• RCCL E-NEWS - APRIL 06, 2016
20 Pearls on Ocular Allergy and Dry Eye
Allergy season is here! Though it can affect any patient at any time, expect more cases in the coming months. And patients with concomitant dry eye pose an even greater challenge. To help, the March 2016 issue of Review of Cornea & Contact Lenses is aimed at broadening your understanding of these common yet complex conditions. Below are 20 pearls from several experts in the field. Click through to read the original articles in full for each, then check out the list on the left for more from this issue.
1. Stay vigilant for factors that suggest the patient may be suffering from several simultaneous conditions. For example, severe itching in a dry eye patient suggests the coexistence of atopic disease, while disruptions in tear film integrity or feelings of burning in a patient with allergic conjunctivitis indicates they may also have dry eye. More
2. Consider recommending cromones for those patients who cannot tolerate antihistamines due to allergy or severe dry eye. Keep in mind, however, these drugs' mechanism of action is slow in comparison to antihistamines and less effective than dual-action medications, and notify patients as such. More
3. Take note of symptoms related to ocular pain, visual disturbance and tear film instability in dry eye sufferers. These patients may be good candidates for scleral lens wear, as the continued hydration and protection provided by the lenses' vault and rigid characteristics improves both visual acuity and comfort. More
4. Tell contact lens users who suffer from ocular allergies to consider daily disposable lens wear. This can help limit clinical reactions, as surface allergens do not build up on these lenses as much as they do on more long-term modalities. More
5. Have scleral lens patients remove their lenses, clean both the front and back surfaces and replenish the liquid in the bowl with nonpreserved saline several times a day during allergy season. Patients with ocular allergies can build up biofilm on both sides of the lens that may affect quality of vision or comfort; also, pollen and other irritants can intrude underneath the lens. More
6. Be aware that certain treatments for ocular allergy can worsen dry eye and vice versa. For example, allergic conjunctivitis treatments that emphasize the use of oral antihistamines may exacerbate dry eye symptoms. More
7. Ask the patient to describe the color and intensity of any ocular discharge upon awakening to help with differential diagnosis. Discharge in patients with bacterial conjunctivitis is yellow or greenish in color, while that in allergic conjunctivitis is grey or white. More
8. Ambient humidity can be easily augmented in both the home and work environments; humidifiers are available in either heated or cool-mist varieties. Recommend dry eye patients try one before requesting more invasive treatments. More
9. Be aware of the binding affinities for muscarinic receptors of current antihistamines to prevent adverse effects. For example, they carry an anti-cholinergic effect that can cause ocular drying. More
10. Ask patients if their eyes have ever burned, itched or watered. Examine them for eyelid or conjunctival edema, and evert the upper and lower eyelids to reveal any papillae. Instill fluorescein to help illuminate these signs more clearly. More
11. While most allergy cases are bilateral, some presentations can be unilateral or asymmetric. Two likely scenarios: if an allergen is transferred to the ocular surface via a vector like the hand rather than being airborne, and if the patient has a dust mite allergy and regularly sleeps on one side. More
12. Remove pseudomembranes that may develop in the upper and lower fornix to prevent the eventual formation of symblepharon. If left untreated, the corneal epithelium can decompensate with the potential for shield ulcer formation and corneal scarring. More
13. Direct ocular allergy patients to first try cool compresses and preservative-free lubricants. If these do not suffice, use a topical antihistamine, mast-cell stabilizer or nonsteroidal anti-inflammatory agent. Short-term judicious use of steroids in severe cases can also help. More
14. In treating keratoconjunctivitis, remember that the vernal form (VKC) typically affects preadolescent to early-adolescent males, and can become exacerbated in certain seasons, while the atopic form (AKC) onsets in late adolescence to early adulthood with no gender predilection. Papillae on the upper tarsal conjunctiva indicate VKC; AKC patients can have a pronounced papillary response, but less so than in VKC. More
15. Discuss ocular allergies with all patients who present for an exam, regardless of whether they are actively symptomatic. Some only demonstrate symptoms at certain times of the year and may forget to mention such when relaying their history to you. More
