Chester Clinic

Managing the spectrum of signs and symptoms for allergic conjunctivitis patients

William J. Faulkner, M.D.

Dr. Faulkner is a consultant for : Al ergan Bausch & Lomb Physicians Recommended Nutriceuticals

Allergy: An Altered Immune Response  From the Greek words "allos" meaning different or  And "ergos" meaning work or action…an "altered  Normal response to exposure to foreign substance is production of IgM, IgA, IgG and elimination of foreign  Allergic individual recognizes foreign substance, becomes sensitized (can take days to years), then on re-exposure over produces IgE which triggers activation of mast cells and release of various inflammatory chemicals.

Allergy Relevance  Sixth leading cause of chronic disease in the US  Annual economic impact: $14.5 billion  Absenteeism and productivity loss: $700 million

Al ergy Target Organs  Eyes: itching, redness, tearing  Nose: discharge, sneezing  Skin: eczema  Lungs: asthma

Managing the Spectrum
of Signs and Symptoms
Al ergic Conjunctivitis
Patients
William J. Faulkner, MD Cincinnati Eye Institute

Prevalence of Allergic Disease  30-50% of population  Ocular symptoms present in 40-60% of al ergic Ocular Allergies Affect Many in the US  70%–80% of people affected by allergies report ocular symptoms1  Up to 40% of the US population is affected by al ergic conjunctivitis2  Seasonal and perennial al ergic conjunctivitis account for 95% of all ocular allergy cases in the US3  More than 41 mil ion bottles of OTC and 4 million bottles of prescription anti-allergy ophthalmic medications are consumed annual y4  OTC=over the counter. 1. Abelson MB et al. Curr Al ergy Asthma Rep. 2011;11:205-211. 2. Bielory L and Friedlaender MH. Immunol Al ergy Clin North Am. 2008;28:43-58, vi. 3. Butrus S and Portela R. Ophthalmol Clin North Am. 2005;18:485-492. 4. Slonim CB and Boone R. Formulary. 2004;39:213-222. Prevalence of Allergic Conjunctivitis  The prevalence of allergic conjunctivitis has steadily increased over the last 40 years  About 20% of the general population is effected by al ergic conjunctivitis • 88% of people with al ergic conjunctivitis experience ocular itching  Allergy seasons are lasting longer • From 1995 to 2009, the length of the ragweed pol en season increased by up Al ergan Lastacaft Allergy: Increasing Incidence  Reduced allergen exposure in childhood  Genetic influence  Increasing industrialization & pollution  Medications and contact lenses Allergic Response: Multiple Inflammatory Mediators Early Phase (0‒1 h)
Late Phase (4‒24 h)
Allergen
Mast Cel s Eosinophils Histamine
Cytokines Cytotoxic Proteins Redness Chemosis Chemosis Pain/Itch Discharge LTs=leukotrienes; PAF=platelet-activating factor; PGs=prostaglandins. 1. Slonim CB and Boone R. Formulary. 2004;39:213-222. 2. Irkec MT and Bozkurt B. Curr Opin Al ergy Clin Immunol. 2012;12:534-539. Allergic Eye Disease Symptoms & Signs  #1: itching, especially over the caruncle  Others: burning, stinging, redness, photophobia, tearing  Usually bilateral, possible symmetric  Chemosis aggravated by rubbing  Clear or ropy discharge (mucoid)  Punctal gape Diagnostic Dilemmas in Ocular Surface Inflammatory Disease Key symptoms:
Allergy- itching inner
Blepharitis-burning Conjunctivochasis-pain on touch or down gaze Dry Eye-Discomfort  Personal, family history & exam  Skin testing: Prick method more sensitive & comfortable than intradermal  Conjunctival scraping positive for eosinophils (present in Diagnosis - Doctor Rx  Disposable test kit, 1000 test included, $4800  6 applicators per patient x 10 al ergens = 60  Prick testing for 60 antigens performed by assistant  Results within 10 minutes  Potential y useful for OSD pts, IOL & Lasik pts Diagnosis - Doctor Rx Diagnosis - Doctor Rx Ocular Allergy – Five categories  1. Seasonal & perennial allergic conjunctivitis…common  2. Vernal keratoconjunctivitis…rare  3. Atopic keratoconjunctivitis…3% of population  4. Giant Papillary conjunctivitis…usually contact lens  5. Contact allergic conjunctivitis…2⁰ to medications or 1. Allergic Conjunctivitis  An IgE medicated hypersensitivity condition that is characterized by ocular pruritus and epiphora  Ocular itching is the most common symptom of allergic  Proper diagnosis is determined most often by history and physical 1. Seasonal Allergic Conjunctivitis – 22% of Population  Spring: tree & flower pollen (Easter)  Summer: grass pollen (Memorial Day)  Fall: ragweed (Labor Day)  Maximum pollen count: 5AM-10AM  Worst city in US this spring: Louisville, KY 1. Perennial Allergic Conjunctivitis  Year round symptoms, 79% have seasonal exacerbations  Common culprits: animal dander, dust mites, feathers,  Often perennial rhinitis  Symptoms same as SAC, also chemosis, possible dellen 3. Atopic Keratoconjunctivitis 3.Atopic Keratoconjunctivitis  Severe allergic often all year, chronic  Often thickened lids, hyperemia, PEK, tarsal papillae  Atopic dermatitis in 3% of population…perhaps ½ of these have ocular involvement; + family history  ITCHING, watery, mucous discharge, red, blurry, pain, photophobia  Skin scaly, "woody"…possible cicatricial ectropion, lagophthalmos, keratitis, loss of vision  Pathophysiology: type I & IV hypersensitivity 3. Atopic Keratoconjunctivitis  Progression of multiple allergic sequellae  Allergic conjunctivitis, atopic dermatitis, rhinitis, asthma…? Co-manage  Immunotherapy (formerly injections) now possible with sublingual allergen delivery (SLIT) 5. Contact Dermatitis / Conjunctivitis 5. Drug Induced Allergic Conjunctivitis  Itching, inferior conjunctival injection, lower lid dermatitis, possible keratitis  Stop med for 2 weeks….? Test for al ergy type  Rechallenge with drop, immediate symptoms= Type I  Irritation after 48-72 hrs = Type IV cell mediated reaction  Possible culprits: Neomycin, Brimonidine, preservatives, other antibiotics 5. Contact Allergic Conjunctivitis/Dermatitis  Type IV delayed hypersensitivity reaction (T cell-  Often due to chemicals in everyday products, usually  Erythema, swelling, dryness, pruritis, possible vesicles, scaling & lichenification, thickened skin  Look at hands…nail polish (formaldehyde) or glue 5. Contact Dermatitis / Conjunctivitis 5. Contact Allergic Conjunctivitis/Dermatitis  Gold…remove and avoid jewelry  Fragrance…perfumes, colognes, soap, shampoo, fabric softeners, cleaners  Balsam of Peru…additive in multiple products  Nickel…glasses frames, eyelash curler, eye make up…even door handles, car keys, zippers & buttons  Benzalkonium chloride 5. Contact Allergic Conjunctivitis/Dermatitis Questions 1. Have you used any new products on eyelids, face or scalp? 2. any prescription or OTC products on face? 3. When did you last buy new makeup? 4. Any recent travels? Allergy testing may be indicated if answers are elusive Treatment Basics  Avoid allergens: No pets in bed, close windows, take up carpet, HEPA filter, special mattress cover  After exposure, wash hands, face, shower to wash hair  Cold artificial tears and cool compresses  Saline nasal rinse or spray  Avoid rubbing eyes or blotting with tissue  Disposable contact lenses  Patients can determine local allergens by entering their  Patients should identify when their SAC allergy seasons starts and peaks and start treatment 1 week prior  If allergy is only ocular, avoid oral antihistamines due to drying side effect (except Montelukast, Singulair)  Pollen counts highest in morning & early evening  Glasses or goggles can minimize allergen load  Allergist may recommend immunotherapy, the only Rx which is disease altering Artificial Tears  Non-preserved is safest  Newer transient preservative acceptable for use 4x/day  Drops containing purite, polyquad, sorbic acid, sorbitol Treatment: Combination Mast Cel  OTC Ketotifen, including Alaway (Bausch & Lomb) and