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Ocular allergy: How the experts diagnose and treat it
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Primary Care Optometry News gathered a group of experts to discuss the theme of our issue: "Allergy Treatment." The panelists debated the issues of diagnosing the allergy type, working with the primary care physician to treat allergy and using prescription vs. over-the-counter drug therapy.
Participants included: Bruce E. Onofrey, OD, RPh; Jimmy D. Bartlett, OD; Bobby Christensen, OD; and Robert A. Ryan, OD.
Primary Care Optometry News: It has been said that the eye has a limited vocabulary, meaning there are only so many symptoms when there is a problem: itching, burning, tearing. When a patient has these symptoms, how do you determine that an allergy is the cause?
--- Bruce E. Onofrey, OD, RPh, is responsible for primary eye care services at Lovelace Medical Center, Montgomery Eye Clinic in Albuquerque. He lectures on the management of ocular disease and the use of pharmaceutical agents.
Bruce E. Onofrey, OD, RPh: History is the key, and it starts with a chief complaint. To differentially diagnose between dry eye or environmental conjunctivitis vs. viral, bacterial and other infectious conjunctivitis, asking certain questions is key: Is it unilateral or bilateral? Does it recur seasonally? Are there any systemic conditions that could lead to the development of ocular surface disease (for example, rheumatoid arthritis)?
For children, is there a family history of atopy, meaning a tendency towards allergy? Pointing you to allergic disease would be a history of atopy. Strengthening that diagnosis would be a history of asthma, as those individuals tend to have a higher level of atopy or sensitivity to antigen.
--- Jimmy D. Bartlett, OD, is a professor of optometry in the School of Optometry and professor of pharmacology in the Department of Pharmacology at the University of Alabama School of Medicine.
Jimmy D. Bartlett, OD: Many patients will come in with tearing and symptoms of itching, and you wonder if this is a mild viral or a mild allergic conjunctivitis. The slit lamp exam doesn't show any significant keratitis and the ocular surface may look good. I flip the upper lids to see if there's any papillary response, and I key in on itching. The more itching, the more my pendulum swings toward an allergy diagnosis.
PCON:Are there tests specific to ocular allergy?
Bobby Christensen, OD, is in group practice in Midwest City, Okla. He was recognized as 1995 Optometrist of the Year by the Heart of America Contact Lens Society.
Bobby Christensen, OD: Fluorescein and rose bengal are key. If fluorescein shows mucin on the upper tarsal plate or if there is stringy matter in the tears, there may be allergy. I use rose bengal to differentiate the diagnosis, as it often stains the conjunctiva at 3 and 9 o'clock in viral infections.
Onofrey: The hallmark of hay fever conjunctivitis is an eye that feels a lot worse than it looks. It is really more a diagnosis of exclusion. You have to differentially diagnose infectious causes through culturing, and negative cultures point you towards an allergic cause.
Simple questioning makes the diagnosis more of a clinical rather than a laboratory diagnosis.
--- Robert A. Ryan, OD, is in private, primary care practice in Rochester, N.Y. He also serves as an adjunct instructor in ophthalmology at the University of Rochester School of Medicine.
Robert A. Ryan, OD: One of the things I look for is lid disease, which can contribute to this generic plethora of symptoms: things like chronic meibomitis or chronic blepharitis that can induce structural changes in the lid margin.
PCON: So allergies tend to be bilateral?
Onofrey: When a person has a red, itchy eye, the first question I ask is, "Are you left- or right-handed?" Have you ever petted a dog and rubbed your eye with your right hand? It's common to have an acute anaphylactic ocular reaction where you touch some antigen and then rub one eye. Environmental allergy is normally bilateral, but acute unilateral presentations still must be differentiated with an allergic reaction as part of the diagnosis.
PCON: Are patients with ocular manifestations typically allergic to other things that their primary care physician would be able to help you with?
Onofrey: I exclude certain things when a patient has a general list of ocular complaints. For example, if a person has rheumatoid arthritis or is taking a medication that may contribute to ocular surface disease, that information is valuable. Interviewing the patient would suggest if there are pre-existing allergic conditions, but it's important to get medical and drug history from the physician and maybe a pharmacist that may lead to diagnosing something other than an allergic condition.
Bartlett: In my opinion, we can do that independently. I rarely call a primary physician to make a diagnosis of allergic conjunctivitis.
PCON: What's your first-line treatment for allergic keratoconjunctivitis? How do you feel about using over-the-counter (OTC) drugs, particularly those that have been recently approved?
Ryan:When I have patients with nonspecific complaints, often my first line of treatment will be more palliative in nature rather than dumping agents into an inflamed eye. I'll recommend cool compresses for the itching and maybe something as simple as OTC lubricating agents to quiet the inflammation. If patients describe symptoms that seem clearly related to ocular allergies, I wouldn't at all discount the usefulness of an OTC oral antihistamine such as a Benadryl (diphenhydramine, Parke-Davis). We don't want to contribute to surface dryness, so we may want to supplement that with surface lubrication.
