Corneal disease has always been a mainstay of optometry, and perhaps the reason we love it is that all the answers are right in front of you. There is no need for added lenses, widefield imaging and other advances. Let’s look at when to refer, as well as revisit new developments in allergic conjunctivitis management.

Infectious Keratitis

While it’s well within our scope to manage microbial keratitis, there are a few cases that warrant a consultation with a cornea specialist. Furthermore, to accurately diagnose microbial keratitis, we need to clearly differentiate an infectious cause, where steroids should be avoided, and from a sterile cause, where steroids are required. I would go so far as to avoid not only steroid drops alone but also combination antibiotic/steroid drops in the following cornea cases where an infiltrate/ulcer is or has:

• Within the central 5mm to 6mm of the cornea.

• Diameter of 3mm or larger.

• Anterior chamber cell and/or flare or hypopyon.

• Significant pain and photophobia.

• Decreasing vision or vision loss.

• Discharge or significant debris/discharge in the tear film.

In the scenarios above, it is imperative that you see the patient back the next day, so begin with an antibiotic drop Q2h (and in-office cycloplegia) if in doubt. The diagnosis usually becomes easier a day later. Many of the above criteria may also require culturing and possibly a cornea specialist referral. 

Speaking of referrals, the best time to send a patient with Fuchs’ dystrophy to a specialist for a potential Descemet’s membrane endothelial keratoplasty/Descemet’s stripping endothelial keratoplasty is if central guttae are present and:

• Pachymetry is 600µm to 640µm.

• There is morning blur for one to two hours before it begins to clear.

• Specular microscopy CellChek SL (Konan Medical) shows an endothelial cell density of less than 1000 cells/mm2.

New Allergy Treatments

Here in Kentucky, pollen counts soar and patients with dry eye flares flood the clinic. Be sure to educate them on the use of corticosteroids like loteprednol 0.2% (Alrex, Bausch + Lomb) loteprednol 0.25% (Eysuvis, Alcon) or fluorometholone 0.1% (Flarex, Harrow) as being essential and, frankly, it’s the only class of drugs that can quiet a dry eye flare.

Rinsada is a lid retractor/irrigation system that removes ocular surface biofilm and irritants such as allergens. It delivers irrigation to the conjunctival fornix, palpebral conjunctiva and the bulbar conjunctiva simultaneously. Although it is primarily used for removing biofilm in the upper, patients get relief especially during the allergy season. 

Allergy cleanser wipes (OcuSoft Allergy) and preservative-free artificial tears can help remove pollen, but one eye drop in particular appears to be most effective for dry eye with allergic conjunctivitis—Allegro (Optase), known as Hylo Dual to our Canadian colleagues. Allegro is preservative- and phosphate-free, has been shown to reduce itchy dry eye symptoms in 30 seconds and is compatible with contact lenses.1 It contains ectoin, which is a naturally occurring molecule produced by microorganisms that flourish in dry environments such as salt lakes and deserts. Ectoin creates a water-rich barrier against allergens combined with hydroxyethyl cellulose, which is known to stabilize mucins that are essential for moisture and foreign particulate removal.2-5

Corneal disorders ranging from infectious keratitis to neuropathic corneal pain or chronic ocular surface pain and allergic eye disease are frequent in an optometry practice. Differentiating the correct diagnosis and subsequent proper treatment is imperative to sparing vision loss and optimizing results. 

Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.

1. Werkhäuser N, Bilstein A, Sonnemann U. Treatment of allergic rhinitis with ectoine containing nasal spray and eye drops in comparison with azelastine containing nasal spray and eye drops or with cromo-glycic acid containing nasal spray. J Allergy (Cairo). 2014:176597.

2. Dwivedi M, Backers H, Harishchandra RK, Galla HJ. Biophysical investigations of the structure and function of the tear fluid lipid layer and the effect of ectoine. Part A: Natural meibomian lipid films. Biochim Biophys Acta. 2014;1838(10):2708-15.

3. Dwivedi M, Brinkkotter M, Harishchandra RK, Galla HJ. Biophysical investigations of the structure and function of the tear fluid lipid layers and the effect of ectoine. Part B: artificial lipid films. Biochim Biophys Acta. 2014;1838(10):2716-27.

4. Araújo DMLD, Galera PD. Ocular lubricants: what is the best choice? Ciência Rural, Santa Maria. 2016;46(11):2055-63. 

5. Vissink A, Gravenmade EJ, Panders AK, et al. A clinical comparison between commercially available mucin and CMC-containing saliva substitutes. Int J Oral Surg. 1983;12(4):232-8.