Getting Allergy Symptoms Under Control
An expert shares ways to maximize the effectiveness of your diagnosis, treatment, and complication management.
By John Sheppard, M.D., M.M.Sc., Norfolk, Va.

Allergies afflict more than 50 million Americans annually, and more than half of these patients present with ocular symptoms. Ophthalmologists, naturally, tend to pay more attention to their cataract or refractive surgery patients. However, far more patients have allergy problems: Cataract extractions and excimer laser photoablation surgery figures combined only add up to about 3 million procedures annually, far below the incidence of allergic conjunctivitis. The cost to our society is also impressive: Allergy sufferers, generally in the prime of their productive years, miss far more work than the typical surgery patient. The resulting losses add up to billions of dollars.

With these numbers in mind, it's clear that cost-effective care for ocular allergy is a valuable asset to all of us. Here, I'd like to share some of what I've learned over the years about the causes, diagnosis and treatment of ocular allergy.

Diagnosing allergy isn't difficult; it can usually be accomplished by referring to two key pieces of evidence: the history and an examination of the ocular surface.

Evaluating the history. Common causes of allergy range from environmental to medical. Environmental causes may include:

• dander or saliva residue from animals and pets such as dogs, cats or birds
• fibers such as cotton and wool
• air quality factors such as dust and pollen
• ingredients in makeup
• dietary indiscretions.

Some allergic reactions are iatrogenic. For example, topical and systemic medications can contribute to ocular allergy:

• Dermatological preparations can create havoc when inadvertently introduced into the eye by patients who forget to wash their hands after application.
• Glaucoma, anti-viral, anti-bacterial, cycloplegic and even anti-allergic drops can cause ocular allergy, especially with chronic use by individuals known to be allergy-prone.
• Use of oral antihistamines can lead to dry eyes, which then fail to lavage allergens away. This can provoke further deleterious rubbing behavior. (For more on this topic, see "Avoiding Systemic Allergy Medications")

Allergies are often inherited, so it's also important for the history to include questions about other family members. Those with ocular allergies can be readily identified.

In short, a careful allergic history should include questions regarding dermatological and systemic medications (including eye drops), environmental and lifestyle factors, and questions about allergies suffered by other family members. (Make sure the staff member who takes the history is aware of this.)

In many cases, the history itself is sufficient to diagnose the problem.

Examining the ocular surface. Along with reviewing the patient's history, examining the ocular surface is crucial to diagnosing an allergic response. This concept was popularized by Richard Thoft, M.D., who reminds us that most of the conjunctiva remains out of view. (The conjunctiva, in fact, has 17 times more surface area than the cornea.) A great deal of information can be obtained by examining the tarsal plates, particularly the superior tarsus.

After eversion of the upper lid, it's easy to see precisely how the conjunctiva responds to allergic stimuli, be it a papillary or vascular response, or a follicular or lymphoid response. Here the conjunctiva is well-fixed to the underlying tarsus, clearly displaying pathology, inflammation or cicatrization. This information can guide us in determining chronicity, etiology and the possibility of infection by viral or chlamydial agents.

In order to adequately assess contact lens allergy, vernal or atopic conjunctivitis, or oculo-cutaneous diseases such as Stevens-Johnson syndrome, examination of the superior tarsus is mandatory.

Non-medical treatment strategies

For many patients, simple, practical options can go a long way toward preventing or minimizing the allergy problem. Useful strategies include:

Preventing eye contamination. The single best advice to give ocular allergy sufferers, particularly children, is to wash their hands frequently. I often hear patients ask, "Why is my right eye so much worse than the left?" The answer is that the patient is right-handed, and right-handed people rub the ipsilateral eye more often, introducing more allergens with each stroke.

Avoiding or removing the allergen. Many allergy patients can be essentially cured by a simple change of environment:

• Get the cat out of the house or the dog out of the bedroom. Give the caged bird to grandma. (Being older, she has a far less hyper-reactive immune system.)
• Eliminate natural fiber materials such as cotton and wool from the bedroom and wardrobe. Replace them with synthetic nylon and dacron.
• Eliminate down pillows.
• Provide a zipper-sealed pillow cover over a hypo-allergenic pillow for the dust-mite-allergic patient. (Who wants to sleep with the feces of 100,000 dust mites anyway?)
• Have your patient change to a quality make-up such as Clinique or Estee Lauder hypoallergenic. (A brief but complete vacation from eye liner and mascara can also make a world of difference.)
• Send your patient on a tax-deductable ocean cruise, away from most allergens. (Response to this treatment has been remarkable in many cases.) Or, send your patient for a week of inpatient allergen withdrawal analysis at the National Jewish Hospital in Denver, Colo.

Enlisting the help of family members. In order for treatment to be effective, the patient must be compliant. Often, making family members aware of the treatment plan helps to ensure that practical and medical instructions are followed correctly. Advice given to the index patient can also benefit the entire allergy-prone household, and often leads to positive practice-building results as well.

Using artificial tears. Allan Flach, M.D., Ph.D., is a great proponent of artificial tears for the allergy patient. This conservative, inexpensive approach to allergy is highly effective because each drop removes offending allergens from the tear film. It's a simple but elegant option, particularly with the introduction of convenient, bottled preservative-free tears like Genteal (from Novartis) and Refresh (from Allergan).

Single-dose units are also available in a wide variety of artificial tears; these may be appropriate for the extremely rare individual who's allergic to the hydrogen peroxide in Genteal or the Purite in Refresh.

Cooling the eyes. The hallmark of allergic conjunctivitis is vasodilation, and the warmer the environment, the more vessels dilate. Histamine, SRS-A and ICAM all contribute to vascular leakage, which quickly adds annoying volume to the ocular surface.

Icepacks are a great treatment for those patients who have the time to prepare one, but gel-filled facial masks are a better solution. These colorful devices are designed to be refrigerated or frozen repeatedly. They're readily available in most pharmacies and department stores.

Topical medications

Isolated ocular allergy is usually very responsive to thoughtfully selected topical medications.

Many of my allergy patients remain attached to their mast-cell stabilizers, such as cromolyn (Crolom from Bausch & Lomb, and Opticrom from Allergan). Meanwhile, newer mast-cell stabilizers like pemirolast (Alamast from Santen) offer new, higher-potency choices for sufferers of giant papillary conjunctivitis or chronic allergic conjunctivitis.

Even newer, more effective, third-generation antihistamine products with multiple mechanism actions are now available. (Some antihistamines can now also stabilize mast-cell membranes.) The newer agents reduce application frequency and have the advantage of rapid therapeutic onset. The first such drug, olopatadine (Patanol, from Alcon) established new records for ophthalmic pharmaceutical sales.

Other agents also enhance efficacy by inhibiting key cellular components of the allergic response. For example, eosinophil basic protein has been shown to be extremely toxic to ocular surface cells, and responsible for atopic keratitis. Thus, immobilization of eosinophils is key to elimination of destructive late-phase allergic disease, which can be potentially blinding. Drugs in this category include ketotifen (Zaditor from Novartis), azelastine (Optivar, from Bausch & Lomb) and nedocromil (Alocril from Allergan).

Maximizing the value of drops

Several strategies can help your patients get maximum value from the drops they use. You should:

Make sure drops are applied correctly. Proper application of ophthalmic medications enhances efficacy, as any glaucoma expert will testify. Make sure your patient uses careful, inferior cul-de-sac application and closes the eye afterward. This will improve clinical response and reduce dosage frequency requirements.

Prescribe higher potency, lower frequency. Fewer drops per day of a potent medication is better than frequent drops of a less potent medication. Not only will this improve compliance and reduce the overall cost of therapy to your patient, but your patient will be able to leave the twice-a-day medication bottle at the bedside for morning and evening application.

Have the patient chill the drops. Allergy drops are more comfortable -- and more efficacious -- when chilled or refrigerated. This is especially true of drops with lower pH formulations. (Your allergy patients will be extremely grateful for this simple tip.)

Recommend preservative-free drops. The only preservative-free topical prescription medication for allergy is ketoprofen (Acular PF, from Allergan). This medication is highly effective for more severely inflamed patients who are willing to pay slightly more.

On the road to the "cure"

Today, our ability to control allergic symptoms is greater than ever before. Our knowledge, and the tools at our disposal, are substantial. By using cost-effective treatment regimens, both practical and medical, and enlisting the help of family members and other physicians, we can achieve acceptable control of most allergic symptoms.

Unfortunately, although we can control the symptoms, we can't actually cure the allergy -- at least not yet. It's important for your patient to understand this. Once your patient has accepted this tenant, your battle will be more tolerable -- and more successful.

Treating allergic symptoms may not be as glamorous (or do quite as much for your bottom line) as cataract or refractive surgery. But the results will make many of your patients just as happy. And that's worth a lot.

Dr. Sheppard is professor of ophthalmology, microbiology, immunology and geriatrics, director of residency training, and clinical director of the Thomas R. Lee Center for Ocular Pharmacology at Eastern Virginia Medical School. He is also president of ProVision Network. He's been honored by the American Academy of Ophthalmology and is associate and mentor examiner for the American Board of Ophthalmology. Dr. Sheppard has been principal investigator for more than 35 clinical research protocols and holds a U.S. patent for topical photodynamic therapy.