OSD: Scratching the surface

Fine tune your dry eye and allergy diagnoses

By Karen Blum, Contributing Editor

Your patient carps about, and obviously has, red, irritated eyes. Do you prescribe an antihistamine for allergy or evaluate further for possible dry eye conditions?

“We get these vague complaints — dry eye, watery eye, itchy eye, scratchy eye, red eye — and we’ve kind of lumped them all together,” says Robert Weinstock, MD, director of cataract and refractive services at the Eye Institute of West Florida and the Weinstock Laser Eye Center in Largo. “I think there’s a new wave of being a little more diligent and scientific in our approach to these patients.”

Here, dry eye and allergy experts explain how to properly diagnose and treat these patients.

DIFFERENTIATE THE DIAGNOSIS

Define the conditions

Without the proper diagnostic tests, ophthalmic professionals can’t accurately treat patients. The same is true for dry eye and ocular surface disease, Dr. Weinstock says. “When you start evaluating a patient for all of these things, it starts to become much more clear what the problem is.”

Dry eye and allergy are two of the most common reasons why patients visit an ophthalmologist, says Eric Donnenfeld, MD, clinical professor of ophthalmology at New York University and a partner of Ophthalmic Consultants of Long Island. About 40% of patients who come in have some form of dry eye disease, and 15% have some type of allergic disease, he says.

The disorders also frequently co-exist, he adds. “Just because you diagnose dry eye, it doesn’t mean that the patient doesn’t have allergy as well. Treating the complete underlying condition is important to achieve optimal results.”

Dry eye symptoms include foreign body sensation, irritation, eye discomfort and tearing, says William Trattler, MD, of the Center for Excellence in Eye Care in Miami. A common but lesser known complaint is blurred or fluctuating vision. Allergy symptoms typically include redness, itchiness and eyelid swelling. But some overlap exists, he says; dry eye also can cause redness and itchiness.

Patient history

Check for patient experience with allergic rhinitis, asthma or atopic disease, all of which are highly associated with allergic eye disease, Dr. Donnenfeld says. Also, see if patients have dry eye risk factors, including cardiovascular disease, rheumatoid arthritis, previous LASIK or PRK surgery, older age, a diet low in omega-3 fatty acids, diabetes mellitus, autoimmune diseases, Sjögren’s syndrome, lupus and thyroid conditions or take medications like antihistamines, antihypertensives and antidepressants. Postmenopausal women also are more likely to have dry eye, says Mitchell Jackson, MD, founder and director of Jacksoneye in Lake Villa, Ill.

“I listen to [patients’] symptoms and then say, ‘Tell me the one most aggravating symptom that made you come in today,’” Dr. Jackson says. If a patient says itching, then he’s more inclined to use a skin test for allergies at the outset of his work-up. He also uses dry eye questionnaires like the Standard Patient Evaluation of Eye Dryness (SPEED) to assist him in the overall review of patient complaints. Other dry eye questionnaires include the Dry Eye OSDI Questionnaire (mydryeyes.com), the Dry Eye–Related Quality-of-Life Score Questionnaire (DEQS), the TearLab Dry Eye Questionnaire and Allergan’s Dry Eye Patient Questionnaire.

Slit lamp photo showing significant dry eye, with diffuse punctate corneal staining.

Patient exam

Start the patient exam by inspecting skin around the lids to identify signs of allergic disease, such as erythema, Dr. Donnenfeld says. Look at lid margin and function, squeeze the meibomian glands and check the quality of secretions.

Also, look at the conjunctiva for signs of mucus. A slit lamp examination can reveal the quality and quantity of the tear film, Dr. Trattler says, and fluorescein can indicate staining of the cornea and rapid tear film break-up time in patients with dry eye. Some ophthalmologists also use Schirmer’s test to evaluate tear production, he says.

CONDUCTING TESTS

Allergy

After the history and exam, ophthalmologists should have a good sense of what further testing to pursue, Dr. Weinstock says. Making the most accurate diagnosis has become easier over the past five years, thanks to a plethora of relatively inexpensive point-of-care tests and devices that have hit the marketplace.

For allergy, Dr. Trattler uses a panel of 60 ocular-specific allergens, such as trees and grasses, dust mites and pollens specific to each region of the country. “It’s a really useful test because it can help us direct therapy, not just offer the typical anti-allergy drop,” Dr. Trattler says. Also, the test can indicate what time of the year patients need to take antihistamines, Dr. Jackson says. Patients with seasonal allergies who have been taking other anti-allergy medicines year-round can be weaned off them, reducing the dry eye side effect of these medications.