Zaditor  Rx Bepotastine (Bepreve, Bausch & Lomb), Alcaftadine (Lastacaft, Allergan), Olopatidine (Pataday, Alcon), …no 3 way comparison  Bepotastine, BID dosing, 5 or 10 ml bottle, 68% had no itching after 3 minutes, 0.005% BAK, "comfortable", selectively inhibits histamine H1 receptor, ↓ rhinitis  Alcaftadine, 1x/day, 3 ml, 0.005% BAK, works within 3 minutes, lasts 16 hours, ↓ chemotaxis & eosinophil activation, only Pregnancy B (studied & no SE found)  Olopatidine, 1x/day, 2.5 ml, 63% had no itching after 3 minutes, 0.010% BAK, old formulation , best insurance coverage 2014 Mast Cell/Antihistamine Rx Drops PATADAY – Insurance Coverage Inflammation: Role of Steroids
Progenitor Cel Proliferation
Topical Steroids
Mast Cell
Work Here
Topical Steroids
Phospholipase A2
Work Here
Arachidonic Acid
Cyclic Endoperoxides
Histamine
Prostacyclin Thromboxane A2
(LTB4, LTC4, LTD4, LTE4)
(PGD2, PGE2, PGF2)
PAF = platelet-activating factor. Adapted with permission from Donnenfeld ED. Refract Eyecare. 2005;9(suppl):12-16. Treatment: Steroids, topical  Inhibit multiple foci in inflammatory cascade, highly  May be unnecessary for SAC & PAC  Side effect profile well known; cataract, ↑ IOP, ↑infection risk  Hydrocortisone 1% cream to skin, short term  SE minimized with ester or "soft steroid"  Lotoprednol, 0.2% (Alrex), 0.5% (Lotemax drops, gel, or Safety of Steroids?  Lotoprednol, 0.2%, used in 397 patients for SAC or PAC  159 patients with continuous use 2-4 x/day > 1 yr some  No reported adverse effects, ester base vs ketone steroid  Ilyas, et.al, EYE & CONTACT LENS, January, 2004 Lotemax Ointment  First new monotherapy steroid ointment in US in over 20  First preservative free steroid ointment in US  On label for post op inflammation s/p cataract surgery  Bonus benefit for patient with dry eye  Option is off label use with bleph/DES patient…a 1-2 punch  Also reuse medication in patient on Azasite still symptomatic  SE profile much more benign than other steroids…potency  Another possible indication: HSV immune stromal keratitis Treatment: NSAID's topical  Ketorolac (Acular), approved indication; Diclofenac  Postroglandin inhibitor decreases itching  Stinging or burning in 40%, not first line treatment Treatment: Severe Cases: Immunomodulators  Cyclosporin, 0.05% (Restasis)…T cell inhibitor  Tacrolimus (Protopic) ointment  Pimecrolimus (Elidel) cream  Safe for long term use on skin, effective but expensive Atopic Treatment-Tacrolimus  Tacrolimus (Protopic) ointment, 0.1 or 0.3%  Macrolide immunosuppressant inhibits T lymphocytes  FDA approved 1994, systemic use for organ transplants,  On label for atopic dermatitis on skin  Off label used in conjunctival fornix BID  Reported case of resolution of symptoms in 2 months after failure on all of above; tapered uneventfully over 4 months…no side effects Atopic Treatment  Coordinate with allergist, environmental  Antihistamines, mast cell stabilizers, cyclosporin, steroids, surgical resection of or cryo of papillae Treatment Failures  Undiagnosed blepharitis and/or dry eye  Eczema (skin al ergy…present on flexor surface of arms & legs) • Itchy lids > itchy eyes • Stop rubbing, stop soap, water & scrubs • Short course hydrocortisone cream (0.5 or 1%) or Lotoprednol • Consider…Dermatology consult  Demodex: diagnosis = cylindrical dandruff Blepharitis – Demodex – cylindrical dandruff New Rx: Allergic Rhinitis • Stallergenes (France), FDA approved April 2, 2014, age 10-65 for 5 grass pol ens, sublingual qd, start •Merck, FDA approved April 14, 2014, for Timothy grass pollen, age 5-65, sublingual qd, start 12 weeks before •Merck, Sharp & Dohme, FDA approval April 17, 2014, age 18-65 for ragweed pol en, sublingual qd. Nasacort Now OTC Allergy: Summary  Avoidance…An ounce of prevention…  Stop the rub to fix the itch  New medications are highly effective

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