Level of corticosteroid use for ocular allergy varies among practitioners

Steroids important part of treatment

Paul M. Karpecki, OD, FAAO: Newer, effective, site-specific steroids have changed the way I treat ocular allergies and have made topical corticosteroids an important component of my treatment protocol. Four conditions make up the type I hypersensitivity classification of allergies: seasonal or acute allergic conjunctivitis (SAC), giant papillary conjunctivitis (GPC), vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC).

Many of these conditions respond better to corticosteroids. One such example is AKC, in which patients complain of burning (even over itching), injection and periorbital eczema. All of the symptoms are clearly inflammatory in nature, and corticosteroids are the optimal treatment. Likewise, in cases of GPC, when the upper tarsal conjunctiva show papillae with hyperemia (hyperemia or edema indicate an inflammatory component), I find quicker resolution with a corticosteroid twice daily for 7 to 10 days (four times daily for severe cases).

Without signs or symptoms pointing to an inflammatory process, I will often choose a combination medication such as Zaditor (ketotifen fumarate ophthalmic solution 0.025%, Novartis Ophthalmics), Patanol (olopatadine HCl ophthalmic solution 0.1%, Alcon) or Optivar (azelastine HCl ophthalmic solution, Muro) twice daily. In cases of GPC without tarsal hyperemia, I will choose a mast-cell stabilizer such as Alamast (pemirolast potassium ophthalmic solution, Santen) or Alocril (nedocromil sodium ophthalmic solution 2%, Allergan) twice daily.

Seasonal allergic conjunctivitis is what we most often think of when managing ocular allergies, and three factors determine when I will choose a corticosteroid: severity of symptoms, severity of signs and systemic involvement. If a patient has the typical allergic conjunctivitis presentation (bilateral itching, chemosis, etc.) and mentions that it is affecting daily activities (such as not being able to go outside or not being able to work), I will choose a corticosteroid first. Likewise, if signs show hyperemia or chemosis/ edema, I will find faster resolution with a corticosteroid because the treatment is focused on the inflammatory-based signs.

Lastly, I prescribe topical corticosteroid inhalers — such as Flonase (fluticasone, Glaxo Wellcome) or Beconase Aq (beclomethasone dipropionate, Glaxo Wellcome) twice daily for 1 to 2 weeks if a patient has significant systemic involvement such as allergic rhinitis, itchy throat or cough. I previously used oral antihistamines but found they often treated the systemic allergy at the expense of drying the eyes and increasing the ocular irritation, which was the primary reason the patient came in.

What has made the treatment of allergies so successful with corticosteroids has been the advent of potent, site-specific steroids, and my first choice is loteprednol — either Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb) or Alrex (loteprednol etabonate ophthalmic solution 0.2%, Bausch & Lomb). It has the potency for treating ocular allergic conditions (SAC, AKC, VKC and GPC) without the risks of other ketone-based steroids. I usually prescribe loteprednol two or four times daily for 7 to 10 days. Although a rare risk, it is still important to monitor intraocular pressure in all patients taking topical corticosteroids, including site-specific steroids or topical inhalers.

Paul M. Karpecki, OD, FAAO, practices at Moyes Eye Center in Kansas City and is a Primary Care Optometry News Editorial Board member. He can be reached at Moyes Eye Center, Barry Medical Park, St. Luke’s Northland Campus, 5844 N.W. Barry Rd., Ste. 200, Kansas City, MO 64154; (816) 746-9800; fax: (816) 587-3555; e-mail: pkarpecki@kc.rr.com. Dr. Karpecki is a clinical consultant to Bausch & Lomb but holds no financial interest in any of the products he mentions.

In limited situations

Robert E. Prouty, OD, FAAO: Corticosteroids for ocular allergy have their place in clinical practice, but it is a very small area. Most ocular allergy that the primary care optometrist sees is seasonal allergic conjunctivitis. It has various levels of presentation, but for the most part has a low morbidity.

