Eyeworld

69 EW CORNEA May 2017 oral medications in advance of the season," he said. Patients with pan-seasonal or chronic inflammation can also pose a challenge. Such cases usually have chronic lid swelling and itching, Dr. Abelson points out. "It's not mon- strous, it's just there through the seasons," Dr. Abelson said, adding that you can sometimes tell if some- one has chronic inflammatory dis- ease because they don't respond to antihistamines. In cases where the prototypical Patanol products don't appear to work, Dr. Abelson advis- es practitioners to give Lastacaft a try. "It doesn't have the problems associated with steroids, has anti-in- flammatory properties, and seems to block the penetration of allergen," he said. Giant papillary conjunctivitis may also be on some practitioners' unusual allergy radar. However, this is not an allergic condition, Dr. Abelson stresses. "It's not allergic, it's traumatic," Dr. Abelson said. "It's inflammatory from the lens' edge." patients' symptoms right away. "It's especially hard to get kids to not rub their eyes, so you really have to treat them aggressively with system- ic and topical medications to quiet things down as quickly as possible, and then taper them down as soon as you can to safer therapies for the long term." One all too common mistake, he finds, is when vernal patients come to the office in the spring, rub- bing their swollen eyes, only to have the practitioner prescribe an oral or topical antihistamine and some artificial tears. "That's not going to do it," he said. "It keeps getting worse and worse and once it gets rolling, it's much harder to treat." He prefers to start full force from the start and then taper as quickly as he can. Dr. Raizman will even start some patients on medication ahead of time. "I'll actually start many of my patients with severe seasonal allergies, especially the children with vernal, on eyedrops or even Michael B. Raizman, MD, Ophthalmic Consultants of Boston, and director of cornea and cataract service, New England Eye Center, Tufts University School of Medicine, Boston, will likewise sometimes use a topical cyclosporine or a topical tacrolimus for atopic cases. He agrees that the typical Restasis dosing is sometimes insufficient in these cases. "That may need to be used four times a day, instead of twice a day, which is the dosing for dry eye," Dr. Raizman said. "Some- times that needs to be formulated at a higher concentration, which is 0.5% cyclosporine." In some cases, he will use chron- ic lotopredenol therapy for those with atopic disease or even take a systemic approach when necessary. "I'll often use systemic therapy, es- pecially if they have systemic atopy with eczema, asthma, or bad rhini- tis," he said. In these more difficult cases, he will have the patient see an allergist and go on systemic therapy as well. "Oral cyclosporine or oral tacrolimus, oral antihistamines—the whole gamut of oral therapies can be brought into play," Dr. Raizman said. When it comes to vernal ker- atoconjunctivitis, particularly in children, Dr. Raizman tends to more aggressively use topical steroids at the start of their symptoms. "I'll use prednisolone acetate every 1–2 hours or sometimes every 2 hours for a couple of days," he said. "I'll also put them on 1 mg per kg per day of oral prednisolone as soon as they get their symptoms, if the drops are not sufficient." Some- times he uses both topical and oral medications to try to shut down " I'll actually start many of my patients with severe seasonal allergies, especially the children with vernal, on eyedrops or even oral medications in advance of the season. " —Michael Raizman, MD Dr. Raizman concurs. "That's not really allergy, it's more of a mechanical irritative effect in my opinion," he said, adding that this is not as big a problem as it used to be because of better contact lens materials. In addition, there is no longer thimerosal in contact lens solution, Dr. Raizman points out. Additionally, the lenses themselves have a better profile that is less likely to cause mechanical irritation of the upper lids, he explained. Most im- portantly, patients today can often switch to daily disposable lenses that require no solution at all and will not develop depositis—sometimes that's all that is necessary to take care of the problem, he stresses. Overall, Dr. Raizman is optimis- tic about the future. "I think there are a lot of exciting potential classes of drugs coming along," he said. Right now, the agents either have nonspecific targets or, like the cyclosporine class, target the T cells, he said. "I think there is research being done on trying to target other places in the pathway with inflam- mation that might be more effective, but we have to wait and see," he concluded. EW Editors' note: Dr. Abelson has consulted on all products in ocular allergy. Dr. Raizman has financial interests with Alcon, Allergan, and Bausch + Lomb. Dr. Udell has no financial interests related to his comments. Contact information Abelson: mabelson@oraclinical.com Raizman: MBRAIZMAN@eyeboston.com Udell: ijudell@aol.com

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