Anti-allergy eye drops can effectively treat nonocular symptoms

Clinicians urge their allergy patients to avoid systemic agents that can cause ocular dryness.

A growing chorus of research and clinical experience is showing that prescribing anti-allergy eye drops to treat nonocular symptoms is a much better solution than relying on oral medications that can cause significant dry eye.

Paul M. Karpecki

“Almost all the topical allergy medications, including anti-histamine/mast-cell stabilizer agents and topical corticosteroids, can improve systemic symptoms of allergies, and some such as bepotastine besilate have clinical data that show an improvement in nonocular symptoms,” Paul M. Karpecki, OD, FAAO, clinical director of cornea services and ocular disease research at Koffler Vision Group in Lexington, Ky., told Primary Care Optometry News. “It makes sense that by putting drops in the eyes, the drops will pass through the punctum and nasolacrimal sac and into the nasal passage, then down the throat. This is the area of the body where systemic allergy symptoms such as nasal congestion, itchy palate and itchy throat play the biggest role.”

Oral agents cause ocular drying

Dr. Karpecki typically recommends that patients discontinue their oral antihistamines until their ocular symptoms are under control because oral agents “can significantly dry the eyes and exacerbate ocular problems,” he said. “The drying can actually cause many more problems on the ocular surface. It is amazing how well eye drops alone help with systemic allergy symptoms.”

The eye drop with the most impact in Dr. Karpecki’s practice has been Bepreve (bepotastine besilate ophthalmic solution 1.5%, Ista).

While Bepreve is not indicated for nasal symptom relief, Dr. Karpecki said, “Patients comment, almost unequivocally, how much this particular eye drop relieves the nonocular symptoms, especially nasal congestion.”

Patients apply Bepreve twice a day for about 2 weeks. “Most people notice a marked improvement in 2 to 3 days, especially for nasal congestion and itchy palate,” he said. “Bepreve has been studied for nonocular effects in clinical trials.”

Patanol (olopatadine HCl ophthalmic solution 0.1%, Alcon) and Elestat (epinastine ophthalmic, Allergan/Inspire) are two other eye drops in the same class as Bepreve that have helped patients with nonocular symptoms, Dr. Karpecki said.

Moreover, preservative-free artificial tears during the daytime “can sometimes help clear the drains,” he said.

Ocular steroids, nasal inflammation

Steroid drops such as Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch + Lomb) or Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb) can also help.

“Because they drain into the same area, these drops probably help with inflammation,” Dr. Karpecki said.

A number of companies have gone to great lengths to promote how their nonocular sprays (such as Veramyst [fluticasone furoate, GlaxoSmithKline]) can help the ocular surface, Dr. Karpecki said. “However, I think the future is that it probably works better the other way around. By putting a product in your eye, gravity is on your side. It will drain down into the nasal pathways and into the throat. This makes much more sense.”

Conversely, the future for oral formulations is bleak, said Dr. Karpecki, unless there are no drying effects. “Optometrists should focus on using ocular medications for nonocular symptoms,” he said.

Related research

Mark B. Abelson, MD, a clinical professor of ophthalmology at Harvard Medical School, as well as senior clinical scientist and trustee at Schepens Eye Research Institute, has conducted studies evaluating the effect of eye drops on nasal airflow, nasal obstruction and congestion, sneezing and nasal discharge.

“We have used some novel fiber-optic technology at the nasal mucosa, before and after an eye drop, to define the scope of clinical, measurable effectiveness for various signs and symptoms of allergic rhinitis,” Dr. Abelson said in an interview. “In a nutshell, these eye drops work – particularly the once-a-day products: Pataday (olopatadine HCl 0.2%, Alcon) and the newsest anti-allergic, Lastacaft (alcaftadine 0.25%, Allergan) and combination agents still in the pipeline. They work for each of the objective and subjective parameters, largely the objective ones, which are structural. The drops increase the nasal mucosal flow and airflow and decrease discharge and sneezing.

“In essence, the pollens and mediators of ocular allergy can induce nasal allergies when draining through the nasolacrimal duct,” he continued. “Topical anti-allergics can modulate the severity of these symptoms.”

