With the start of allergy season upon us, now is a good time to take a step back and look at just how we treat patients with ocular allergy. Allergies affect a significant portion of our patients. Although statistics vary, a 2003-2004 Gallup Poll found that nearly 50% of Americans are affected by allergies, and more than 80% of these individuals reported ocular symptoms.

Most allergy sufferers experience symptoms only during certain times of the year. So, odds are that many of these patients will be asymptomatic at their exams and often neglect to mention allergies when discussing ocular history. It’s no wonder that a lot of allergy sufferers go undiagnosed and untreated in clinical practice. By identifying allergy-related discomfort, you can proactively improve patients’ treatment experience and loyalty, as well as enhance your practice’s profitability.

Clinical Pearl
Don’t ask the patient about his or her allergy symptoms only during the history. Ask the patient about allergy symptoms a second time when looking through slit lamp at his or her lower lids. You often get a more realistic response from the patient, which could possibly reveal a bigger underlying problem.
Do Patients Value Ocular Allergy Care?
Unfortunately, a lot of patients with ocular allergy believe that their symptoms are “no big deal.” For these individuals, symptoms will often be undetected, undiagnosed, or just flat out ignored. Additionally, “no big deal” patients may elect to treat their ocular condition with only systemic allergy medications, such as Allegra (fexofenadine, Aventis Pharmaceuticals), Clarinex (desloratadine, Schering-Plough) or Zyrtec (cetirizine, Pfizer). But, as we know, these agents rarely provide total relief from ocular allergy symptoms. 

“No big deal” patients may have tried to self-medicate with sub-optimal over-the-counter eye drops, such as Claritin Eye (ketotifen fumarate, Schering-Plough) or Zyrtec Itchy Eye Drops (ketotifen fumarate, Johnson & Johnson), and/or have discontinued contact lens wear during allergy season. Even worse, these patients may self-treat while still wearing their lenses. With all these different OTC options, it probably boils down to simple marketing––our patients will likely choose the most colorful box on the shelf or the least expensive medication.

I believe that our patients value our opinions and expertise when discussing ocular allergy. But, they often think that they can diagnose and/or treat this common condition without our help. It takes an allergic crisis to actually get these patients to present in our offices with complaints. That is why it’s our job to educate them and discuss the value of allergy treatment before reaching the crisis phase.

Be Proactive

Sample Allergy Season Mailer
Dear Mr. Jones,

Allergies can ruin your day! And for some people, allergies can ruin a week, a month or perhaps even the entire year.

As your eye care professional, I am concerned with the health of your eyes as well as your vision. As a result, I want to make you aware that the seasonal or year-round allergies that plague so many people can be treated, improving your quality of life in the process.

If you experience red, itchy, watery eyes, relief could be a phone call away. Contact our office for an evaluation of your symptoms. If you suffer from allergies that affect your eyes, let me prescribe a medication that offers immediate as well as long-term relief.

Contact my office today at (555) 123-2020.
Visit our website at www.xyzeyecare.com

Dr. Xyz, O.D.

Fortunately, you can regain some control over your patients’ wellbeing by addressing ocular allergy proactively. Even if your patient is asymptomatic, at least discuss common signs and symptoms of allergy and schedule an office visit just prior to peak allergy season. If you can proactively diagnose and treat seasonal allergic conjunctivitis, you can decrease the more severe allergic crisis issues.

During the physical exam, pay close attention to possible mild eyelid edema, and look for conjunctival redness or chemosis. Eversion of the upper and lower eyelids may reveal the presence of papillae or other complicating factors. These can be seen more easily with the use of sodium fluorescein.

 Simplify your life and save on chair time by asking three simple questions during the physical exam:

1. Do you ever suffer from red eyes, itchy eyes, watery eyes or swollen eyelids?
2. Do you ever use over-the-counter eye drops to treat red, itchy or watery eyes or swollen eyelids?
3. Do you take any oral allergy medications?

This small step will help you unveil a larger portion of allergy sufferers, especially those who are asymptomatic at the current office visit. And, by revealing previously undiagnosed allergy patients, you will grow the medical arm of your optometric business and provide full-scope optometric care to your patient base.

There are many ways to do this, but it starts by letting your patients know that you treat allergies. For example, you can send out a mailer (see “Sample Allergy Season Mailer,” below) or an electronic newsletter.

What’s Your Treatment Protocol?
The development of your ocular allergy treatment protocol will enable you to quickly analyze the data available and provide a personalized solution in the most efficient manner. This protocol may be very simple, such as prescribing preservative-free eye drops if the patient uses a medication that contains a common offending agent.

