Rx Perspective
Allergy in Kids: No Small Problem
A pediatric ophthalmologist explains her approach to treatment.
BY KIMBERLEE M. CURNYN, M.D.

Often, we assume that allergic conjunctivitis is a benign disease. We forget that it actually has a huge impact on our patient population.

In children especially, if we can make an early diagnosis and begin therapy, we can prevent more serious conditions later in life and also cut down on school absenteeism and poor behavior.

MAKING THE DIAGNOSIS

The best place to start is a detailed history. Have the parents describe the child's behavior. They often report eye rubbing, excessive blinking, tearing, photophobia, or puffiness when the child first wakes up in the morning. Sometimes you'll need to help them unravel the story. Make sure you ask how long the behavior has been there and whether it's been seasonal.

If you're suspecting allergic conjunctivitis, keep in mind that in children the bulbar conjunctiva will often have a milky appearance from swelling in the conjunctival layer and obscuration of the blood vessels. So, instead of having a hyperemic eye like we see in a lot of infectious conjunctivitis, these kids will have no to mild injection.

Also, parents will often report that it takes the child a while to open his eyes in the morning. And the discharge they see holding the lashes together is stringy, white, and mucousy, as opposed to a purulent, infectious discharge.

Also, I can't emphasize this enough: Before you diagnose allergic conjunctivitis and send a child on his way, always perform a thorough exam.

Examine the cornea, but also get a cycloplegic refraction and examine the fundus. (You'd be surprised how many dilated pediatric exams show pathology.) The last thing you want to do is treat a child for allergies, who then doesn't return for 3 or 4 years, and then find you missed amblyopia or a coloboma or an optic nerve hypoplasia. It's not good if a child has been to an ophthalmologist and diseases were missed.

CHOOSING A TREATMENT

If my diagnosis is allergic conjunctivitis, and I believe that a medication is in the child's best interest, I prescribe ketotifen (Zaditor) for several reasons:

We've become more familiar with the late-phase allergic reaction and recognize that we need to treat that in children as well. It's that chronic allergic- reaction release of eosinophils that actually causes cellular damage.

Newer medications, such as Zaditor and azelastine (Optivar), are labeled for treating all three stages of allergic conjunctivitis: the acute stage, where histamines are released; the next stage, where we need mast-cell control; and the final stage, where we need to prohibit eosinophils from being attracted into the area. (Some recent studies have indicated that the mechanism of action of olopatadine (Patanol) may also delay the eosinophil migration.)

Parents are reassured by the fact that the medication has 20-year track record of use for asthma and respiratory complications as well as a 10-year history as an ophthalmic solution in Japan.

Also, it has been cleared by the FDA as appropriate for children.

It stops itching, and itching is what compounds the allergic reaction, especially in children, who rub their eyes.

It works quickly, which is important to parents.

It has a long duration of action. In the pediatric population, you don't want to initate drops more than twice a day because you'll lose compliance. If a child uses Zaditor before he goes to bed, it continues to work while he sleeps.

It has anti-inflammatory actions. I want my young patients to have good vision for the rest of their lives, and if an inflammatory response is going to cause any problems with the cornea, I'd rather stop it now.

KEEPING THE KIDS COMFY

In addition to prescribing the medication, I explain to the parents that they can do several other things to keep their child comfortable:

• avoid exposure to the allergen
• have the child shower when he comes in from playing outside during pollen seasons
• use air conditioning and room air purifiers
• apply cold compresses
• use lubricating eyedrops, which dilute and wash away antigens.

Dr. Curnyn is a pediatric ophthalmologist on staff at the University of Illinois in Chicago. This information was drawn from her talk during the 2001 AAO meeting.