Eyeworld

EW NEWS & OPINION 20 April 2015 by Vanessa Caceres EyeWorld Contributing Writer Testing can help track the causes of ocular itch I t used to be that patients with ocular allergy-related com- plaints were given a few drops and sent away quickly. "We tended to blow them off like we did with dry eye 15 years ago," said John D. Sheppard, MD, president of Virginia Eye Consul- tants, and professor of ophthalmol- ogy, microbiology and molecular biology, Eastern Virginia Medical School, Norfolk, Va. With today's emphasis on ocu- lar surface disease (OSD) and teasing away the real cause of problems, that's changing. "With so many interventions available, we need to know we're doing the right thing," Dr. Sheppard said. A number of ophthalmologists are turning to allergy skin testing to pinpoint what allergens trigger a re- action or whether allergies are truly the cause of a patient's ocular woes. As allergy testing companies enter ophthalmology, ophthalmol- ogists are discovering the clinical relevance of allergy testing. How they work Physicians using Doctor's Allergy Formula (Jacksonville, Fla.), the largest in the specialty right now with about 1,500 ophthalmologists, decide if a patient could benefit from skin testing. The test is a per- cutaneous skin test that does not use needles and involves no blood. The test also has a histamine control. At most practices, an office technician is trained to perform the test, and there is a particular day or days of the week when testing is conducted, said Robert J. Weinstock, MD, the Eye Institute of West Florida, Largo, whose practice now offers allergy skin testing. Dr. Weinstock is chair of the Doctor's Allergy Formula advisory board. Doctors Allergy Formula has developed various panels of indoor and outdoor antigens specific to regions of the country. There is no testing for food allergies. Although the risk for a serious reaction is rare, an ophthalmologist must be onsite during the test, and the practice should have epinephrine available. It comes in various forms, such as ampules in which 0.3–0.5 ml of 1:1000 is administered, self-inject- able formulations, e.g., an EpiPen (epinephrine auto-injector, Mylan, Canonsburg, Pa.), and Auvi-Q (epi- nephrine injection, Sanofi, Paris). The practice should also have an un- derstanding of all aspects involved in the treatment of anaphylaxis systemic allergic reaction. Testing itself takes about 10–20 minutes, followed by time to go over the results with the technician or the physician. Practices file for reimbursement using a medical code commonly used for allergy testing. Reimburse- ment is traditionally $400, accord- ing to information from Doctor's Allergy Formula. In addition to the clinical data it provides for a patient, the testing can help a practice financially, said Marguerite B. McDonald, MD, Ophthalmic Consultants of Long Island, Lyn- brook, N.Y., and clinical professor, Evaluating allergy testing in ophthalmology to start these combination therapies at least 2 to 3 weeks before the trou- ble period," he said. Dr. Lindstrom said that for those who have acute allergic conjunctivi- tis, who may, for example, be aller- gic to cats, it is likewise a good idea to begin the combination medica- tion before an impending encounter. "You want to take the drop before you get exposed and then you won't have a problem because you will have your mast cells stabilized and histamine receptors blockaded," he said. A few ophthalmologists are starting to do skin testing in their offices, Dr. Lindstrom noted. "We've got a new skin test [Doctors Allergy Formula, Norcross, Ga.] where you prick the skin with around 40 dif- ferent allergens rather than sending [patients] to an allergist," he said. Practitioners could then educate patients on what to avoid. However, it is the rare ophthalmologist who wants to take the next step, which is allergy desensitization, he said. For more on this test, read "Evaluating allergy testing in ophthalmology." For the future, Dr. Holland is eyeing a couple of new options for fighting allergic conjunctivitis. He said there is a higher concentration of olopatadine that has just been approved. "It has been available as 0.14% and 0.2%, but there's a recent FDA approval of 0.7%, which looks like it might be the most effective combination medication that will be available," Dr. Holland said. Also, there is currently a clinical trial of topical cyclosporine underway for approval for allergic eye disease, he said. "It has been my clinical impres- sion that it has a role in chronic allergic conjunctivitis and hopefully we'll see some efficacy and approv- al," Dr. Holland said. EW Editors' note: Dr. Holland has finan- cial interests with Alcon, Allergan, and Bausch + Lomb. Dr. Lindstrom has financial interests with Alcon and Bausch + Lomb. Contact information Holland: eholland@holprovision.com Lindstrom: rllindstrom@mneye.com Weathering continued from page 18

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