ALLERGY AND LENS WEAR
Allergies and Contact Lens Wear: Finding the Successful Balance
Don’t let ocular allergy symptoms rule out contact lens wear for your patients.
|Dr. Brujic is a partner of Premier Vision Group, a four-location optometric practice in northwest Ohio. He has received honoraria from Alcon Laboratories Inc., Aton Pharma (Valient), Bausch + Lomb, Odyssey, Rapid Pathogen Screening Inc., TelScreen, Transitions, Vistakon, and VMax Vision.|
|Dr. Kading is in practice in Seattle and is an adjunct faculty member at Pacific University. He has been a consultant/advisor to and has received research/education grants from Art Optical, Alcon, Contamac, Paragon, Valley Contax, and Unilens.|
By Mile Brujic, OD, & David Kading, OD
Allergic disease is a peculiar condition, in that substances that are usually harmless may trigger a significant inflammatory response in people who are sensitive to them. According to recent estimates, allergies affect 20 percent to 40 percent of individuals in westernized nations (Saban et al, 2013). Many of these people experience ocular symptoms, which we diagnose as allergic conjunctivitis. Often, we don’t see these patients until their symptoms are so severe that they feel they need professional consultation. Some may come to us before they’ve tried any over-the-counter or home remedies, while others come to us only after attempts to relieve their symptoms have failed. Whatever their current status, we must evaluate these patients quickly, make our diagnosis, and start treatment as soon as possible.
When patients who have allergies also wear contact lenses, an important question arises: Can we alleviate their allergy symptoms so that they can continue to wear their contact lenses? Usually we can, but we must take a strategic approach that begins with identifying patients who have allergies (Figure 1) and then providing them with options to help them manage their ocular symptoms.
Figure 1. When a patient complains of itchy eyes, blepharitis should be included in your differential diagnosis.
Who Has Allergies?
When patients come to our offices with active allergy symptoms, we know what to do—but if we identify patients who have allergies before they are symptomatic, we can often help them avoid or minimize their symptoms.
Most of us have questionnaires that ask patients about their general health, including whether they have allergies. I’ve noticed that patients will report allergies to medications, but often they don’t think to report seasonal allergies, especially if it’s not allergy season. To put it another way, if a patient who lives in the northeast has springtime allergies but he has his annual eye examination during the winter, he may not think to mention seasonal allergies because he’s not symptomatic. If we can identify these patients before they become symptomatic, we can let them know that we have various effective therapies, some available only by prescription, that can help alleviate their ocular symptoms. By having this brief conversation, we can reassure patients that treatments are available and that they should return to see us as soon as they start noticing their allergy symptoms.
Figure 2. Note the deposits on the surface of this contact lens worn by a patient who has ocular allergy.
Usually, our first recommendation to patients who have active allergies is to avoid the allergens, if possible. This is often difficult, so patients may use artificial tears to try to wash away the offending agent (Bielory et al, 2012). Unfortunately, any relief is often short-lived, as the tears have no therapeutic effect and simply diffuse the allergen and histamine. Cold compresses will usually help patients feel better by decreasing excessive heat produced by inflammation and by reducing eyelid edema (Hingorani and Lightman, 1995).
Any tactic that removes allergens from the environment may be helpful. For example, some people have found that washing their hair before bedtime is beneficial. This removes any allergens that may be bound to the hair and could be rubbed into the eyes during sleep. Frequent replacement of pillow cases during allergy season is also recommended.
Pet dander is another common allergen. Dog owners who struggle with allergy symptoms may find a recent study of interest. Researchers found that washing a dog two times a week significantly reduces the amount of recoverable antigen from the animal (Hodson et al, 1999).
Although environmental modifications can improve a patient’s allergy symptoms, they may not completely alleviate them. Often, we need to intervene with pharmacologic agents.
