Various options available to contact lens patients with allergies

Issue: April 2000

Change cleaning regimen

Glenda B. Secor, OD: During the height of their allergy season, allergic contact lens patients are among the most unhappy patients with whom practitioners must deal. In addition to being miserable, their contact lens tolerance usually varies from mildly irritable to intolerable. Noncompliance with lens care and replacement can often trigger the allergic reaction. Giant papillary conjunctivitis (GPC) has not been eliminated with disposables and planned replacement, but the severity has often been reduced.

Depending upon the severity, practitioners can approach the problem from simply reducing wearing schedules to changing cleaning regimens. Switching to an oxidative disinfectant, adding an alcohol-based cleaner and/or adding a periodic enzyme soaking cycle can help reduce the protein deposition on a lens. If necessary, refitting contact lens materials that are more deposit resistant and possibly refitting into rigid gas-permeable lenses may be necessary.

Pharmacological help can often begin with nonpreserved lubricants and current over-the-counter ocular antihistamines. I prefer a mast-cell stabilizer as an initial approach. Drops should be used twice a day (before and after lens wear) to avoid lens accumulation. Patanol (olopatadine HCl 0.1%, Alcon) works very well when an additional need for an antihistamine/mast-cell stabilizer combination is indicated. Unfortunately, patients may require some time before any symptomatic relief is noted.

When tissue-damaging inflammation is a concern, a bigger “gun” is a topical nonsteroidal anti-inflammatory drug (NSAID) or steroid. “Soft” steroids such as Flarex (fluorometholone acetate 0.1%, Alcon) or loteprednol may be more effective in offering almost immediate relief. Patients must often discontinue contact lenses, use the drop three times each day and taper their usage after a few weeks before resuming lens wear. You must council patients that although giant papillary conjunctivitis and allergic conditions are annoying, they are manageable with good compliance and appropriate care.

Glenda B. Secor, OD, is in private practice. She can be reached at 17742 Beach Blvd., Huntington Beach, CA 92647; (714) 842-0651; fax: (714) 848-7826. Dr. Secor has no direct financial interest in the products mentioned in this article, nor is she a paid consultant for any companies mentioned.

Use step-wise treatment plan

Robert A. Ryan, OD: Contact lens wearers are especially susceptible to allergens. Not that present-day HEMA or gas-permeable materials act as allergens themselves, but they may certainly predispose patients or exacerbate symptomatology. Lens wear can compromise the quality of the precorneal tear film and affect tear volume. Hydrophilic lenses, by their very nature, absorb natural proteins, immunoglobulins, calcium and other inorganic salts, in addition to debris and biologically active agents.

This bioburden creates a challenge to the normal tear film and reduces oxygen transmission through the material in question, resulting in altered corneal physiology. This cascade alerts the immune system to be on guard for a potential battle. When we consider that even our thinnest contact lenses available today are more than 10 times the thickness of the normal precorneal tear film, it is not surprising that problems occasionally arise.

Certainly, modern-day care systems have contributed tremendously to the reduction in lens-related complications. Efficacious disinfecting agents with greater molecular weights discourage incorporation of these agents into the matrix of the lens, resulting in shorter contact time and decreased likelihood of hypersensitivity reactions. Preservative-free systems, oxidative systems and in-hand disinfecting are all viable options for our more sensitive patients. Thermal disinfecting, with its propensity to spoil materials more rapidly, has all but disappeared from the contact lens industry despite its effectiveness.

Our typical approach to managing environmental allergies in our contact lens wearing population is based on a step-wise treatment plan. Recognizing the benefit of diluting allergens, we recommend lubrication therapy at least every 2 to 3 hours (depending upon severity of symptoms) and nonpreserved saline lavage prior to and following contact lens wear. Extended wear schedules may need to be reduced until symptoms are well controlled to minimize risk of sequela.

Cool compresses are beneficial to treat edema and congestion as well as itching. In mild cases, this may be sufficient action to allow uninterrupted wear. For more aggressive responses, we must increase the sophistication of our management. Discontinuing lens wear is universally effective, but is not the answer most of our dedicated lens wearers are in search of.

