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OSN New York round table: Management of a patient presenting with persistent allergic irritation
Four experts discuss diagnosis and management of allergic sensitivities and eczema.
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In this edited excerpt from the Cornea Health round table at OSN New York 2015, OSN Cornea/External Disease Board Member Eric D. Donnenfeld, MD, uses case-based examples to lead a group of experts through thoughtful discussion on diagnosis and management of the ocular manifestations of allergic sensitivities and eczema.
Eric. D. Donnenfeld, MD: Here is the case: A 43-year-old man has itching, irritation and redness for several months that does not respond to topical antibiotics (Figure 1). He has been on tobramycin drops and has not gotten better. He has some lichenification of his lower lids. There is some white, some hyperemia and some fissuring of his skin. What is this?
Marguerite B. McDonald, MD, FACS: It looks atopic to me. The lichenification, the asymmetry of it, too, when looking at both eyes, is different than classic allergic conjunctivitis. Airborne allergens usually bother both eyes at the same rate to the same degree, whereas atopic disease does not.
Alan R. Faulkner, MD: Another sign is the allergic shiner [not shown]. The patient has an inferior shiner that resembles a punch to the nose. And that is typical of a chronic allergic disease, hyperpigmentation.
Donnenfeld: Eczema, atopy, would certainly look like this. What is the pathology of the white skin?
Roundtable Participants
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Moderator
- Eric D. Donnenfeld
- Alan R. Faulkner
- Marguerite B. McDonald
- Henry D. Perry
Henry D. Perry, MD: The pathology here is increased activity of melanocytes under the skin, which causes the hyperpigmentation, and the chronic inflammation stimulates these melanocytes. It is good for these patients to stay out of the sun. One of the problems is that these patients keep rubbing their eyes, and they get little hemorrhages and hemosiderin deposits in this area that further darkens their skin.
Donnenfeld: Was the antibiotic a good idea?
Perry: No.
Donnenfeld: Why not?
Perry: It makes them worse.
Donnenfeld: That is a very concise answer. Much appreciated. This is clearly not an infection. This is an inflammation. And that is one of the things we do sometimes, we keep people on antibiotics or antivirals for a long time when the infection is gone.
McDonald: You mentioned the fissures. Old age gives you horizontal wrinkles, but atopic disease gives you vertical wrinkles, and eventually they break down and become actual fissures. In this case, they are more accentuated nasally.
Donnenfeld: The patient has eczema, which sometimes can be seen by looking at the patient’s flexor/extensor surfaces (Figure 2). This patient obviously needs systemic therapy to be treated. Besides stopping the tobramycin, how should this case be managed?
Perry: This is one of the toughest patients to take care of because you are not only dealing with a patient who has a significant allergic eye disease — blepharitis — but you are also looking for systemic problems, and often when you have a patient with this severity of disease, you need to keep him on various systemic medications. I usually manage these patients in conjunction with a dermatologist, and we do a complete profile in terms of allergens. I think it is important to do sensitivity testing in these patients.
Faulkner: I agree with Hank. These are difficult patients to manage, and you need the assistance of a systemic specialist, typically an allergist or sometimes a rheumatologist. We do have some new local medications that are helpful, that are preservative-free and that can be applied around the eye. An ointment formulation of loteprednol etabonate that is preservative-free is very useful in helping with these patients because it gets rid of the benzoyl chloride or the other allergens that make the condition worse and includes an ester corticosteroid that is less likely to cause elevated IOP or cataract genesis in this phakic individual.
Perry: Is that applied to the eye or to the lid skin?
Faulkner: The lid skin. Typically, a topical mast cell stabilizer antihistamine is not enough for these patients. Sometimes they do need some topical pulse steroid. I have used topical cyclosporine, usually about 2%, and they do feel burning and stinging. The other option is to use the brand emulsion and increase the dose to four times a day, which is tolerated very well.
Donnenfeld: I do not see a role for 2% cyclosporine any longer. Restasis (Allergan) brand of cyclosporine given four times a day would be a very reasonable thing to do in these patients, as well as giving low-dose steroids and systemic therapy.
Images: Donnenfeld ED
A lot of patients have allergens that affect them, and they can do some simple things such as getting rid of feather pillows or getting rid of the rugs. Marguerite, you have been doing allergy testing for a while. Tell us about it.
McDonald: When I test with Doctor’s Allergy Formula (Valeant/Bausch + Lomb), it is a bit different than what allergists do because I am testing for 60 airborne allergens, 50 common to the Eastern seaboard plus 10 other things, including cat dander, dog dander, dust mites and feather mix, whereas a lot of the things that an allergist will test for are things you ingest — peanuts or shellfish — or creams that go on the skin. They test for some airborne allergens, but not as exhaustively as we do because we care about what is in the air. We schedule patients on a day when they do not have an eye exam, they go straight to the allergy suite, and in 10 minutes we know what they are allergic to. It helps us guide our topical and/or systemic therapy and helps the patient with avoidance therapy.
Donnenfeld: Or it may dictate therapy as well as eliminating possible allergens from their environment. Say you are using an anti-allergen drop once a day. You find that the patient is allergic to dander, which causes them trouble sleeping at night, so you give them a drop at night before they go to sleep. Well, if they are allergic to something outdoors, you give it to them when they wake up.
McDonald: One more thing about a patient with eczema. If you see someone with unilateral blepharitis, meibomian gland disease, it is often caused by weeks and months of tobramycin or Viroptic (trifluridine, Pfizer) use. It can cause a closure of the meibomian gland orifices, so that is kind of a red flag for this sort of abuse.
- For more information:
- Eric D. Donnenfeld, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 N. Village Ave., Rockville Centre, NY 11570; email: ericdonnenfeld@gmail.com.
- Alan R. Faulkner, MD, can be reached at Aloha Laser Vision, 100 Ward Ave., Suite 1000, Honolulu, HI 96814; email: dralan@alohalaser.com.
- Marguerite B. McDonald, MD, FACS, can be reached at Ophthalmic Consultants of Long Island, 360 Merrick Road, Lynbrook, NY 11563; email: margueritemcdmd@aol.com.
- Henry D. Perry, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 N. Village Ave., Rockville Centre, NY 11570; email: hankcornea@gmail.com.
Disclosures: Donnenfeld reports he is a consultant for AcuFocus, Allergan, Alcon, Abbott Medical Optics, AqueSys, Bausch + Lomb, Beaver-Visitec, CRST, Elenza, Glaukos, Icon Biosciences, Kala Pharmaceuticals, Katena, LacriPen, Mati Pharmaceuticals, Merck, Mimetogen, NovaBay, Novaliq, OcuHub, Odyssey Medical, Omega Ophthalmics, Omeros, Pfizer Ophthalmics, PRN Pharmaceutical, RPS, Shire, Strathspey Crown, TearLab, TearScience, The Laser Centers, TrueVision, Versant Venture, WaveTec and Carl Zeiss Meditec. Faulkner reports he receives consulting fees from Alcon; is on the speakers bureau for Alcon, Bausch + Lomb and WaveTec Vision; and has ownership interest in Strathspey Crown/Alphaeon. McDonald reports she is a consultant for Abbott Medical Optics, Alcon, Allergan, Bausch + Lomb, Focus Laboratories, Oculus, TearLab and TearScience. Perry reports no relevant financial disclosures.