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Effectively managing ocular allergies can be a challenge for physicians
As ocular allergic reactions differ, so do therapies. But there is no scarcity of treatment alternatives.
As ocular allergy symptoms differ among the hundreds of millions of people they affect worldwide, physicians are faced with selecting appropriate agents for management. Their choices are based on efficacy, safety, convenience of dosing and comfort of administration for the patient. The objectives of treatment include decreased inflammation, minimal dosing, increased compliance, minimal side effects and increased tolerance to triggers.
Common complaints
The most common complaint among ocular allergy sufferers, physicians agree, is itchy, watery eyes. Ocular allergic reactions cause the release of mediators from the mast cells, including histamine, which creates the symptoms of allergic ophthalmological problems. “But not only is this a histamine phenomenon,” said Dennis L. Spangler, MD, an allergy specialist in Atlanta. “It also is a chronic inflammation phenomenon. As the allergic reaction continues, there is infiltration of the eye by the cells of chronic inflammation, including eosinophilia and lymphocytes, that contribute to a hyper-irritability state that occurs not only in the lung and the nose, but also in the eye.”
Dr. Spangler added that if you want to get control over the allergic symptom process, both acute and chronic inflammation has to be addressed. Inflammation is many times overlooked. Patients complain about nasal stuffiness and asthma, but the ophthalmologic symptoms, which are just as significant and chronic, are overlooked or ignored by patients, according to Dr. Spangler.
“They have a tendency to overlook that symptomatology,” Dr. Spangler said. “It’s important to ask for these symptoms.” Other symptoms include lid swelling, redness, hyperemia, chemosis, eyelid edema and significant mucous discharge.
Artificial tears
Approaches to ocular allergy management differ as symptoms vary. “First is the obvious, the easiest, the cheapest and has the least amount of problems and that is using tears,” Dr. Spangler said. “It provides a washing agent, it increases the barrier, but it has a limited benefit.” Artificial tears are to be used frequently by patients to be effective; however, if the allergy is symptomatic, artificial tears may not be the best treatment choice.
“A lot of doctors forget about artificial tears as a means of helping in the realm of ocular allergies,” Charles B. Slonim, MD, FACS, told Ocular Surgery News. “Artificial tears are an important part of ocular allergies mainly because you get pollen stuck on the tear film and a portion of the artificial tears is literally washing these potential allergens off the surface of the eye.” Artificial tears provide a safe, inexpensive means of washing away allergens and mediators.
Vasoconstrictor/antihistamine combos
At one time, vasoconstrictors and antihistamine combination products were available mostly through prescription, but now the majority of them are available over the counter. These include products such as OcuHist (pheniramine maleate, Pfizer), Opcon-A (naphazolin hydrochloride, pheniramine maleate, Bausch & Lomb Pharmaceutical) and Naphcon-A (pheniramine maleate, Alcon Laboratories). Dr. Slonim tends to prescribe these frequently. “Patients love them,” Dr. Slonim said. He noted that among his patients that have used vasoconstrictors for long periods of time, there has been no ill effect.
However, some ophthalmologists have complained that these products are associated with rebound effects. Patients tend to get hooked on vasoconstrictors, which make the eye white temporarily.
“I tend not to use vasoconstrictors because I don’t like them,” said Michael B. Raizman, MD, of Boston. “I don’t think they address the underlying problems. They can lead to major problems if they are used for a long time, like rebound hyperemia.” According to Dr. Raizman, the antihistamine in these combination products is weak. If patients have pure itching and no other symptoms, Dr. Raizman usually gives them an antihistamine. If patients have burning and irritation, Dr. Raizman usually recommends a topical non-steroidal anti-inflammatory medication.
“There are antihistamines and decongestants that work in the eye, and I would say most people tend to use something with a vasoconstrictor or decongestant and an antihistamine combined,” allergist Ira Finegold, MD, told Ocular Surgery News. “That had been the tradition until about a year ago.” According to Dr. Finegold, Patanol (olopatadine hydrochloride ophthal mic solution, Alcon), a combined antihistamine and mast cell stabilizer, has been quite effective since it became available. Dr. Finegold reports that in the past, physicians were instructed to build up ocular allergy therapies by starting with a less potent drug and gradually working their way up. “Now, you can come in and hit it hard and avoid the whole [allergic response],” Dr. Finegold said.
