Eyeworld

EW CORNEA 62 byline plus fade March 2016 concentrated as the tear osmolarity increases, Dr. Bielory explained. Dr. Abelson likewise has con- cerns about the drying effects of these. "People get confused with all of the new oral antihistamines," he said. "They're non-sedating, but they're not non-drying." You want to have a robust tear film to wash the pollens away, he stressed. While systemic antihistamines like Zyrtec (cetirizine, Johnson & Johnson) can be problematic, there may soon be a topical version of cetirizine, being developed by Nicox (Sophia Antipolis, France) coming to market, Dr. Abelson noted, adding that this will likely occur by the spring of 2016. Andy Whitlock, PhD, director of preclinical development, Ora, thinks that future use of novel anti-inflam- matory therapies holds promise. Those drugs have made headway in autoimmune and systemic inflam- matory diseases. "We see a lot of work repurposing those classes of compounds to eye drops," he said, adding that the hope is to get a steroid-like response but without having steroid-like safety issues. Dr. Abelson noted that there are exciting programs on splenic tyro- sine kinase (syk) inhibitors that are winding through the development process. This may interfere with the intracellular signaling cascade within the mast cell, preventing the release of pro-allergic and pro-in- flammatory mediators, he explained. "That looks perhaps to be our next drug class," he said. EW Editors' note: Dr. Abelson has financial interests with all companies mentioned. Dr. Bielory has financial interests with Allergan, Bausch + Lomb, Merck (Kenilworth, N.J.), and GlaxoSmithKline (Brentford, U.K.). Dr. de Luise, Dr. Udell, Dr. Whitlock, and Mr. Gomes have no financial interests related to their comments. Contact information Abelson: mabelson@oraclinical.com Bielory: drlbielory@gmail.com de Luise: vdeluisemd@gmail.com Gomes: pgomes@oraclinical.com Udell: ijudell@aol.com Whitlock: awhitlock@oraclinical.com "Soft" steroids For patients with more severe forms of ocular allergy, such as peren- nial allergic conjunctivitis, Dr. de Luise has found that off-label, short courses of topical "soft" ester ste- roids can be helpful. These include agents such as Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch + Lomb) and Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb). Dr. de Luise describes these as ester steroids. "Steroids have either ke- tone moieties or ester moieties on them," he said. "Ketone moieties have more strength, power, and effi- cacy, but also have a greater chance of IOP rise, potential for glaucoma, potential for cataract formation, and potential to reduce the immune response to allow for infection to oc- cur, especially herpes simplex." The more power a steroid has, the more side effects it is going to have, Dr. de Luise explained. Ester steroids are not as potent, but do not have the risk profile of the ketone steroids. On occasion, Dr. Udell will use a low dose of a preservative-free tra- ditional steroid. "We generally use a very low dose of dexamethasone, which is one-tenth the strength of the standard agent," he said, adding that he finds there is a subgroup of patients who don't benefit from steroids because the preservative irritates their eyes and counter- acts the effect. "You can feel more comfortable using it because there is less chance it's going to raise the pressure in the eye and minimal risk of causing cataracts," Dr. Udell said. Oral antihistamines Other allergy sufferers may look to the use of oral antihistamines. While these may work for some, Dr. Bielory warns that there is a downside. "It makes a mild ocular allergy toler- able, but the problem is as we get older, we have an overlap with dry eye symptoms," he said. "If patients take an antihistamine, it's going to dry the eye and make the osmolarity increase even more—they're going to make the eyes even saltier, which will be an irritation in itself." While this may block histamine, it doesn't block the other allergic chemical mediators, which become even more Ocular continued from page 61

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