NOV 2012

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November 2012 EW NEWS & OPINION Eyeing new approaches to treat and prevent ocular allergies by Vanessa Caceres EyeWorld Contributing Writer SLIT undergoes scrutiny in review article P atients who suffer from ocular allergies may soon benefit on a widespread basis from a newer kind of immunotherapy. Sublingual immunotherapy, commonly known as SLIT, involves receiving an allergy tablet under the tongue instead of via the usual al- lergy shots. Although SLIT does not necessarily have a shorter treatment time than shots, some patients like the idea of a tablet versus a shot. Side effects are usually minimal. SLIT is already used in Europe, and various studies have shown it is effective for allergic rhinitis. How- ever, its effects on allergic conjunc- tivitis were not previously well identified. A review published in Cochrane Reviews reported that SLIT can help to reduce allergic conjunctivitis symptoms. The review study, led by Moises A. Calderon, M.D., Department of Allergy and Respiratory Medicine, Royal Brompton Hospital, London, included an analysis of 42 trials with 3,958 participants total to evaluate the efficacy of SLIT in allergic conjunctivitis. All were randomized, double-masked, placebo-controlled trials. Investigators reported that ocular symptom scores for red eyes, Touch continued from page 26 "It decreases patient pain and makes treatment more palatable for patients," he said. Imagine that each laser pulse is like a pin prick, Dr. Cohen said. Previously, patients were treated with individual spots, he said. Now, patients can be treated with multiple spots at the same time. "That way, they're not feeling each spot going in," he said. "Rather, they feel one burst that covers 8-12 spots." Lower power settings also make treatment less painful, as does less treatment time, which is currently about 10-15 minutes with the Pascal Photocoagulator, compared to 45 minutes for the same number of spots in older lasers, he said. Lasers vs. injections in the retina space Laser innovation in the retina space is there, but is it as important as advances in intravitreal injections? Admittedly, this is an apples and oranges comparison, but Dr. Cohen's practice is a reminder of just how effective intravitreal injections have become for AMD. "In our practice here and in Iowa, intravitreal injections have really taken off, and the laser is not used as much," Dr. Cohen said. AMD also occurs more frequently than diabetic retinopathy in the U.S., he said. It is, after all, a leading cause of blindness in Americans 60 and older, and injections are work- ing. "In Oklahoma, we see more AMD than diabetic retinopathy," he said. Dr. Kozak sees things differently. "There is an epidemic of diabetes all over the world," he said. "The num- bers are constantly increasing due to various factors. As we know with AMD, there are risk factors linked to certain races [and genders]—with Caucasian females being typical. Also, age is the most important risk factor for AMD. So that isolates the population of patients. Diabetes af- fects all age ranges and ethnicities. With current trends of how many diabetic patients there are and costs of intravitreal injections, the indica- tion for laser therapy will be there much more so than AMD." EW Editors' note: Drs. Kozak and Cohen have no financial interests related to this article. Contact information Cohen: 405-271-1095, Alex-Cohen@dmei.org Kozak: 858-534-8975, ikozak@ucsd.edu itchy eyes, and watery eyes were significantly reduced with SLIT com- pared with placebo, with a standard- ized mean difference (SMD) of –0.41. Study participants also showed an increase in the threshold dose for the conjunctival allergen provoca- tion test (SMD=0.35). Investigators also tracked any changes to the use of ocular eye drops, but they did not find a significant reduction (SMD= –0.10). "Overall, SLIT is moderately effective in reducing total and individual ocular symptom scores in participants with allergic rhinocon- junctivitis and allergic conjunctivi- tis," investigators concluded. However, the investigators also noted that some of the trials raised concerns about statistical heterogeneity and the possibility of publication bias. Better-designed studies that assess SLIT head-to-head against other immunotherapies are needed, the investigators wrote. Future studies should focus on impact on quality of life and cost-effectiveness, they added. Weighing in What do these results mean for ophthalmologists who treat ocular allergies? "We've come to appreciate that dry eye and ocular allergies are cousins, and we're looking more closely at immunological processes," said Leonard Bielory, M.D., professor, Center of Environmental Prediction, Rutgers University, and attending, Robert Wood Johnson University Hospital, New Brunswick N.J. "SLIT is under investigation and within the next 5 years, it will likely be approved by the Food and Drug Administration, but will not be for everyone as it has limited scope of treatment." Dr. Bielory has done an extensive amount of work with ocu- lar allergies. "This massive review shows that SLIT seems to work consistently for both ocular and respiratory allergy," said John D. Sheppard, M.D., professor of ophthalmology, microbiology, and molecular biology, Eastern Virginia Medical School, Norfolk. SLIT may have great potential, particularly in pa- tients with the most severe forms of ocular allergy: vernal and atopic ker- atoconjunctivitis, Dr. Sheppard said. However, SLIT focuses on single allergens versus combining the serum of various allergens as is com- monly used with shots, Dr. Bielory said. This approach, more common in Europe, is not yet ready for prime time in the U.S., said allergist Michael S. Blaiss, M.D., clinical professor of pediatrics and medicine, University of Tennessee Health Sci- ences Center, Memphis. Some of the studies with SLIT in the U.S. have failed due to study design, he said. "The bottom line is that this is not applicable with what's going on in the United States as we don't have FDA approval for use at this time," Dr. Blaiss said, adding that the treatment is not yet covered by insurance. Dr. Blaiss said he is not against SLIT, but he would like to see "good clinical proof and FDA approval" that it would be an effective approach in the U.S. Referring to an allergist Whether or not SLIT will prove to be just as effective as shots in the U.S. remains to be seen. However, the physicians interviewed for this arti- cle hope the review study will call attention to the need for greater collaboration between ophthalmolo- gists and allergists and a greater push toward immunotherapy in general. "I consider immunotherapy like going to the gym," Dr. Bielory said. "It takes time for the immune system to build up." Considering that the majority of allergy patients have both nasal and ocular symp- toms, immunotherapy serves to help reduce both kinds of symptoms, he said. "If you treat the nose, the eyes will improve as well." Dr. Bielory encourages ophthal- mologists to refer to an allergist any time the patient has nasal symptoms in addition to ocular symptoms. continued on page 30 29

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