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Review of Optometry > When Allergy and Dry Eye Collide
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When Allergy and Dry Eye Collide
Patients who present with concurrent allergy and dry eye can be challenging to treat. Here are several
strategies you can use to minimize their symptoms.
Richard B. Mangan, O.D.
8/17/2009
Fifty million Americans are affected by allergy each year, and 30 million of these individuals suffer from
seasonal allergies.1 Meanwhile, ocular surface disease (OSD) affects approximately 20.7 million people in the
U.S. every year.2 Of these, nearly 4.25 million individuals have chronic ocular surface disease.3 While many
clinicians still ascribe to the general notion that "allergy affects the young and dry eye affects the old,"
international epidemiology data suggests that allergic disease is on the rise across all age groups.4 The
prevalence of allergic rhinitis (AR) has increased during the last three decades and is now estimated to affect
20% of the adult population in the U.S.4 AR is actually considered the most common chronic condition in both
adults and children.6 And, 75% of those diagnosed with AR actually have allergic rhinoconjunctivitis.5
It can be challenging to differentiate ocular surface disease from allergic conjunctivitis, as seen in this patient.
Courtesy: Jason R. Miller, O.D.
eye symptoms. Treating a patient who presents with concurrent allergy and dry eye symptoms, however, can
be an even greater challenge. Whether you are considering a true type I IgE-mediated allergic reaction or a
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type IV delayed cell-mediated reaction, the likelihood of allergy colliding with ocular surface disease in
patients of advanced age is significant.
In the following case, the patient presents with concurrent allergy and OSD. What risk factors does she face?
How should she best be treated? And, what general management tips and strategies can you recommend to
her?
A Case of Concurrent Allergy and Ocular Surface Disease
History. A 49-year-old postoperative LASIK patient presented to our Lexington, Ky., office on a warm April
morning with complaints of watery, itchy eyes. She had been doing well since we inserted silicone punctal
plugs one week after undergoing LASIK three months earlier.
At first, the patient was miserable because she did not want to rub her eyes and disturb her corneal flap. She
reported some relief after taking Claritin (loratadine, Schering Corporation) and using Refresh Liquigel
(Allergan) q.i.d. O.U., but noted that her eyes still bothered her noticeably.
Her medical history was unremarkable. Her ocular history was positive for preoperative spectacle correction
and wavefront-guided LASIK for compound myopic astigmatism (spherical equivalent of -7.25D O.U.).
Interestingly, she reported no history of allergies on her pre-LASIK questionnaire.
Diagnostic data. Her best-uncorrected visual acuity measured 20/20 O.U. A slit lamp examination
confirmed conjunctival papillae and palpebral conjunctival injection, with mild bulbar conjunctival chemosis
O.U. Also, there was mild thickening and hyperemia of the lid margins. There was adequate lid and punctal
apposition O.U., and her silicone punctal plugs were in place. Despite intermittent reflex tearing, her tear
prism was poor, and there was mild lissamine green staining involving both the nasal and temporal
conjunctiva O.U.
Upon further questioning, the patient indicated that she had suffered from seasonal allergies in the past, but
that they had not bothered her since she moved to Lexington from Chicago nearly a year ago. She noticed that
her symptoms were worse in the morning, especially while jogging outside. When asked if she had a family
history of allergies, she revealed that both of her children used nebulizers for mild asthma when they were
young, but no longer require treatment. The patient also mentioned that her father had hired a lawn service to
mow his grass several years ago because of his allergies.
