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Case report shows ocular allergy agent treats rhinitis symptoms
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PHOENIX – Treatment with bepotastine 1.5% solution for allergic conjunctivitis was shown to relieve allergic rhinitis symptoms as well, according to a case report presented in a poster here at Academy 2012.
Agustin L. Gonzalez, OD, stated in his poster that drainage through the nasolacrimal system of agents applied ocularly is usually considered as a potential route for systemic toxicity. Punctal occlusion is often recommended for decreasing the systemic absorption of ocular agents. However, Gonzalez shows in this case report a “coincidentally beneficial side effect secondary to the management of allergic symptoms by the use of topical bepotastine 1.5% ophthalmic solution.”
A healthy 32-year-old man showed signs and symptoms of allergic conjunctivitis and elevated IOP after treatment with fluticasone propionate every day, sometimes three times a day, for 3 years, despite the fact that intranasal corticosteroids have been shown to decrease ocular symptoms in additional to nasal.
Upon clinical exam, the patient’s best-corrected visual acuity was found to be 20/20 OU, refraction was -6.25 D sph OD and -6.75 D sph OS, and IOP was 24 mm Hg OD and 26 mm Hg OS. Pupils were equal, round and reactive to light, and there was no afferent pupillary defect. Dilated evaluation was unremarkable.
Agustin L. Gonzalez
Other relevant history was unremarkable, but it was noted that his father had glaucoma.
“At this time, a tentative diagnosis of steroid-induced elevated IOP was made,” Gonzalez reported.
The fluticasone was discontinued with no substitution pending consultation with the patient’s primary care physician. The patient was prescribed bepotastine 1.5% ophthalmic solution twice daily.
One week later the patient returned for his follow-up appointment and reported that the bepotastine as prescribed was effective for his allergic conjunctivitis symptoms. However, he noted a metallic aftertaste.
At this visit, the patient’s IOP was 19 mm Hg OU, and “he voluntarily reported no symptoms of allergic rhinitis associated with the discontinuation of fluticasone,” according to the poster.
After 9 weeks of treatment, the patient’s IOP was 18 mm Hg OD and 19 mm Hg OS and he also reported continued relief of his allergic rhinitis symptoms.
Findings at 30 weeks were similar.
“In this patient, the unique characteristics of the bepotastine molecule have helped alleviate the nasal rhinitis while limiting the use of nasal steroids,” Gonzalez stated in the poster.
The package insert for fluticasone propionate describes it as a glucocorticoid steroid indicated in allergic reactions, allergies, allergic sinusitis, allergic rhinitis and sinus congestion, with an incidence of elevated IOP of 0.25%. The package insert for bepotastine 1.5% describes it as an H1 receptor antagonist indicated in the relief of itching associated with allergic conjunctivitis.
It is believed that steroid-induced glaucoma is primarily caused by increased outflow resistance, which elevates IOP, Gonzalez stated. “Increased responsiveness to steroids may be facilitated by the upregulation of glucocorticoid receptors on trabecular meshwork cells,” he said.
One study showed that glucocorticoids increased the expression of the extracellular matrix protein fibronectin, glycosaminoglycans and elastin in cultured human trabecular meshwork cells.
Steroids also suppress phagocytic activity, Gonzalez reported, which may increase deposition of material in the juxtacanalicular meshwork of eyes with steroid-induced glaucoma. He added that some have postulated on the actual physical obstruction by a steroid because white crystals were observed in the angle of a patient whose IOP increased after injection of intravitreal triamcinolone.
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Disclosure: Gonzalez is a consultant for Bausch + Lomb.