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Experts explore possible treatments for seasonal allergic conjunctivitis
The panel looks at the effectiveness of several options, including topical antihistamines, mast cell stabilizers and patient education.
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 Eric D. Donnenfeld |
Eric D. Donnenfeld, MD, FACS: This is a simple, common case that we see every day in our office. A 19-year-old woman presents with seasonal conjunctivitis — itching, tearing, burning, redness (Figure 1). On examination there is chemosis, hyperemia, papillae and clear discharge. This is a disease that we see every spring on the East Coast.
How do you manage this disease? Table 1 has a variety of options that you might want to offer a patient who has seasonal allergic conjunctivitis.
Christopher J. Rapuano, MD: Typically I would start with a combination topical antihistamine and mast cell stabilizer. I think that works well. Cool compresses are fine. The topical vasoconstrictors I do not like. The topical nonsteroidal anti-inflammatory drugs I do not think work that well.
Dr. Donnenfeld: NSAIDs are approved by the U.S. Food and Drug Administration for this indication. Does anyone use NSAIDs for managing seasonal allergic conjunctivitis? I do not. I included it on the list for completeness sake.
Dr. Rapuano: They sting, and I do not think they work well.
Dr. Donnenfeld: Exactly. So you like to use a combination mast cell stabilizer and antihistamine.
Dr. Rapuano: As a first step, and then I move up from there.
Dr. Donnenfeld: Give us a few brand names that you might want to consider.
Dr. Rapuano: I think Patanol (olopatadine hydrochloride 0.1%, Alcon), now Pataday (olopatadine hydrochloride 0.2%, Alcon), and Elestat (epinastine HCl ophthalmic solution 0.05%, Inspire Pharmaceuticals) are probably my two favorites, but they all work relatively well.
Michael B. Raizman, MD: I agree pretty much with Dr. Rapuano. The one thing you do not have on the list that I think is important is education. The main reason I see patients in consultation with allergy that is not adequately treated with drops is they have not been educated about avoiding allergens. There are a number of simple things we can tell our patients about avoiding allergens that can be helpful. But the majority of my patients do well with cold compresses and artificial tears to wash out the eyes when they have encountered a lot of pollen or when their eyes are irritated.
One of the newer topical antihistamines I have been impressed with is Pataday. I think it is better than Patanol. I think the extra concentration helps a lot. But all of the antihistamines available are excellent and safe; our patients can use them as much as they want. Some patients may want to use these drops two or three times a day, and I think that is safe and I let them do that. I give them a prescription for 1 year, for instance. Elestat is also good. Optivar (azelastine HCl ophthalmic solution 0.05%, Meda) is a good product, but it tastes a little bad when I put it in my eye and it goes down my throat, so I tend to avoid that one. But these are all safe, effective products for our patients.
Dr. Donnenfeld: Are any of them available without a prescription?
Dr. Raizman: Zaditor (ketotifen fumarate, Novartis) is available as a generic. That is another good product.
Dr. Donnenfeld: I have been impressed by Pataday, Elestat, Zaditor — all very good products. Dr. D’Arienzo, you have a lot of experience with Pataday.
Peter A. D’Arienzo, MD, FACS: I think the future for allergy drugs will be once-a-day dosing, so I think we will see other companies come out with allergy products that are once a day.
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I think Dr. Raizman is correct with education. One pearl I want to share with you: A 19-year-old woman usually wears makeup. I see a lot of these young women, and they have dry eye and allergy, and they are contact lens failures, so I have done some research with respect to makeup. I find that women who use oil-based makeup removers, things such as baby oil, Ponds cold cream, Vaseline, even just soap and water, are not removing the makeup effectively. Clinique sells a product — I have no financial interest in it — that is water-based (Rinse Off Eye Makeup Solvent). Sephora and Neutrogena also make products like this. Women who use water-based products will improve their lid function and help the dry eye. I think a great pearl is women should spend as much time removing their makeup as they do applying it.
Marguerite B. McDonald, MD: One other thing is, besides eye drops, which of course wash out the allergens, if somebody finds that they try to avoid the garden but they are forced to go to an outdoor wedding and they are miserable afterward, to get sterile eye irrigating solution because it comes out with a little head of pressure, you really cannot hurt yourself with it, and they can wash out their inferior cul-de-sac right after exposure.
Dr. Donnenfeld: Let’s give a real-world situation. This happens to all of us. We have patients we manage, and I think we all agree that a good education, tears and an antihistamine mast cell stabilizer are first-line therapy. What do you do when patients comes back and they say, “My eyes are still itchy and tearing, despite the fact that I’m already on this therapy.” What is your next line of therapy? That is the more difficult decision that we need to make.
 A 19-year-old patient presented with itching, tearing, burning and redness. On physical exam there was chemosis, hyperemia, papillae and clear discharge. Image: Ophthalmic Consultants of Long Island | ||
Charles B. Slonim, MD, FACS: Some of these patients, because they may have already purchased some products over the counter, may already be on oral antihistamines. And oral antihistamines, specifically Zyrtec (cetirizine, Pfizer) and Allegra (fexofenadine, Sanofi Aventis), have been shown to dry the eye. We know that if the eye is drier, these symptoms are just exacerbated, and all of their symptoms will be exacerbated. Although I use a mast cell stabilizer/antihistamine as a first-line drug, if I see chemosis, I start a steroid. I do not believe the mast cell stabilizer/antihistamine products really get rid of chemosis the way a steroid will, so I will typically give them both. I will give them a drop of Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch & Lomb) four times a day. I will give them a mast cell stabilizer/antihistamine, Optivar. If you have a safe steroid, such as Alrex, you could probably use that as a first-line drug, but I do not. But when I see chemosis, I do. So chemosis is the key for me. If they are severely symptomatic, I will start a second steroid, also.
