Consider systemic disease when treating ocular allergies, surgeons say

Coexisting conditions and concurrent diseases should be taken into account in treating patients for ocular allergy symptoms.

Diagnosing and treating patients with ocular allergy can be a clinical challenge, but the presence of coexisting systemic diseases and other conditions can make the situation even more complex.

“I think the diagnosis is so critical,” Gregg J. Berdy, MD, FACS said. “The problem with ocular allergy is once you get the diagnosis, the treatment can be cumbersome.”

Gregg J. Berdy

A patient with a concurrent systemic disease may need a more tailored approach to allergy treatment than an otherwise healthy patient, Dr. Berdy said. Similarly, patients with immunodeficiency, children, and people who wear contact lenses may also require special treatment.

Certain diseases or coexisting conditions should set off a “red light” in practitioners minds before they select a treatment regimen, he said.

“Allergy has always been a disease process that is overlooked,” Dr. Berdy said. “People never really thought of allergies as a true disease that either was debilitating or serious. In reality, the more we learn about ocular allergy, there are serious diseases that are ocular allergic disease.”

Proper diagnosis is critical

The vast majority of allergy cases seen by comprehensive ophthalmologists are seasonal allergic conjunctivitis or perennial allergic conjunctivitis, which can be uncomfortable for the patient but not necessarily debilitating, Dr. Berdy said. But some cases may be more complex than they first appear.

“A lot of physicians do not take the time to fully examine patients as they should,” he said. “Diagnosis is really crucial because a lot of times you either miss the diagnosis, or you may make the right diagnosis but miss other concurrent diseases.”

For instance, a patient whose eyes itch and burn could have dry eye disease, but he could also have blepharitis.

“Treatments for one condition may aggravate another,” Dr. Berdy said. “You really need to diagnose the patient and use vital dye staining to see if they have staining on the ocular surface to judge whether they are experiencing corneal dryness or conjunctival irritation.”

It is imperative to have a firm grasp on the diagnosis before moving forward with treatment, Dr. Berdy said.

Immunocompromised patients

Patients who are immunocompromised and present with ocular allergies should be treated carefully to minimize the risk of infection, Dr. Berdy cautioned.

“The second or third line treatment for ocular allergy may be topical steroids,” he said. “In these patients you may not want to use steroids because they are already immunosuppressed, and if you suppress the ocular immune system that could make the patient more vulnerable to infection.”

Eric D. Donnenfeld

Eric D. Donnenfeld, MD, said the first step in his treatment of ocular allergy is to decide whether the patient requires the help of a systemic allergist.

“Anyone who comes in with ocular allergy is immunocompromised by their very nature,” said Dr. Donnenfeld, an OSN Cornea/External Disease Section Member. “They all have some form of cellular immunity. Very commonly these patients will have systemic problems.”

Often, the best treatment for patients who have significant systemic immune disease, such as severe atopy, is a systemic immunosuppressive agent, Dr. Donnenfeld said.

“As an ophthalmologist, I am not comfortable using those agents on a routine basis, although some ophthalmologists are,” he said. “I usually recommend to patients who have significant systemic findings as well as ocular findings to make certain they are under the care of a good allergist. The allergist can work with you to provide a synergistic treatment plan that involves not only the patient’s ocular health but their systemic health as well.”

Systemic allergies

Patients who have systemic allergies, such as hay fever, are often prescribed oral antihistamines or decongestants, which may exacerbate dry eye, Dr. Berdy said. This may make the patient’s ocular allergy disease worse rather than better.

“It may seem counterintuitive, but it happens all the time,” he said. “If they have ocular allergy and a little dry eye, the oral antihistamines might dry the eye out further, making it less comfortable, which could make them more susceptible to ocular allergies because they cannot clear out the pollen that is landing in their eye because their tear film is not very thick.”

Dr. Berdy suggests to patients in this situation that instead of the oral medication they use a nasal spray to relieve their nasal symptoms and an eye drop for ocular symptoms.

“It may sound silly, but in those cases we try to treat topical diseases topically,” Dr. Berdy said. “If that does not work you may have to resort to oral antihistamine-decongestants, and then you just have to realize that the eye may dry a little bit and you may have to add treatment for dry eye as well,” he said.

Dr. Donnenfeld noted that current generation oral antihistamines are not as drying to the ocular surface as earlier generations were.

