Contact Lens Business
Helping Patients Survive SAC
Seasonal allergic conjunctivitis and contact lenses can be a tough combination. One doctor offers his advice.

BY JASON M. JACOBS, M.D.

During the spring and summer, contact lens patients may present with the signs and symptoms of seasonal allergic conjunctivitis (SAC): itching, tearing, red, edematous lids, chemosis and/or a papillary reaction. This can be especially un-pleasant for a contact lens wearer.

To help, of course, you should try the simple things first: air conditioners or filters at the patient's home, artificial tears or rewetting drops, and cool compresses. It's also worth switching the patient to a lens that's replaced more frequently, because allergens can stick to the polymers. In fact, two daily wear lenses -- Focus Dailies from CIBA Vision and 1-Day Acuvue from Vistakon -- have received FDA clearance to claim that SAC sufferers will experience less discomfort wearing their lenses.

In theory, switching from soft contacts to rigid gas permeable (RGP) lenses is another option that might help, but in my experience most patients prefer to stick with soft lenses if that's what they're used to.

MEDICAL THERAPY

If these options aren't the answer, the next step is medical therapy. Generally, my contact lens patients have had the best results with mast cell stabilizers on a b.i.d. schedule. I advise patients that peak efficacy may take 1 to 2 weeks and that best results come from consistent use.

Other points to keep in mind:

The dosing schedule is key. I avoid prescribing medications that require q.i.d. dosing. These will force patients to remove their lenses at least twice during the day for instillation. In contrast, b.i.d. dosing allows patients to insert one drop in the morning 5 minutes before contact lens insertion and one in the evening after removal.

Don't use systemic therapy. Although this is effective for rhinitis, it's generally not useful for treating SAC; systemic antihistamines, nasal steroids, and desensitization therapy often have little effect. Systemic antihistamines can even make the patient's eyes drier, increasing irritation.

Many topical medications have drawbacks. For example:

• NSAIDS can be problematic for contact lens wearers because they decrease corneal sensation and may increase the risk of epithelial microtrauma and infectious keratitis.
• Topical vasoconstrictors can cause rebound vasodilation.
• Steroids are effective, but routine use should be avoided because of the risks of infection, glaucoma, and cataract. However, a short steroid pulse can provide the quickest relief when a patient presents in the midst of a major flare-up. In this situation I have the patient discontinue contact lens wear and start both a steroid, q.i.d. (usually Pred Forte, Lotemax, or FML) and a mast cell stabilizer, b.i.d. In 4 to 7 days the patient tapers the steroid but continues the mast cell stabilizer and resumes contact lens wear.

Prevention helps. If patients suffer from SAC every year at the same time, I advise them to initiate mast cell stabilizers before symptoms develop. This can prevent the worst of the acute flare and the emergence of late-phase chemical mediators of inflammation.

To help patients remember the medication in the absence of symptoms, I tie their schedule to familiar holidays such as Easter and July 4.

Ultimately, the easiest solution for a contact lens wearer suffering from SAC may be a holiday from wearing contacts. (Of course, your patient may not be too happy with this option.)

REMEMBER THE GOOD SIDE

SAC is teary, itchy and uncomfortable. However, you can always remind patients that, like everything in life, it has it's good points. After all, it's the price we pay for the lush vegetation of spring and summer. And eventually, it goes away.

Dr. Jacobs practices at Cherry Creek Eye Center and Rose Medical Center in Denver, Colo. A summa cum laude graduate of Harvard University, Dr. Jacobs holds several patents on excimer laser techniques.