Corticosteroids have a significant side-effect potential: reduced immunology with long-term use; increased incidence of and potential to develop glaucoma; and a dosage-duration relationship where the higher the concentration or rate/frequency of administration, the more rapid a cataract development.

Therefore, the severity of presentation and underlying nature of the allergy dictates if corticosteroids are worth being used. Clinically, all ocular allergies improve with topical steroids, but it is not in the best interest of the patient to subject him or her to potentially harmful side effects. A severely chemotic presentation of an acute allergic dermatitis mandates topical steroid creams and ocular solutions to be used frequently and aggressively. Once resolution has been achieved, rapid tapering or discontinuation of the medication is the best pharmacological approach. In conjunction with oral antihistamines, these symptomatically miserable patients can be helped quickly.

However, the chronic SAC patient will require longer-term care. Topical mast-cell stabilizers along with topical antihistamines (or their combinations) effectively eradicate the symptoms and signs without risking adverse reactions.

An example from my practice was a patient whose practitioner had fitted him with weekly disposable extended-wear contact lenses in the late winter. Come spring, the patient developed SAC. As per the package insert and Food and Drug Administration approval, the doctor prescribed a commercially available, low-dose steroid preparation. Approximately 3 months later, the patient developed a small central corneal ulcer. The doctor was panicked that an association could be made with the use of a topical steroid and the corneal ulcer. Fortunately for everyone, the condition resolved well without loss of vision, the loss of function or litigation.

So, I limit my use of topical corticosteroids in ocular allergy to only those cases where the benefits of the rapid relief of signs and symptoms outweigh the risk of adverse reactions. I never use them for allergy for more than 2 to 3 days, and I never use them for chronic seasonal allergic conjunctivitis. I also never use low-dose steroids to treat allergy because, if the condition warrants the use of these powerful medications, it deserves to be treated with the stronger concentrations of these medications.

With the advent of the very successful, safe and available mast-cell stabilizer/antihistamine solutions now on the market, topical corticosteroid use for chronic allergy should be part of the past.

Robert E. Prouty, OD, FAAO, is the center director for Omni Eye Specialists in Denver. He can be reached at 55 Madison St., Ste. 355, Denver, CO 80206; (303) 377-2020; fax: (303) 377-2022; e-mail: rpomni@juno.com. Dr. Prouty has no direct financial interest in the products he mentions, nor is he a paid consultant for any of the companies he mentions.

Always for VKC and AKC

Mark B. Abelson, MD: The specific mechanism of action of corticosteroids has yet to be elucidated. However, it is generally accepted that they inhibit inflammation by passing through target cell membranes to bind steroid receptor proteins in the cytoplasm. This complex is then shuttled into the cell nucleus, where it interacts with DNA to alter the transcription of specific inhibitory proteins (lipocortins). These lipocortins inhibit the release of arachidonic acid, which is the precursor to inflammatory mediators such as prostaglandins and leukotrienes, from membrane phospholipids.

As a corollary to this mechanism, however, steroids have a number of potential side effects including cataracts, IOP elevation, delayed wound healing, increased susceptibility to infection and steroid myopathy, which can cause ptosis.

To understand when a topical corticosteroid should be used, it first must be understood that ocular allergy has four categories of disease: seasonal and pan seasonal allergic conjunctivitis (SAC, PAC) and atopic and vernal keratoconjunctivitis (AKC, VKC). The former (SAC, PAC) and latter (AKC, VKC) have important differences in mechanism of action, with the latter two being more t-cell mediated and exhibiting significant late-phase effect. We estimate in our experience of more than 100,000 ocular allergen challenges that late phase exists in fewer than 2% of SAC/PAC patients (late phase being defined as sufficient release of mast-cell mediators to cause cellular infiltration sufficient for expression of clinical signs and symptoms).

