Optometrists have been treating allergic conjunctivitis for decades with agents such as antihistamines/mast cell stabilizers and topical steroids, so the words new and allergic eye disease don’t often end up in the same sentence. But recent advances are likely to have profound impact on our methods and may result in substantial change and faster relief for your patients. From allergy and compounding agents to RASP inhibitors, we discuss these new developments and their benefits below.
New Approvals and Advances
Verkazia (Santen) was recently approved for the treatment of vernal keratoconjunctivitis (VKC). The drug is cyclosporine in a higher concentration (0.1%) than we’ve previously seen, and a cationic formulation. The latter helps with delivery of therapeutics by creating electrostatic attraction between positively charged droplets of the agent and the negatively charged ocular surface. The higher concentration may also have contributed to Verkazia meeting its primary and key secondary endpoints in the treatment of severe VKC in patients ages four to 18 years old.
Zerviate (cetirizine ophthalmic solution), from Eyevance, became available last year for the treatment of allergic conjunctivitis (AC)—the first antihistamine/mast cell stabilizer prescription medication to enter the market in over two decades. This product is approved for itching associated with AC and has two moisturizers, HPMC and glycerin, in the formulation. Cetirizine, the active ingredient in Zyrtec, is an oral antihistamine highly recommended by physicians, so patients should be familiar with it.
OTC Allergy Agents
A new development in the OTC allergy space is a preservative-free antihistamine/mast cell stabilizer version of Alaway (Bausch + Lomb). A preservative-free option can be helpful, especially since as many as 57.7% of allergy patients suffer from clinically significant dryness.1 Also note that Alcon’s Pataday and Pataday Extra Strength (formerly called Pazeo) have moved from prescription to OTC.
A new lid wipe, Ocusoft Lid Scrub Allergy, is another novel idea, as allergens such as pollen and animal dander need to be removed to prevent further allergic responses. Since aggressive scrubbing could amplify allergy symptoms, this product uses a soft pad as well as effective moisturizers. It contains ingredients such as green tea extract, which has been shown to calm the inflammatory response; tea tree oil, which has been shown to relieve itching; and PSG-2, an ingredient used in rosacea creams that reduces redness.
New agents can also be obtained via compounding pharmacies, such as ImprimisRx. The most recent one is Elestat (epinastine) HCL 0.05% plus brimonidine 0.025% in a preservative-free multi-dose bottle. The low-dose brimonidine, which is the same as that found in Lumify, helps whiten the eye, making Elestat an effective allergy medication.
The Future: RASP Inhibitors
Reactive aldehyde species (RASP) lead to significant inflammatory responses and are highly elevated in allergic conjunctivitis and dry eye disease. RASP affects NFkB, scavenger receptor A binding and inflammasome activation, which all lead to cytokine release. Reproxalap (Aldeyra Pharmaceuticals), a drug candidate in Phase III FDA testing for both dry eye disease (DED) and AC, is showing evidence of RASP inhibition.
This drug has the potential to work like a corticosteroid without the risks associated with steroids. Reproxalap also significantly suppressed symptoms of itch in AC patients and SANDE scores as well as dryness and discomfort in DED patients. The drug has the potential to be approved for one or both conditions.
We’re on the cusp of a new era in allergic eye disease care. Being aware of current and future developments will greatly help your patients who suffer from itching, ocular allergies and even dry eyes.
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. Ansari Z, Miller D, Galor A. Current thoughts in fungal keratitis: diagnosis and treatment. Curr Fungal Infect Rep. 2013;7(3):209-18.