At Issue: Tears, cold compresses popular first-line treatment for ocular allergy

Issue: April 1999

Bruce E. Onofrey, RPh, OD, FAAO: It may surprise many people that my first-line therapy for seasonal allergic conjunctivitis is artificial tears. I am a strong believer in “step” therapy of ocular disease, that is, starting conservatively and fitting the treatment to the severity of the disease. More aggressive therapy can be added only if initial therapy proves unsuccessful.

I believe that the symptoms associated with mild to moderate allergic conjunctivitis can best be relieved initially with intensive artificial tear therapy. Artificial tears help “soothe” the eye by normalizing tear chemistry. They are able to debulk the antigen via dilution and a rinsing effect. In conjunction with this treatment, Livostin (levocabastine HCl, Ciba Vision) or a topical mast-cell stabilizer/antihistamine agent such as Patanol (olopatadine HCl, Alcon) can be added to the treatment regimen. More severe allergic disease (ocular anaphylaxis) can be managed with short-term use of a soft steroid such as Alrex (loteprednol etabonate 0.2%, Bausch & Lomb), the only topical steroid specifically approved for the management of seasonal allergic conjunctivitis. The drug is extremely effective with a very low incidence of steroid adverse effects.

The key to appropriate therapy is to tailor treatment to the individual. Start simple, but be aggressive if the severity of the presentation demands aggressive, yet safe therapy.

Bruce E. Onofrey, RPh, OD, FAAO, is responsible for primary care eye services at Lovelace Medical Center, Montgomery Eye Clinic, 9101 Montgomery Blvd., NE, Albuquerque, NM 87111; (505) 275-4226; fax: (505) 275-4203; e-mail: Eyedoc3@aol.com. Dr. Onofrey has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Joseph P. Shovlin, OD: Choosing the proper therapeutic agent as a first-line therapy depends on the severity of signs and symptoms. A simple first-line or adjunct remedy includes cold compresses, which stabilize mast cells and cause vasoconstriction. Artificial tears (unpreserved or suitable substitutes are recommended with frequent dosing) may also be used as an effective adjunct to dilute the allergen.

When conjunctival inflammation and irritation are the main findings, topical nonsteroidal anti-inflammatories are a safe and effective treatment. Their mechanism of action includes blocking the cyclooxygenase pathway and formation of inflammatory mediators. Increased epithelial toxicity is likely with prolonged use, especially in the dry eye patient.

Topical antihistamines can be the drug of choice when itching is the primary symptom, and concomitant use of oral antihistamines can relieve systemic allergic response. Oral medications are often necessary because allergic conjunctivitis may be coupled with allergic rhinitis. Most of the topical antihistamines include a decongestant. The absence of an alpha-adrenergic vasoconstrictor is a better choice for patients with cardiovascular disease or patients who may be taking monoamine oxidase inhibitors.

Broader spectrum efficacy and relative safety make a mast-cell stabilizer attractive, despite the fact that this agent requires a loading time of a few days and continuous use for maintenance therapy. With the recent addition of combination topical agents such as Patanol, a mast-cell stabilizer/antihistamine with significantly increased efficacy, practitioners now have a potent first-line topical therapy with an attractive safety profile. A twice-a-day dosing regimen helps with compliance.

Topical steroids are reserved for severe atopic, allergic and vernal reactions of the eye. Although these agents can suppress allergic cascades, and although some of the newer site-specific options minimize risk, steroid use is fraught with potential ocular complications such as cataract formation, glaucoma, delayed wound healing, enhanced susceptibility to infection and rebound anterior uveitis. Those steroids with poorer corneal penetration (i.e., loteprednol, fluorometholone and medrysone) will minimize risk. Once the symptoms diminish, other anti-allergy medications should be substituted.

Joseph P. Shovlin, OD, is in private practice at the Northeastern Eye Institute; 200 Mifflin Ave., Scranton, PA 18503; (717) 342-3145; fax: (717) 344-1309; e-mail: jshovlin@aol.com. Dr. Shovlin has no direct financial interest in the products mentioned in this article. He is a paid consultant for Alcon on a per diem basis.

Gary E. Oliver, OD: My first-line medication for seasonal allergic conjunctivitis is Patanol. This drug is a mast-cell stabilizing agent with antihistamine properties, which makes it ideal for seasonal therapy, particularly when therapy is required for several weeks. It has the ability to inhibit the basis of seasonal allergy — mast-cell degranulation — and block the action of histamine in the tear film. Both of these processes are involved in creating the patient’s allergic symptoms and clinical findings, which usually consist of itching, redness, tearing, chemosis and papillary hypertrophy. Patanol is usually prescribed twice per day and should be continued throughout the patient’s allergy season to be most effective. If necessary for more severe exacerbations of the allergic conjunctivitis, other ocular allergy medications, such as the topical antihistamines levocabastine HCl or emedastine difumarate, or topical steroids can be used concurrently with Patanol. These medications would be used more in a pulse dose fashion for 3 to 4 days with Patanol and then discontinued. Patanol is then continued for seasonal maintenance therapy.

Gary E. Oliver, OD, is the executive director of the TLC Plymouth Meeting Laser Center. He can be reached at TLC The Laser Center, 600 W. Germantown Pike, Ste. 160, Plymouth Meeting, PA 19462; (610) 940-3937; fax: (610) 940-9566. Dr. Oliver has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

John P. Herman, OD, FAAO: I recommend that patients either avoid the allergen or take an over-the-counter antihistamine prior to an activity that results in a significant allergic reaction. I further advise patients:

Cold quells itching and reduces edema. Therefore, a swollen, red, itchy eye can frequently be helped by simply applying cold washcloths or ice wrapped in a wet washcloth.
Saline rinses, artificial tears or topical decongestants can be used to rinse the allergens from the eye, as well as reduce the hyperemia and chemosis.
Mast-cell stabilizers can be applied two to four times per day as needed, but I most frequently recommend Patanol, as it combines the mast-cell stabilizer with antihistamine, and it can frequently be used less often. I usually prescribe it two times per day and up to three times per day as needed.
Where the problem is acute and short-lived, nonsteroidal anti-inflammatories can be used; I most often recommend Acular (ketorolac tromethamine, Allergan). I avoid the use of steroids as much as possible in these cases and prescribe them only when other therapies are inadequate.

The simplest method of managing things clinically is most likely to be carried out by the patient. I do not necessarily believe in “blasting away” with maximum therapy when the patient has a mild complaint of allergic-based itching. One must gauge the degree of anxiety associated with the signs and symptoms and prescribe accordingly. Another factor I always consider is the cost of the treatment for the patient.

John P. Herman, OD, FAAO, is in private group practice in Pittsfield, Mass., where he has practiced since 1973, and can be reached at 217 South St., Pittsfield, MA 01201; (413) 499-3937; fax: (413) 499-3834. He has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Mark W. Swanson, OD: It’s very dependent on the individual circumstances. Most seasonal allergic conjunctivitis I see is accompanied by seasonal allergic rhinitis. I generally prescribe one of the nonsedating oral antihistamines in those instances. Patients seem to do will with Claritin (loratadine, Schering) or Claritin-D (loratadine and pseudoephedrine, Schering). Patients like the once-a-day dosing, and side effects are rare. In instances where the complaint is strictly ocular, I generally recommend one of the over-the-counter topical antihistamines first.

Mark W. Swanson, OD, can be reached at (205) 934-6769; fax: (205) 934-0911. Dr. Swanson did not disclose if he has a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.