All patients with SAC/PAC must first be started on a topical mast-cell stabilizer/antihistaminic (MCS/AH) agent. Some patients may have already tried over-the-counter antihistamines with vasoconstrictors, which may provide intermittent relief for the mildest cases. It must be understood that in acute allergy, the causative mast cell-derived mediators are already present, and a corticosteroid will have negligible effect on these. Even with loading of corticosteroids, it has been our experience in the clinical trial setting that when comparing a corticosteroid to Patanol in acute allergic conjunctivitis, the olopatadine was significantly superior in managing allergic signs and symptoms.

The cases of SAC and PAC that fail to respond to MCS/AH agents, while rare, are deserving of therapy. For these cases, I select Alrex as the drug of choice for its efficacy and safety profile and its proven effects. For VKC and AKC, steroids are nearly always necessary. Their use can be reduced with concomitant use of an MCS/AH agent, but they are required when measures such as cold compresses, avoidance and tear substitutes are inadequate. For these cases, Lotemax should prove appropriate therapy based on its risk/benefit ratio. In occasional cases, Pred Forte (prednisolone acetate, Allergan) may be necessary or, very rarely, immunomodulators.

We look forward to agents such as FK 506 and P38 MAP kinase to allow further decreases in steroid use in the most severe conditions.

Mark B. Abelson, MD, is associate clinical professor of ophthalmology, department of ophthalmology, and senior clinical scientist at the Schepens Eye Research Institute, Harvard Medical School. He can be reached at Ophthalmic Research Associates, 863 Turnpike Street, North Andover, MA 01845; (978) 685-8900; fax: (978) 689-0020. Dr. Abelson has no direct financial interest in the products he mentions. He consults in ophthalmic pharmaceuticals.

Anytime except with underlying infection

Charles Slonim, MD, FACS: Let it be known that I am not “steroid shy.” The only circumstance where I will not use a topical steroid in managing an ocular allergy is when I suspect an underlying infectious process. Fortunately, there are numerous clinical signs and symptoms that help the eye care practitioner differentiate allergic from infectious ocular inflammations.

Therefore, my generous use of topical steroids in managing ocular allergies is based on a high success rate in treating these conditions and a very high patient satisfaction rate. Ocular allergy patients love topical steroids, and they should. Topical steroids essentially work at virtually every phase of the allergic reaction’s inflammatory cascade. They work both inside and outside the mast cell. No other currently available, topical ophthalmic anti-allergy product treats more phases of allergic inflammation than a topical steroid.

The ocular allergic response produces many inflammatory chemical mediators that target a variety of ocular tissues, which creates the signs and symptoms associated with an allergic conjunctivitis. I, personally, prefer to use medications that treat the greatest number of these chemical mediators, not just one or two. In this way, I feel confident that I am treating the entire condition and not just a part of it.

In the past, I used to “work my way up” the ophthalmic pharmaceutical ladder and partially treat an ocular allergy with a nonsteroid anti-allergy medication, only to have the patient return with continued signs and symptoms. Now, I prefer to initially treat the condition completely with a steroid, satisfy my patient and wean him or her onto an “after-steroid” medication, if needed, for chronic symptoms.

With my clinical data now published (Ilyas H. et al., Long-term safety of loteprednol etabonate 0.2% in the treatment of seasonal and perennial allergic conjunctivitis. Eye & Contact Lens: Science and Clinical Practice, 2004;30:10-13.), I feel more comfortable than ever in selecting a topical steroid for the management of both acute and chronic ocular allergies.

Charles Slonim, MD, FACS, is affiliate professor of ophthalmology, University of South Florida College of Medicine, Tampa. He can be reached at 4444 E. Fletcher Ave., Suite D, Tampa, FL 33613; (813) 971-3846; fax: (813) 977-2611; e-mail: cslonim@tampabay.rr.com. Dr. Slonim is a paid consultant for Bausch & Lomb Pharmaceutical, but he has no direct financial interest in any of the products he mentions.

For patients with moderate to severe symptoms

Glenn S. Corbin, OD: We are fortunate today to be able to manage most seasonal and perennial ocular allergy patients with combination antihistamine/mast-cell stabilizers, such as Patanol.

