20 Pearls on Ocular Allergy
and Dry Eye
Ocular allergy and dry are two of the most common ocular conditions worldwide, affecting an estimated quarter of the global population. This prevalence makes understanding their respective pathologies, symptoms and treatment options key to building and maintaining a successful practice. To help, the March issue of Review of Cornea & Contact Lenses is devoted to improving your understanding of ocular allergy and dry eye. Below are 20 great pearls shared by several experts in the field. For more detail, click through to read the original articles for each.
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1. Vernal keratoconjunctivitis presents as either limbal (Horner-Trantas dots and epithelial infiltrates), palpebral (enlarged papillae of upper tarsal conjunctiva, superficial keratitis and hyperemia) or mixed (elements of both). Superior punctate keratopathy exists in both forms of the disease. More
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2. It’s feasible to use steroids with a reduced IOP-elevation profile in ocular allergy, particularly in severe cases, but other risk factors make long-term use for non-complicated allergy questionable, so proceed with caution. More
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3. Seasonal allergic conjunctivitis patients first and foremost should reduce exposure by keeping windows closed and avoiding outside activities when pollen levels are high. When outside they should wear close-fitting, wraparound glasses, then wash hands once inside again. Allergens can also become attached to hair, so patients should wash hair prior to sleeping and change pillowcases daily. More
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4. Because VKC can closely mimic SAC, but with the potential for permanent vision loss, always test all patients who present with severe itching, stringy discharge and other signs and symptoms suggestive of VKC. More
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5. Allergic conjunctivitis may be more prevalent than you realize. A study found it in 73.2% of 258 ocular surface disease patients, either alone or in combination with aqueous deficient or evaporative dry eye. It was also the most commonly encountered unique condition (41.7%) of the three. More
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6. VKC can be treated using combination eye drops that act as both an antihistamine and mast cell stabilizer; however, in more severe cases, topical steroids may be needed instead. Topical cyclosporine may also be used to treat VKC. More
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7. While the effects of ocular cicatricial pemphigoid on mucous membranes prompts signs and symptoms of dryness that mimic true dry eye disease, it can be differentiated by observation of widespread involvement of conjunctival tissue. More
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8. Switch patients to a daily disposable contact lens to reduce contact lens-associated GPC recurrence; while symptoms of lens-induced GPC are associated with all types of contact lenses, increasing lens replacement frequency decreases incidence of GPC. More
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9. A small number of VKC patients develop reduced vision from sterile corneal ulceration and scarring. The corneal lesions (shield ulcers) appear in the superior cornea and may involve the visual axis. These lesions arise from a mix of cationic protein release and mechanical eye rubbing that traumatizes the cornea. More
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10. Peroxide disinfection helps prevent GPC reoccurrence when the contact lens material cannot be changed, e.g., in patients with irregular astigmatism from keratoconus or penetrating keratoplasty. Also effective: use of an alcohol-based cleaner for 30 seconds daily or a two-component cleaner with sodium hypochlorite and potassium bromide for 30 minutes one to two times a week. More
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11. Signs that differentiate epithelial basement membrane dystrophy from dry eye include corneal epithelial microcysts (“dots”), whirling defects (“fingerprints”) and positive and negative fluorescin staining. Observing how inter-blink dynamic changes in the tear film impact the corneal reflection in the keratometer can also help. More
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12. If a patient’s GP lenses progressively dry out throughout the day, schedule a late afternoon exam to check the lens surface for deposits consisting of protein or lipids. If discovered, switch solutions or add a more aggressive lens cleaning regimen to help reduce deposits. More |
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13. While itch is the classic, primary diagnostic factor in allergic conjunctivitis, a study found three others—burning, soreness and scratchy sensation—were just as significant in making the diagnosis. Also, intensity of burning and soreness was more statistically significant than that of itching. More |
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14. To mitigate recurrence of contact lens-associated GPC, modify the lens edge and/or change the polymer, as surface deposits depend on the lens type. For example, higher water content contact lenses develop more deposits than lenses with lower water content. More |
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15. When treating allergic conjunctivitis, consider dual-acting mast cell stabilizers/antihistamines. These newer agents reduce allergy-induced itching and their effects are better tolerated and longer lasting than single-action antihistamines. More |
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16. If a GP lens patient experiences dry eye even with their lenses removed, the problem may be with the ocular surface itself, not the lens. Examine carefully—note the lid appearance, look for any capped meibomian glands or scalloped margins, check their tear prism and do a Schirmer’s test or the phenol thread test to determine aqueous tear production. More |
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17. Examine patients for a localized area of GPC on the superior tarsal conjunctiva overlying a suture to diagnose suture-related GPC. Treatment should involve the removal of these loose, exposed sutures, with additional pharmacologic treatment as needed. More |
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18. Consider changing lens type to alleviate dry eye in GP lens patients. Patients who experience dry eye symptoms may benefit from a lower dK material because of its advantageous wettability properties. Inadequate surface wettability can compromise lens wear. More |
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19. In GPC related to ocular prostheses, a mucus coating may form on the device; thus, treatment should involve an increase in frequency of device removal, cleaning and polishing. Mast cell stabilizers/antihistamines may also be used, but should not be the primary treatment. More |
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20. Parenteral first-generation antihistamines commonly used in systemic allergy may be counterproductive in managing ocular allergic disease because they can bind to histamine receptors in the central nervous system, causing sedation, dry mouth, dry eye and tachycardia. The overall effect is an increase in the concentration of allergens in the tears. More |
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