16. Clinical signs to differentiate allergy vs. dry eye: large papillae on the upper tarsal conjunctiva or limbus is a hallmark of vernal allergic conjunctivitis, while fluctuating vision, corneal staining or disruptions in tear film quality suggest dry eye. More
17. Look at type, severity and duration of signs and symptoms when differentiating between the early and late stages of seasonal or perennial allergic conjunctivitis. Patients in the early phase present with itching and chemosis, while those in the late phase demonstrate eosinophil and basophil infiltration and accumulation in the ocular tissues. More
18. Inform patients of the potential for hair to trap airborne allergens throughout the day and transfer them to the patient’s pillow and into their eyes overnight. Suggest patients rinse off prior to bed to limit the ocular allergic response. More
19. Consider treating acute episodes of VKC and AKC with topical steroids like loteprednol or prednisolone drops, but avoid overuse. Immune modulators like cyclosporin A and tacrolimus may be better options for long-term use. More
20. Avoid initiating antihistamine therapy in patients with chronic allergic diseases. The allergic late phase, which forms the basis for these conditions, is not the result of histamine release; thus, treatments geared towards inhibiting this process will be ineffective. More
Scleral Lenses for Keratoconic Dry Eye Considered
Short-term scleral contact lens wear may be beneficial for patients with keratoconus who also suffer from dry eye, reports a study in the February 2016 Optometry & Vision Science. The rigid lenses are currently indicated for use in patients with severe corneal irregularities, including keratoconus, and have also been slated as a means to manage dry eye due to their ability to improve ocular surface integrity. To date, however, no study has investigated the effects of scleral lens wear on the ocular surface physiology of patients with keratoconus.
Cellular Therapy for Dry Eye Evaluated
Application of topical tumor necrosis factor (TNF)-stimulated gene protein-6 (TSG-6) may be a suitable alternative to cyclosporine use in patients with inflammation-mediated dry eye, suggests a study published online in the journal Cornea. Previous research on the protein produced by mesenchymal stem/stromal cells within the body has indicated therapeutic effects in animal models of the heart, cornea, brain and other organs; however, further research and widespread clinical application remains limited due to production issues and variations in chemical stability.
Growing Bacterial Keratitis Risk Identified
A once-rare pathogen may be more prevalent than initially believed in cases of fungal keratitis, reports new research published online in Cornea. Researchers identified 47 of 1,542 culture-proven cases of keratomycosis as being caused by Exserohilum, which is generally associated with paranasal sinus, skin and subcutaneous infections.
New Multifocal Soft Lenses Released
Bausch + Lomb has announced the release of new Ultra lenses for Presbyopia. The multifocal lenses are specifically designed to combine the company’s three-zone progressive design in the Biotrue OneDay for Presbyopia daily disposable lenses with its MoistureSeal lens technology.
Potential Dry Eye Treatment Tested
Moisture chamber spectacles (MCS) may be useful to treat dry eye, suggests a study in the February 2016 issue of Optometry & Vision Science. Researchers in China randomized 30 patients with dry eye into a group instructed to wear MCS for 90 minutes and a second group instructed to instill a drop of sterile non-preserved 0.9% sodium chloride solution. Results indicated improvements in ocular comfort, tear meniscus height (TMH) and noninvasive tear film break-up time (NIBUT) in the former.
Scleral Lens Workshop Tour Dates Announced
Blanchard Contact Lenses has announced its list of cities and dates for the 2016 Beyond the Limbus Scleral Lens Workshop tour. A component of the company’s educational division for the sixth year running, the workshops are designed to provide scleral lens training for eye care practitioners.

My Perspective:
Contact Lens Biosensors: Finding the Holy Grail?

Pharma Science & Practice:
A Firm Foundation

Out of the Box:
Are You Allergic to Change?

Practice Progress:
Scratching the Itch

The GP Experts:
Springtime for Sclerals

Double Trouble: When Allergy and Dry Eye Coexist

Environmental Considerations: How the World and the Ocular Surface Relate

Understanding Ophthalmic Antihistamines and Histamine Receptors

Managing the Complex Ocular Allergic Reaction

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