Discussion. Our patient demonstrates several risk factors for seasonal allergic conjunctivitis (SAC):
1. Springtime in the southeastern U.S. In general, cities in the southeast tend to have high levels of tree
pollen in the springtime. Most importantly, a 2008 report from the Asthma and Allergy Foundation of
America suggested that Lexington is the worst city for springtime allergies in the U.S.7
2. History of SAC. Our patient has a personal history of SAC, and her recent move from Chicago explains her
brief sabbatical from allergic symptoms. Additionally, the patient has a family history of both allergy and
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asthma. If a patients family history is negative for SAC, then he or she has just a 10% to 15% chance of
developing SAC. If one parent has a history of allergic disease, the patients risk increases to 30%. Finally, if
both parents have a history of allergy, the patient has a 45% to 50% chance of developing SAC.8
Additionally, if both parents have the same type of allergic disease, the risk increases to 72%.8
3. Morning symptoms. Our patient's allergic symptoms are worse during the morning hours when pollen
counts are highest (usually between 5:00 a.m. and 10:00 a.m.).
Additionally, our patient demonstrates several risk factors for ocular surface disease:
1. Post-menopausal female. According to the Women's Health Study, 3.2 million women age 50 or older
suffer from clinically significant dry eye.9 In this demographic, ocular surface disease tends to affect females
at a rate of 3:1 vs. males.9 Additionally, the risk of dry eye increases both during and after menopause.
Advancing age and varying hormonal changes are also associated with ocular surface disease.10
2. History of refractive surgery. The creation of a corneal flap disrupts normal corneal innervation and
results in hypoesthesia that may persist for six months or longer.11 Hypoesthesia, or decreased corneal
sensitivity, contributes to the disruption of the normal neuronal-feedback loop, causing decreased tear
production, tear film instability, decreased tear clearance, increased tear osmolarity and epitheliopathy.12
Superior hinge flaps decrease innervation to an even greater degree; the main branches of the long posterior
corneal nerves enter the eye at both a 3 o'clock and 9 o'clock position. When a nasal hinge flap is created, the
nasal arm is preserved.13 Femtosecond flap technology (e.g., IntraLase, Abbott Medical Optics) provides more
flexibility with respect to flap size, hinge location and flap thickness--all of which can be adjusted to improve
post-LASIK dry eye symptoms and recovery time.14 Some clinicians have also proposed that the greater the
refractive error (thus, the greater ablation depth in laser vision correction), the greater the decrease in corneal
sensitivity and the longer the recovery time.8,15
3. Oral antihistamine use. According to a 2008 survey conducted by Pharmacy Times, U.S. pharmacists
make more than 2.3 million recommendations per month for oral over-the-counter antihistamine drugs.16
Almost half of these recommendations were for Claritin (see The Top Five Most Frequently
Recommended Oral OTC Antihistamines, below).
Also, oral histamine H1-receptor antagonists are the most frequently prescribed class of agents used for
allergic rhinitis management.17 Unlike first-generation antihistamines, second-generation agents are highly
selective peripheral histamine blockers that demonstrate little or no side effects upon the central or autonomic
nervous systems.18 While second-generation agents are actually "minimally-sedating," they still exhibit a
tendency to reduce tear volume and may exacerbate symptoms of ocular irritation, itching and dryness.19
After considering these factors extensively, I suggested that our patient modify a few of her lifestyle activities,
including jogging in the evening instead of the morning. Also, I started her on a regimen of Elestat (epinastine
HCL 0.05%, Allergan) b.i.d. O.U. and Refresh Plus (Allergan) q2h; I instructed her to refrigerate both
products. Finally, if our patient's ocular symptoms improve but her nasal congestion persists, I will remove her
silicone punctal plugs.
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Top Five Most-Frequently Prescribed Oral OTC Antihistamines16
Drug
1. Claritin (loratadine, Schering Corporation)
2. Zyrtec (cetirizine, Pfizer)
3. Benadryl (diphenhydramine, Warner Lambert)
4. Chlor-Trimeton (chlorpheniramine maleate,
Schering Plough)
5. Alavert (loratadine, Wyeth)
Prescription
Frequency
Classification
48.5%
(Second-generation, nonsedating)
15.0%
(Second-generation, nonsedating)
7.5%
(First-generation, sedating)
6.8%
First-generation, sedating)
4.1%
(Second-generation,
non-sedating)
Five Tips for Allergy Sufferers
1. Avoid the avoidable. Allergy testing is a critical first step in determining precisely what is causing
your patient's allergic reaction. Narrowing the list of potentially offending allergens through skin-prick or
blood testing allows for more targeted avoidance techniques and treatments, including immunization therapy.
