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56 EW SECONDARY FEATURE February 2011 Ocular allergies April 2012 Calming allergic conjunctivitis by Faith A. Hayden EyeWorld Staff Writer How to treat and diagnose ocular allergies A pril showers bring May flowers and endless mis- ery to those suffering from seasonal and peren- nial conjunctivitis caused by pollen, mold, and grasses. 'Tis the season for red, itchy eyes, so EyeWorld spoke with two experts about diagnosing and treating patients with these ocular issues. Seasonal or perennial? The differences between seasonal and perennial allergies are limited, said Leonard Bielory, M.D., Springfield, N.J. Other than their frequency, primary differences are severity of symptoms and root cause. Seasonal allergies occur dur- ing the spring and fall months and are typically caused by pollen, grass, and ragweed. The intensity of sea- sonal allergic conjunctivitis (SAC) can be explosive for a number of weeks, depending on the level of exposure to the specific allergen circulating. "Tree pollen counts can go up into the thousands in Washington, D.C., and 47% of it is oak pollen," Dr. Bielory said. "In the Northeast, from Delaware up through Con- necticut and hitting Boston, birch pollen is the highest pollinator into the thousands of cubic meters." Perennial allergic conjunctivitis (PAC) is chronic and, as its name suggests, isn't limited to certain months. Many people with PAC are literally sleeping under a roof of al- lergens with a house full of pet dander, dust, or mold shelling their system and causing a chronic condi- tion. Signs of SAC and PAC are, how- ever, the same. "The symptoms are basically itching, irritation, burning, a sandy sensation, and red eyes," said Ira J. Udell, M.D., chair, ophthalmology department, North Shore-LIJ Health System, New York. "For the most part, the redness is more of a pink- ness than an intense redness. If you see an intensely red eye, you have to be thinking of other diagnoses." Make sure it's allergies Just because patients present in your office with conjunctivitis during suspect months doesn't mean their problems are allergy related. There are many causes of conjunctivitis, and because certain kinds are highly infectious it's important to distin- guish between them. For example, be suspicious if an adult patient comes in with con- junctivitis and does not have a his- tory of allergies. Pay attention to the redness. Allergic conjunctivitis is pinkish while viral conjunctivitis can be an intense red. Patients with viral cases may also get little pe- techial hemorrhages in the conjunc- tiva, Dr. Udell said. Occasionally patients will have some itching, but not much. If patients do have viral conjunctivitis, you'll want to isolate them for about 2 weeks. "There are some very mild viral conjunctivitis that may look like an acute allergic reaction, but what generally differentiates them is the itching," Dr. Udell said. "If you see itching or hear about itching, think more of an allergic process." Episcleritis, however, is an ex- ception to that rule. It's character- ized by itching, inflammation of the surface layer of the sclera, and eye redness. A patient with SAC Source: Ira J. Udell, M.D. "What generally differentiates [episcleritis] in most patients is it's in one eye or in more of one eye than the other," Dr. Udell said. "It may be in a sector of the eye where only part of the eye is red. So if you see anything sectorial, that's not generally going to be allergic." SAC and PAC treatments Avoidance is the first line of defense against ocular allergies, Dr. Bielory said. "Secondary treatments are lubri- cation and washing the eye out upon exposure," he said. "There is literature to support that disposable contact lenses improve ocular aller- gies. If you can get rid of those con- tact lenses that are loaded with pollen from the week before that you're allergic to, you'll decrease the allergic triggers associated with the reaction on the conjunctiva sur- face." A topical decongestant with or without an antihistamine is another option. This will decrease redness but won't affect itching. Allergy shots can be helpful for patients with both ocular and nasal symp- toms, but won't improve ocular al- lergies alone. "What I generally do is cut to the chase," Dr. Udell said. "If pa- tients come in and their symptoms are moderately severe, you can use artificial tears and those things, but it's not going to give them much re- lief. I would move right to the com- bination agent, which is a topical antihistamine and mast cell stabi- lizer. "The nice thing about the com- bination is it helps stabilize the membrane so there's less release of mediators," Dr. Udell continued. "For the histamine that's released, which is one of the main culprits of ocular allergy, it will help block the receptors from causing some of the irritating symptoms." For severe cases, an over-the- counter vasoconstrictor antihista- mine can be extremely effective, but Dr. Udell warns this is temporary and should only be used occasion- ally for a short duration. Overuse can lead to rebound redness. Topical steroids for SAC and PAC are another option, albeit a controversial one. Dr. Bielory and Udell recommended them for extreme situations in a burst of therapy, but said steroids are unnec- essary for minor to moderate cases. "There's a risk of raising intraoc- ular pressure, and if [patients] take it for prolonged periods of time, [they] may get a cataract," Dr. Udell said. EW Editors' note: The doctors mentioned have no financial interests related to this article. Contact information Bielory: drlbielory@gmail.com Udell: ijudell@aol.com