Antihistamines and steroids
Drugs such as Patanol, which is an antihistamine demonstrated to have in vitro mast cell stabilizing properties, have replaced the use of topical steroids to some degree, according Dr. Finegold. “We tend not to use topical steroids in the eye because if it turns out as a misdiagnosis and it is a virus disease, steroids tend to make the virus worse,” Dr. Finegold said. “With topical steroids, you do have certain side effects and I like to save the severity of illness for the ophthalmologist.” Dr. Finegold said that when it seems a topical corticosteroid is needed, the patient is referred to get a second or third opinion. Dr. Finegold said with a drug such as Patanol doctors seldom have to follow that route any longer.
After using vasoconstrictors as a first line of treatment, Dr. Slonim said he may turn to antihistamines such as Livostin (levocabastine HCl, Ciba Vision), Emadine (emedastine difumarate ophthalmic solution, Alcon) and Patanol. “I think Patanol is a good antihistamine, but I’m not impressed by its mast cell stabilizing properties,” Dr. Slonim said. “I have used tons of cromolyn.” Cromolyn sodium is the active chemical in Crolom (cromolyn sodium, Bausch & Lomb) and Opticrom (cromolyn sodium, Allergan).
Dr. Slonim added that Patanol is a good antihistamine, but a problem lies in the dosage of the drug, which is one to two drops a day at 6 to 8 hours apart. “If you only use it twice a day, you don’t keep a therapeutic level because patients go into the trough level overnight,” Dr. Slonim said. When Patanol is used 3 times a day, he said, it works better. Dr. Slonim said he tends to use an over-the-counter antihistamine/decongestant and will add cromolyn as his first and second line drugs.
Non-steroidal anti-inflammatories
Acular (ketorolac tromethamine, Allergan) is the only non-steroidal anti-inflammatory drug with an ocular allergy indication for seasonal allergic conjunctivitis. According to Dr. Slonim, patients frequently complain about this product because of the burn level. “I don’t use it for that reason,” Dr. Slonim said. Acular only works on the cyclooxygenase arm of allergic reactions and not the lipoxygenase pathway. This would prevent the production of the prostaglandin but would not prevent the production of the leukotrienes, which also are potent inflammatory chemical mediators, according to Dr. Slonim. “Acular only affects one area of the inflammatory chain; therefore, why bother unless you are going to get both arms.”
According to Dr. Slonim, researchers are seeking a non-steroidal anti-inflammatory drug that works specifically on both the cyclooxygenase and lipoxygenase pathways. Other research includes use of cyclosporin for allergies.
Dr. Slonim mentioned that he uses other topical steroids for the treatment of both acute and chronic seasonal allergic conjunctivitis. “I use Alrex (loteprednol etabonate, Bausch & Lomb) because of its efficacy in treating the signs and symptoms of seasonal allergic conjunctivitis, but mainly because of it safety profile,” Dr. Slonim said. “Relief from itching and redness is less than 1 hour.”
Dr. Slonim said many ophthalmologists are “steroid shy” in treating external ocular inflammatory processes. Dr. Slonim had similar concerns until he started administering Alrex. “I appreciate Alrex’s safety profile, which has made me less ‘steroid shy’ in using topical steroids as a first-line drug for ocular allergic reactions,” Dr. Slonim said.
| Therapeutic Options | |||
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| Topical treatments for ocular allergies and what they do
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For Your Information:
- Ira Finegold, MD, can be reached at 121 E. 60th St., New York, NY 10022 U.S.A.; +(001) 212-758-4633; fax: +(001) 914-722-9175; e-mail: ifinegold@aol.com. Dr. Finegold has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Michael B. Raizman, MD, can be reached at the New England Eye Center, Tufts University School of Medicine, 750 Washington St., Boston, MA 02111 U.S.A.; +(001) 617-636-7625; fax: +(001) 617-636-4866. Dr. Raizman has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Charles B. Slonim, MD, FACS, can be reached at 4444 E. Fletcher Ave., Ste. D, Tampa, FL 33613 U.S.A.; +(001) 813-971-3846; fax: +(001) 813-977-2611. Dr. Slonim did not disclose whether or not he has a direct financial interest in any of the products mentioned in this article or if he is a paid consultant for any companies mentioned.
- Dennis L. Spangler, MD, can be reached at Atlanta Allergy and Asthma Clinic, Atlanta, GA U.S.A.; +(001) 404-252-4207; fax: +(001) 404-303-2758. Dr. Spangler has no direct financial interest in any of the products mentioned in this article. He is a paid consultant for Alcon speaker’s bureau.