Contact Lens Wear and Ocular Allergy
Proper diagnosis and management of ocular allergies will help symptomatic patients continue with lens wear.
By Paul M. Karpecki, OD, FAAO
|Dr. Karpecki is clinical director of Corneal Services and Ocular Disease Research at the Koffler Vision Group in Lexington Ky. He has served as medical director of cornea for three of the top cornea practices in the United States and is also a consultant to Alcon, AMO, Allergan, B +L, Cynacon Ocusoft, Focus Laboratories, Hydrogel Vision, and Ista Pharmaceuticals.|
Allergy is one of the leading causes of chronic disease in the United States, affecting approximately 30 percent of the population (Bielory, 2002). There are almost 40 million contact lens wearers in the United States (Nichols, 2009) and, therefore, approximately 12 million contact lens-wearing patients who may suffer from allergies. The incidence of ocular allergies is closer to 20 percent, although studies also indicate that up to 40 percent of the population has experienced ocular symptoms at least once in their lifetime (Singh et al, 2010). Furthermore, Americans spend more than $6 billion annually on allergy treatments (Reed et al, 2004), with the majority ($3.4 billion) spent on allergic rhinitis (Law et al, 2003). Therefore, it is extremely important that eyecare practitioners be aware of the latest options for diagnosing and managing allergies in contact lens wearers.
In fact, the number of lens wearers suffering from ocular allergies might well be a higher percentage because the presence of a contact lens could possibly allow allergens to remain on the eye for a greater period of time or even be caught under the lens. It is also possible that patients who have allergies may self-treat with oral antihistamines, which cause significant drying effects. These drying effects could then result in more contact lens wear problems. New oral antivirals are advertised as non-sedating, but that does not mean that they are nondrying (Welch et al, 2002).
One of the most significant challenges for eyecare practitioners is managing the co-morbidities of dry eye and ocular allergies. We know that oral antihistamines can dry the mucous membranes, including the eyes, possibly reducing the washing out of the allergens from the ocular surface. Furthermore, the symptoms of contact lens intolerance, dry eye, and allergy can mimic each other. Complaints of tearing, burning, grittiness, stinging, and itching can be common in all three conditions (Stevensen et al, 2000).
Economic Impact of Allergies on Contact Lens Wear
When contact lens wearers suffer from seasonal allergies, they may find that contact lens intolerance develops (Podmore and Storrs, 1989). According to surveys conducted and published by Dr. Jason Nichols (2011), the most common treatment that practitioners recommend in contact lens wearers who have symptoms is to change out the contact lens, followed by changing care solutions. If this is the case, patients may feel frustrated with the blame being the contact lenses rather than the ocular disease. Such patients may choose to take a hiatus from contact lens wear. If just one-sixth of these patients decide to drop out of contact lenses, that would amount to 1.3 million patients in the United States. Each patient generates approximately $300.00 per year to an optometric practice, which would be the equivalent of $400 million dropping out of contact lens wear each year. So it is imperative that we both diagnose and manage our contact lens wearers who suffer from allergic conjunctivitis from a financial perspective and, more importantly, from a patient care and morbidity perspective.
Types of Allergic Eye Disease
It is important to recognize that there are four different types of ocular type 1 hypersensitivity reactions or allergic eye disease forms. These include seasonal allergic conjunctivitis (SAC), atopic keratoconjunctivitis (AKC), vernal keratoconjunctivitis (VKC), and giant papillary conjunctivitis (GPC). One other possible subset is perennial allergic conjunctivitis (PAC). The forms most likely to affect contact lens wearers are the SAC, the PAC, and the GPC diseases. It would not be unheard of that patients who wear contact lenses may also be diagnosed with AKC, so let's begin with the differential diagnoses of AKC.
Atopic Keratoconjunctivitis AKC is a chronic and potentially severe form of allergic eye disease that can actually be sight-threatening. It is a perennial condition that tends to go through remissions and exacerbations, and the ocular symptoms can worsen at any point—including during the winter—but tend to increase in the presence of airborne allergens (Nivenius et al, 2012). This condition most commonly affects patients in their teens and early 20s, an age common to contact lens wear. The primary symptom is actually burning rather than itching. We most often associate allergic eye disease with symptoms of itching, and although itching is the most common symptom of most ocular allergy conditions, this is one example in which itching is usually a secondary complaint.
