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Steroids vs. nonsteroidals for ocular allergy
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INDIANAPOLIS — While steroids, mast cell stabilizers and nonsteroidal anti-inflammatory drugs (NSAIDs) all have a place in ocular allergy treatment, some practitioners use NSAIDs more often to control ocular pain and inflammation.
Linda Casser, OD, director of the Indianapolis Eye Care Center, told Primary Care Optometry News that she typically starts allergy treatment with over-the-counter decongestants and antihistamines. Depending on the etiology and severity of the allergy, she then will use levocabastine or a mast cell stabilizer.
"If it is a short-term or a severe problem, I tend to go to a mild topical steroid," she said. "They are effective, inexpensive and have fewer side effects. If there is a history of failed therapy, I will go to the NSAIDs, but I do not reach for them initially."
Dr. Casser said that although NSAIDs provide a benefit in terms of an absence of side effects when compared to other drugs, she does not use them for first- or second-line therapies. "Some of the more traditional classes of drugs are just as efficacious," she said.
Dr. Casser added that some of her allergy patients complain of stinging when using NSAIDs. In addition, the cost of NSAIDs can be a prohibitive factor for some patients. She prefers to use NSAIDs to control ocular pain and inflammation.
NSAIDs good for vernal conjunctivitis
Bobby Christensen, OD, a private practitioner, has found NSAIDs helpful in managing vernal conjunctivitis in patients, usually men, between ages 12 and 20. "For a case such as this, I would use an NSAID and maybe an antihistamine and cold compresses to make the person as comfortable as possible," he said.
These patients usually outgrow the vernal conjunctivitis once they get beyond the teen years.
Dr. Christensen explained another instance in which NSAIDs play a therapeutic role: in patients with advanced dry eye who are also suffering from keratitis. "Patients with advanced dry eye have a lot of discomfort despite using lubricants and punctal occlusion," he said. "To help make them more comfortable, I will periodically cycle them through Voltaren (diclofenac sodium, Ciba Vision) twice a day."
While NSAIDs are useful in these cases, Dr. Christensen said he uses them more often for pain relief, "because they are effective and work well for that. They're a nice, short-term drop that you can use for 4 to 5 days, and the dose does not have to be tapered. If you have a severe allergy or are concerned about using steroids, then you could use the NSAIDs."
Dr. Christensen said that when Acular (ketorolac tromethamine, Allergan) was first approved for ocular allergy, he prescribed it many times during a 12-month period only to learn that many patients complained of stinging upon instillation and discontinued using the drops.
For that reason, Dr. Christensen moved away from NSAIDs as allergy drops and to medications such as Livostin (levocabastine HCl, Ciba Vision) to treat ocular itch along with cold compresses and saline rinses.
Mast cell stabilizer for chronic care
Robert Wooldridge, OD, of Salt Lake City, uses Acular for acute or semi-acute allergic reactions that are mild in presentation, but avoids using NSAIDs on a chronic basis. "If the allergic conjunctivitis is severe, I begin treatment with a corticosteroid, which I feel is more effective, and I may concurrently prescribe a mast cell stabilizer for chronic care."
Dr. Wooldridge said he always considers side effects or complications in using topical corticosteroids but has found that one bottle of a topical steroid does not cause problems for most patients.
"We see a moderate amount of allergy patients, and NSAIDs can be valuable," he said. "I tend to use them more for pain and discomfort related to refractive surgery."
For Your Information:
- Linda Casser, OD, is an associate professor at the Indiana State University School of Optometry and a charter member of the Editorial Advisory Board of Primary Care Optometry News. She may be contacted at Indiana State University School of Optometry, 501 Indiana Ave., Suite 100, Indianapolis, IN 46202; (317) 321-1470; fax: (317) 321-1475. Dr. Casser did not disclose whether or not she has a direct financial interest in the products mentioned in this article or if she is a paid consultant for any companies mentioned.
- Bobby Christensen, OD, is in practice at Heritage Park Medical Center, 6912 E. Reno, Ste. 101, Midwest City, OK 73110; (405) 732-2277; fax: (405) 737-4776. Dr. Christensen did not disclose whether or not he has a direct financial interest in the products mentioned in this article or if he is a paid consultant for any companies mentioned.
- Robert Wooldridge, OD, is in practice at the Eye Foundation of Utah, 201 East 5900 South, Ste. 201, Salt Lake City, UT 84107; (801) 268-6408; fax: (801) 262-9216. Dr. Wooldridge has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.