Eyeworld

EW NEWS & OPINION April 2015 21 try one intervention at a time—say, avoiding a certain trigger or using a certain anti-allergy product—to truly understand what makes a difference, Dr. Sheppard said. "The testing has allowed us to identify their trigger allergens and what times of year they may need to be treating themselves," Dr. Weinstock said. "It has also helped us decide whether an antihistamine or an anti-inflammatory is best suit- ed to alleviate their symptoms." Close follow-up is also part of the routine, Dr. Parekh said. After testing, he will schedule patients back in approximately 6 weeks, and he finds the majority of pa- tients return at that time. The next follow-up is 3 months later, and the one after that is in a year or so. Some words of caution Allergist Leonard Bielory, MD, principal investigator for the U.S. Environmental Protection Agency on climate change and allergic air- way disease, Rutgers University, and attending, Robert Wood Johnson University Hospital, New Brunswick, N.J., and past professor of medicine, pediatrics and ophthalmology, sees value in the new trend of testing, although with a few caveats. First, ophthalmologists should know that allergists will still often perform their own skin tests when patients are referred to them, if there is consideration for a personalized If allergies require medical treatment, antihistamines, mast-cell stabilizers, and steroids are possibil- ities, Dr. Sheppard said. Although treatment with various drops may be cumbersome for patients, those interviewed said patients are usually compliant because they feel miser- able from symptoms. Plus, patients seem to respond well to receiving customized test results followed by a tailored treatment plan, Dr. Parekh said. There are situations where ophthalmologists will refer to a local allergist for broader testing or immu- notherapy/allergy shots. "This has increased our referrals to them," Dr. McDonald said, noting that she ini- tially wondered how local allergists would react. What she has found is that she refers patients who oth- erwise would not be referred—and in turn, they sometimes refer their patients to her. Dr. McDonald refers if the aller- gies a patient has appear to be more than just airborne, such as when pa- tients mention they get hives from eating something or feel very itchy when wearing wool. If the patient has concurrent rhinitis or hyperac- tive airway disease, Dr. Parekh will refer to a primary care physician or allergist. Dr. Weinstock refers to other specialists if a patient has a particularly strong positive reaction on the skin test. For moderate to severe ocular al- lergy patients, Dr. Sheppard is using sublingual immunotherapy (SLIT). SLIT has been available in Europe for several years and in the U.S. in tablet form since 2014. With SLIT, patients place the extract of a certain allergen under their tongue for a time period to build up a resistance. Although patients pay out of pocket for it, they avoid weekly allergy shot visits and the anaphylaxis risks associated with shots. "It's a premium service," he said. Clinical results Ophthalmologists performing allergy testing said it is too soon to have clinical data to measure how testing and the subsequent diagnosis and treatment of any allergies has helped improve patients' symptoms or quality of life. As physicians try to measure results from testing and treatment in the future, it will be crucial to Department of Ophthalmology, NYU Langone Medical Center, New York. The other company now in the market is The Allergy Matrix (Ft. Lauderdale, Fla.), led by CEO Patrick Marcus. The test offered by his com- pany follows the same principles, Mr. Marcus said. He hopes to distin- guish his company's offerings with electronic medical record-friendly testing summaries that can be used by both the physician and patient. The summaries give physicians an easy checklist-like format to show patients what they are allergic to and steps they can take to avoid their allergic triggers or treat them. "Lifestyle modification is the first thing people should do, but it's also the most difficult," Mr. Marcus said. The summary also provides conversation starters for ophthal- mologists who need a little more guidance with the allergy discussion, he added. Treatment options One advantage of allergy testing thus far is weeding out patients who actually do not have allergies, Dr. Sheppard said. The percentage of patients who do not have allergies will vary, although it's 40% for Dr. Sheppard's practice. If a test rules out allergies, Dr. Sheppard will go on to perform other OSD-related tests, such as tear osmolarity. Of course, some pa- tients suffer from allergies and other conditions such as dry eye, said Jai G. Parekh, MD, MBA, Center for Ocular Surface Excellence of NJ/ Brar-Parekh Eye Associates, Wood- land Park, N.J., and clinical associate professor of ophthalmology, New York Eye and Ear Infirmary. If a patient tests positive for a few antigens, Dr. Sheppard will go over a number of lifestyle modifica- tions, such as avoiding certain pets, removing mold, or using special pillowcases. "There are so many things that patients can do to reduce their load," he said. He gives pa- tients a catalog that shows products they can order to help avoid their triggers. For certain outdoor allergies, Dr. McDonald gives ideas to avoid trig- gers, such as finding out the kinds of grass in the yard and changing it if necessary or avoiding lawn mowing. vaccine to be developed or addition- al food allergy testing; that is some- thing valuable to tell patients. "I don't know what allergens were used, and the patient likely still has persistent symptoms. That's why they are referred to me," Dr. Bielory said. Dr. Bielory said that allergies rarely affect just the eyes, so oph- thalmologists want to be mindful of signs that warrant a more systemic examination. "Allergists are more holistic in their approach," he said. There have also been some clos- er examinations by insurance audi- tors, including Medicare, recently regarding who is trained to perform skin tests and the training that they have, Dr. Bielory said. Still, Dr. Bielory sees a collaborative role between the 2 specialties to treat patients with ocular allergies. EW Editors' note: Dr. Weinstock has financial interests with Doctor's Allergy Formula. Mr. Marcus has financial interests with The Allergy Matrix. The other sources have no financial interests related to their comments. Contact information Bielory: drlbielory@gmail.com Marcus: theallergymatrix@gmail.com McDonald: margueritemcdmd@aol.com Parekh: kerajai@yahoo.com Weinstock: rjweinstock@yahoo.com In the news FDA defers approval of CXL T he Food and Drug Administration sent a complete response letter to Avedro (Waltham, Mass.) on its riboflavin ophthalmic solution/KXL System for corneal crosslinking (CXL), the company said. FDA identified "a small number of areas of the application concerning the device that require additional information, none of which pertain to the clinical study safety or efficacy data presented in the New Drug Application," Avedro stated in a press release. In late February, Avedro received a vote for approval from the Dermatologic and Ophthalmic Drugs Advisory Committee and Ophthalmic Devices Panel of the Medical Devices Advisory Committee. EW

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