Itchy and Scratchy: Ocular Allergies
BY TIMOTHY T. MCMAHON, OD, FAAO
Allergy season is upon us (in North America, that is), producing the aggravating symptoms of sneezing, coughing, scratchy throat and itchy, watery eyes. For those suffering from seasonal allergies, contact lens wear can be a real problem. About XX million Americans suffer from allergies. With 30 million U.S. contact lens wearers and 80 million worldwide, allergies and lens wear should intersect quite frequently, and they do. In my playbook, allergies are one of the "big three" that account for the majority of lens wearing failures among our patients: dry eye, blepharitis and allergy.
Figure 1. Papillary response with allergic
conjunctivitis in lower cul-de-sac.
Seasonal allergic eye symptoms consist of itching, excess lacrimation, mild diffuse conjunctival injection and conjunctival edema. Lid swelling may also occur. The palpebral conjunctiva will show a carpet of small papillae primarily involving the lower lid, as opposed to GPC, in which a papillary response of the upper palpebral conjunctiva predominates. Mucoid discharge is a frequent companion to the excessive tearing.
Chronic atopy is a different story. Those with chronic allergies, often continuing year round, can have the aforementioned symptoms but frequently don't. They are apt to present with symptoms of scratchy, irritated eyes with itching being either absent or a minor component. The skin of the lids may appear crenated (fine folds and cracks), thickened, erythematous or feel scaly to the touch. These folks will typically have multiple allergies and often have a history of asthma. Corneal involvement may be present and has been associated with significant visual impairment.
Ocular Allergy Treatment
Treatment of ocular allergies in contact lens wearers often makes a real difference. For seasonal cases, my first line of attack is cold compresses and one of the newer multi-action antihistamines such as Patanol (Alcon), Alocril (Allergan) or Zaditor (Novartis). I reserve topical steroids for severe acute presentations. Cessation of lens wear during treatment is severity dependent. None of the listed medications have been approved for use with lenses, so concurrent use represents an off-label prescription. In most cases, you can either keep the patient in lenses during the allergy season or shorten the interval when the patient is not able to wear them.
For chronic allergy patients, I will initially use a topical steroid until the signs and symptoms are markedly reduced. Concurrently, I will prescribe a mast cell stabilizer such as Alomide (Alcon). After tapering the steroid a few weeks later, I will continue these patients on the mast cell stabilizer for years, adding topical steroids again during symptomatic breakthroughs.
The chronic allergy patient is a much greater challenge from a diagnostic, therapeutic and contact lens fitting perspective than the seasonal allergy sufferer. In patients with severe and chronic conjunctival responses or corneal disease from atopic origins, I will take a more aggressive course when able, and limit lens wear during exacerbation of symptoms.
Dr. McMahon is an associate professor and Director of the Contact Lens Service at the University of Illinois at Chicago Dept. of Ophthalmology & Visual Sciences.