Eyeworld

EW CORNEA 68 May 2017 by Maxine Lipner EyeWorld Senior Contributing Writer Bepreve (bepotastine besilate oph- thalmic solution 1.5%, Bausch + Lomb, Bridgewater, New Jersey), and Zaditor (ketotifen fumarate ophthal- mic solution, Novartis, Basel, Swit- zerland), the latter of which is the only one available over the counter, Dr. Udell said. "The newest one on the block is Lastacaft [alcaftadine, Allergan]," he said. "There is some laboratory data indicating that it has a greater affinity for H1 and H2 receptors than olopatadine, but hav- ing done a lot of research in allergy over the years, I would suggest that test tube data doesn't necessarily translate into patient experience." In cases of mild to moderate allergy, Dr. Udell may begin patients with over-the-counter Zaditor for cost reasons. However, he is quick to move these cases to another agent. "If they don't get relief with Zatidor or Pataday in a moderately severe ocular allergy, I would try Pazeo," Dr. Udell said. He does this because with a 0.7% concentration, which is 7 times that of standard Patanol, there is greater chance that severe sufferers will have long-lasting relief. "From there, I will sometimes offer a third agent, but generally if two combined agents don't provide effective relief, I believe you need to move on to a different class of agents," Dr. Udell said. Some cases may require steroids. A typical case, Dr. Udell finds, may be someone with severe atopic or vernal keratoconjunctivitis, where simple strategies are not working. Short of steroids which he prefers in such cases, Dr. Udell will try a topi- cal immunomodulatory drug such as cyclosporine A or tacrolimus. While Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) is the prototypical cyclosporine A medica- tion for dry eye, this tends to be too weak a concentration to be effective for ocular allergy. "If you're going to try cyclosporine, it is generally used in the 1–2% range and is typically considered for more severe chronic conjunctivitis cases," he said. Dr. Udell suggested that tacrolimus is actually a better agent, which, when necessary, can be formulated by a compounding pharmacy. Tacrolim- us theoretically has 100 times the potency of cyclosporine, and the concentrations can be anywhere from 0.01% (solution) to 0.03% (ointment), he said. different medications. For seasonal cases, of course, one of the main- stays is the dual-acting antihista- mine mast-cell stabilizers. Although more severe cases may also benefit from such medications, it may be necessary to try more than one, observes Ira J. Udell, MD, chair, Department of Ophthalmology, Hof- stra Northwell School of Medicine, Long Island Jewish Medical Center, and Northshore University Hospital, Hempstead, New York. The historical gold standard combination agent in this class re- plete with choices has been Patanol (Alcon, Fort Worth, Texas), a 0.1% concentration that is taken twice a day, Dr. Udell said, adding that 0.2% Pataday (Alcon) is taken just once a day and can relieve itch for up to 18 hours. "Subsequently, the next ver- sion of olopatadine, Pazeo (Alcon), which is a 0.7% concentration, was awarded [Food and Drug Adminis- tration] approval for itch for up to 24 hours," Dr. Udell said. Other options include Optivar (azelastine, Meda Pharmaceuticals, Somerset, New Jersey), Elestat (epi- nastine hydrochloride ophthalmic solution, Allergan, Dublin, Ireland), down because patients knuckle-rub it so much that their lashes come off," Dr. Abelson said, adding that such patients' eyes are very red and often present with ulcers, vascular corneal invasions, and even anterior polar cataracts. Meanwhile, vernal keratocon- junctivitis (VKC) tends to be rare. "VKC occurs in young boys, and it usually resolves by puberty," Dr. Abelson said. "They have a histami- nase deficiency, in addition to other T-cell mediated chronic inflamma- tory mechanisms." He describes it as a metabolic disease masquerading as an allergic one. Such patients, he continues, respond best to high- dose steroids. "They get shield ulcers, which are really caused by eosinophils," he said. "The ulcer is filled with eosinophilic major basic protein, a very epithelially destruc- tive chemical." As a result, vernal patients get bumps under the upper lid, akin to huge cobblestones, Dr. Abelson noted, adding that the condition usually subsides with the onset of puberty, pointing to an endocrine component as well. Treatment for more severe ocu- lar allergies may or may not require What you need to know about unusual ocular allergies W hile the fickle winds of seasonal allergies blow into town from time to time, there are other sometimes more severe ocular allergies that can be just as vexing. From atopic to vernal keratoconjunctivitis and more, here's what to keep in mind when faced with one of these more unusual cases. Mark Abelson, MD, clinical professor of ophthalmology, Har- vard Medical School, and emeritus surgeon, Massachusetts Eye and Ear, Boston, points out that there tends to be a genetic component to some of these unusual and more severe allergic diseases. Atopic keratocon- junctivitis, he finds, is often asso- ciated with people who are very allergic and the disease is at its peak in infancy as well as in men in their 40s. "Atopic keratoconjunctivitis is associated with significant dermati- tis around the lid, much like allergic blepharitis, and the skin breaks Beyond the seasonal pale

• Blank Page
• Blank Page (1)
• Blank Page (2)