How to approach the management of seasonal allergies

Every spring, ophthalmologists typically see a big influx of patients seeking relief from the itching and watery eyes that come with allergies.

Eric D. Donnenfeld, MD, Ophthalmic Consultants of Long Island, Rockville Centre, NY, said the first thing ophthalmologists should do is to be certain that allergic conjunctivitis is the right diagnosis.

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“Sometimes diseases like dry eye can mimic allergy, so you want to make certain what you are dealing with,” Dr. Donnenfeld said. “Allergies usually present as itching, and there may be some systemic component to it as well. It can be a little difficult to diagnose.”

Looking at the pallor of the conjunctiva or presence of pale discharge can point toward allergies, he added. In bad cases, Horner-Trantas dots and papillary changes also can be evident.

New diagnostic tool

Dr. Donnenfeld said a new point-of-service testing option that identifies a patient’s allergy is available through Doctor’s Allergy Formula (Bausch & Lomb). This in-office device takes about 3 minutes to use, with results in 15 minutes. It uses a panel of 60 allergens that are specific to each region of the country.

With findings such as these in hand, ophthalmologists can be certain of their diagnosis, as well as help patients maximize the effectiveness of any medications they use. For example, someone who is allergic to pollen might want to dose before going outside. Someone who is allergic to dust mites might be advised to do it before going to bed.

Patient education

Education is an essential part of helping patients manage seasonal allergies, said Michael B. Raizman, MD, New England Eye Center, Tufts University, Boston.

“There are many excellent eye drops available, but many patients won’t be satisfied with eye drops alone if we don’t help them reduce their exposure to allergens,” Dr. Raizman said.

The following are clinical tips for limiting patients’ exposure to allergens.

Outside exposure

Patients should limit their time outside on high pollen count days, Dr. Raizman said, noting that local pollen counts are easily found online. Keeping windows closed in the car and home is important. Many car ventilation systems have good air filters, so he recommends patients use them throughout allergy season. Use them on a low setting even if the car’s temperature is comfortable enough to not require air conditioning, Dr. Raizman advised.

If a home doesn’t have central air conditioning, he suggests patients get a window unit for their bedroom so they can sleep without pollen blowing into their windows.

Change lifestyle routines

Dr. Raizman tells patients to change their clothes, wash their face and hands, and brush their hair after they come in from being outdoors in allergy season. Failing to do so only spreads the pollen inside the house, including onto their pillow, which puts it near the patient’s face all night.

He also encourages allergy sufferers to avoid touching their eyes when they are outside to reduce transferring pollen via their hands. Eye rubbing also causes ocular blood vessels to dilate and release inflammatory mediators and mechanical degranulation of mast cells.

“This can be a vicious cycle. Your eyes itch, you rub,” Dr. Raizman said. “Histamine gets released from rubbing. Your eyes itch more. You rub more. It can go on for days or weeks.”

Dr. Donnenfeld said he counsels patients on ways to minimize exposure to their specific allergen. “For example, if you're allergic to dust mites, it's a good idea to change your sheets and bedding and avoid having rugs and drapes in the room. If you're allergic to pollens, avoid cutting the lawn,” he said.

Using hypoallergenic bedding can be good idea, he added.

Contact lens use

Dr. Raizman typically does not tell allergy sufferers to discontinue contact lens use unless the lenses are very uncomfortable. However, he does encourage lens wearers to be vigilant about their cleaning regimen during allergy season.

Replacing lenses frequently during allergy season, or even switching to daily disposable lenses, can be a good choice for allergy sufferers. However, even aggressive cleaning routines can still leave some proteins behind and cause discomfort, he said.

Dr. Donnenfeld noted that contact lenses could make allergic conjunctivitis worse. Patients with mild disease may be able to continue wearing them with treatment, but more severe cases might require a break from lens use.

“For some patients, continuing contact lens use will prevent resolution of the disease,” he said.

He agreed that extended wear lenses are the worst option in allergic conjunctivitis patients. Daily wear is better, and gas-permeable contact lenses are even better than that.

There are many therapies used in the management of allergic conjunctivitis, including topical antihistamines, mast cell stabilizers, topical corticosteroids, and systemic therapies.

Topical antihistamines

Both ophthalmologists said topical antihistamines are excellent first-line therapy, especially when used by a patient who is following the tips mentioned here for reducing exposure to allergens.

“Most patients will get good relief from topical antihistamines,” Dr. Raizman explained. “There are some that are quite effective that are available over the counter. Some of the prescription options can be more convenient because they are once-a-day dosing and they may be more effective, although there aren’t many good head-to-head trials comparing them to one another.”

Dr. Raizman is okay with patients exceeding the recommended dose for short time periods when their symptoms are at their worst. “If a patient is having a really bad allergy day, I am fine with letting them use them at will,” he added.

Dr. Donnenfeld noted that some of the newer allergy medicines can last 18 to 24 hours, helping patients avoid the peaks and troughs that can come with more frequent dosing regimens.

Both doctors suggest patients, who need a little more relief than what their antihistamine drops are providing, should put the bottle in the refrigerator–using them cold can enhance their effect. Rinsing out the eyes with water first can help too, as patients can apply cold compresses as needed, Dr. Donnenfeld added.

Mast cell stabilizers

Dr. Raizman no longer prescribes mast cell stabilizers for seasonal allergies because he feels antihistamines are more potent and most contain some mast cell stabilizing properties.

Dr. Donnenfeld will sometimes add a mast cell stabilizer, or use a dual-action mast cell stabilizer that can work on both processes for people with chronic disease.

Topical corticosteroids

Both physicians will prescribe topical corticosteroids for patients with severe allergic conjunctivitis.

“They are safe to use short term, especially the ones that are designed to reduce the risk of elevated IOP and cataract formation,” Dr. Raizman said.

If patients need to use any steroid drop for more than 2 weeks, he asks them to return to get their pressure checked before refilling their prescription.

Dr. Donnenfeld said corticosteroids can be the most effective options, but he limits their use because of the higher risk of side effects. “For severe cases, it is a wonderful therapy to provide a corticosteroid topically with an antihistamine, and then once the disease is under control, taper off the corticosteroid,” he said.

Systemic therapy

Dr. Donnenfeld said he avoids prescribing systemic therapy for patients who only have ophthalmic allergies because they tend to dry out eyes and are not as effective as topical drops.

Oral anti-histamines also can be quite helpful for patients who also have nasal symptoms, Dr. Raizman said, but he does warns patients about the drying effect.

“Some patients will do better with a topical antihistamine drop paired with a nasal spray,” he said. “Artificial tears are an effective treatment for when the dry eye gets bad. They are inexpensive and easy to use. Sometimes they are the only things an allergy patient needs, especially (patients) who wear contact lenses.”

Dr. Raizman is not concerned about patients “mixing” allergy relief products during peak allergy season. “These products are safe. Patients should use whatever works for them,” he said.

Consider a referral

Some patients with severe allergies could benefit from seeing an allergist, Dr. Raizman said, especially if their nose or skin are involved.

“Sometimes allergists can provide other systemic treatments that ophthalmologists are less familiar with,” such as shots or sublingual therapy, he said.