If it’s not a cold, is it ocular allergy?

Ophthalmologists see many people with misery written in red across their globes. But is it allergy?

By Eric Rosenberg, DO, Marguerite McDonald, MD and Eric Donnenfeld, MD

Up to 40% of the U.S. population has experienced allergic ocular symptoms at least once.¹ Allergies as a whole comprise the fifth-leading group of chronic diseases, while allergic conjunctivitis is a prime reason for a child’s visit to an ophthalmologist.^2,3 Ocular and nasal allergy patients may present with any number of symptoms, including sneezing, stuffy or runny nose, and/or watery, itchy, red, dry or puffy eyes.

Figure 1. Allergic contact dermatitis due to medications.

In a 2012 telephone survey, researchers asked 2,765 people, who had never been diagnosed with an allergy, if they had allergy symptoms. This study, dubbed the Allergies, Immunotherapy and Rhinoconjunctivitis survey, revealed that red, itchy eyes caused most patients to seek medical treatment.⁴ It also showed what allergy sufferers have long known: a bimodal seasonal distribution of allergy symptoms, with peaks in March to May and resuming in September.⁴

Ocular allergy complaints alone account for 15% of new patient visits at our practice, underlying the importance of a detailed understanding of the disease process, diagnostic modalities available and treatment plans. (To review a diagram of the cascade of events leading to an allergic reaction, see page 28.)

Over the past decade, translational research and medicine have brought allergy and immunology bench research to the forefront of individualized patient treatment. In the past, generations of ophthalmologists would subcategorize and brush aside ocular allergies. Now, we can identify and treat these patients in a multidisciplinary approach with targeted therapies. This shift represents a more comprehensive and global view of pathologic etiologies that are not exclusively localized or restricted to one domain or field of study.

DIAGNOSING ALLERGY

Ask the right questions

Diagnosing ocular allergy is not always straightforward. Defining the etiology responsible for a patient’s disease process begins with an in-depth history and physical. Asking appropriate questions assists in deciphering the difference between dry-eye syndrome, allergy, rheumatoid disease or infection.⁸ To tease out pertinent details, ask about home medications, medical problems and family history; these can alter treatment.

For example, if the patient has a systemic medical condition, such as rheumatoid arthritis, pemphigus or Vogt-Koyanagi-Harada (VKH) syndrome, it can turn away from an ocular allergy diagnosis (although the two could co-exist). Also, familial or individual conditions, such as psoriasis, urticaria, asthma or atopic eczema, might suggest a patient’s abnormal susceptibility towards allergens.^9,10 Understanding your patient population and probing living conditions (i.e., urban versus rural) could uncover a reduced allergen exposure in childhood — this otherwise trivial detail might reinforce a presumed allergic pathway etiology.¹¹ Similarly, certain over-the-counter decongestants, anticholinergics, antidepressants or systemic acne medications may induce or further exacerbate symptoms.^8,12

Lab testing

Laboratory testing for underlying diseases also offers a new tier for accurate in-office diagnoses. Doctor’s Allergy Formula released a FDA-approved, noninvasive, no-needle ocular allergy, objective diagnostic system created for ophthalmologists. This skin-scratch test uses 58 regional specific allergen panels. It takes three minutes to administer; the results are ready within 20 minutes. The Doctor’s Allergy Formula kit includes items the practitioner needs to administer, such as a resource guide that depicts images of each allergen, allergen avoidance tips and techniques and positive and negative controls.

Providing clear, quick, relevant information helps us to provide an effective targeted treatment protocol. Rather than treating allergic disease without knowing the cause of the disease, we can use basic allergic protocols, such as allergen avoidance, and treat when the patient is most likely to be in contact with the allergen.

Interestingly, approximately 80% of patients who have presented to our office with ocular allergy or ocular surface disease have never been tested. In-office allergy testing offers our practices, and patients, a high degree of comfort and satisfaction.

