by Vanessa Caceres EyeWorld Contributing Editor
At a glance
• Seasonal and perennial ocular allergies appear to be on the rise as recognition of ocular allergies grows and the number of allergy patients seems to increase
• Avoidance is the initial treatment advocated by ophthalmologists, followed by a dual-action topical antihistamine/mast-cell stabilizer
• Steroids are another treatment option in acute cases
• Allergists play a role in helping ocular allergy patients, as symptoms frequently occur with other systemic symptoms—
immunotherapy provides long-term relief in many patients
• Future treatment options include cyclosporine, contact lenses with allergy medicine, and other approaches
Treatment approaches for a growing patient group
Figure 1: Stepwise treatment
No matter what time of year you see the largest number of ocular allergy patients, one thing is certain—the number of patients you treat for this condition will likely increase.
That’s because awareness of ocular allergy as its own problem—not just an afterthought with nasal rhinitis—is growing as more medications are available for treatment. Additionally, research is showing that allergies appear to be on the rise, due to climate changes around the globe as well as other factors.
Here’s a rundown of current treatment approaches used by ophthalmologists and allergists for seasonal and perennial ocular allergies.
Start with avoidance
“The keystone is a focus on avoidance,” said C. Stephen Foster, M.D., clinical professor of ophthalmology, Harvard Medical School, Boston. He believes avoidance is a commonly ignored aspect of treatment. However, he discusses with patients special bedding if they are allergic to dust and the use of high-quality air filtration systems to lower exposure.
Other avoidance measures include staying inside when outdoor factors pose an exposure risk and using cool compresses on the eye area, said LeonardBielory, M.D., STARx Allergy Center and Clinical Research Center, Rutgers University, Springfield, N.J.
A detailed patient history—more common in an allergist’s office than an ophthalmologist’s office—can start to help pinpoint what exactly patients need to avoid, said allergist Mark R. Neustrom, D.O., Overland Park, Kan. Patients may not initially consider how household pets or new skin products trigger allergies, he said. Although many patients may not want to give up the family pet, they can take certain cleaning measures to reduce allergens, Dr. Neustrom said.
Patients who are allergic to pollen may find it harder to avoid, Dr. Bielorysaid. He is involved with a three-year grant from the U.S. Environmental Protection Agency to investigate how climate changes are affecting plant growth. Some research is finding that pollen season has become more acute and prolonged in recent years, which increases the number of patients affected by allergies/allergic asthma and the severity of disease, he said. The research is underway both in the U.S. and around the world, he added.
Additionally, clinicians such as Andrea Leonardi, M.D., Department of Neurosciences, Ophthalmology Unit, University of Padua, Italy, are noting a phenomenon of conjunctivitis that does not appear to be exactly related to allergies, infections, or dry eye. Called “urban eye allergy syndrome,” its cause seems to be related to air pollutants and pollens, particularly in urban areas. Dr. Leonardi and a co-investigator reported on this in 2008 in Current Medical Research and Opinion.
Although various ocular allergy treatments are available, physicians who treat allergy seem to agree that the dual-action antihistamine/mast cell stabilizers on the market now seem to work well in many patients.
“Antihistamines with mast cell stabilizing abilities, also known as dual-acting agents, have been shown to inhibit mast cell degranulation both in the conjunctival mast cell in vitro model and in the in vivo model of allergen challenge,” Dr. Leonardi said.
“Treatment preferences are based on the convenience of use, with reduced frequency of instillation, patient preference, costs, and avoiding or limiting treatments with potential side effects, such as corticosteroids or vasoconstrictors.”
Dual-action therapy can help increase compliance, with patients having to take fewer drops, Dr. Foster said. Dr. Neustrom often tries dual-action therapy when over-the-counter drops such as Claritin Eye (ketotifen, Schering-Plough, Kenilworth, N.J.), Zyrtec (now available as an eye drop—ketotifen, McNeil Consumer Healthcare, Fort Washington, Pa.), and Zaditor (ketotifen fumarate ophthalmic solution, Novartis, East Hanover, N.J.) do not work.
Another option physicians are talking about is the recent U.S. Food and Drug Administration (FDA) approval of Bepreve (bepostastine besilate ophthalmic solution 1.5%, Ista Pharmaceuticals, Irvine, Calif.), which is for the treatment of ocular itching associated with allergic conjunctivitis. For example, a Phase III study published in the September 2009 issue of Clinical Therapeutics reported that bepostastine 1.0% and 1.5% were associated with a statistically significant reduction in ocular itching within 15 minutes and that the effect was maintained for at least eight hours. “The percentage of people [in studies] who went to zero itch was strikingly high,” Dr. Bielory said.
Patients might also take oral antihistamines, as ocular allergies are often accompanied by nasal symptoms, but these sometimes can lead to tear film dysfunction problems—or exacerbate existing tear film issues. Although the current crop of antihistamines do not provoke this problem as often, ophthalmologists should still check for tear film dysfunction in allergic patients, particular in the elderly and in perimenopausal females, Dr.Bielory said. This is also important as allergy and tear film dysfunction symptoms often overlap.
Similarly, patients who are being treated by other specialists for allergies may take nasal corticosteroids—a great option to reduce symptoms but one that can have side effects, such as cataracts or lens opacity. Ophthalmologists should monitor for these conditions if patients are chronically using nasal steroids, Dr. Bielory said.
