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Help allergy sufferers wear contact lenses more comfortably
Allergies affect about 25% of the general population and are even more widespread among young patients and those with keratoconus.
“These two groups represent the core of my contact lens practice,” said Arthur B. Epstein, OD, FAAO, a senior partner of North Shore Contact Lens and Vision Consultants, in Roslyn Heights, N.Y. “Between 40% and 50% of my contact lens patients have ocular allergies, and that rate is even higher among the keratoconus subgroup.”
For this reason, practitioners should make every effort to keep allergy sufferers comfortable in their contact lenses.
Making a differential diagnosis
Differentiating between true allergies and contact lens-related conditions can be a challenge for the practitioner, according to Sara L. Butterworth, OD, FAAO, of the department of ophthalmology at the University of Iowa.
“One of the primary items on the differential list is giant papillary conjunctivitis (GPC),” she said in an interview with Primary Care Optometry News. “To better help determine the true cause of the patient’s symptoms, I ask the following questions: Does your itching increase when you remove your lenses? Do you have any stringy mucous discharge? Do your contact lenses feel like they are moving around a lot?”
| Indications of Allergy in Contact Lens Wearers | |
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It is important clinically to evert the eyelids of all contact lens patients, Dr. Butterworth said, but especially those who are demonstrating allergy symptoms. She said if a patient answers “yes” to the above questions and has giant papillae when the lids are everted, GPC is the most likely diagnosis.
“If the patient has smaller papillae, often both inferiorly and superiorly, and the itching is more consistent throughout the day, the diagnosis is more likely allergies,” she said.
The increased use of silicone hydrogel contact lenses has also been connected to GPC, Dr. Butterworth added.
“Silicone hydrogel wearers can get a type of GPC that I refer to as ‘mechanical GPC.’ The papillae are more sectoral, occurring on the medial and lateral aspects of the everted upper lid, as opposed to hypersensitivity GPC occurring with “standard” hydrogel (non-silicone hydrogel) lenses, which tends to be more diffuse in its pattern,” she said. “Patients who suffer from this mechanical GPC may have a spectrum of symptoms, from being asymptomatic to itching and experiencing a lens sensation that causes them to remove the lenses.”
According to Dr. Epstein, contact lens solutions can reduce or exacerbate allergy symptoms, but are rarely the source of them.
“Early solutions containing preservatives such as thimerosal did cause allergic reactions, but modern care products rarely do,” he said in an interview. “Most allergy-related problems in contact lens wearers are caused either by seasonal (hay fever) or perennial allergy, which occurs year-round from contact with allergens in their environment.”
Lens recommendations
For contact lens wearers who suffer from allergies, Dr. Butterworth said she recommends daily disposable soft lenses. “Not only does this allow the patient to have a fresh, clean lens on the eye every day, but it eliminates several factors that can make patients’ ocular allergies worse,” she said. “Daily disposables also minimize a lot of debris buildup, which can exacerbate allergies.”
In addition, she said, the disposable modality minimizes patient noncompliance in care and cleaning.
For patients who are unable to wear a daily disposable lens, Dr. Butterworth said gas-permeable lenses are her preferred alternative. “For most patients, deposition of debris on the lens surface tends to occur less with gas-permeable lenses, and this may help minimize some allergy symptoms,” she said.
Dr. Epstein said he also recommends single-use lenses as often as possible for allergy sufferers. “Daily disposable patients generally do not require care products, but I do recommend frequent use of lubricants or rewetting drops,” he said.
For his many patients who are unable to wear daily disposable lenses, Dr. Epstein said he recommends a special lens care regimen. “For soft lenses, I have patients increase replacement frequency (if possible) during allergen spikes, or use Miraflow (CIBA Vision, Duluth, Ga.), an alcohol-based surfactant that removes proteins and allergens effectively. I also recommend the frequent use of rewetting drops.”
For his patients in gas-permeable lenses, Dr. Epstein said he recommends preconditioning with Systane (Alcon, Fort Worth, Texas) and minimizing lens wear during peak allergy seasons.
