Drops, new solutions offer relief for contact lens wearers with seasonal allergy

Issue: April 1999

Springtime is here, and the pollen and other environmental allergens that accompany it will bring into the office allergy sufferers who are finding it difficult to wear their contact lenses due to ocular itching, irritation and redness. What is the best course of action for these patients who are suffering with seasonal allergies but want to continue wearing their lenses?

Before considering the medication and contact lens options, the practitioner should determine the nature of the allergy, said Charlotte Tlachac, OD, who is in private practice and also teaches part time at the optometry school at the University of California in Berkeley. “There are two basic categories of allergies to consider,” said Dr. Tlachac in an interview with Primary Care Optometry News. “If patients are allergic to the contact lens system itself, giving the patient new lenses and changing the system will fix the problem. They’re either allergic to the solutions that are being used or the buildup of the chemical solution on the lenses over time. If they have environmental allergies, their eyes are irritated and itchy, so the main issue there is to control the allergy.”

Systemic medications cause dryness

Eye dryness and itchiness experienced during allergy season can be a direct result of oral medications that the patient may already be taking to relieve other allergy symptoms, said Robert Ryan, OD, in private group practice in Rochester, N.Y. “Many of the systemic antihistamines may carry the side effect of drying the ocular surface,” he said. “That would further exacerbate any allergic-type responses because a healthy pre-corneal tear film will help offset some of the effects of an allergic response.”

Dr. Tlachac agreed that the worse the allergies, the more medication the patients take, which results in increased dryness. “When that happens, they will need to use more drops or a lens that’s a little friendlier for dry eyes.” For a patient with minimal ocular allergies, she said, using a lubricant drop just to rinse the eye and rid it of pollen or related environmental irritants is usually effective.

Tears, saline effective

Dr. Ryan advises a similar course of action, employing either rewetting drops or saline solution. “Our stepladder approach is to simply lubricate and lavage the surface to dilute any allergens that may be present,” he said. “If patients with relatively mild allergies rinse their eyes with a balanced salt solution early in the morning before they put their lenses in, again in the middle of the day and toward the end of their wear schedule, they find that simple dilution process is sufficient to keep them comfortable. During the course of the day, they can use lens lubricating drops if they are wearing their contacts or additional rinses. As simple and benign as it sounds, it can be very effective.”

OTC drops for moderate symptoms

A patient with more moderate ocular allergies may benefit from a drop containing agents that will help relieve some of the symptoms rather than just keep the surface moist. “If the symptoms are a little more dramatic — more itching and discharge — but the patient is not miserable and doesn’t have a lot of other systemic symptoms, we’ll go with an over-the-counter type ocular drop such as OcuHist (pheniramine maleate, naphazoline HCl, Pfizer),” Dr. Tlachac said. “Any drop that has a mild decongestant and a mild astringent will keep the eyes comfortable and allow the patient to continue wearing the lenses the majority of the time.”

Dr. Ryan agreed, recommending Opcon-A (naphazoline HCl, pheniramine maleate, Bausch & Lomb) as a decongestant and to aid in easing redness.

Thomas G. Quinn, OD, MS, in group practice in Athens, Ohio, considers each symptom separately when prescribing medication. “If patients are having most of their problems with itching, then I’ll consider prescribing an anti-inflammatory nonsteroidal drop such as Acular (ketorolac tromethamine, Allergan),” he said. “If their chief complaint is redness, I’ll lean toward Livostin (levocabastine HCl, Ciba Vision). If their complaints concern mucus production, I’ll lean more toward a mast-cell stabilizer such as Alomide (lodoxamide tromethamine, Alcon) or cromolyn sodium.”

Treating severe allergies

All three practitioners agreed that when the condition is more severe, an ocular drop such as Patanol (olopatadine HCl ophthalmic solution, Alcon) is the next line of therapy. “We use Patanol when patients have quite severe symptoms,” Dr. Tlachac said. “Usually, by that time, they’re also taking a systemic medication, which tends to work on the eye area just as it does on the nasal area. So, the benefit is that the medication decreases the itching; the downside is that it often decreases the tearing, so patients have to supplement with a lubricant drop. The severe allergy patients are generally using everything, and they’re pretty in tune with the fact that they’re not going to be a full-time contact lens wearer on their bad days.”

Dr. Ryan said that using either Alomide or the combination mast-cell stabilizer and antihistamine Patanol is an effective prophylactic approach for a patient who develops an allergy every spring. “If someone has an acute response, a mast-cell stabilizer isn’t going to alleviate his or her symptoms immediately,” he said. “But it’s going to help prevent any further release, and it’s a very safe drop for patients to be on prophylactically.”

Dr. Quinn advised using the twice-daily Patanol once before inserting the lenses and once after removal. Dr. Tlachac, however, said that the contact lens can actually work in conjunction with solutions that are used to help alleviate allergic reactions. “Particularly if patients are using a shorter life lens, the drug isn’t going to damage the lens in the long run, so they can put the drop in with the lens on,” she said. “The lens releases the drug slowly during the course of the day, and patients get more effect from it, so the contact lens actually becomes part of the treatment.”

When to change the lens

Before making the decision to change a patient from one type of lens to another, Dr. Tlachac said, the practitioner should first try a topical solution to alleviate the symptoms. “It’s always simplest to change drops and solutions; it’s more difficult to go through a re-fitting and try to guess what aspect of the contact lens is causing the problem,” she noted. “It rarely is the lens causing the problem, so you have to manage the allergy first. Once you’ve done that and the patient is still having problems you can consider evaluating the lens, even though there’s a likelihood of limited success with full-time wear.”

