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Allergy, dry eye, or both?
Milton M. Hom, OD, FAAO.
Course description (1 hour): Allergies or dry eye? New research shows that up to
60% of patients have both. Learn new ways to simplify potentially confusing
diagnosis. Topics include treatment algorithms, TOSS/OSDI scoring, the rhinitis
connection, polypharmacy, and indoor environmental allergies.
Learning objectives:
1.Understand the differences and similarities between ocular allergy and dryness
2.Know how to diagnose each condition
3.Learn about treatment strategies
I. Introduction
a. Ocular allergy and dry eye are highly connected
b. Differential diagnosis can be difficult and confusing
c. Leads to treatment strategies that are similar yet very different
d. Does allergic conjunctivitis and dry eye co-exist?
II. Pathophysiology
a. Innervation
i. It’s all about the pterygopalatine ganglion
ii. Most tear secretion is parasympathetic
iii. Nuclei are located in pterygopalatine ganglion
iv. Nasal innervation for nasal secretion also in pterygopalatine
ganglion
v. High connection between allergic rhinitis and allergic
conjunctivitis
b. Venous system
i. Nasal venous system and superior ophthalmic vein are
connected to pterygoid plexus and cavernous sinus
ii. “Danger triangle of the face”
1. No venous valves-prior thinking
2. Cavernous sinus thrombophlebitis
3. Valves are present in 75% of superior ophthalmic veins
4. But venous flow is still bidirectional in some areas that
can connect nose and eye
iii. Rhinitis connection: inflammatory factors can flow from nose
to eye triggering ocular allergy
III. Clinical connection
a. Over 57% itch patients have dryness
b. Hom MM. Nguyen AL. Bielory L. Allergic conjunctivitis and dryness.
Annals of Allergy, Asthma and Immunology. 2011;107(5)suppl:A117
#P353.
c. Over 70% allergic conjunctivitis have rhinitis
d. Signs and symptoms are very similar between allergic conjunctivitis
and dry eyes
e. Both conditions are co-morbidities and present in patient at the same
time
f. Treat rhinitis connection because it affects ocular allergy
IV. Tests
a. TOSS Total Ocular Symptom Score (see below)
i. Questionnaire
ii. 4 domains
iii. Easy to score
iv. Easy to administer
b. OSDI Ocular Surface Disease Index
i. Questionnaire
ii. 3 domains
iii. 12 question
iv. Minutes to administer
V. Treatment algorithms
a. Compare score between TOSS and OSDI
b. Determine and weight each condition
c. If one condition is significantly higher, then it is the predominant
condition
d. Predominant allergy, then itch is main concern, rhinitis connection is
probably present
i. Stage 1: Itch medications, rhinitis and avoidance
1. Topical allergy drops
2. qD or bid
3. Add nasal spray
a. Steroid
b. Antihistamine
c. Nasal-crom OTC
4. Add Neti-Pot
a. Use Neti-Pot as a lavage, then follow with nasal
spray increases efficacy
5. Avoidance
a. Cat allergies
i. Male cats higher in Fel d1
ii. Males castrated much lower (5.46 to
1.28)
iii. Washing/baths only effective for 3 hours
iv. HEPA vacuum + HEPA room filtration
works, each alone has diminished effect
b. Air fresheners
i. Plug-ins have 20 Volatile organic
compounds (VOC) and 1/3 classified as
toxic or hazardous
ii. Scented candles produce: soot, lead,
organic compounds and VOC.
ii. Stage 2: Add steroid
1. Lotemax/Alrex
e. Predominant dry eye
i. Determine if aqueous or evaporative
ii. Aqueous
1. Stage 1: Artificial tears, nutritional support if desired
2. Stage 2: Restasis
3. Stage 3: Add steroid
iii. Evaporative
1. Stage 1: Lid hygiene and emulsion
2. Stage 2: AzaSite
f. Both allergic conjunctivitis and dryness
i. Stage 1: Topical allergy medication
1. Restasis OR lid hygiene/emulsions if evaporative
2. Use polypharamcy: Restasis/lid hygiene and topical
allergy meds
3. Rhinitis present: Nasal spray and/or Neti-Pot
4. Avoidance
ii. Stage 2: Add steroid
g. Philosophy: Assume both conditions can be present at the same time
and treat accordingly.
i. About half are purely dry, 40-50% are purely allergic
conjunctivitis and 40-60% have both
TOSS Questionnaire
Total Ocular Symptom Score
Please answer the following questions by marking the box that best represents your
answer
Have you experienced any of the
following during the last week?
All of
the
Time
Most
of the
Time
Half
of the
Time
Some
of the
Time
None
of the
Time
N/A
1. Itchy?
2. Red?
3. Tearing (eyes watering)?
4. Swelling (puffy eyes)?
Visit #________
Total score:
Patient Name: ________________________________________ Date: ___________________________
9/24/11 Email: [email protected]
TOSS Questionnaire Scoring
Total Ocular Symptom Score
1. Add up scores
All of the Time = 4
Most of the Time = 3
Half of the Time = 2
Some of the Time = 1
None of the Time = 0
2. Divide by maximum score
All 4 questions answered divide by 16
3 questions answered divide by 12
2 questions answered divide by 8
1 question answered divide by 4
3. Multiply by 100
Example:
Have you experienced any of the
following during the last week?
1. Itchy?
2. Red?
3. Tearing (eyes watering)?
4. Swelling (puffy eyes)?
All of
the
Time
Most
of the
Time
Half
of the
Time
Some
of the
Time
None
of the
Time
N/A
x
Visit #________
x
x
x
Total score:
Patient Name: ________________________________________ Date: ___________________________
9/24/11 Email: [email protected]
Score example:
Itchy = 4
Red = 3
Tearing = N/A
Swelling = 2
Total: 9
“3 questions answered divide by 12”
9/12 x 100 = 75.0
TOSS = 75.0