Dr. Abelson noted that 90% of patients afflicted with allergic conjunctivitis have nasal allergies as well.

“When looking at the eye, do not forget that there is a nasolacrimal duct connecting the eye to the nose,” he said. “Speak to the patient about his or her symptomatology in the nose as well as the eye. Insofar as it helps with the diagnosis, selection of therapy and monitoring the effectiveness of therapy, it is reasonable to consider that rhinoconjunctivitis is really the condition we are treating.”

Prescribing ocular agents for asymptomatic patients

Blair B. Lonsberry, OD, MS, MEd, FAAO, clinic director at Portland Vision Center, Pacific University College of Optometry, pointed out that 50% of the population has allergies, and 80% of that group also has ocular symptoms.

“Hence, for any of my allergy patients, even if they are not exhibiting ocular symptoms, I recommend a topical medication such as Patanol, Pataday, Elestat or Bepreve,” Dr. Lonsberry told PCON. “I suspect the rhinitis improves because the tears drain into the back of the nose.”

However, Dr. Lonsberry typically shies away from prescribing oral allergy medications such as Benadryl (McNeil Consumer Healthcare), Claritin (Schering-Plough) and Zyrtec (McNeil Consumer Healthcare).

“I find they do not help much with ocular conditions,” he said. “For the most part, I find oral agents tend to dry the eyes and do not address the itchy symptoms.”

As for the future of ocular allergy medications to treat nonocular symptoms, many of the newer agents “are very potent, like histamine 1 (H1) blockers,” Dr. Lonsberry said.

“We are also looking at the dual mechanism of a Patanol/Pataday, for example, where not only do you achieve the histamine blockage, but mast-cell stabilization, too,” he said. “This actually prevents the release of histamines from the mast cells. We need to find ways to stabilize the mast cells so they don’t degranulate in the first place.”

The topical Bepreve originated in Japan as an oral antihistamine, according to Mel Friedman, OD, a private practitioner in Memphis, Tenn. The eye drop formulation is targeted “specifically for allergic conjunctivitis,” he said in an interview. “Its primary endpoint is to relieve itching.”

Dr. Friedman said at least one study shows that oral antihistamines cause a 30% reduction in tear volume. “This is extremely significant,” he said. “I’ve been able to take many of my patients off their antihistamine and use Bepreve instead. The secondary endpoint of Bepreve reduces the rhinitis or the runny nose, and it does so without drying the eyes. There are no contraindications for Bepreve.”

Furthermore, the eye drop is appropriate for children as young as 2 years.

“Bepreve is a highly H1-specific antihistamine,” Dr. Freidman said. “As a result, the muscarinic effect – dryness of eyes, dryness of mouth and drowsiness – is reduced.”

On-label use of Bepreve is twice daily. For off-label use of Bepreve in contact lens wearers with giant papillary conjunctivitis, Dr. Freidman may prescribe the drop once in the morning with the contact lenses in place and once in the evening with them removed. “Unlike any other drug, Bepreve has allowed me to take my patients off oral antihistamine,” he said. “These patients are also able to wear contacts much more comfortably.”

Alcon is marketing Patanase (olopatadine HCl nasal spray) and Ista is developing a nasal spray formulation of Bepreve. – Bob Kronemyer

• Mark B. Abelson, MD, can be reached at (978) 685-8900; mbabelson@oraclinical.com.
• Mel A. Friedman, OD, can be reached at (901) 737-4393; dfried007@aol.com.
• Paul M. Karpecki, OD, FAAO, is a PCON Editorial Board member. He can be reached at (859) 263-4631; paul@karpecki.com.
• Blair B. Lonsberry, OD, MS, MEd, FAAO, can be reached at (503) 352-2510; blonsberry@pacificu.edu.
• Disclosures: Drs. Abelson, Friedman, Karpecki and Lonsberry have no direct financial interest in the products mentioned in this article. Dr. Abelson is a consultant for Alcon. Dr. Friedman is a paid national consultant for Ista. Dr. Karpecki is a paid consultant for Alcon, Inspire and Ista. Dr. Lonsberry is a paid consultant for Alcon, Inspire and Ista.