Drs. Bielory and Neustrom also added that while some nasal steroids are promoted for the reduction of ocular as well as nasal symptoms, the jury is still out on to what extent they do that—and which nasal steroid works the best. “It’s probably a class effect,” Dr. Neustrom said. A head-to-head comparison with nasal steroids that focuses on reducing ocular allergy symptoms would need to be done to answer this question, Dr. Bielory said.
Topical steroids are yet another option for ocular allergy treatment, particularly if patients were not previously aware of their condition and present with an acute case. Low-dose topical steroids such as Alrex (loteprednol etabonate, Bausch & Lomb, Rochester, N.Y.) can “put out the fire and be continued long-term,” Dr. Foster said.
When to refer to an allergist
A visit to a local allergist can make a big difference in quality of life for a patient with seasonal or perennial ocular allergies, ophthalmologists said. “I’m ill-equipped to take a detailed history and do skin testing,” Dr. Foster said. “Allergists are helpful, and they like these patients.” Dr. Foster, who does not hesitate to refer ocular allergy patients to allergists, used to think that allergists would find the concerns of ocular allergy patients trivial. However, he has since found allergists like these patients because they can make a big difference in the patients’ lives quickly, unlike with some of the severe asthmatic patients they treat.
The role of the allergist is crucial when you consider that ocular symptoms are often part of other systemic allergic reactions, Dr. Bielory said. “A systemic approach is necessary. If you’re treating just the eyes, it’s like putting a Band Aid over the wound,” he said. He will refer ocular allergy patients to an allergist if they report that their nose, skin, or lungs are affected.
An allergist can take a detailed history and do a prick skin test. For example, Dr. Neustrom’s office will test for 40 possible allergens. If the test shows the need for immunotherapy, patients will typically receive shots for 3 to 5 years, starting with once a week and then gradually receiving shots just every few weeks.
Patients who have a longer course of shots (e.g., 5 years) tend to have a longer-lasting effect than those who get shots for a shorter period of time, Dr. Neustrom said. Allergy shots are known to be effective 80% of the time. Although immunotherapy can be inconvenient and it takes a few months to feel the benefits, it ultimately improves quality of life in many patients and can help patients reduce the number of medications they use, Dr. Neustrom said.
If patients move to a new area, they need to live there several months before they will notice they have an allergic reaction to pollen or other environmental factors native to that area, Dr. Neustrom said. For that reason, he does not perform testing on patients until they have lived in the same area for about a year.
Investigators now have a better understanding of the cellular and chemical causes involved in the pathogenesis of allergies, and newer treatments are underway. For example, sublingual immunotherapy (SLIT)—which involves taking a tablet or an oral drop instead of receiving an injection—is popular in Europe right now.
SLIT is not yet approved in the U.S., and U.S.–based studies have not yet produced the same results as in Europe, Dr. Neustrom said. The most success seems to come with patients who are principally allergic to one thing, such as cat dander or a certain kind of grass. This is because the SLIT developed thus far focuses on one allergen treatment at a time.
Some studies show that immunotherapy can lower health care costs. A study published in the January 2010 issue of Annals of Allergy, Asthma and Immunotherapy reported that immunotherapy-treated children had significantly lower total health care costs, outpatient costs, and pharmacy costs compared with a control group. For example, the total 18-month healthcare costs in the immunotherapy patients was a median of $3,247 versus $4,872 in the control group. “Greater use of this treatment in children could significantly reduce [allergic rhinitis]-related morbidity and its economic burden,” wrote the investigators, led by C.S. Hankin.
Referral between specialties is a two-way street, Dr. Bielory said. “Allergists should consider evaluation by an ophthalmologist if the patient has pain, is chronically using oral steroids, and has suspected cataracts or lens opacity,” he said.
Future treatment possibilities
A number of future treatment possibilities are under consideration for allergy, although they focus more on severe forms of allergy, such as vernal keratoconjunctivitis (VKC) or atopic keratoconjunctivitis (AKC). Cyclosporine has been “life changing” for some AKC patients, Dr. Foster said.
“In poor responders, or when only prolonged steroids are effective, my choice is topical cyclosporine 0.5%-2%, which significantly ameliorates the signs and symptoms of moderate to severe VKC and AKC without side effects,” Dr. Leonardi said. A dermatological form of topical cyclosporine called tacrolimus is approved by the FDA but is not yet available as an ophthalmic preparation, Dr. Leonardi said. “I’ve been using tacrolimus topically applied externally or into the fornix in a small number of patients with severe allergic conjunctivitis, and it has been shown to reduce signs and symptoms without significant toxicity,” he said.
Another treatment approach under investigation is the use of contact lenses impregnanted with medications for allergy. Vistakon Pharmaceuticals (Jacksonville, Fla.) has reported the completion of a trial with contact lenses and ketotifen on ClinicalTrials.gov, but the results are not yet available, Dr.Bielory said.
Editors’ note: Dr. Bielory has financial interests with Alcon (Fort Worth, Texas), GlaxoSmithKline (Middlesex, England), and Schering-Plough (Kenilworth, N.J.), among other ophthalmic and allergy companies. The other physicians interviewed did not indicate any financial interests related to their comments.