Dr. Donnenfeld: I think that is a very good point.
Dr. Raizman: The treatment for chemosis is to get the patients to stop rubbing their eyes because we know from the research setting if you put a high dose of allergen directly on the patient’s conjunctiva, chemosis can be severe but it never lasts more than 20 or 30 minutes and then it disappears. If you allow the patient to touch and rub their eyes, the chemosis will go on for hours or days. So, again, education is the key. Tell patients to use effective products, don’t rub and put ice packs on the eye as needed. As Dr. McDonald said, wash out the eyes with tears or saline, but keep your hands away from the eyes and then they will not have redness. They will not have chemosis. They will not need steroids.
Dr. Slonim: The rubbing of an eye does increase the tryptase level, so we know it degranulates mast cells. So just eye rubbing itself triggers the whole inflammatory cascade.
Dr. Rapuano: I just want to add to McDonald’s suggestion. Not only should patients wash their eyes out at that time, but then when they go home at night, they should probably take a shower because the allergens are in their hair, and if they go to sleep, it is still going to be inches from their eyes. Or if they have been outside in the afternoon, they can change their clothes at nighttime because the allergens are in their clothes. So changing clothes when they get in from the outside and washing the hair at nighttime are things that I have told patients and can be very helpful.
Dr. Donnenfeld: When patients break through with seasonal conjunctivitis, it can be episodic. For example, the guy who mows his lawn every 2 weeks and has allergic conjunctivitis. There, I think steroids make sense — hit him with steroids, even pre-treat with steroids, and you get a great response. But how about the guy who breaks through all summer long and is having problems in which steroids might not be ideal to use for a 4- or 5-month period, and they break through while they are on mast cell stabilizer combinations with antihistamines? What do you do for that type of breakthrough?
Dr. Raizman: I think I would still go to steroids for a breakthrough in patients with chronic, more severe allergy. Steroids are good acutely. For chronic therapy, I would consider topical cyclosporine. This is safe and well-tolerated — a good long-term T-cell inhibitor. So I would not hesitate to put those folks on Restasis (cyclosporine ophthalmic emulsion, Allergan) and leave them on long term.
Dr. Donnenfeld: I think that is a great combination. For long-term breakthrough problems, a combination of an antihistamine with Restasis for a whole summer, that is my second-line therapy for these patients.
Dr. Raizman: I would still put them on a steroid early on because Restasis is not going to have an effect for several weeks.
Dr. Donnenfeld: And if they break through while they are on that, they can use a steroid periodically. They will break through less. There is also a suggestion in some patients that some dedicated mast cell stabilizers may have more activity than the combination mast cell stabilizers. Dr. Raizman, you have done a lot of work in this area. What do you think about that? Is there any role for pure mast cell stabilizers in these patients?
Dr. Raizman: I think that topical cyclosporine is probably the most useful way to stabilize mast cells chronically. Sometimes I formulate it. I am not sure Restasis in its current formulation is strong enough for treating allergy, unless you use it three, four or even more times a day, so formulating cyclosporine at a higher concentration is useful. I like the pure mast cell stabilizers for chronic use, and then I will give patients an antihistamine as needed, something like Alocril (nedocromil sodium ophthalmic solution 2%, Allergan), Alamast (pemirolast, Santen) or Alomide (lodoxamide, Alcon). All of those pure mast cell stabilizers may work a little bit better chronically than the combined mast cell antihistamine products.
For more information:
- Peter A. D’Arienzo, MD, FACS, can be reached at Manhasset Eye Physicians, PC, 1615 Northern Blvd., Manhasset, NY 11030; 516-627-0146; fax: 516-365-4750; e-mail: eyedoc63@aol.com. Dr. D’Arienzo has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Eric D. Donnenfeld, MD, FACS, can be reached at OCLI, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com. Dr. Donnenfeld is a consultant for Alcon, Allergan, Bausch & Lomb, InSite and Inspire.
- Marguerite B. McDonald, MD, can be reached at OCLI, 266 Merrick Road, Lynbrook, NY 11563; 516-593-7709; fax: 504-232-3641; e-mail: margueritemcdmd@aol.com. Ocular Surgery News could not confirm whether Dr. McDonald has a direct financial interest in the products mentioned in this article or if she is a paid consultant for any companies mentioned.
- Michael B. Raizman, MD, can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; e-mail: mraizman@tufts-nemc.org. Dr. Raizman receives research support from, consulting fees from or is on the speaker’s bureau of Alcon, Allergan, Bausch & Lomb and Inspire.
- Christopher J. Rapuano, MD, can be reached at Wills Eye Institute, 840 Walnut St., Suite 920, Philadelphia, PA 19107; 215-928-3180; fax: 215-928-3854; e-mail: cjrapuano@willseye.org. Dr. Rapuano is a consultant and lecturer for Allergan and a lecturer for Alcon and Inspire.
- Charles B. Slonim, MD, FACS, can be reached at Older and Slonim Eyelid Institute, 4444 East Fletcher, Suite D, Tampa, FL 33613; 813-971-3846; fax: 813-977-2611; e-mail: slonim@eyelids.net. Dr. Slonim is a consultant for Bausch & Lomb and Meda Pharmaceuticals.