Eyeworld

EW FEATURE 46 Navigating the red eye • May 2018 for seasonal allergies for a couple of years but still has not gotten enough relief. One option that allergists may offer is testing and subcutaneous injections, or allergy shots. "Some- times patients can have shots. It's commonly done if testing can iden- tify what the trigger is," Dr. Jeng said. Subcutaneous injections can be a nuisance, he said, but they also are effective. Dr. Sheppard's office is able to do allergy testing with exposure to 59 different stimulants. This is offered to patients who do not have an allergist, and patients find the testing convenient as they do not have to seek out another physician for their care, he said. "Once you have results, you can make strict recommendations for lifestyle changes. If the patient is still mis- erable or sensitive, we'll refer to an allergist for skin hyposensitization therapy," Dr. Sheppard said. Dr. Bielory, who frequently studies the link between rhinitis and SAC, continually encourages collab- oration among ophthalmologists and allergists. Allergists also are a potentially useful contact if a patient may one day want to try sublingual immuno- therapy, or SLIT. This newer treat- ment option involves oral tablets or drops under the tongue to create progressive desensitization to gen- erate immunological tolerance. It can be used on its own or in tandem with allergy shots, Dr. Bielory said. Sublingual immunotherapy typical- ly targets one allergen at a time. "If sublingual immunotherapy is shown to be effective for the eyes, more ophthalmologists may recom- mend it," Dr. Jeng said. Subcutaneous immunothera- py, when properly formulated, can assist a patient in being exposed to 10 to 100 times more pollen before having the severe clinical symp- toms, Dr. Bielory said. Pearl 7: Preach about persistence Patients with SAC sometimes need to be seen frequently throughout allergy season until both physician and patient find the right treatment mix. "There's no magic bullet," Dr. Jeng said. "I tell my patients this so they know if we try one over-the- counter or prescription medication, it doesn't mean we're done. It's trial and error," he said. Pearl 8: Have patients return early before allergy season starts Dr. Starr likes to start patients on treatment a week or two before allergy season kicks in to mute or potentially avoid the acute allergic response. He reminds SAC patients to keep a diary or calendar entry re- garding when their symptoms start each year so they will know when to see him or when to prophylactically begin their medications. EW Reference 1. Bielory L, et al. Ocular and nasal allergy symptom burden in America: the Allergies, Im- munotherapy, and RhinoconjunctivitiS (AIRS) surveys. Allergy Asthma Proc. 2014;35:211–8. Editors' note: Dr. Sheppard has finan- cial interests with Alcon, Allergan, Bausch + Lomb, and other ophthalmic companies. Dr. Starr has financial interests with Alcon, Allergan, Bausch + Lomb, Shire, and other ophthalmic companies The other physicians have no financial interests related to their comments. Contact information Bielory: drlbielory@gmail.com de Luise: vdeluisemd@gmail.com Jeng: bjeng@som.umaryland.edu Starr: cestarr@med.cornell.edu Sheppard: jsheppard@vec2020.com and the use of contact lenses height- en the chance of dry eye. "If they have bad symptoms, it's reasonable to use the oral antihis- tamines if they can control dry eye with artificial tears," Dr. Jeng said. "But if there's still a problem, I rec- ommend they don't use the drying antihistamines." Dr. Jeng does not use Restasis (cyclosporine, Allergan) or Xiidra (lifitegrast, Shire Pharmaceuticals, Lexington, Massachusetts) in SAC patients with dry eye. He prefers, if necessary, to offer a short course of steroids. However, other ophthal- mologists will give the more potent dry eye medications a try. When allergy symptoms go beyond the eyes, Dr. Sheppard recommends use of an oral antihistamine along with Singulair (montelukast sodium, Mer- ck, Kenilworth, New Jersey), which is not an antihistamine and does not have a drying effect. Pearl 6: Involve allergists and allergy testing when necessary If allergy control is still a problem after the use of topical drops or ste- roids or if the allergic problems go beyond just the eyes, get your local allergist involved. Another time to involve an allergist is if a person has been using an oral antihistamine Guide continued from page 44 by Michelle Stephenson EyeWorld Contributing Writer AT A GLANCE • Hyperacute bacterial conjunctivi- tis can be sight-threatening and life-threatening. • It is primarily caused by Neisseria gonorrhoeae, which is a sexually transmitted disease. • The cornea is involved in almost half of the cases of hyperacute bacterial conjunctivitis. perforation, and panophthalmitis. These organisms can also potentially cause a secondary meningitis, which can be life-threatening. "Less severe than hyperacute bacterial conjunctivitis, acute bac- terial conjunctivitis is primarily due to Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influ- enzae," said Vincent de Luise, MD, New Haven, Connecticut. "Other pathogens responsible for acute disease are Pseudomonas aeruginosa, Moraxella lacunata, Streptococcus viridans, and Proteus mirabilis. These organisms may be spread from hand to eye contact or through adjacent mucosal tissues colonization, such as nasal or sinus mucosa." The most common acute bac- terial conjunctivitis pathogens are H yperacute bacterial con- junctivitis requires prompt diagnosis and treatment because some types, specif- ically conjunctivitis caused by Neisseria gonorrhoeae or Neisseria meningitides, can cause corneal ulcer- ation, corneal opacification, corneal Diagnosis and treatment of hyperacute bacterial conjunctivitis continued on page 48 Dramatic acute purulent discharge in a patient with Neisseria gonorrhoeae conjunctivitis Source: Vincent de Luise, MD

• Blank Page
• Blank Page (1)