Here is a general list of allergy medications that you might wish to include in your treatment protocol:

• Antihistamines. Antihistamines relieve allergy symptoms by blocking histamine in the allergy cascade. Antihistamines can be classified as H1 blockers and/or H2 blockers. H1 receptors are located in human tissues that contain capillaries, while H2 receptors are predominately located in the stomach lining. Topical antihistamines help reduce the itching, redness and swelling associated with ocular allergies. Although antihistamine eye drops provide quick relief, the effect may last for just a few hours. In fact, some antihistamine drops must be dosed four times a day to provide relief.

• Mast cell stabilizers. Mast cell stabilizers prevent the release of histamine and inhibit eosinophil migration into tissues, which cause allergy symptoms. Mast cell stabilizers must be taken prior to allergen exposure and typically do not provide immediate symptom relief. Common mast cell stabilizing medications include Alamast (pemirolast potassium, Vistakon), Crolom (cromolyn sodium 4%, Bausch + Lomb) and Alomide (lodoxamide tromethamine, Alcon).

Clinical Pearl
If a patient presents with the intention of purchasing new glasses and his or her vision plan is reimbursing you for the visit, ask the patient to schedule allergy testing at a subsequent visit. When the patient returns at a later date, take the time to do a proper assessment of his or her allergy situation and initiate your treatment protocol. This medical visit may be billed as a mid-level office visit.
Bepreve (bepotastine besilate 1.5%, Ista Pharmaceuticals) is a new mast cell stabilizer that was approved by the FDA in September 2009. Bepreve is highly H1-specific and is dosed b.i.d. Also, there are reports that Bepreve may offer a “bonus” nasal effect that improves allergic rhinitis symptoms.1 Currently, however, allergists use steroid or antihistamine nasal sprays to treat specific nasal symptoms. 

Be aware that nearly 25% of patients who use Bepreve experience a transient, mild taste of the drug after instillation.1 So, be sure to inform your patient of this side effect before he or she begins dosing.

• Combination mast-cell stabilizers/antihistamines. These combination agents offer the benefits of a dual mechanism of action in one drop. They provide relief from itching by anti-histaminic activity and protect against future allergen encounters by reducing mast-cell degranulation.

There are five available antihistamine/mast-cell stabilizers combination drops with a b.i.d. dosing regimen: Optivar (azelastine hydrochloride 0.05%, Meda), Elestat (epinastine hydrochloride 0.05%, Allergan), Zaditor (ketotifen fumarate ophthalmic solution 0.025%, Novartis), Patanol (olopatadine hydrochloride 0.1%, Alcon) and Alaway (ketotifen fumarate 0.025%, Bausch + Lomb), which is available over the counter. Since Zaditor (Novartis) went over-the-counter in 2006, ketotifen fumarate has become the most common OTC allergy eye drop and it is available in multiple products.

Pataday (olopatadine hydrochloride 0.2%, Alcon) has a higher concentration of olopatadine than Patanol, which provides the advantage of a once-a-day dosing regimen. So, if you are treating contact lens wearers or younger patients, Pataday may be a good option to reduce potential compliance issues by medicating 10 to 15 minutes prior to contact lens wear.

• Topical steroids. A mild topical steroid may also be an option for patients who require topical treatment for their ocular allergy symptoms. Typically, steroids are used when a patient requires immediate relief. Alrex (loteprednol etabonate 0.2%, Bausch + Lomb) or Lotemax (loteprednol etabonate 0.5%, Bausch + Lomb) are commonly prescribed steroids for acute allergic conjunctivitis.

• Oral antihistamines. There are several available OTC oral antihistamines and a few prescription products that can be effective in relieving itching associated with ocular allergies. Many of the prescription agents do not cause the same sedating side effects as OTC antihistamines. Nonetheless, prescription oral antihistamines can cause dry eye and other associated side effects, such as drowsiness, dizziness, headache, loss of appetite, stomach upset, vision changes, irritability, dry mouth and dry nose.2

Treatment Protocol in Action

Clinical Pearl
With so many therapeutic options available, be sure to prescribe a specific product and then design a follow-up plan. If your initial approach fails, it is a medical necessity to change your treatment and prescribe a different product.
A 39-year-old white female patient with two kids, two dogs and one cat presented as a new patient for her annual eye health check. She was a contact lens wearer and wanted to renew her prescription. She did not mention any allergy complaints during the history questioning.

The anterior segment evaluation revealed a moderate amount of papillae on her inferior palpebral conjunctiva in both eyes. Upon questioning, she revealed intermittent blurred vision and difficulty wearing her contacts during the spring and fall. For the last few years, she limited her contact lens wear for four to six weeks and wore a five-year-old pair of back-up glasses. Also, she has used OTC Zyrtec Itchy Eye Drops to help reduce her symptoms.