One of the keys to diagnosing AKC is to inquire about a history of atopic dermatitis such as eczema, most commonly located on the elbows and in the scalp. In many cases these patients will suffer from periorbital eczema, which can be observed on patient presentation. The conjunctivitis associated with AKC may be cicatrizing, leading to chronic scarring and hypertrophy. Other signs include corneal findings such as superficial punctate keratitis, corneal infiltrates, and neovascularization. There is also a high association with keratoconus and anterior polar cataracts (Tuft et al, 1991). Some experts surmise that keratoconus is secondary to eye rubbing (Jain et al, 2010).
Instruct patients who have this form of severe ocular allergy to discontinue contact lens wear and treat the condition aggressively. If conjunctivalization is present or neovascularization is migrating into the cornea, treat the patient with corticosteroids, which are angiotensive and therefore can prevent further blood vessel growth (Alzaga et al, 2010). Medications such as Durezol (Alcon) shortterm and Lotemax (Bausch + Lomb [B +L]) long-term, as well as cyclosporine 0.05% (Restasis, Allergan), appear to be very effective and necessary in treating this condition (Mishra et al, 2011). Patients could also be placed on combination medications such as Bepreve (bepotastine besilate, Ista Pharmaceuticals), which has been shown to work exceptionally well in moderate-to-severe allergic conjunctivitis (Abelson et al, 2009) and may also be successful in this severe form of allergic eye disease.
As mentioned, patients who have AKC often manifest periorbital eczema and severe blepharitis that must also be treated. Treatment options include corticosteroid ointments such as triamcinolone 0.1% cream. Ophthalmic ointments may be safer should they accidentally get into the eye. Lotemax ointment would be a very good treatment option because it will help if it gets onto the ocular surface and, because it may be required long-term due to the chronic nature of AKC, the ointment is preservative-free. Atopic patients are very prone to reacting to preservatives (Wijnmaalen et al, 2009). Lid scrubs are contraindicated due to the significant inflammation present on the ocular surface.
Vernal Keratoconjunctivitis Another form of allergic eye disease is VKC. This typically affects young males between the ages of 7 and 21. It is also a condition that is much more prevalent in warmer climates. The hallmark symptom of VKC is severe, incapacitating itch. The key signs also include a ropy discharge and often ptosis. Everting the eyelids will typically display giant papillae with significant hyperemia (Figure 1). The papillae are much larger than in other forms of allergic eye disease such as GPC and are often described as a cobblestone appearance. Other hallmark signs include Horner-Trantas Dots, which are accumulations of the eosinophils at the limbus. This is an extremely important area to observe in all children who suffer from allergies so that a diagnosis of VKC will not be missed in a patient who presents with SAC. If patients are not treated, they can often go on to develop shield ulcers, which can be secondary to the trauma from the upper eyelid cobblestone papillae but may also result from proteins that are released by inflammatory mediators related to the pathophysiology of this severe disease (Singh et al, 2001).
Figure 1. Vernal keratoconjunctivitis.
Patients who have VKC should discontinue contact lens wear. Prescribe combination agents such as Bepreve, Patanol/Pataday (both Alcon), Lastacaft (Allergan), and ketotifen-based products to reduce the incapacitating itch. As with AKC, the severity of the itch lends itself to treatment with bepotastine, given the data related to severe itch improvement (Abelson et al, 2009). These patients also typically require the use of topical corticosteroids to control the severe inflammation and large papillae (Mantelli et al, 2007). Should a shield ulcer develop, the ideal treatment would be cyclosporin 0.5% (Restasis), which has been shown to effectively treat vernal shield ulcers (Cetinkaya et al, 2004). Patients should also be prophylactically treated with an antibiotic whenever the epithelium is compromised, such as in the case of shield ulcers.
Giant Papillary Conjunctivitis GPC is most commonly related to contact lens wear, although it can also be caused by any form of long-term irritation or trauma, such as the presence of a loose suture in a penetrating keratoplasty patient or in patients who have a prosthetic eye (Bozkurt et al, 2007). These patients present with giant papillae on the upper tarsal conjunctiva and significant hyperemia (Figures 2 and 3). The most common symptoms are contact lens intolerance or decreased wearing time as well as a clear, ropy mucous discharge. Patients may complain that their contact lens moves on the eye, or slit lamp examination may reveal a lens that is riding high due to being captured by the giant papillae on the underside of the tarsal plate. Anecdotally, the frequency of GPC appears to be increasing and may be related to the overuse of silicone hydrogel lenses. These patients appear to develop GPC much later in their contact lens-wearing life, and the presentation appears to be much more persistent. It can present sectorally at times, with or without hyperemia.
