discovering dry eye
Caring for CL Patients Who Have Dry Eye and Allergies
BY KELLY K. NICHOLS, OD, MPH, PHD
As I sit here in my office with my nose itching and my eyes watering, I realize that allergy season is here once again. For some, allergy season can last nine months -- from spring through the first snowstorm -- and can wax and wane from bad to worse. My local paper tells me the pollen count has been high lately, which is probably the root of my problems (not to mention the air circulation in our building). This brings me to ask, "What do we do to help our dry eye, contact lens-wearing patients who have seasonal allergies (beyond booking an extra exam)?"
Sorting Out Symptoms
Many dry eye patients report "eye itching;" however, many contact lens patients (those who have dry eye and those who don't) and non-contact lens patients who have seasonal allergies also report ocular itching. Studies have shown that dry eye patients (Nichols et al, 2004), contact lens patients (Begley et al, 2001) and ocular allergy patients (Ableson et al, 2003) all report itching.
So based on symptoms, how do we determine which condition is behind them? In general, it's the "company the symptom keeps" that aids us in the differential diagnosis of dry eye vs. allergy in contact lens wearers and in non-wearers. You'll often find a conjunctival papillary reaction, conjunctival injection and possibly chemosis and watery discharge in ocular allergic conjunctivitis. Dry eye is usually a diagnosis of exclusion, and a papillary reaction and conjunctival chemosis are generally absent.
Three in One
I have patients who have dry eye, who wear contact lenses and who are bothered by seasonal allergies. What do you do when the worst scenario is happening? The key is to manage each condition. Of course, overlap between treatments can prove helpful.
Dry Eye Consider Restasis (Allergan). Several of my contact lens-wearing patients who have mild-to-moderate dry eye have reported reduced ocular allergy symptoms during their allergy season while using Restasis.
Ocular Allergy Site-specific steroids, such as Alrex and Lotemax (Bausch & Lomb) can help patients get through a rough spot, either at the beginning of treatment (concurrent with a topical antihistamine/mast cell stabilizer for allergy or Restasis for dry eye) or during a flare up of symptoms while on other treatment. Usually such steroid use is limited to one or two weeks in duration.
Contact Lens Issues During allergy season, contact lens wearers may have to limit wearing time, or at a minimum clean their lenses more vigorously and replace them more frequently. Comfort and staining of the cornea and conjunctiva aid us in recommending an appropriate wearing/replacement schedule during this time of year. Frequent use of rewetting drops may also help flush potential allergens out of the eye. Patients are more likely to comply if they understand that the recommended wearing and replacement schedule is temporary and will improve comfort.
Careful evaluation of the superior tarsal plate for giant papillary conjunctivitis (GPC) and careful questioning about solutions can also shed light on chronic cases of ocular "itch." The symptoms of GPC are similar to both seasonal ocular allergy and solution sensitivity. Learn about a recent change in solution or chronic use (and long-term development of sensitivity to a solution) through adequate history, and then make the appropriate changes. But don't change too many things at the same time so that next year the answer will be clear.
To receive references for this article, please visit http://www.clspectrum.com/references.asp and click on document #106.
Dr. Nichols is assistant professor of clinical optometry at The Ohio State University College of Optometry in the area of dry eye research.