“The first generation antihistamines certainly did create a lot of ocular dryness,” Dr. Donnenfeld said. “But second and third generation antihistamines have much less drying effect and tend to help the eyes more than hurt them.”

Concurrent dry eye

“The biggest contingent of patients who have concurrent disease are those who have dry eye along with ocular allergy,” Dr. Berdy said. “The ideal thing would be to use a medication for their ocular allergy that doesn’t exacerbate their dry eye problems.”

For these patients, Dr. Berdy suggests using allergy drops with twice-daily dosing to minimize preservative toxics that may irritate the ocular surface. The dry eye can be treated using preservative-free drops or lubricant drops three to four times a day.

“Sometimes with ocular surface inflammation, where you cannot even see what is going on, we have begun using topical steroid eye drops twice daily to get rid of the inflammation from dry eye, and that helps with inflammation from allergy as well,” Dr. Berdy said.

Contact lens wearers

Contact lenses can act as a reservoir for antigens and make allergic disease worse, sometimes resulting in giant papillary conjunctivitis, Dr. Donnenfeld said.

“Many times, for patients who have very bad disease, the only thing you can do for them is discontinue contact lens wear,” he said. “However, with newer therapies, sometimes you can work through their allergies and treat them while they are wearing their contact lenses.”

One key is to make sure patients do not wear extended wear contact lenses, Dr. Berdy said.

“The lenses most helpful for allergy patients are gas permeable contact lenses,” he said. “Sometimes you can take patients out of soft lenses and put them into gas permeable contact lenses and their allergies resolve.”

Dr. Donnenfeld said it is also common that people who have significant allergies need to wear contact lenses for visual rehabilitation.

“I will put those patients on the normal topical therapy, and if that is not enough, I will add a mild topical steroid. Working with the steroid and the antihistamine I can usually stabilize them and stop the steroid after a couple of weeks,” Dr. Donnenfeld said.

In severe cases, however, it may be better to stop contact lens wear altogether, he said.

Ocular allergy drugs included in online database of medication side effects by Matt Hasson New online resources are available to ophthalmologists and their patients providing information on potential ocular side effects of prescription and nonprescription drugs. Potential vision-related side effects of some over-the-counter and prescription ocular allergy drugs are included in the information. Siret D. Jaanus Transitions Optical Inc. has launched a database on its Web site that allows eye care professionals and their patients to look up medications — both ocular and systemic — that might adversely affect their patients’ vision. A media release from Transitions notes that a number of nonprescription allergy medicines are available, and eye care professionals may not be aware that their patients are using them. This online tool may help professionals draw their patients attention to potential ocular side effects, the release said. In the Ocular Side Effects Database, users can search for a particular drug name and then read about the potential side effects of the drug. The tool has a “smart search function” to help users who are not sure how to spell the drug’s name. The company has also posted a clinical review paper on the site. The paper, “Ocular Effects Associated with Medications,” is authored by Siret D. Jaanus, PhD, of the Southern California College of Optometry. Dr. Jaanus lists drugs that can affect the quantity and quality of vision, such as photosensitizers, mydriatics, cycloplegics and miotics. The paper includes an extensive list of systemic and topical drugs known to have potential ocular side effects, including allergy medications, cardiovascular agents, dermatologic agents, HIV/AIDS-related agents, hormones, analgesics, antibiotics and herbal or nutritional supplements. These resources are available online at www.transitions.com/medications.

Children and allergies

Dr. Donnenfeld said allergies are much more common in children than adults.

“They tend to outgrow them and they are not serious in most cases, but they can be serious in some cases. Debilitating allergic findings such as atopy and shield ulcers can cause vision loss in these children,” he said. “You have to be aware and look for corneal neovascularization and shield ulcers to make certain the patients do not have significant problems.”

For the most part, children with allergies can be managed with topical therapy in conjunction with environmental adjustments such as removing rugs from the home, changing pillowcases and installing air purification systems.

“A lot of these environmental treatments can reduce the need for topical medications,” he said.

In more serious cases, Dr. Donnenfeld suggested working closely with an allergist to treat children with concurrent systemic disease.

For more information:

• Gregg J. Berdy, MD, FACS, can be reached at 456 North New Ballas Road, Suite 386, St. Louis, MO 63141; 614-993-5000; fax: 314-993-5558; e-mail: drberdy@youreyedoc.com.
• Eric D. Donnenfeld, MD, can be reached at Ryan Medical Arts Building, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com.

• Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology, focusing on optics, refraction and contact lenses.