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Immunization final step in the allergy treatment protocol
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While ocular allergy is usually successfully treated by the optometrist, resilient conditions with systemic involvement may necessitate referral to an allergist for more aggressive treatment, such as injection therapy.
Dry eye and allergy
Dry eye and allergy often occur in partnership, Robert A. Ryan, OD, FAAO, said in an interview with Primary Care Optometry News. “Typically, the precorneal tear film is plentiful enough to rinse allergens away, and with the balance of proper tonicity, immunoglobulins and a lipid layer to help reduce evaporation, the tear film is able to handle common allergens,” he said. “When that system is compromised by dryness, it makes individuals more susceptible to allergy.”
Patients with ocular allergy should be closely evaluated for a superimposed dry eye, he said.
Allergist Bob Lanier, MD, first conducts a Schirmer’s test to confirm the diagnosis. “If the eyes burn, it’s more likely to be dry eye,” he told PCON in an interview. “If they itch, it’s more likely to be allergy. People will often tell you that eye drops [for allergy] don’t work for them, which makes me think maybe it’s not allergy.”
When to refer to an allergist
According to J. Patrick Smith, OD, optometrists should refer patients to an allergist when therapeutic options provide no resolution.
“For severe cases of ocular inflammatory disease, when a disease is sight-threatening, when a person is in pain or when ocular morbidity is possible, it’s a good idea to involve a specialist that deals with inflammation,” he said.
Dr. Ryan refers his patients to an allergist when his treatment regimen fails to keep them comfortable. “My initial approach is to try to calm the eye and make the patient feel better,” he said. “The next line of defense is combination antihistamine/mast-cell stabilizer drops or the combination drops in conjunction with lubrication throughout the day. If that therapy fails, oral antihistamines might be helpful.
“In addition, eye drops in topical steroid form can calm more aggressive allergic responses,” Dr. Ryan continued. “If that doesn’t hold them, then I would consider referring them to an allergist to identify the agent to which they’re sensitized and determine if some sort of periodic injection would lessen their sensitivity to it.”
Injection therapy
When patients are referred to an allergist, Dr. Lanier said, it does not necessarily mean their condition warrants the most aggressive treatment.
“The treatment should be to avoid [the allergen] if you can, medicate it if you can’t avoid — usually with a potent antihistamine eye drop — and try to stay away from steroids in the eye,” he said. “When we look at the overall package of the unavoidable sensitivity and complications that require lots of medicine, doctor visits or recurrent infections, then we think about trying to re-program the immune response. And you do that with allergy injections.”
Injection therapy, or immunization, is the only known way to cure allergy, by putting patients into long-term remission lasting perhaps 10 or 15 years. The injections can be completed in 2 years or less, depending on patient sensitivity and tolerance.
“The person who’s successful with an allergy shot would be the same person who would be successful with piano lessons,” Dr. Lanier said. “When I see people are committed, disciplined, have a bent for preventive medicines and are really looking to cure it, I then offer that option.”
Advances in allergy
As more becomes known about inflammation, researchers are trying to get to the root of the problem instead of just treating the symptoms.
“We’re looking for a way to cripple the antibody that causes allergy,” Dr. Lanier said, “and we’re looking past histamine. Histamine is the most common chemical released with an allergic reaction, but there must be 50 more.”
According to Dr. Smith, target-specific agents that pinpoint certain molecules involved in inflammation will help improve disease control and minimize undesirable side effects.
“The future of allergy treatment will likely involve better modulation of specific inflammatory mediators that control the allergic response,” said Dr. Smith.
For more information:
- Robert A. Ryan, OD, FAAO, can be reached at Visionary Eye Associates, 169 Rue de Ville, Rochester, NY 14618; (585) 271-2990; e-mail: visionary@rochester.rr.com. Bob Lanier, MD, can be reached at 6407 Southwest Blvd., Fort Worth, TX; (817) 731-9198; e-mail: boblaniermd@gmail.com. J. Patrick Smith, OD, can be reached at Togus VA Medical Center, 1 VA Center, Augusta, ME 04330; (207) 623-8411; e-mail: james.smith20@va.gov.