OCT 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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28 EW NEWS & OPINION October 2012 Allergic conjunctivitis and dry eye by Michelle Dalton EyeWorld Contributing Writer A new study suggests an overwhelming percentage of patients present with both A t their best, ocular aller- gies are an annoyance; at their worst, they adversely affect quality of life and may result in patients discontinuing contact lens use. Simi- larly, dry eye disease complaints can range from mild redness and irrita- tion to a level of severity significant enough to cause substantial declines in quality of life activities (such as no longer being able to drive or reduced ability to use a computer). A new article1 has highlighted the potential link between the two con- ditions, said Leonard Bielory, M.D., Center for Environmental Predic- tion, Rutgers University, and Robert Wood Johnson University Hospital, Springfield, N.J. Up to 40% of the people in the U.S. have experienced ocular symp- toms of allergies at least once in their lifetime, with peaks typically occurring in the summer months, Dr. Bielory said. Various studies report similar rates for dry eye— anywhere from 5-35% prevalence, he said. In the past, these two disorders have been discussed and typically treated as two separate entities, with ocular allergies predominantly treated by combination mast cell stabilizers and antihistamines and dry eye predominantly treated with artificial tears, topical cyclosporine 0.05%, or punctal plugs in more se- vere cases. Dr. Bielory first reported on the potential link between aller- gies and dry eye in 2004, he said.2 "Whenever we mention the re- lationship between allergic conjunc- tivitis and dry eye syndrome, most clinicians nod their head in agree- ment," said Milton M. Hom, O.D., in private practice, Azusa, Calif. "To many, it's very obvious. What has not been shown is the prevalence of each condition relating to one an- other. The point of [our] study was to fill in the blanks with some num- bers." In both disorders, patients com- monly self-medicate and may only seek professional help "once the dis- comfort gets to a point of being ex- cessive," Dr. Bielory said. "Anterior surface disease is underdiagnosed, underappreciated, and under- treated." Because patient-reported symptoms often overlap, the two conditions can be confused, he added. The new study underscores the relevance of the two disorders exist- ing concomitantly, Dr. Bielory said, adding the new study evaluated 689 patients randomly selected from an optometric practice; about 20% of the population was white and 68% was Hispanic. "Symptom overlap was demon- strated in many of the patients," the authors wrote. For example, redness existed in 62% of patients who com- plained of itch and in 50% of pa- tients who complained of dryness. "Self-reported itchiness, dryness, and redness were not independent of one another," they wrote. But "if you look at the anecdotal literature there seems to be almost an obsession with differential diag- nosis between the two," Dr. Hom said. "Our emphasis is the overlap between the two. We feel these two conditions occur at the same time." In their study, somewhere between 40-60% of the participants had both conditions, which was "far more than we expected," Dr. Hom said. The group plans further study, and will look for "both conditions first since that's the most common." In the study, about 35% of the pa- tients were also taking medications such as oral, topical, or inhaled corticosteroids/antihistamines that could have a negative impact on the ocular surface, Dr. Bielory said; this correlated well with the 36% who also reported "dry eyes." Pollen's role Pollen "absolutely" has a link to ocular dryness, Dr. Hom said. When tear volume is decreased, the pollen concentration per tear increases, he explained, coupled with an in- creased concentration of inflamma- tory factors as well. Itch is the hallmark of allergic conjunctivitis, but in the U.S., the combination of an incredibly warm winter in most regions has led to pollen counts 2. Bielory, L. Ocular allergy and dry eye syndrome. Curr Opin Allergy Clin Immunol. 2004;4(5):421-424. Editors' note: The sources have no financial interests related to this article. Contact information Bielory: drlbielory@gmail.com Hom: eyemage@aaahawk.com being at "an all-time high—off the charts in some regions," Dr. Hom said, adding the allergy season in regions like California "started in January; in June allergies were still raging." Additionally, people nor- mally unaffected by pollen counts and allergy have been presenting "in droves" this year, he added. Dr. Bielory—who has been following pollen counts for more than 25 years—also noted in the New York metropolitan area an "extraordinar- ily high" pollen count. He is currently the principal investigator for the Environmental Protection Agency's grant evaluating the role climate change may have on allergic diseases. "There's also an iPhone app (iPollencount) for the region that's in beta testing," Dr. Bielory said. "It provides patients the ability to score allergy symptoms of their eyes, nose, lungs, and [answers] queries about dry eyes." Scores are graphed with local pollen counts and can be emailed to healthcare providers to assess the link between pollen counts and the individual's symp- toms. The group's findings have led to pollen modeling, Dr. Bielory said. A major goal will be to study climate change, pollination, and the effects both have on the ocular surface. Right now, the supposition is just that—a theory, Dr. Hom said. The take-home message for clinicians should be to be less concerned about differentiating between ocular allergy and dry eye. "Some will have pure allergic con- junctivitis and some will have pure dry eye, but a bigger segment is pre- senting with both," Dr. Hom said. EW References 1. Hom MM, Nguyen AL, Bielory L. Allergic conjunctivitis and dry eye syndrome. Ann Al- lergy Asthma Immunol. 2012;108(3):163-6.

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