Christensen: Usually I use one of the OTCs such as Naphcon-A (pheniramine maleate-naphazoline HCl, Alcon). It contains a decongestant-antihistamine that works well. I also like to use a soft contact lens saline solution to rinse the eye out—cold compresses are usually added to that—and prescribe the drops four times a day for the first 5-7 days, depending on the severity, and then taper and let them use it as needed when the itch and irritation flare up.
Bartlett: Patients with seasonal conjunctivitis are aware they have it every fall or spring. If they've used OTC products in the past, I stick with those. For patients who have more swelling, lid involvement or itching, or if they've tried OTC products to no avail, then I'll go with some Livostin (levocabastine, Ciba Vision) or Acular (ketorolac tromethamine, Allergan).
Onofrey: We should mention avoidance. Patients can do certain things to minimize their exposure to the antigen. But I always start treatment with either a preservative-free product or a new product called GenTeal by Ciba Vision, which is mildly preserved. In severe cases, I use a mast cell inhibitor right away in combination with something that will relieve the patient's acute symptoms, which may include an OTC product. But I don't like to use sympathomimetics or decongestants, so I generally stay with Alomide (lodoxamide tromethamine, Alcon) and maybe a Livostin-type product initially along with an artificial tear as my initial approach.
I want to stress that corneal involvement is not normal with seasonal allergy. You'd simply see a red, inflamed eye or even an eye that looks normal, but has the symptoms associated with allergy: itching, watering and foreign body sensation. I'm approaching a chronic disease with a well-understood mechanism and trying to short circuit that mechanism quickly, as well as trying to short circuit the continuation of the disease process.
PCON: How do you decide when to use Livostin or Alomide? What about combination therapy?
Bartlett: If I find a case is going to be difficult to treat with OTC products, lubrication therapy or cold compresses, then I'll prescribe Livostin four times a day, sometimes maybe every 2 hours for 24-48 hours. I don't like mast cell stabilizers for initial therapy if the condition is churning along, because they take too long to work. Sometimes I'll use mast cell inhibitors in combination with something that works more acutely, like Livostin plus Alomide, or cromolyn sodium plus Livostin, or Acular plus Alomide. Combination therapy does work nicely, and then you can begin to taper off the antihistamine and keep the patient on the mast cell stabilizer.
Christensen: I have pharmacists who mix up cromolyn sodium 4% for me without a preservative. It's inexpensive, but you need to be careful of bacterial contamination. I don't want patients to keep it more than 6 weeks, and I want them to keep it refrigerated. Livostin works well; it's the best itch drop I've found. I'll prescribe those two together, and I will taper the Livostin after the first week and keep the patient on the cromolyn four times a day for another week, and sometimes longer.
Onofrey: There's no singular approach, because the presentation of allergic problems is so diverse. First you must determine if it's seasonal or one of the forms of allergic disease with inflammatory consequences like vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC) and giant papillary conjunctivitis (GPC). You must be careful about staging patients and determining the type of allergic condition they have before you initiate therapy. There's no cookbook way to do this.
Some people require a steroid right off the bat, but I try to approach things from a short- and long-term concept of treating the disease. Mast cell inhibitors can take a while to kick in; that's why they should be started right away. If a patient gets allergies every fall, and it's now June, I'd start Alomide several weeks before the allergy season starts. I want to try to control that mechanism of the mast cells breaking open in the long run to minimize the process of disease and minimize the intervention of acute medications.
PCON: How important is it to you to make the distinction between AKC and VKC or seasonal allergy?
Onofrey: It is important, because AKC and VKC involve tissue damage. If we see corneal involvement or tissue damage, it's going to take more than using an antihistamine or a mast cell inhibitor; we have to ratchet our treatment up a step. The point is when we assess someone with a symptomatology that we determine to be allergic in nature, we say, "This is not hay fever conjunctivitis, this is something else."
Bartlett: The prognosis for VKC and AKC is considerably poorer than for hay fever conjunctivitis. I've seen some patients who have significant neovascularization of the cornea and, in fact, are approaching legal blindness because of this devastating allergic disease. We have to be aggressive with those patients. I'm much more likely to use a steroid right off the bat for VKC or AKC than I would be for hay fever conjunctivitis.
PCON: How does it get that bad?
Bartlett: I remember a 19-year-old pregnant female had significant neovascularization and pannus and about 20/80 visual acuity. Doctors had given her topical antibiotics, topical steroids or artificial tears. She'd been on Pred Forte (prednisolone acetate 1%, Allergan) for a year. She wanted to know if she should continue the steroid. It was a pretty straightforward diagnosis: she had asthma, all the full-blown constitutional symptoms. I took her off the Pred Forte and put her on Alomide, and she did beautifully. Of course the neovascularization and pannus are still there, but she feels more comfortable.