Many people self-treat for allergies incorrectly, adds Dr. Jackson. “They think they’re allergic to mold or animal dander but then find out they’re not, or think they’re allergic to trees and grass and find out they’re not, or vice versa. People are highly surprised by what they find out.”

Dry eye

Many tests are available for dry eye, Dr. Jackson says:

• InflammaDry (RPS). A rapid test for MMP-9, an inflammatory marker elevated in the tears of dry eye disease patients.

• LipiView II (TearScience). Takes images of the tear film lipid layer and meibomian gland structure to assess meibomian gland dropout.

• The OCULUS Keratograph 5M. A corneal topographer with a built-in keratometer and color camera. It can be used to examine the meibomian glands, study tear film break-up time and evaluate the lipid layer.

• The TearLab osmolarity system reader. Calculates and displays tear osmolarity.

• The AcuTarget HD. The device can assess tear film quality over time and evaluate vision quality, including an objective ocular scatter index.

• Sjö (Valeant). A finger-stick test that measures blood biomarkers affiliated with Sjögren’s syndrome at the earliest stage of disease.

In particular, tear osmolarity is an excellent predictor of dry eye disease severity, Dr. Jackson says. Tears higher than 300 mOsm/L demonstrate a loss of homeostasis and likely become pathogenic over 308 mOsm/L, while a difference of more than 8 mOsm/L between the eyes is a hallmark of tear film instability, he says. The readings can be used to gauge response to therapy by comparing readings before and six weeks after therapy. And, patient compliance improves when they see the numbers improve, he says.

A 56-year-old male s/P RK with significant corneal staining consistent with dry eyes.

TREATMENT OPTIONS

Allergy

Diagnostic test results can lead to targeted treatments. For allergy, Dr. Trattler says there are combination prescription antihistamine/mast cell stabilizers, such as olopatadine hydrochloride ophthalmic solution 0.2% (Pataday, Alcon), bepotastine besilate 1.5% (Bepreve, Bausch & Lomb) and alcaftadine 0.25% (Lastacaft, Allergan), and over-the-counter drug ketotifen (Zaditor, Novartis).

Topical steroids, such as prednisolone acetate (Pred Forte, Allergan) or loteprednol etabonate ophthalmic gel (Lotemax, Bausch & Lomb), can be used “for acute episodes, where we really want to get things better faster,” Dr. Trattler says.

Dry eye

For dry eye, patients should use a combination of topical steroids like prednisolone acetate and loteprednol etabonate as a pulse therapy twice a day for two to three weeks, along with cyclosporine (Restasis, Allergan) twice a day for the long-term, Dr. Trattler says. Second-line therapies may include placement of punctal plugs to help raise the tear film or lid hygiene products to disinfect bacteria on the eyelashes. Because dry eye is progressive, patients should stay on cyclosporine long-term, he says.

Dry eye treatments should be tailored based on diagnostic objective tests and clinical signs and symptoms, Dr. Jackson says. “You have to get patients on the right therapy from the outset, as most patients already have failed some sort of therapy.” For example, if they have meibomian gland dysfunction, put them on an artificial tear that replaces the lipid layer. If osmolarity is an issue, use products designed with a hypotonic formulation that can reduce osmolarity, he says.

For evaporative dry eye, Dr. Jackson also uses a treatment that applies a combination of heat and pressure directly to the eyelid, restoring meibomian gland function.

He also recommends nutritional supplements containing omega gamma linolenic acid (GLA) because of GLA’s anti-inflammatory effect.

Why not both?

Some drugs treat allergy and dry eye disease, a medical two-fer not to be ignored.

“Lubricating drops can both lubricate dry eye disease and dilute antigens in the tear film. Corticosteroids are helpful for both by controlling inflammation, and T-cell modulators such as cyclosporine are helpful for both diseases,” Dr. Donnenfeld says.

PRIORITIZE THE OCULAR SURFACE

Consider creating a subspecialty

In large practices in which a significant percentage of patients complain of red, itchy eyes, it may be cost effective and efficient for an optometrist or ophthalmologist to become subspecialized in ocular surface disease, Dr. Weinstock says.

“We know that dry eye and ocular surface disease tend to be brushed under the carpet a little bit by most of the specialists,” he says. “So, if there’s a home within the practice where patients can get a little more TLC and testing/treatment for ocular surface disease, it brings up the overall level of care that practice is giving.” OM