Pre-emptive strategies for exacerbations guided by seasonal fluctuations
New York-Taking into account seasonal variation in disease severity of ocular surface disease can help clinicians optimize care for patients with allergic conjunctivitis and dry eye disease.
“Ophthalmologists are well aware that due to changing environmental conditions, patients with dry eye disease generally experience exacerbations during the late fall and winter while those with seasonal allergic conjunctivitis (SAC) can develop flares in the early spring and fall,” said Christopher E. Starr, MD, associate professor of ophthalmology, Weill Cornell Medical College, New York.
“Adapting management strategies to these calendar fluctuations can help minimize the intensity of disease-related signs and symptoms,” Dr. Starr said. “It is far better to try to prevent an exacerbation than to have to treat one with more aggressive therapy.”
Rather than instituting office-generated reminders for patients to schedule follow-up visits, Dr. Starr said he prefers to empower patients to take charge of their care. When a patient’s disease shows a pattern of recurrent flares at certain times of the year, he discusses establishing a reminder and even asks patients to take out their smartphones to oversee their cooperation in creating an alert.
“Contacting patients to set up seasonal follow-up visits or to initiate seasonal management strategies for allergy or dry eye is a time- and resource-intensive task, whereas with today’s electronic tools, patients can easily create their own reminders,” explained Dr. Starr, who is also director, refractive surgery service, and director of the cornea, cataract and refractive surgery fellowship, and director of ophthalmic education at Weill Cornell Medical Center, New York-Presbyterian Hospital, New York.
“Furthermore, patients who are motivated to be more involved in their health care may be more likely to adhere to their physician’s recommendations,” he said. “Nevertheless, it is still the physician’s responsibility to initiate the process.”
For patients with a history of recurring seasonal allergic conjunctivitis, