Recall Strategies Can Enhance Allergy Care
Advice for effective management of these patients from diagnosis to relationship building.
GAIL TORKILDSEN, M.D.

The elusive and transient nature of the ocular allergic reaction can make it difficult to observe. However, the severity of an acute ocular reaction is often characterized by patients as intense, distracting, and extremely uncomfortable. Additionally, allergic conjunctivitis can be severe when it is occurring, yet nearly invisible when an acute attack is not present.

How do you manage a disease with such an uncooperative presentation? It can be a challenge, but the rewards of correctly managing allergy can infinitely surpass the time invested, not only for the health of patients, but also for your practice.

Several basic steps will facilitate allergy patient treatment: identification of the allergy, implementation of treatment, and maintenance of contact with your population of allergy patients.

Medical history. Every good treatment starts with a quality medical history. Yes, it may take a bit of time, but will yield a more satisfied, faithful patient. In fact, asking a few pointed questions regarding the occurrence of ocular allergy can be quite efficient. Questions such as: Do you get itchy eyes? When and where are you when your eyes itch or bother you? Do you ever take over-the-counter (OTC) antihistamines, such as Allegra or Claritin? Do those around you ever comment or do you notice in the mirror any redness of your eyes or puffiness of lids? Does anyone in your family have allergies? Do you recall being bothered by your eyes at the same time last year?

Intake form. Incorporate questions into an intake form: one to three questions regarding whether the patient's eyes itch, and whether the patient currently takes any OTC allergy medication can be just the thing needed to raise a red flag. Asking a couple of questions about itchy eyes can be particularly effective. Itchiness is a hallmark symptom and its presence immediately indicates that allergy is the most likely cause. Ask about OTC medications: do you take Claritin or Visine A? Often patients will be more specifically forthcoming with concrete information such as medications taken, and you can then work backwards from that point, ascertaining when, why, and for what symptoms they take these medications.

Medical examination. Though testimony from the patient about itchy eyes may be the primary factor we must rely on for diagnosis of ocular allergy, don't discount ophthalmic observations entirely. Typically, there are no laboratory tests performed for a diagnosis of allergy, though a skin-prick test can be used to identify specific allergens to which an individual is sensitive. A general idea of an individual's sensitivities can be estimated from when they experience symptoms: spring symptoms typically correspond to grass allergies, fall to ragweed, though there are regional variations. Beyond identifying when symptoms occur, the full range of allergy signs (e.g., redness, chemosis, lid swelling) can be looked for, though the majority of allergic patients will not be in the midst of an acute reaction with severely itchy, red, watery, and chemotic eyes at the exact moment of their annual appointment. However, there may be clues present. Residual redness or irritation of the eye or skin around the nasal region may be present as a result of the patient rubbing his/her eyes. In addition, residual swelling or chemosis may be evident. Eyelid swelling is typically the slowest sign of allergy to depart after an acute reaction, and may be the one clue that is evident and sparks further questioning into the possibility of allergy.

These tools can be integrated to form a fluid system, and the intake questionnaire can act as the initial filter. Patients can then be questioned further to pinpoint the allergic problem according to seasonality. Any signs or symptoms that are present or reported by the patient can then confirm the diagnosis, and lead to appropriate treatment assignment.

Implementing a treatment regimen is an important step, regardless of whether allergy season starts tomorrow or in 6 months. Pre-emptive therapy should be the strategy of choice when it comes to treating seasonal allergic conjunctivitis. This will prepare the patient for the allergy season, whenever it may occur, and will exert an influence over the therapeutic agent selected. It is important for both patient and practitioner to keep in mind that there are differences among the many available treatments for ocular allergy, and not any one treatment will suit each patient perfectly.

The categories of medication differ according to mechanism of action, frequency of dosing regimen required, comfort, safety, and efficacy. With regard to allergy eye drops, there are several categories: OTC eye drops are typically antihistamine or antihistamine/vasoconstrictor combinations, which offer quick, though short-lived relief of an acute allergic reaction. The duration of action of these agents typically ranges from 2 to 4 hours, though indications limit dosing to q.i.d. This limits the patient's ability to maintain prevention throughout the entire day. Tachyphylaxis, mydriasis, and irritation are known side effects of OTC eye drops.

Mast-cell stabilizers work by maintaining the integrity of the mast-cell membrane so that histamine is not released. These medications require loading doses and a regular dosing regimen, typically b.i.d. or q.i.d. It is often difficult to get busy patients to adhere to both a prophylactic loading period and frequent dosing schedule. The most recent class of ocular allergy medications is dual-action agents, combination antihistamines, and mast-cell stabilizers. Dual-action agents allow for blockage of histamine receptors and for prevention of mast-cell degranulation, thus blocking the reaction at two points. This provides greater prevention against the signs and symptoms of ocular allergy. This class also has the least frequent dosing schedule with b.i.d. dosing being the typical indication (though at least one of these dual-action agents, olopatadine (Patanol), is scheduled to debut in a once-daily formulation in the near future). Overall, patients care about their quality of life, not the mechanism of action of their medication. If the treatment assignment is safe, comfortable, and convenient to use the patient will be satisfied.

One strategy that may be useful to get patients on the right track for treatment may be to have a block of allergy-patient days at your clinic in early spring and in late summer; prior to the peak of some of the more severe pollen seasons for grasses and ragweed, respectively. During this block of 2 to 3 days, patients from your database -- either current or suspected allergy patients -- can be scheduled for a specific pre-allergy season assessment. Educational materials and/or samples might also be dispensed.

The final step to the process is regular follow-up. One possibility is that a postcard could accompany the educational materials dispensed at a pre-allergy season visit incorporating questions regarding patient satisfaction with his/her treatment, complaints, requests, or questions. While one might anticipate a barrage of questions, few patients may take advantage of it. For the remainder, it shows that his/her doctor is accessible and eager to communicate. Thus, most patients will feel a positive and supportive relationship with their eyecare practitioner's office, though typically few will exercise the option for further communication.

Beyond a feedback card, it can be helpful to schedule a follow-up visit during allergy season when an individual patient typically experiences his/her most severe symptoms. This can be useful in evaluating firsthand the symptoms and signs the patient finds most bothersome, and can serve as an excellent interim point at which to evaluate how well his/her anti-allergy treatment is working. Depending on the efficacy and satisfaction with the current agent, the patient can be switched to another medication, given a different medication to sample, or add additional agents to his/her current treatment.

Overall, implementing some of these tools and strategies should aid in the identification and treatment, and ultimately the satisfaction of allergy patients, who know that their allergy complaints will carefully be addressed when they walk in the door.

Gail Torkildsen, M.D., is a principal investigator for Ophthalmic Research Associates of North Andover, Mass. She is also affiliated with Andover Eye Associates. Dr. Torkildsen has no financial interest in the information contained in this article.