Some patients don't understand their condition or haven't been told by the doctor, or the doctor doesn't know. I have presented slides of this patient at a number of meetings, and I am appalled at how few optometrists are familiar with the term "atopic keratoconjunctivitis." We need to get the word out that this is a very real condition that does exist, and it can be devastating. This is a chronic process that may not bother the patient at first, or you may not see significant signs for years.
Onofrey: People who undertreat these conditions mask the symptoms of the disease—reducing some of the redness in the eye, perhaps with a decongestant—while the inflammatory phase churns along and does the damage.
Bartlett: You need to go in and crush the inflammatory process right away with steroids in those cases.
PCON: How are the symptoms masked?
Onofrey: By using a topical antihistamine/decongestant agent or Livostin. There is a Type 1 anaphylactic phase at the onset of these types of conditions, but they also have a late phase cellular inflammatory response that does all the tissue damage. With antihistamine therapy, the blood vessels are constricted by decongestant therapy, so the eye looks better, but it isn't getting better.
The late-phase inflammatory response, which would be mediated by steroid or nonsteroidal anti-inflammatory (NSAID) use, keeps chugging along. If you run into VKC, GPC or AKC, the initial treatment is with something like a steroid or an NSAID, but you can't treat a long-term condition with short-term therapy. The idea of using short-term therapy such as steroids is to reduce the stage of the disease, to bring it from a level 3 or 4 down to a level 1 or 2. Then a long-term medication such as a mast cell inhibitor does its job much more safely. Watch these people, because seasonal allergies can be fired up again and reach a new level, and you may have to pulse a steroid or NSAID.
Ryan: Often when you see one of these conditions early on, you don't think the worst. Because many of these cases are mild, patients are often started on first-line defense mechanisms, which may, to some extent, mask the symptoms or problems. Clearly in some of the worst conditions, perhaps with VKC that we see in youngsters, it's obvious their defenses are inadequate. It's often neither neglect nor lack of appropriate treatment, but instead the inadequacy of the body's defense mechanisms. One thing to consider in some of these patients who have severe involvement of the superior tarsal conjunctiva is a soft bandage lens in an effort to protect the cornea, if you will, from the mechanical insult or trauma.
Onofrey: Sometimes patients are doing their own self-treatment, and they can mask the severity of disease by using decongestant therapy, or they may induce medicamentosus by long-term use of OTC topicals. Sometimes when you have these people with vague or mixed complaints, it's a good idea to go back to a nonpreserved artificial tear. Observe the patient under a more benign type of therapy, and see what happens, unless this clearly occurs every spring or fall. Then you can pretty much jump in with both feet.
Ryan: Just a word of caution: don't get too excitable and see a condition and say, "Wow, I want to use this fantastic new drug." Sometimes the appropriate course is a palliative, conservative treatment that we've described before.
Christensen: We send chronic cases to the allergy clinic for a work-up and to determine the specific allergy problem. We've found that allergy shots have been very helpful. We have to treat the whole patient rather than just the eyes. If this is happening often or if patients have chronic laryngitis or rhinitis, then it's time to find out what the problem is. Many of them can go on allergy shots. The shots may not totally eliminate ocular reaction, but sometimes will help.
PCON: Let's say you have a patient you diagnose and treat for AKC. When the topicals aren't working, where do you go from there?
Christensen: In Oklahoma we can go on to that next step with antihistamines such as Seldane (terfenadine, Marion Merrell Dow), the nonsedative types of oral medications. While we lean towards the allergy clinic referral, we may use an oral antihistamine, sometimes antihistamine with Livostin, and maybe we'll just use lubricants to keep the eye wet. I try to stay away from decongestants because these patients often don't have a lot of tear volume, so they can't rinse the antigens out of the eye. Keeping the eye wet and cool is often a good route to take.
Onofrey: We're in an HMO, so we have free consultation among all departments. My situation is more a concern of what's happening with the eye, and it may involve different departments. For example, in AKC you can have cicatrization or scarring of the fornix conjunctiva to the point that if you have anatomical changes in the lid, you could end up with true exposure eye disease. That may require surgery.
I don't feel there is any oral medication that would specifically be useful for this inflammatory phase that's damaging the patient's eye. The amount of drug in topical steroids is sufficient to take care of the localized, inflammatory response. I don't believe any oral drugs are appropriate besides antihistamines, which may be utilized to control the allergic, histamine-based response.
The bottom line is in these conditions we have to understand that the more advanced stages or problems are a result of local inflammation. I don't think there's any need to use oral medication in these individuals for these specific conditions.
PCON: What about the contraindications for these drugs?
Christensen: If you have a glaucoma patient who has allergy and itch, you don't have as many things to work with. Livostin gives you a good option. It is a suspension, and you have to remember to tell the patient to shake the bottle.
Onofrey: Our allergy department asked us not to send patients who are on topical beta-blockers over for desensitizing shots, because if a person has a reaction to an antigen during this desensitization therapy, the topical beta-blocker reduces their response to epinephrine in terms of reducing the anaphylactic response.