I consider concurrent short-term steroid use when my patients have moderate to severe symptoms because I am concerned about the potential toxic effects from the release of inflammatory mediators, as in vernal keratoconjunctivitis. Steroids inhibit the production of arachidonic acid, thereby decreasing the production of all the eicosanoids, including prostaglandins, thromboxanes and leukotrienes. Ultimately, I want to quickly alleviate symptoms and will prescribe Alrex along with Patanol when I feel that the therapeutic benefit of the steroid outweighs the risk associated with steroid use.

I do, however, have minimal concern because of the safety profile of Alrex and the fact that it will be prescribed for a limited time. Regardless, follow-up to assess efficacy and monitor IOP is appropriate. Remember, too, that many of these allergic or atopic patients may be immunosuppressed for a variety of reasons, and a steroid could place them at increased risk for infection. The presence of large papillae would influence me to prescribe a steroid, especially for a contact lens wearer. If a shield ulcer is present, I would start with a topical antibiotic and cycloplegia along with a combination drug, adding a steroid only after the epithelium is intact.

A careful detailed history is critically important to determine if patients can remove themselves from the offending allergen or if they can modify their lifestyles to limit their exposure. I rarely ever find the need to prescribe long-term steroid use for ocular allergy.

Let’s not forget cool compresses, lubricants and other palliative or adjunctive treatment options as well as extensive patient education.

Glenn S. Corbin, OD, is in private group practice in Wyomissing, Pa., and is a member of the Quality Assurance and Improvement Committee for the Pennsylvania Optometric Association. He can be reached at Wyomissing Optometric Center Inc., 50 Berkshire Ct., Wyomissing, PA 19610; (610) 374-3134; fax: (610) 374-0484; e-mail: glenn.corbin@verizon.net. Dr. Corbin is a paid consultant for Alcon Laboratories, but he has no direct financial interest in any of their products.

A systematic, stepwise approach is important

Sara L. Butterworth, OD, FAAO: Whether acute, chronic, seasonal or contact lens-related, ocular allergy is a clinical entity we all encounter. Although we learned during training that itching is the hallmark sign of ocular allergy, this is not necessarily clear-cut in practice. Patients may experience itching or burning to varying degrees, so making the correct diagnosis is important.

The clinical picture may be clouded by dry eye or blepharitis in addition to allergies. I often see patients who bring in “the bag of eye drops” — everything from Visine (tetrahydrozoline HCl, Pfizer Consumer) to antibiotics to antihistamines to steroids to mast-cell stabilizers. In these cases, I find that a washout period of no drops or artificial tears alone before initiating treatment can be useful.

A systematic, stepwise approach to ocular allergies is important. I make treatment decisions based on severity of symptoms. If patients have mild itching and occasional conjunctival injection, I have them try frequent use of artificial tears. If the itching is moderate, the conjunctiva is more inflamed and the lids appear irritated, I will opt for one of the dual-action allergy drops such as Patanol or Zaditor.

Corticosteroids become my drop of choice for more severe allergy symptoms — moderate to severe itching, greater conjunctival inflammation and distinct lid hyperemia or edema. With these symptoms, I choose a “soft” steroid, such as Lotemax or Alrex. While both are highly effective, Alrex is specifically FDA-approved for the treatment of ocular allergy. Although some clinicians shy away from long-term use of corticosteroids, studies have shown that these “soft” steroids have minimal risk of side effects (increased IOP, cataract formation and increased susceptibility to infection) commonly linked with steroids. Some patients respond to short courses of steroids while others require chronic use.

Overall, topical steroids are a very effective weapon in our arsenal against ocular allergy, even for long-term use.

Sara L. Butterworth, OD, FAAO, is assistant professor of clinical ophthalmology at the University of Iowa Department of Ophthalmology in Iowa City. She can be reached at the University of Iowa, 200 Hawkins Dr., Iowa City, IA 52242; (319) 353-7044; fax: (319) 353-7699; e-mail: sara-butterworth@uiowa.edu. Dr. Butterworth has no direct financial interest in the products she mentions, nor is she a paid consultant to any companies she mentions.