ALLERGY TREATMENT

In-office

The treatment can be simple, yes, or as complex as a pharmacy cocktail with immune-modulatory injection therapy. The “shotgun approach” — aiming with a packed prescription pad of artificial tears, antibiotics, steroids and/or antihistamines, with nary a thought to the disease’s etiology — should be a protocol of the past.⁵

Identifying the specific allergen causing the problem is a perfect starting point in any treatment plan. For example, if the patient tests positive for a specific airborne allergen, such as feathers, oftentimes the simplest and most effective way to relieve symptoms is removing the offending agent. In patients who test positive for pollen, educate and prescribe topical antihistamine to be applied in the morning, before the patient steps outside. Conversely, if mites are the culprits, drops should be administered before bed along with attempts at removing the source. Other allergens, such as animal dander, have both systemic and ocular effects, and treatment should be aimed at the ophthalmic issue as well as the systemic effects by prescribing oral medications.

Patients may even experience an allergic reaction to medicines prescribed by the ophthalmologist. For example, we have found that 15% to 20% of our patients may experience an allergy related to their glaucoma medications, which may present as follicular conjunctivitis with extreme hyperemia and/or chemosis. For these patients, stop the offending agent, treat the current symptoms and consider changing the class of medication, while noting whether the offending agent contains a preservative, such as benzalkonium chloride.

Figure 2. Eczematous blepharitis and conjunctivitis worsened by animal dander allergy.

Figure 3. Atopic lid disease and conjunctivitis secondary to hay fever allergy.

Severity of the test reaction may also be a valuable measure when developing a plan. If the reaction is mild to moderate, start with an antihistamine. If the reaction is severe, add a topical steroid.

When choosing personalized treatment regimens, note that second-generation H1-antihistamines are inverse receptor agonists that do not affect other pro-inflammatory mediators in the cascade.¹² Furthermore, if patients also are taking OTC decongestants that could decrease redness, advise them that chronic use can lead to rebound hyperemia and conjunctivitis.^5,12

Referrals

A referral to an allergist/immunologist may be considered in rare mild-to-moderate allergy cases that do not resolve with personalized treatment, which we’ve found in about 10% to 20% of allergy cases.

If the patient experiences severe, diffuse or multifocal reactions to the test, or if the patient shows any systemic signs of allergy not limited to the eye, direct the patient to undergo a formal allergy evaluation. Also, refer individuals who desire to become desensitized to specific antigens as they could benefit from immunotherapy injections or sublingual immunotherapy treatments.¹² In all these cases, the allergist will frequently conduct more invasive tests in a controlled environment; however, we can provide our allergy and immunology colleagues with the original baseline testing prior to patient interaction, which may serve as a useful guide.

Doctor-to-doctor relationships continue to be an institution and key asset for patients. As with all referrals, seek practitioners with whom you are comfortable. When building relationships with allergists, it is important to have a strong foundation and basic understanding for the mechanisms of disease and treatment. Look for an allergist who is well qualified and has a desire to work with ophthalmology. There has to be a comfort in the relationship that both specialties can work together to improve patient care. The key to building the relationship is communication. Both specialists must be comfortable in their respective roles and communicate with each other. Also, consider that most allergists are delighted with the referral and will refer back with new patients.

In the end, we have the same end-point: patient care. Allergy is one of the most common reasons patients present at an ophthalmologist’s office, so consider the above information to diagnose and treat these patients. OM

REFERENCES

About the Authors
	Eric Rosenberg, DO, MSE is a post-doctoral research associate in the department of ophthalmology at Westchester Medical Center, Valhalla, NY.
	Marguerite McDonald, MD, FACS, is a cornea and refractive surgery specialist at Ophthalmic Consultants of Long Island in Lynbrook, NY.; clinical professor at NYU Langone Medical Center, New York; and adjunct clinical professor at Tulane University, New Orleans. Her email is margueritemcdmd@aol.com. Financial disclosures: Dr. McDonald is a consultant to Alcon and Allergan.
	Eric Donnenfeld, MD, is clinical professor of ophthalmology at New York University and a partner at Ophthalmic Consultants of Long Island, Lynbrook, N.Y. Dr. Donnenfeld is a consultant to Doctors Allergy Formula, Alcon and Allergan.