Eyeworld

55 EW FEATURE February 2016 • Ocular surface disease AT A GLANCE • Itching can differentiate allergies from dry eye. • Although no diagnostic test has been developed, some tests can help. • Immediate comanagement with an allergist or immunologist can be helpful. • Treatments range from cold compresses to steroids, depending on severity. He echoed the use of steroids for acute, severe symptoms. "In using steroids my goal is to hit it hard and get the symptoms to abate and then taper off the steroids," Dr. Mah said. "Then I put them on something a little more long term, like a combination mast cell stabilizer/antihistamine type therapy, which is much safer." Among novel treatments uti- lized by Dr. Barney is off-label use of tacrolimus for the vision-threatening chronic allergic eye diseases of atop- ic keratoconjunctivitis and vernal keratoconjunctivitis. For vernal keratoconjunctivitis, which is difficult to control and can cause blindness, Dr. Mah uses steroids to get the symptoms under control, and mast cell stabilizers and antihistamines provide long-term management. In addition to and short of tacrolimus ointment, Dr. Mah has found off-label Restasis (cyclosporine, Allergan, Dublin) relatively effective for treating atopic and vernal keratoconjunc- tivitis. However, its relatively low concentration and difficulty pene- trating the epithelium at high doses sometimes necessitates the use of compounded cyclosporine in atopic or vernal patients. EW Editors' note: Dr. Barney has financial interests with Comparative Ophthalmic Research Laboratories (Madison, Wis.). Dr. Mah has financial interests with Alcon (Fort Worth, Texas), Bausch + Lomb, Allergan, and Ocular Therapeutix (Bedford, Mass.). Contact information Barney: npbarney@facstaff.wisc.edu Mah: Mah.Francis@Scrippshealth.org allergic conjunctivitis, such a pre- sentation leads Dr. Mah to consider other causes, including a reaction to eye drops. Among key symptoms is perior- bital redness, swelling and leathery skin, or raccoon eyes, which is com- mon in contact dermatitis but may also be present in punctate keratitis, blepharitis, or meibomitis. Meanwhile, white, ropey discharge is more associated with allergic conjunctivitis than dry eye. "Discharge usually makes us think infection, but if it is a white ropey discharge in the morning and there is a lot of itching going on for a couple of weeks, that is probably allergies, as opposed to infection, which usually has thick, goopy dis- charge that is more gray or green," Dr. Mah said. Testing help Until the perfect diagnostic test is developed, such symptoms can help determine the diagnosis. A growing number of tests can further help differentiate the condition. For instance, the TearLab Osmo- larity System (TearLab, San Diego) can help differentiate dry eye from seasonal allergic conjunctivitis. A test primarily designed to identify dry eye is the InflammaDry (Rapid Pathogen Screening, Sarasota, Fla.). However, since it identifies any type of inflammation in the eye, which can include allergic condi- tions, infections and blepharitis, the test wouldn't help specifically separate the diagnosis. Although Dr. Barney relies on patient histories for dryness and allergy relief, the tests he uses to confirm dry eye diagnosis include Schirmer's tear collection values, fluorescein dye staining and lissa- mine green dye staining, and tear meniscus height. Another option is the Doctor's Allergy Formula test (Bausch + Lomb, Bridgewater, N.J.), which is a skin test administered by physicians and uses pinpricks in the forearms to identify the patient's specific allergies. The test includes the most common allergens in their local area. The findings can help identify patients with atopic and allergic conditions such as conjunctivitis; however, it's not specifically diag- nosing the etiology of the conjunc- tivitis. Dr. Mah warned that physi- cians utilizing the test need access to an epinephrine auto-injector—if not a crash cart—because the test can elicit an anaphylactic reaction. "It does help to identify those patients with a sensitivity, and the clinician can initiate therapy for al- lergic conjunctivitis if other clinical findings corroborate the pinprick test. More importantly, it can get these patients off to an immunol- ogist or allergist and really impact quality of life," Dr. Mah said. Referral help Dr. Mah invokes co-management with an allergist or immunologist for systemic treatment right away. Although ocular complaints often are the driver for patient visits, allergies are still a systemic condition. And systemic treatment can not only improve the patient's lifestyle and day-to-day activities but can also optimize the ocular man- agement. For example, some systemic medications may have a drying effect. Minimizing such effects through topical agents for the eyes or through the use of nasal medi- cations for rhinitis could ease their lifestyles, Dr. Mah said. Other ophthalmologists have concluded that systemic treatment is rarely needed when blepharocon- junctivitis is the main manifestation of the allergic phenotype. "When symptoms and signs are unable to be controlled by local, topical treatments, a short course of oral steroids may be utilized," Dr. Barney said. Treatments used Meanwhile, mild treatments Dr. Mah uses for seasonal allergic conjunctivitis or perennial allergic conditions begin with cold com- presses or artificial tears then move up to antihistamines or combination antihistamine/mast cell stabilizers. Dry eye/keratitis Source: Francis Mah, MD

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