Figure 2. Giant papillary conjunctivitis (parallelpiped view).
Figure 3. Giant papillary conjunctivitis (diffuse view).
The presence of hyperemia is critical to the aggressive treatment of GPC. Many patients, for example, who are aggressively treated with corticosteroids and cessation of lens wear were able to successfully return to contact lens wear. However, examination of the upper tarsal plate six months to a year later often may show persistent papillae, but no hyperemia and the patients are not symptomatic.
This condition is usually bilateral, unless it is secondary to a foreign body. Everting the upper tarsal plate will easily help you identify the diagnosis, although it is much easier to recognize the papillae after instillation of sodium fluorescein dye (Doughty et al, 1995). Milder forms of GPC can easily be missed if you do not evert and stain the upper eyelids.
If there is no hyperemia and the patient is asymptomatic, treatment may not be necessary but patients should be monitored. Other options may be to decrease lens wearing time, switch to a daily disposable contact lens, or opt for a hydrogel contact lens material. However, in symptomatic conditions, the ideal therapy would be to have patients remove their contact lenses for two weeks. During that time, loteprednol 0.5% can be prescribed four times a day for two weeks, and then b.i.d. when lens wear resumes at two to four weeks. Loteprednol has been the only steroid to date shown to be effective in the management of GPC (Bartlett et al, 1993; Asbell and Howes, 1997; Howes, 2000). Instruct patients to apply the loteprednol 10 minutes prior to contact lens application and after removal b.i.d. Long-term, you might consider combination allergy medications and, as mentioned, changing to daily disposable lenses, hydrogel lenses, or even consider refractive surgery options. Proper compliance, such as adhering to contact lens wearing schedules, is highly advisable. Compliance with proper lens hygiene is also critical.
Seasonal and Perennial Allergic Conjunctivitis The most common forms of ocular allergies in contact lens wearers, and in the general population, are SAC and PAC. SAC typically occurs, as the name dictates, during particular seasons such as spring and fall. It usually results from high counts of pollens, grass, ragweed, or molds. In the case of perennial allergies, which tend to be less severe but chronic, the typical causes are allergens that are always present such as dust mites, molds, and animal dander. It is very important in younger patients that we are aware of the high association between allergic conjunctivitis and asthma (Austin et al, 1999). Patients who have perennial allergies tend to suffer year-round and, of course, tend to be worse indoors. It is not uncommon, however, to get exacerbations during high pollen-count times of the year (Rowe et al, 1986). One of the most common causes of perennial allergic conjunctivitis is dust mites, which are approximately 10 microns in size (Platts-Mills et al, 1986), making it practically impossible to eliminate this allergen.
In the case of SAC, the most common causes are ragweed, grass pollen, tree pollen, and molds. The most common presentation of both conditions is a very typical “glossy-eyed look” in which patients present with hyperemia, chemosis, clear mucus, watery discharge, and often lid edema (Figures 4 to 6). SAC can be differentiated from other forms of conjunctivitis. Bacterial conjunctivitis tends to manifest significant injection often described as “meaty” red. Bacterial conjunctivitis also has mucopurulent discharge and is less likely to present with lid edema, unless a preseptal cellulitis or keratitis is also present. Viral conjunctivitis, which has a clear discharge, typically has lymphadenopathy associated with it, subepithelial infiltrates, and significant follicles. Patients who have viral or bacterial conjunctivitis typically have recently suffered from an upper respiratory infection or are aware of family members or friends who have had a “pink eye” recently. Another diagnostic option to help in the differentiation is the Adeno Detector (Rapid Pathogen Screening, Inc.), which can help make a positive diagnosis for viral conjunctivitis.
Figure 4. Seasonal allergic conjunctivitis (straightahead view).
Figure 5. Seasonal allergic conjunctivitis (superior gaze).
Figure 6. Perennial allergic conjunctivitis.
Although the hallmark symptom of allergic conjunctivitis is itching, other secondary symptoms include tearing, redness, burning, photophobia, foreign body sensation, and blurred vision. It is also important to differentiate the symptom of itching in allergic conjunctivitis from that of eyelid conditions such as blepharitis. The key, besides observing the eyelid margins, is to note where the patient describes the location of the itching. If it is the lid margin, that points to a diagnosis of blepharitis if concurrent signs are present. The most common location for itching associated with allergic conjunctivitis is the ocular surface including the canthal region.