We are fortunate to have a number of pharmacologic agents available to treat our patients who have ocular allergy. I have found that the combination antihistamine-mast cell stabilizers are effective in treating allergic conjunctivitis and are my first choice of medication for these patients. Often times, this class of medications is so effective that it will be the only one that is required to control their symptoms. This category includes the following medications:
• Alcaftadine 0.25% (Lastacaft, Allergan) is available by prescription and is approved for once-a-day dosing.
• Azelastine 0.05% (Optivar, Meda Pharmaceuticals) is available by prescription and is dosed twice a day. It is available in a generic formulation.
|The Allergic Cascade|
|Allergic conjunctivitis is a complex process whereby an allergen binds to immunoglobulin E (IgE) that is bound to sensitized mast cells in the bulbar and palpebral conjunctiva (Roitt et al, 2001). When the allergens bind to IgE, they cause a crosslinking of the IgE molecules, triggering a series of intracellular signaling events and causing granules full of histamine to fuse with the cell membrane. This causes a massive release of histamine from the sensitized mast cells (Roitt et al, 2001). Free histamine binds to blood vessels, causing localized vasodilation and hyperemia. This vasodilation leads to excessive fluid leaking into the surrounding tissues and causes a chemotic response. This activity can also lead to swollen eyelids. Additionally, when histamine binds to nerve endings, it causes a rapid-onset itching response (Bielory, 2011). The eye attempts to flush away the allergens and histamine through excessive tearing.|
• Bepotastine besilate 1.5% (Bepreve, Bausch + Lomb [B+L]) is available by prescription and is approved for twice-a-day dosing.
• Epinastine 0.05% (Elestat, Allergan) is available by prescription and is approved for twice-a-day dosing. It is available in a generic formulation.
• Ketotifen 0.025% (Alaway, B+L; Zaditor, Novartis) is an over-the-counter drug. It is approved for twice-a-day dosing.
• Olopatadine 0.1% (Patanol, Alcon) is approved for twice-a-day dosing, and olopatadine 0.2% (Pataday, Alcon) is approved for once-a-day dosing. Both are available by prescription.
When prescribing these agents, instruct your patients to instill the drops at least 15 minutes before applying their contact lenses. This allows sufficient time for the drug to absorb into the target tissue and clear from the ocular surface, thus minimizing absorption into the lenses. All of these agents are effective for alleviating ocular allergy symptoms. Many patients appreciate once-daily dosing, as it simplifies the medication regimen (Scoper et al, 2006).
At times, a steroid may be warranted. A topical corticosteroid would be indicated for those patients who do not adequately respond to a topical antihistamine-mast cell stabilizer. Often times, a topical corticosteroid would be added to the treatment regimen as opposed to replacing an antihistamine-mast cell stabilizing agent. Corticosteroids have multiple mechanisms of providing anti-inflammatory effects. They will enter the cell nucleus and prevent the transcription of a number of inflammatory mediators. Additionally, they will also stimulate the production of proteins that act in an anti-inflammatory capacity. Corticosteroids also have immediate acting effects that are independent of gene transcription (Bartlett and Jaanus, 1995). Eyecare professionals have embraced the ester-based steroids because they have been found to be highly effective with few ocular side effects (Bielory et al, 2012).
A number of steroids are available for topical ophthalmic use, but the one most commonly used to treat allergic conjunctivitis is loteprednol 0.2% (Alrex, B+L). In a recent study, researchers found that loteprednol 0.2% was equivalent to olopatadine 0.1% in reducing signs and symptoms associated with allergic conjunctivitis (Gong et al, 2012). One factor that should be considered, particularly for contact lens wearers, is that loteprednol 0.2% is dosed four times a day. Patients will likely need to discontinue lens wear temporarily while using this steroid. When a steroid is warranted, a more convenient option for contact lens wearers is a steroid ointment for use at bedtime. With this option, patients receive the benefits of the steroid without needing to discontinue contact lens wear. Fluorometholone 0.1% (FML, Allergan) and loteprednol 0.5% (Lotemax, B+L) are available as ointments. I usually advise patients to place a strip of the ointment, about the length of a dime, in the lower palpebral conjunctiva. This gives them an adequate quantity of medication to maximize efficacy.
