MD

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