Treating contact lens wearers who suffer from SAC or PAC begins by first treating the ocular disease. In his annual report “Contact Lenses 2011, Dr. Jason Nichols suggested that most practitioners will first try switching contact lenses or solutions. Neither of these steps will significantly decrease the presence of histamine or any allergic immune mediators, nor get at the root cause of the patients' contact lens intolerance. Most patients who have mild-to-moderate allergic conjunctivitis can continue to remain in their contact lenses if being effectively treated with topical allergy medications, especially those medications that can be prescribed on a b.i.d. or less frequent basis. We all know that most allergy patients tend to use allergy medications p.r.n. even though they may be prescribed b.i.d. or q.d., so instruct them to use their drops prior to contact lens wear and then after contact lens removal. Overnight lens wear should be contraindicated as significant inflammatory markers are often present in patients who suffer from allergic conjunctivitis, or corneal edema may develop (Bucci et al, 1997). Initial treatment should begin with educating patients about proper compliance with their contact lens wear. Besides no overnight wear, patients should not extend the length of the replacement schedule of their prescribed contact lenses. For example, a two-week lens should not be used beyond 14 days. Higher frequency replacement may be recommended.
Patients who suffer from significant allergies may benefit from preservative-free hydrogen peroxide care solutions and from avoiding allergens by staying indoors during the peak allergy season, showering before bed, changing sheets and pillows more often, and lowering the speed of or turning off ceiling fans, which can kick up allergens. Patients should also increase their use of rewetting drops or artificial tears to help wash out allergens. Other palliative recommendations such as cool compresses may be recommended.
With that being said, it is difficult for patients to return to normal contact lens wear unless the cause of the decreased wear time itself is managed. For this reason, focusing on treating the allergic conjunctivitis is critical. Many patients will treat ocular allergies by taking oral or topical antihistamines. Neither is recommended given the better options available by prescription from eyecare clinicians. Oral antihistamines have been shown to cause significant ocular surface drying and could potentially contribute to contact lens dryness as well as prevent irrigation of allergens that are present on the ocular surface (Welch et al, 2002). Likewise, topical vasoconstrictors and antihistamines, such as Naphcon (Alcon) or Visine-A (McNeil-PPC), could result in rebound hyperemia (Bielory et al, 2005).
So what is the key in deciding which therapeutics to prescribe for contact lens wearers suffering from allergic conjunctivitis? The answer depends on signs and symptoms. If we look at the immediate response in cases of acute allergic conjunctivitis, the primary immunological components include histamine, heparin, chymase, and tryptase. Mass cell degranulation results in significant release of histamine and other mentioned mediators that typically manifests significant symptoms of itching. It appears that the most effective medications for symptoms of itching primarily focus around the combination antihistamine/mast cell stabilizer agents. These include Bepreve, Lastacaft, Pataday, and Patanol, as well as over-the-counter versions that include ketotifenbased drops such as Zaditor (Novartis) and Alaway (B +L).
However, for patients whose clinical signs such as chemosis, lid edema, and hyperemia are greater than their symptoms are, which is often the case in longer-standing forms of allergic conjunctivitis, a topical steroid such as Alrex (B +L) or even Lotemax will typically work better. If you look at longer-term allergic response, synthesis takes place that results in the formation of leukotrienes, prostaglandins, cytokines, and platelet activating factor (PAF). These, particularly leukotrienes and prostaglandins, are all inflammatory mediators and immunological cells that are expressed from the arachidonic acid pathway. Corticosteroids are known to inhibit the arachidonic acid pathway.
Because many seasonal and perennial allergy sufferers take oral anti-histamine medications, select topical medications that are less drying for patients who wear contact lenses. The ideal approach includes combination allergy medications that are highly H-1 specific (Kida et al, 2010), which are less likely to affect the muscarinic receptors that can cause drying or the serotonin receptors that can result in drowsiness and drying effects. The new allergy medication Bepreve is known to be highly H-1 specific.
When you prescribe a corticosteroid, educate patients about the recommended treatment of applying the first drop 10 minutes before contact lens application and the second drop after removal, or ideally recommend discontinuing contact lenses because of the significant ocular surface inflammation and using the corticosteroid at a much higher frequency for the initial one to two weeks. For SAC, use Alrex or Lotemax in more severe cases.