The optometrist should consider the patient’s history as well when considering a lens switch, said Dr. Ryan. “If patients say they have never had a problem while wearing lenses until now, and I determine that the problem is allergic in nature, I will try to treat the condition rather than changing the lens,” he said. “If a patient has had a recurring history of this problem, I may consider a combination of prophylaxis and changing their lens care system.”

Recommend frequent replacement

As a general rule, said Dr. Quinn, the more often contact lenses are replaced, the better. “In terms of soft lenses, the most frequently replaced lens is the best lens,” he said. “People with ocular allergies tend to coat their lenses more quickly, which then aggravates the allergy and sets up a negative cycle. Another benefit of the 1-day lens, the extreme of frequent replacement lenses, is that we don’t have to expose that lens to chemicals, because allergic eyes tend to also be sensitive to chemicals in care systems.”

Sometimes, deciding whether to treat the allergy with medication or change to a different type of lens simply depends on the appearance of the lens the patient is currently wearing, said Dr. Quinn. “If all indications suggest that the patient is changing the lens with the frequency that he or she is supposed to, then prescribing a drop may do the trick,” he said. “But if the presentation is more severe, or if there’s something in the history that makes me doubt the patient is really taking care of the lens the way he or she should, I’ll be more likely to suggest a switch to a more frequently replaced lens. Then maybe we’ll combine that with a drop, depending on the level of inflammation present. Sometimes I’ll leave that up to the patient.”

Keep a lens that works well

Dr. Tlachac agreed that if the lens appears well cared for and relatively free of deposits, keeping a patient in his or her current lens type is the best route. “If patients are wearing a dirty annual lens, you may want to change the lens first because the lens is obviously stimulating the eye and causing more problems,” she said. “But if what they’re wearing looks good, fits well and looks fairly clean, it makes sense for them to wear this material. You don’t change the material if you haven’t gone through the full range of controlling the disease process itself.”

She urged that if you do make the switch to another lens, make a conscious effort to choose one with a varying thickness or water content. “The common wisdom now for dry eyes is that you look for a lower water contact lens, which tends to desiccate more slowly, so it will stay moister for a little bit longer,” she said. “Among all of the standard materials, there doesn’t seem to be a tremendous benefit in changing patients from one to the other if you don’t make a significant change in either thickness or water content. Disposables are very similar in water content and thickness, so you don’t often get much benefit from going from one disposable to another.”

Consider daily disposables

The practitioners agreed that for some patients, switching to a 1-day disposable lens during their peak allergy period is the solution. “From an economic point of view, it might not be feasible for them to wear a daily disposable every day,” said Dr. Tlachac. “During most of the year, they may be comfortable with a 1- or 2-week lens, but they just can’t get that much time out of them during their really bad season. If they use a daily disposable, they’re always putting in a clean lens and not stimulating the allergy by putting in a lens that has debris, mucus and pollen on it.”

Dr. Quinn said that after trying a 1-day lens, many patients have such success that they never go back. “In my experience, most people enjoy the 1-day lens and end up staying with it all year round,” he said.

Recommend protein removers

Some advise tailoring the lens care regimen to the severe allergy season. Dr. Quinn said that patients should concentrate on digital cleaning more than ever, and even consider protein removers, even if the lenses are the frequent replacement type. “I am convinced that a lot of patients, when they take their lenses out, do not rub them,” he said. “If they’re not getting that abrasive action of rubbing the lenses before they store them, encourage them to do that. Usually I don’t recommend to patients with 2-week replacement lenses SupraClens (Alcon) or any kind of a care system that requires protein removal. But if they’re in the throes of allergy or showing superior tarsal plate changes, I think it’s a nice addition, even if they’re changing the lens every 2 weeks.”

Dr. Ryan said that the lens care system should contain a surfactant to aid in the cleaning process, something often not found in multipurpose solutions. “The regimen changes when I become aware of a patient who has an allergic profile,” he said. “These patients should try a preservative-free product, such as an oxidative system.”

He recommended Quick Care (Ciba Vision), an in-hand disinfection system preserved with a mild peroxide-based system that quickly breaks down on contact with the tear film to a solution of oxygen and water. “It’s a very homeopathic, non-aggravating system,” he said. “The other benefit is that its cleaner contains isopropyl alcohol, which is an effective surfactant to debulk the lens of debris and minimize the deposition of proteins and lipids. Therefore, it also frees the surface of many allergens with which it may come in contact.”

While Dr. Tlachac touts the use of nonpreserved systems for the allergy-prone patient to reduce the incidence of ocular stimulation and irritation, she said that such a lens care system should be the norm for such patients. “Once patients start using that, it’s best to keep them on it,” she advised. “When patients have an allergy profile, there are usually some things that irritate them minimally all year long and then they just blow up during ragweed season or in the spring or the fall, depending on their specific allergy,” she said. “Switching back and forth between solutions is probably more complicated for patients than to just find something that works during their most difficult time and will certainly work during times when life is a little easier.”

For Your Information:

Charlotte Tlachac, OD, can be reached at Island Eyecare, 1429 High St., Alameda, CA 94501; (510) 522-5097; fax: (510) 522-0815. Dr. Tlachac has no direct financial interest in the products mentioned in this article nor is she a paid consultant for any companies mentioned.

Robert Ryan, OD, can be contacted at 169 Rue de Ville, Rochester, NY 14618; (716) 271-2990; fax: (716) 271-6321. Dr. Ryan has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Thomas G. Quinn, OD, MS, may be reached at 416 West Union St., Athens, OH 45701; (740) 594-2271; fax: (740) 594-2270; e-mail: tquinn@eurekanet.com. Dr. Quinn has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.