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Allergic conjunctivitis identified by symptomatic giveaways
Newer-generation antihistamines can provide quick relief for those with allergies.
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Allergic conjunctivitis can result in eye inflammation caused by an allergic reaction to mold or pollen spores, but several treatments are available to decrease and alleviate symptoms.
Patients who complain of itchiness and present with white, stringy discharge are “dead giveaways” for a diagnosis of allergic conjunctivitis, Melissa Toyos, MD, FACS, told Ocular Surgery News.
“Mainly, I listen for the patient’s complaint of itchiness. It’s a dead giveaway. They will also nod their heads when you ask about white, stringy discharge. In Tennessee, where our allergy season blazes year-round, it is common for me to make the diagnosis as soon as I lay eyes on them. Many of our patients have that classic boggy-appearing conjunctiva that you can spot across the room. Papillary conjunctival changes at the slit lamp generally confirm what I already suspect,” she said.
Rule out underlying causes
A confirmed diagnosis of allergic conjunctivitis is typically made after an examination by an eye care professional rules out any other underlying condition such as blepharitis, dry eye disease, meibomian gland dysfunction or preservative toxicity, Alice T. Epitropoulos, MD, FACS, told OSN.
Common hallmark signs and symptoms of the disease include redness, itching, lid swelling and papillary reaction involving the palpebral conjunctiva, she said.
“Allergy skin testing, such as Doctor Rx’s Allergy Formula (Bausch + Lomb), can be performed to aid the clinician in diagnosing ocular surface disease, when to treat allergies and what allergens to avoid. The company’s tests are designed precisely for each area of the country and its allergic triggers. The test takes about 20 minutes and is performed by a technician with a physician in the building,” Epitropoulos said.
Avoidance of the causative agent is the first step toward managing allergic conjunctivitis. However, for mild allergic presentations, patients can use artificial tears along with cool compresses, and instructions to avoid eye rubbing can work well, she said.
Antihistamines are effective
Treatment can also begin with patients taking a newer-generation antihistamine, Toyos said.
“They are fast and effective ways to control and prevent symptoms and can be used year-round. I also look for signs of dryness, which often accompany allergy because of the common inflammatory pathway. Shoring up a patient’s natural tear film is another way to help them protect themselves from environmental allergens. I’ll add a steroid for a week or two if the allergy is particularly debilitating and save T-cell inhibitors for the worst of the worst cases,” she said.
If medications are needed, Epitropoulos said topical steroids such as Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch + Lomb), which contains a glycerin moisturizer, can provide relief for patients. Other categories include mast cell stabilizers, which help prevent the release of pro-allergy mediators, and antihistamines, which block histamine from binding to its receptors after it already escaped from the mast cell.
“I prefer combination therapy, which includes a mast cell stabilizer and selective H1-blocking agent such as Bepreve (bepotastine besilate ophthalmic solution 1.5%, Bausch + Lomb) or Lastacaft (alcaftadine ophthalmic solution 0.25%, Allergan). Not only do they provide rapid and long-lasting relief of the itch, but they also prevent exacerbating dry eye disease and prevent the allergic cascade from occurring. Other therapies include topical NSAIDs, which may reduce itching secondary to prostaglandin release,” she said.
Wean off medications
Despite the effectiveness of allergy medications, ophthalmologists should try to wean patients off medications if they begin to adversely affect their ocular health, Toyos said.
“I work hard to get patients off systemic allergy medications, as they all contribute to ocular dryness, and to treat dry eye when I see it in allergy patients. My best solution is usually some combination of topical eye drops with nonsteroidal antihistamine nasal sprays. Worrying about side effects of indiscriminate over-the-counter Flonase (GlaxoSmithKline) keeps me up at night,” she said. – by Robert Linnehan
- For more information:
- Alice T. Epitropoulos, MD, FACS, can be reached at The Eye Center, 262 Neil Ave. #430, Columbus, OH 43215; email: eyesmd33@gmail.com.
- Melissa Toyos, MD, FACS, can be reached at Toyos Clinic, 2204 Crestmoor Road, Nashville, TN 37215; email: mtoyos@toyosclinic.com.
Disclosures: Epitropoulos reports she is a consultant and speaker for Allergan and Bausch + Lomb. Toyos reports no relevant financial disclosures.