Solutions and drops
For daily disposable wearers, there is a minimal need for solutions, Dr. Butterworth said. But for 2-week or 1-month replacement lens wearers, she typically changes the solution prior to switching lenses.
| Lens and Solution Recommendations for Allergy Patients | |
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“My first choice is a hydrogen peroxide-based system to minimize the introduction of preservatives that may exacerbate a patient’s allergy symptoms,” she said. “Although, theoretically, all of the hydrogen peroxide is neutralized by the end of the soaking and disinfection cycle, I prefer to have patients rinse with saline to eliminate the chance of introducing H2O2 into the eye.”
Dr. Epstein added that he generally prefers multipurpose solutions such as OptiFree Express (Alcon, Fort Worth, Texas), but also uses ClearCare (CIBA Vision, Duluth, Ga.) for some allergy-prone soft lens wearers. “I prefer Unique-pH (Alcon) or Optimum GP (Lobob, San Jose, Calif.) for GP wearers,” he said.
Dr. Epstein said he does find it helpful to pre-treat patients with topical allergy medications prior to allergy season. “All of my allergy patients — but especially contact lens wearers – are managed with a modern combination antihistamine/ mast-cell stabilizer beginning at least 2 weeks prior to allergy season and continuing until the first frost,” he said. “Pre-treating before allergy season begins helps keep patients in lenses by short-circuiting allergy before it takes hold.”
Dr. Epstein said once-a-day Patanol (olopatadine HCl ophthalmic solution 0.2%) will make it even easier for lens wearers, as it can be dosed before bedtime. According to Alcon, the product is not yet available on the market.
Dr. Butterworth said her drop recommendations depend on the severity of the patient’s symptoms. “If a patient has mild to moderate ocular allergy symptoms, frequent use of preservative-free or gently preserved tears can sometimes alleviate the problem,” she said. “However, in patients with more severe ocular involvement in their allergies, I find that the mast-cell stabilizer/antihistamine combination drops are very effective.”
Dryness from oral medications
When patients are being treated for systemic seasonal allergies with oral allergy medications, dryness can sometimes result. According to Dr. Butterworth, patients are not necessarily aware of this side effect.
“Internists, family practitioners and allergists will sometimes educate patients that ocular dryness can be a side effect, but patients often come to me unaware of this,” she said. “I find that usually the need for the systemic medication supersedes any issues specific to contact lens wear.”
Dr. Epstein said systemic medications are prescribed so frequently that patients may have problems without realizing that their allergy medications are the cause.
“I recommend more frequent use of lens lubricants, which washes away allergens and also counters drying effects of systemic medication,” he said. “I also prescribe a topical agent such as Patanol for these patients.”
Dr. Butterworth said she makes a systematic effort to provide these patients with options so that they can continue contact lens wear. “Initially, I may institute a regimen of artificial tears/re-wetting drops during the day and a thicker gel preparation at night,” she said. “Also, one of my first strategies is to change patients to a hydrogen peroxide system to ensure that a preservative in a multipurpose solution isn’t exacerbating the dryness problem.”
If these steps do not alleviate the problem, Dr. Butterworth then considers a change in lens material. Because Group 1 lenses (low water, non-ionic) are less likely to attract tear film debris, she finds them helpful in minimizing further allergy problems.
“The silicone hydrogel lenses are a good option in this case,” she said. “Not only are they Group 1 lenses, but they tend to be effective in patients for whom dryness is a problem. For the most part, I tend to fit these on a daily wear schedule instead of a continuous wear schedule.”
Dr. Butterworth said she is hesitant to insert punctal plugs in these patients as a first-line option. “I don’t want surface allergens to be retained in the tear film as a result of the plugs,” she said. “By keeping more tears on the ocular surface to address the dryness, more allergens are also present, which can then cause allergy symptoms to flare.”
For Your Information:
- Arthur B. Epstein, OD, FAAO, can be reached at fax: (516) 299-4542; e-mail: artepstein@artepstein.com. He is a member of the Allergy Advisory Board and Speaker’s Bureau for Alcon.
- Sara L. Butterworth, OD, FAAO, can be reached at fax: (319) 353-7699; e-mail: sarabutterworth@uiowa.edu. PCON could not determine if Dr. Butterworth has a paid financial interest in the products mentioned in this article or if she is a paid consultant for any companies mentioned.