Quality of Life
Because allergic conjunctivitis is so common to eyecare practice, it may seem like less of a debilitating condition; and yet patient quality of life surveys shows that SAC has a significant effect on the ocular surface, contact lens wear, and daily activities. Studies show that more than 70 percent of patients are not able to comfortably go outdoors during the allergy season and that they find it interferes with reading and productivity. More than 60 percent said that it affects their driving, and 58 percent reported a reduced ability to concentrate on daily tasks (Juniper, 1998). More than 50 percent of patients who have allergic conjunctivitis mention that it interferes with their sleep (Ellis et al, 1999). So our aggressive treatment of allergic eye disease in all patients is extremely important.
What recommendations should we make for our contact lens wearers who suffer from allergies and have a significant systemic involvement, such as rhinitis, itchy palette or throat, cough, or sinus congestion? I've already discussed the research showing that oral medications have significant drying effects on the ocular surface in contact lens wearers. For this reason, it may be best to treat the allergic conjunctivitis topically and hope that there is some benefit systemically as the drops drain through the lacrimal system.
The one exception may be a patient who presents with allergic sinusitis. This is not uncommon, and most patients will describe the pain as being peri-ocular. In these cases, it is unlikely that topical medications will quickly suppress the pain that can be associated with sinus headaches. These patients may be better served with an oral antihistamine/decongestant combination such as Allegra-D (Chattem/Sanofi), Claritin-D (MSD Consumer Care, Inc.), or Zyrtec-D (McNeil-PPC). These are now available over-the-counter. Each contains pseudoephedrine as the decongestant, so avoidance in patients who have hypertension is advisable (Gordon et al, 1992). If a systemic treatment is required, options for these patients include seeing an allergist or perhaps prescribing nasal sprays or steroid inhalers. Nasal sprays, such as Astelin (Meda Pharmaceuticals), are antihistamine-based and are successful for many patients. Steroid inhalers work well but still have risks that include increased intraocular pressure, conjunctivitis, potential for glaucoma, and posterior subcapsular cataract formation (Bui et al, 2005).
Educate patients who have allergic eye diseases to avoid eye rubbing. Many patients feel that rubbing their eyes provides some relief for a brief time, but they are actually mechanically degranulating the mast cells, which will result in much greater amounts of histamine and other allergic mediators being released and resultant greater incidence of clinical signs and symptoms. Furthermore, eye rubbing can cause problems to the ocular surface, including to the cornea, and can even dislodge the contact lens.
It might be a good recommendation to have patients refrigerate their eye drops, which can result in a soothing effect and can help patients be more aware that the drops have been instilled in the eyes. It is also important to recommend environmental management tips such as replacing pillows at least every three to five years in your perennial allergy sufferers, reducing ceiling fan speed or turning it off during peak allergy seasons, washing sheets more often, and showering (particularly washing hair) before going to bed.
As far as when to discontinue contact lens use in patients who suffer from SAC, the answer really depends on observing the key signs upon eversion of the upper eyelid. If the upper eyelid shows significant papillae, and especially hyperemia, even in cases of SAC or PAC, then it is possible that the trauma from the contact lens is contributing to the patient's symptoms. If this is the case, a short-term hiatus from contact lens wear during aggressive treatment would be recommended. However, if the upper tarsal plate shows no hyperemia or significant papillae, then it is possible to begin treatment with topical medications before and after contact lens wear, as the lens is not likely contributing to the symptoms.
Treat Allergies First to Maintain Lens Wear
Diagnosing and managing allergies in contact lens wearers poses its own unique challenges. It is critically important to focus on treating the allergic conjunctivitis first before addressing contact lens options. Treatments range from palliative measures and patient education to corticosteroids and oral allergy medications.
It is also important to be aware of the various forms of allergic conjunctivitis, ranging from sight-threatening diseases such as AKC and VKC to the more common SAC and PAC. With the increased prevalence of GPC, it is highly important to evert the upper eyelids of all of the patients and to instill fluorescein dye to help in the assessment of GPC. Aggressive treatment may be warranted in light of more recent forms of GPC.
SAC is one of the most common diseases in America and is growing in frequency secondary to clean environments and less exposure to allergens in children (Rook and Brunet, 2002). This condition will only continue to increase and play a key role in our contact lens wearers. Being aware of all of the keys to diagnosis and management is critical to maintaining successful contact lens wear for our patients. CLS
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