If symptoms persist, medical intervention is indicated. This may include topical over-the-counter decongestants with astringent agents to treat milder presentations, initially once or twice a day, applied without lenses in place. Caution patients with fair complexions and those with blue irides that these agents may cause pupillary dilation, more likely if used with a contact lens in place. This is due to a greater effect as a result of the contact lens facilitating increased drug contact time.

More severe conditions may require the use of prescription-strength topical antihistamines or mast-cell stabilizers. If the patient’s history predicts when the response is likely to occur, we suggest Crolom (4% cromolyn sodium, Bausch & Lomb) or Alomide (lodoxamide tromethamine TN, Alcon) four times daily 3 weeks prior to the presumed onset, continuing through the exposure. When necessary, the addition of Livostin two or three times a day can be quite helpful to ameliorate symptoms. In fact, Patanol, a dual-action drug, may make sense to achieve relief and prevention while increasing compliance.

The question of whether to discontinue lens wear during treatment is multifactoral. Clearly, the eye may be less challenged or compromised in the absence of lens wear. However, motivated patients are seeking your expertise to enhance their lens-wearing experience. Advocating discontinuance, albeit temporary, is not likely to earn referrals or create ecstatic patients. In many cases, disposable lenses afford us the luxury of allowing patients to continue with lens wear during allergy seasons, perhaps with reduction in wear schedules while increasing replacement frequency.

Patients using single-use, daily disposable contact lenses are rarely directed to interrupt lens wear in our office, while frequent replacement patients may be encouraged to pursue a daily replacement schedule. Finally, don’t lose sight of the fact that the presence of a contact lens can actually enhance your prescribed medical treatment regimen and allow less frequent dosing to achieve a similar effect.

Robert A. Ryan, OD, is in private group practice. He can be reached at 169 Rue de Ville, Rochester, NY 14618; (716) 271-2990; fax: (716) 271-6321. Dr. Ryan has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

“Time out,” strict attention to lens care, hygiene

John P. Herman, OD: Giant papillary conjunctivitis patients are managed in the following manner:

Remove the offending lens.
If the upper lid papillary response is severe, apply 1% prednisolone acetate (less expensive) or cromolyn sodium every hour for 12 hours and every 2 hours for another 24 hours. Then, taper. This should quell the mucus, itching and discomfort.
If the corneal epithelium is severely mechanically traumatized by the giant upper lid cobbles, this may need to be done in conjunction with wearing a daily disposable soft lens, perhaps changing it at 8- to 12-hour intervals. If the epithelium is very compromised, possible coverage with an antibiotic may be in order.
Once the acute phase is over, a contact lens “time out” is recommended (2 to 3 weeks), and refitting with a daily disposable for 1 to 2 months on a trial basis can begin, followed by weekly disposable contact lens wear. No extended wear (ever), proper lens care and no overwear of disposables should keep the eye quiet.
The exception to this is allergy season, where daily disposables may be advisable once again. Also, Patanol before and after lens wear during allergy season can be a great help in preventing recurrence.

Allergy sufferers need to avoid symptoms and allergy-induced limbitis and/or corneal infiltrates. For the contact lens wearer, this usually means the following:

Reduced contact lens wear time or cessation of wear if needed.
Strict attention to lens care and hygiene. Cold compresses/unpreserved saline (chilled) rinses as needed.
Avoidance of rubbing, as this exacerbates the limbal folliculosis/conjunctival histamine response, which in turn sets off the immune response that causes infiltrates.
Acular (ketorolac tromethamine, Allergan) usage every 15 to 30 minutes (1 to 2 hours duration of treatment) for severe itching attacks. This is an excellent drug for managing acute attacks.
Patanol or Livostin (levocabastine HCl, CIBA Vision Ophthalmics) for chronic use as a preventive aid. It cannot be used with laser in situ keratomileusis.
Obtain further professional evaluation if symptoms are significant or continual.

John P. Herman, OD, in private group practice, can be reached at 217 South St., Pittsfield, MA 01201; (413) 499-3797; fax: (413) 499-3834; e-mail: jphermanod@aol.com. Dr. Herman has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.