Contact Lens Strategies
When contact lens wearers have allergic conjunctivitis, we need to consider some additional strategies, not only to relieve their symptoms but also to help them continue with lens wear. If possible, I prescribe daily disposable lenses. That way, the lenses—along with the allergens and histamine that may adhere to them—can be discarded at the end of the day (Figure 2) (Lemp, 2003). Fortunately, we have many daily disposable lens options available.
Figure 3. When you ask your patients to bring in their lens storage cases, what you find may surprise you.
If a patient is wearing soft contact lenses and his prescription is not available in the daily disposable modality, we recommend a two-fold approach. First, we advise the patient to modify his environment to avoid or remove suspected allergens. Second, and equally as important, we re-educate the patient on proper lens care, particularly the rub-and-rinse regimen, to ensure that he is thoroughly removing allergens from his contact lenses.
We always advise practitioners to have patients bring their lens care solutions, storage cases, and any eye drops they may be using to their appointments. This gives you a true appreciation of how they are caring for their lenses and whether they are using any over-the-counter drops. You will also find out whether they are still using the solutions that you instructed them to use. Inspecting their lens cases will also give you insight into how well they are caring for their lenses (Figure 3).
If comfort continues to be an issue for patients experiencing ocular allergy symptoms, a hydrogen peroxide care system may be helpful. Peroxide is a remarkably strong disinfecting agent (Kiel, 1993; Retuerto et al, 2012).
Giant Papillary Conjunctivitis (GPC)
Much of what we have discussed thus far involves strategies to limit the allergic response by decreasing exposure to the offending agent. When the contact lens is believed to be the cause of the ocular surface allergic insult, however, we are faced with a challenging clinical situation.
Repeated exposure of the upper eyelid to protein deposits on the surface of a contact lens in conjunction with mechanical factors may cause a papillary response on the superior tarsal plate. A significant number of inflammatory cells are recruited to the area and release mediators that further exacerbate the process (Ehlers and Donshik, 2008; Richard et al, 1992; Allansmith et al, 1978; Allansmith et al, 1977).
Figure 4. A) Initial clinical presentation of a patient who has contact lens-related GPC; B) two weeks after treatment with loteprednol 0.5% and olopatadine 0.2%; C) four weeks after initial presentation and two weeks after switching to a daily disposable contact lens and using olopatadine.
What is the ideal protocol for treating these patients? We believe most practitioners would agree that temporarily removing the contact lenses for a period is beneficial, but then other questions arise: For how long? Should any medications be used while affected patients are not wearing lenses?
Most practitioners use topical steroids for treating GPC because of their high level of clinical efficacy (Friedlaender and Howes, 1997). We usually prescribe a steroid four times a day and have the patient return for a follow-up visit in one week. Additionally, we would begin an antihistamine-mast cell stabilizer combination concurrently with topical steroid therapy to help with any itching and also to help stabilize the mast cells to prevent further degranulation. In a recent study, researchers found that a steroid used with an antihistamine-mast cell stabilizing agent resulted in better outcomes compared to either agent used alone (Khurana et al, 2010). Some improvement will likely be seen at the one-week visit, but you will need to use your clinical judgment to determine when to reintroduce contact lenses (Figure 4).
The contact lens strategies we mentioned previously—daily disposables and a peroxide care system—may also be applicable to patients who have GPC.
Target Your Therapy
Ocular allergies are challenging for patients to deal with, especially those wearing contact lenses, and they are challenging for clinicians to treat. Identifying patients who have allergies—even before they are symptomatic—and creating a targeted treatment strategy will give us the best chance of keeping them successfully wearing their contact lenses. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #208.