Also, patients with seasonal allergies should pay attention to local weather and pollen counts on a daily basis
to avoid acute allergic reactions. Instruct your patients to remain indoors in the air conditioning as much as
possible when pollen counts are high. When spring arrives, most people have a natural tendency to want to
open all of the windows and let fresh air in. Despite this natural impulse, seasonal allergy sufferers need to
remember that this could incite or worsen allergy symptoms.
Instruct your patients with allergic conjunctivitis to remain indoors when local pollen counts are elevated.
Courtesy: Jason R. Miller, O.D.
is the classic sign of an IgE-dependent hypersensitivity response. In susceptible individuals, initial exposure of
an allergen to the ocular surface stimulates the production of specific immunologic antibodies, which bind to
and degranulate mast cells that contain several preformed mediators, including histamine. Histamine, once
released, binds to H1 and H2 receptors located on the conjunctiva, resulting in vaso-endothelial dilation and
secondary chemosis, redness, tearing, lid swelling and intense itching. Unfortunately, this intense itching and
reflex tearing can lead to a vicious cycle of eye rubbing, which subsequently degranulates more mast cells and
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furthers the response.
Instead of rubbing, instruct your patients to apply cool compresses and instill refrigerated eye drops. While
icepacks work well, gel-filled facemasks work better and are readily available at most drug stores. The chilled
drops soothe the eye, decrease vascular permeability of the conjunctiva vessels and reduce chemosis.
Finally, tell your patients to shower at night before they go to bed. Pollen and spores may get deposited on the
skin or in hair after prolonged outdoor activity. Washing away these allergens before bedtime ensures they do
not get transferred to sheets and pillowcases, which could make symptoms more chronic.
2. Lower viscosity preservative-free artificial tears. Just like our postoperative LASIK patient, it
is not uncommon for someone with moderate ocular surface disease to be on a more viscous artificial tear,
such as Refresh Liquigel, Refresh Celluvisc (Allergan) or Bion Tears (Alcon). When allergy strikes, however,
a less viscous tear, such as Preservative Free Optive (Allergan) or Systane Ultra (Alcon), used more frequently
would be better at washing out environmental allergens and inflammatory mediators from the ocular surface.
3. Limit punctal plug use. When confronted with a type I IgE mediated allergic reaction, the goal is
usually to flush inflammatory mediators from the ocular surface. Punctal plugs are counter-productive for this
goal. Also, intense itching promotes eye rubbing, which could put the patient at risk for several punctal plug
associated complications, such as extrusion or canalicular migration with secondary nasolacrimal obstruction,
canaliculitis or dacryocystitis.
If your patient has moderate ocular surface disease, and closure of the lacrimal punctum is warranted despite a
history of seasonal allergic conjunctivitis, you might decide upon occlusion with extended-duration plugs.
Extended-duration punctal plugs, which typically demonstrate a partial occlusive effect at four months postinsertion, are ideal for dry eye patients during the allergy "off-season."
For patients who present with seasonal allergic rhinoconjunctivitis and have already undergone punctal
cautery, dual therapy of topical antihistamine/mast-cell stabilizers and nasal corticosteroids should adequately
reduce symptoms and histamine-related flare-ups.
4. Avoid oral antihistamines. As noted above, all oral antihistamines including newer-generation
antihistamines, such as Claritin, Zyrtec (cetirizine, Pfizer) and Allegra (fexofenadine, Aventis
Pharmaceuticals) dry the eye. This can worsen ocular allergies in two ways. First, less tear production means
less tear flow and inadequate flushing of environmental allergens from the ocular surface. Second, decreased
tear volume results in an increased concentration of inflammatory mediators on the ocular surface.