So, what is your treatment protocol for this patient? Below are four primary options. Which is the best choice?

1. Complete the exam; renew her contact lens prescription; forget about her allergies; let the patient continue with her “developed protocol.”
2. Complete the exam; renew her contact lens prescription; hand her a script for allergy drops; tell her to fill the prescription if the symptoms become severe.
3. Complete the exam; discuss the option of daily disposable contact lenses; address the allergies if they present later on; let the patient decide if she needs to follow-up with you.
4. Complete the exam; renew her contact lens prescription; schedule a follow-up for ocular allergy testing a month before peak allergy season.

You could pursue other options as well, but your treatment protocol obviously is going to depend on many factors. Option #1 is not the best choice––neither for the patient nor for your practice. Addressing the patient’s needs must be a high priority.

Option #2 may work, or it may not, depending on how responsible the patient is. Bottom line: There is a high likelihood that the prescription will become “misplaced,” and then the patient will revert back to using an OTC product.

Option #3 warrants similar concern, because the patient will almost certainly rely on her developed protocol.

Option #4 provides the highest level of patient care. You should always take the time to describe the disease process and stress the importance of treating ocular allergies.

In this situation, the treatment protocol may include refitting her contact lenses. A viable option for allergy sufferers is to change the modality to daily disposable contact lenses. Because a new lens is placed on the eye each day, patients who use daily disposable contacts typically have minimal issues with lens deposits and cleaning compliance. In fact, one study showed that patients with ocular allergies experienced a significant increase in comfort when fit with daily disposable contact lenses.3

Keep in mind that this treatment protocol often requires a medical prescription. It could be for any of the aforementioned medications; however, it is important to not only use a consistent approach, but also to customize the treatment plan according to this patient’s particular needs.

Take the time to educate this patient about her condition and how your intended treatment plan should help curtail her symptoms. Though many patients have a general understanding of allergies, few actually understand how ocular allergy affects their meibomian glands or how the condition relates to ocular symptoms.

Now that you have determined that allergies may be undermining this patient’s ocular comfort and/or successful contact lens wear, engage her in the decision-making process to ensure compliance with the treatment plan. Use eye models or digital technology to review the cause in patient-friendly terms. If possible, show her a “nasty” picture of possible ocular reactions induced by the allergy cascade. This can reinforce the importance of treating and following this condition.

Complete the Circle
In any case of ocular allergy, the follow-up varies depending on the severity of the patient’s specific condition:

• Asymptomatic allergy patients. Asymptomatic allergy patients typically have very few or no associated allergic symptoms at their visit, but may have minor clinical signs, such as the presence of mild papillae. These patients may or may not require a prescription; however, you can educate them about their disease and possible symptoms as well as recommend ocular allergy testing near peak allergy season.
• Active allergy patients. For active allergy patients, your treatment protocol requires greater analysis. In severe cases, patients may need to use steroid eye drops to control their allergy response and then switch to an antihistamine/mast-cell stabilizer for maintenance. Monitor these patients closely.
• Perennial allergy patients. Perennial allergy patients usually have chronic, low-grade allergies that are always present but at fluctuating levels. Treatment varies with these patients; they may already be taking an oral anti-allergy medication year round, and they also may require topical ocular allergy treatment during certain times of the year.

The development of a sound ocular allergy treatment protocol will help you more effectively manage patients who present with various allergy-related complaints and symptoms.

By proactively managing ocular allergies in your practice, you will not only provide your patients with relief and minimize contact lens dropouts, but also grow the medical arm of your practice.

Dr. Miller is a partner at EyeCare Professionals of Powell, a private practice in Powell, Ohio. He serves as an extern preceptor for fourth-year Ohio State University optometry students. He is on the speaker’s bureau for Alcon, CooperVision and Hoya, and is the founder of Codex PracticeWorks, a practice consulting company.

1. Karpecki P, Depaolis M, Hunter JA, et al. Besifloxacin ophthalmic suspension 0.6% in patients with bacterial conjunctivitis: A multicenter, prospective, randomized, double-masked, vehicle-controlled, 5-day efficacy and safety study. Clin Ther. 2009 Mar;31(3):514-26.
2. Ousler GW, Wilcox KA, Gupta G, Abelson MB. An evaluation of the ocular drying effects of 2 systemic antihistamines: loratadine and cetirizine hydrochloride. Ann Allergy Asthma Immunol. 2004 Nov;93(5):460-4.
3. Stiegemeier M, Thomas S. Seasonal allergy relief with daily disposable lenses. Contact Lens Spectrum. 2001 April 16(4):24-8.