Eyeworld

EW FEATURE 44 Navigating the red eye • May 2018 AT A GLANCE • Check for hallmark signs of redness, itching, and rhinitis to determine if a patient has SAC. • Start with a topical antihistamine/ mast cell stabilizer to help quell SAC symptoms. Recommend oral antihis- tamines with caution. • Determine how you will treat dry eye, which is common in SAC patients. • Work closely with local allergists, who can provide systemic treatment such as allergy shots or sublingual immunotherapy. by Vanessa Caceres EyeWorld Contributing Writer Pearl 1: Determine what kind of allergy the patient has Redness and itching are the hall- mark signs of SAC. If the patient presents with these symptoms during key times of the year associ- ated with the allergy season, that's another strong clue to indicate SAC. Tearing, lack of discharge, swelling, papillary tarsal conjunctival reac- tion, and chemosis also are signs of SAC, said Vincent de Luise, MD, assistant clinical professor of oph- thalmology, Yale University School of Medicine, New Haven, Connecti- cut. The patient also likely has other systemic symptoms, such as a runny nose. During your exam with these patients, it's important to check for any potentially serious findings as- sociated with other types of allergy, such as vernal keratoconjunctivitis, Dr. Sheppard said. Pearl 2: Encourage avoidance of allergens Although there are plenty of medi- cations patients can use, avoidance is usually far more effective, Dr. Sheppard said. However, he realizes this can be hard if not impossible to do with certain allergic triggers, including pollens, dust, fungus, and mold. Still, Dr. Sheppard's office will give patients a handout with tips on avoiding triggers and minimiz- ing the allergic effect. Suggestions include eliminating dust from the home, chilling any drops that are used, and not rubbing the eyes. Other advice can include wearing protective eyewear, washing clothes frequently, and keeping windows closed, said Christopher Starr, MD, associate professor of ophthalmol- ogy, Weill Cornell Medical Center, New York-Presbyterian Hospital, New York. Also in the realm of non-drug solutions, Dr. de Luise encourages the use of cold compresses to reduce histamine release and non-preserved artificial tears to help flush out allergens. Pearl 3: Start with a topical an- tihistamine/mast cell stabilizer "The advantage is rapid action from the antihistamine and the long-term benefits of mast cell stabilization," Dr. de Luise said. Using just one of these agents on its own is not as effective as the dual action, said These often-miserable patients can find relief with a stepwise approach S ome ophthalmologists may think of seasonal al- lergic conjunctivitis (SAC) as less exciting than sur- gical treatment, said John Sheppard, MD, president, Virginia Eye Consultants, Norfolk, Virginia. Yet he thinks SAC doesn't deserve a bad rap. "As a doctor, you get your full fee, it's a quick visit, and you'll have [medication] samples in the office. You've made patients happy, and they'll love you forever," he said. Ocular allergy may seem like just an annoyance, but it has a real impact on quality of life. In fact, SAC symptoms can potentially be worse than nasal symptoms, said Leonard Bielory, MD, professor of medicine, Seton Hall University School of Medicine, and adjunct professor, Rutgers University Center for Environmental Prediction, New Brunswick, New Jersey. 1 This leads him to describe some presenta- tions of SAC as conjunctivorhinitis instead of the traditional rhinocon- junctivitis name. As SAC patients enter your office more frequently—Dr. Bielory and others have shown in various studies that allergy seasons around the globe are getting longer and more intense—you'll want a strategy to maximize their treatment. Here are several pearls. a lower risk of IOP pressure rise and cataracts than ketone steroids. Dr. Starr also will occasionally consider oral steroids such as the meth- ylprednisolone dose pack. "The eyelids often require steroid or tac- rolimus ointment as well," he said. Oral steroids may come into play if severe cutaneous disease is involved, and nebulized steroids have a role if there is severe pulmonary disease, Dr. Sheppard said. Pearl 5: Make a plan to treat dry eye disease It's common for patients with SAC to also have dry eye, said Dr. Bielory, who has co-authored several studies on the topic. "One has to appreciate that there may be an overlap, and what may sound good for one con- dition may exacerbate the other," Dr. Bielory said. Case in point: Treating SAC with oral antihistamines may help allergy symptoms, but they also can lead the patient to experience dry eye, Dr. Jeng said. Plus, older age Bennie Jeng, MD, professor and chair, Department of Ophthalmol- ogy and Visual Sciences, University of Maryland School of Medicine, Baltimore. The once-daily Pataday (olopa- tadine, Alcon, Fort Worth, Texas) and the once-daily Lastacaft (alcafta- dine ophthalmic solution, Allergan, Dublin, Ireland) are more conve- nient and improve compliance, Dr. de Luise said. Other combination agents are effective and available, but they require twice-daily dosing. Pearl 4: Consider a short dose of pulse steroids if the topical antihistamine/mast cell stabi- lizer is not effective enough This is similar to what an allergist might use to treat an asthmatic patient, Dr. Bielory said. "You do a short burst without a high penetrat- ing value," he said. Dr. de Luise recommends the use of an ester steroid such as loteprednol 0.2% (Alrex, Bausch + Lomb, Bridgewater, New Jersey) or loteprednol 0.5% (Lotemax, Bausch + Lomb) as they are associated with Guide to treating seasonal allergic conjunctivitis continued on page 46 Papillary vernal conjunctivitis Seasonal allergic conjunctivitis Source: Vincent de Luise, MD

• Blank Page
• Blank Page (1)