Instead, consider treating topical allergy topically. The third-generation topical antihistamines/mast-cell
stabilizers, such as Pataday (olapatadine hydrochloride 0.2%, Alcon), Patanol (olapatadine hydrochloride
0.1%, Alcon) and Elestat have shown to be fast-acting and quite effective in quelling the allergic cascade,
while reducing allergic ocular symptoms without the secondary effects of surface drying.19,20 As an added
benefit, olapatadine 0.2% has shown potential in reducing allergic rhinitis symptoms in patients with a patent
nasolacrimal duct system.21 For patients without prescription drug coverage, Zaditor (ketotifen 0.025%,
Novartis Pharmaceuticals) is now available over the counter.
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For exaggerated, late-phase allergic responses (i.e., conjunctival inflammation, including chemosis and lid
edema), the safer topical ester-based steroids, including Alrex (loteprednol etabonate ophthalmic suspension
0.2%, Bausch & Lomb) and Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb),
are ideal. Pulse therapy in conjunction with a fast-acting medicine, such as Patanol or Elestat, can minimize
congestion and abort ocular symptoms.
For persistent symptoms of AR, intranasal glucocorticosteroids--delivered topically as a spray to the nasal
mucosa--are generally considered very safe and effective. Contraindicated in patients with a history of nasal
polyps or surgery, steroid nasal sprays, such as flunisolide, were found to be more effective at improving
symptoms of AR when compared with intranasal antihistamines, such as azelastine HCl.22 In addition to
flunisolide, this group of medications includes fluticasone propionate, mometasone, budesonide,
triamcinolone, beclomethasone and fluticasone furoate.
For patients with contraindications or aversions to nasal sprays, oral leukotriene inhibitors such as Singulair
(montelukast sodium, Merck) may be the answer. The FDA has approved montelukast for the treatment of
AR. Additionally, Singulair has the added benefit of being non-drying.23 And, several studies show that
montelukast was more beneficial than placebo and was equally as effective as loratadine for the treatment of
seasonal AR.24,25
5. Remember Restasis. Restasis (topical cyclosporine A 0.05%, Allergan), a T-cell immunomodulating
agent, was approved by the FDA in 2002 for the primary indication of treating immune-mediated dry eye.
However, since that time, Restasis has shown tremendous off-label benefits in the management of other ocular
disease entities, such as allergic keratoconjunctivitis, posterior blepharitis and keratomycosis.26
Additional data show that Restasis also inhibits activation of mast cells and eosinophils.26 One of its most
beneficial off-label uses is against vernal and atopic keratoconjunctivitis.26,27 Because Restasis is a very
effective anti-inflammatory agent with a superb safety profile (no deleterious effect on intraocular pressure,
premature cataract formation or phagocytosis), it has allowed physicians to decrease or limit the long-term use
of topical steroids in managing many sight-threatening conditions.
That said, can Restasis play a role in the management of SAC? As a primary or first-line agent, probably not.
However, in a patient with chronic OSD, Restasis may lesson the severity of future seasonal allergic attacks.
With adequate inquiry into a patients personal and family history of allergy, followed by education on lifestyle
modification and treatment strategies for SAC, your dry eye patients will be better prepared for the onslaught
of allergy season.
Dr. Mangan is chair of the refractive surgery and research committees for the Eye Center Group, a
multi-specialty comanagement center in central Indiana and western Ohio. Additionally, he oversees
the groups ocular surface disease clinic. He has no financial interest in any of the products
mentioned.
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16. Terrie YC, Bowling EL. Update on the OTC treatment of allergies: focus on allergic conjunctivitis. Pharmacy Times. ACPE program number: 290-999-09005-H01-P. Available at: https://secure.pharmacytimes.com/lessons/200903-02.asp (Accessed June 16, 2009).
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24. Meltzer EO, Malmstrom K, Lu S, et al. Concomitant montelukast and loratadine as treatment for seasonal allergic rhinitis: a randomized, placebo-controlled
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25. Pullerits T, Praks L, Ristioja V, Lotvall J. Comparison of a nasal glucocorticoid, antileukotriene, and a combination of antileukotriene and antihistamine in
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