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Make allergy treatment your first step to a therapeutic practice
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BIRMINGHAM, Ala. - Have you hesitated to begin using therapeutics? This allergy season, why not try treating itchy eyes? It can be gratifying to treat seasonal allergic conjunctivitis (SAC) because it tends to be intermittent and self-limited. Jimmy Bartlett, OD, FAAO, says SAC is a good place to start, because "Many of the drugs are non-toxic and available over the counter. You don't have to worry too much about side effects," he said.
He recommends Naphcon A (naphazoline and pheniramine, Alcon), particularly the "generic version - Opcon A (naphazoline HCl and pheniramine maleate, Bausch & Lomb) - because it doesn't sting as much as Vasocon A (naphazoline and antazoline, Ciba Vision), and it's less expensive than Naphcon A. It's easy to use, and you don't have to worry about systemic effects, like elevated blood pressure, cardiovascular or central nervous system problems. One drop four times a day is adequate for mild to moderate allergies."
Dr. Bartlett also advocates starting even simpler for those with very mild symptoms. "Start with artificial tears. They're very effective because they dilute the antigenic stimulus," he said. Patients should also try to refrain from rubbing the eyes because that causes a mast cell release and could introduce a secondary bacterial infection.
Offer various options
Allan Panzer, OD, from Houston, said, "I offer the patient various options before I actually give him or her medications. Something that works very well is irrigating the eyes." He advocates streaming irrigation with saline or a balanced salt solution.
"If patients don't want to irrigate, I prescribe Patanol (olopatadine, Alcon)," he added.
Dr. Bartlett is not so sure Patanol is necessary. "If a patient with SAC hasn't improved with over-the-counter products, write a prescription for Livostin (levocabastine HCl, Ciba Vision), one drop four times per day," he said. "Patanol is very expensive, and although it does have the mast-cell stabilizer as well as the H1 antagonistic effect, I don't know that it is any better except for the twice-a-day dosing. But it is innocuous. You're not going to kill anybody. Topical anti-allergy drugs are very safe.
"If a patient has a recurring seasonal allergy, then mast-cell stabilizers are really good for use 2, 3 or 4 weeks prior to allergy season," to substantially limit the allergic response and symptomatology, continued Dr. Bartlett. He finds many patients willing to undergo treatment this way to avoid the brunt of the allergy season.
Conditions to avoid
Are there any allergic conditions you should avoid treating as you begin using therapeutics? Dr. Panzer recommends at least trying. "If you cure it, you're a hero; if you don't, you can always refer the patient."
He says the only conditions to be wary of are those in which the cornea is seriously involved. Dr. Bartlett agrees. For instance, "atopic keratoconjunctivitis tends to be very difficult. These patients often require topical steroids in conjunction with antihistamines and mast-cell stabilizers, and it is, by definition, associated with systemic atopic conditions such as asthma and dermatitis," he said. "Another difficult condition is vernal conjunctivitis."
Arthur A. Medina Jr., OD, from San Antonio, agrees that while SAC may respond fairly easily, vernal and atopic conjunctivitis are more difficult. He sees a lot of allergy in the San Antonio area where the saying goes: "If an allergist can't make it in practice in San Antonio, he's not going to make it anywhere." He differs from Dr. Bartlett in the use of over-the-counter products, stating, "I don't want patients to spend a lot of money to see me and then find out they could have self-medicated with over-the-counter products. My drug of choice for mild seasonal allergic conjunctivitis is cromolyn (Crolom, Bausch & Lomb) plus lots of lubricants. I tell the patient it's going to take some time."
Future attacks
Dr. Medina also discussed future attacks and prophylactic mast-cell stabilizer use. Patanol is his drug of choice for moderate allergic conditions, and he is looking forward to the release of a unit-dose Acular (ketorolac tromethamine, Allergan). "Without the preservatives," he said, "Acular does not sting, and I think we'll find the new unit-dose Acular very useful for allergies."
Steroid use
Dr. Medina feels most optometrists are reluctant to use steroids. He trained under an ophthalmologist and learned to, as he said, "hit allergies hard, fast and then get out." To quiet a severe allergic response, he will prescribe Pred Forte 1% (prednisolone acetate, Allergan), four times per day for 4 days, then two times per day for 2 days and once a day for 2 days.
Dr. Panzer believes "Steroids are the last choice, after all else fails. The key to avoiding problems with patients who are not getting better is to refer after a few days," he added.
Too much conflicting advice? Dr. Medina agrees that "treating allergy is very subjective. I look at the condition of the eyelids and the conjunctiva and assess how bad the symptoms are before I decide what to use."
Finding the culprit
In a nutshell, start with an allergy history. Find out what precipitates the symptoms and try to avoid that situation. Lock the cat out of the bedroom, hire someone to mow the lawn in the spring - whatever seems to be the culprit may be avoidable. When it is not, wash out the antigen with artificial tears or saline.
For mild conditions with mild, intermittent itching and few or no symptoms, try nonpreserved artificial tears, used frequently to irrigate out the antigens. Cold compresses will alleviate itching, and over-the-counter oral antihistamine-decongestants may alleviate any systemic response, although they tend to be drying.
If necessary, add an over-the-counter decongestant-antihistamine combination or a mast-cell stabilizer, realizing the latter will take at least a week to have an effect. Dr. Bartlett and Dr. Medina both prefer cromolyn out of all the available mast-cell stabilizers. Naphcon A is available over-the-counter now because it was deemed extremely safe, and it is very effective. If you want to use that new prescription pad, write for Livostin or Patanol.
See also "Clinicians favor Livostin, Patanol among newer anti-allergy agents" for more information. Seasonal allergy is self-limiting, and the patient will feel better in time. You can help make him or her more comfortable while riding it out.
For Your Information:Jimmy Bartlett, OD, FAAO, may be reached at the University of Alabama at Birmingham School of Medicine and Optometry, 1716 University Boulevard, Birmingham, AL 35294-0010; (205) 934-3036; fax: (205) 934-6758; e-mail: Bartlett@ICARE.OPT.UAB.edu. Dr. Bartlett is a consultant to Alcon Laboratories.
Arthur A. Medina Jr., OD, may be reached at 1110 McCullough, San Antonio, TX 78212; (210) 225-4141; fax: (210) 229-9400; e-mail: artmedina@aol.com. He has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
Allan Panzer, OD, may be reached at 4760 Beechnut, Houston, TX 77096; (713) 664-4760; fax: (713) 665-4760; e-mail: eyemech @juno.com. He has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
Susan E. Marren, OD, FAAO, can be reached at (609) 829-4229; e-mail: SMarren@aol.com. Dr. Marren has no direct financial interest in the products mentioned in this article, nor is she a paid consultant for any companies mentioned.