Q: It seems that this year, I’ve had more patients complain about seasonal allergies. What can I suggest to help them? Even my non-contact lens-wearing patients are affected.
A: “Well, you can tell them that just about everyone is affected, whether they wear contact lenses or not,” says Ernie Bowling, O.D., of Gadsden, Ala. “It seems that complaints rise with the pollen count, and this is the time of year when it’s at its highest.”
Depending on where you practice, different allergens appear first. For example, in the Northeast U.S., tree pollen comes first, followed by grasses and then weeds.
You can start with simple remedies that should lessen patients’ symptoms. “There are some very basic palliative therapies that are always helpful to start with,” says Gregg Russell, O.D., of Marietta, Ga.
If patients’ symptoms seem severe and they seem to have additional symptoms relating to sinus or breathing difficulties, don’t hesitate to comanage them with a primary care physician. “In highly symptomatic patients (those who have sinus discharge, voice changes, or difficulty breathing that affects their work or leisure time), it might warrant a trip to the doctor—either the primary or eye care physician,” says Dr. Russell.
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“It doesn't have to be unbearable,” says Dr. Bowling. “A few of ‘grandma's old home remedies’ can apply to all. First: avoidance. If you are terribly sensitive, stay indoors. While it is tempting to push open the doors and windows, if you let Mother Nature in, you'll also be letting in all those allergens. Keep the doors and windows closed. Change the air filters on your heating/air conditioning unit. If you must work outside, wear a mask. Keep a bottle of artificial tears handy to wash offending agents out of your eyes. And, a cold compress really makes the eyes feel better and helps reduce swelling.”
For patients whose eyes are easily irritated, Dr. Russell suggests non-preserved artificial tears. “In cases in which patients are highly irritated, a preservative seems to make the condition last longer. In my experience, non-preserved tears seem to help more.”
Patients who are susceptible to allergies should wash their hair more frequently, as well. “The theory behind washing your hair is that if there’s pollen in it, you’re lessening your exposure to the allergen,” says Dr. Russell.
Those patients who wear lenses need to be more vigilant. “Contact lens wearers suffer more, as they already have a foreign object in their eye,” says Dr. Bowling. “First, I recommend combination mast-cell stabilizers/antihistamine drops—Pataday (olopatadine hydrochloride 0.2%, Alcon) especially, as dosing is only once a day. I instruct them to use that drop in the morning before they insert their lenses. I also recommend frequent use of rewetting drops during the day.”
A peroxide disinfection system may prove beneficial as well.
Other options for your contact lens patients: a more frequent replacement schedule (such as daily disposable lenses) or shortened wear duration (e.g., daily wear vs. extended wear), say Drs. Bowling and Russell.
“If the patient has minimal ocular signs, I tell him or her to watch for increased itching, and then wear spectacles for a while,” says Dr. Russell. “But, if a patient is severely affected, he or she needs to come out of the lenses immediately––no ifs, ands or buts about it. It depends on the patient and the kinds of symptoms being manifested. Rewetting drops are helpful, but palliative. If the lenses are proving to be too much to handle with the allergens, then they have to come out.”
Dr. Bowling agrees. “Even though contact lens patients may not want to hear it, sometimes it is necessary to discontinue lens wear for a short while until signs and symptoms subside.”
Sometimes, the patient will present with signs of severe allergies; these aren’t limited to the cornea, either. “Most allergy signs are going to be related to the conjunctiva, so I look for conjunctival chemosis, severe changes on the tarsal conjunctiva, and heavy staining changes to the cornea,” says Dr. Russell. “You don’t typically see corneal staining as a result of allergy, but allergy aggravates dry eye, so look for signs of that too.”
Don’t underestimate signs of allergy. “The main things I see in seasonal allergic conjunctivitis are redness, swelling and mucus discharge that are usually worse with contact lens wear,” says Dr. Bowling. “If I see corneal staining beyond some scattered superficial punctate keratitis, that’s a signal that I need to do something different—I don’t want to invite an opportunistic bacterial infection.”
Again, don’t hesitate to refer the patient for specialized treatment, as needed—e.g., if you see vernal shield ulcers in patients, says Dr. Bowling.
“Steroids can be beneficial, but they are not a first-line choice in cases of seasonal allergies,” says Dr. Russell.
Dr. Bowling agrees. “Severe allergies require heavier action. I'll use a topical steroid in a pulse dose to quiet the eye down, then go to my combination drug of choice,” he says.
Don’t forget to step back and look at the whole case, though. “While treating the ocular components with the range of medications at our disposal, we have to look and listen for additional symptoms. For example, is the patient having trouble breathing? Does he or she demonstrate signs of upper respiratory congestion?” asks Dr. Russell. “That many require coordination with the primary care physician or the allergist. I can’t recall a time when I’ve had as many patients being sent to their primary doctor to manage concurrent upper respiratory infections.”
