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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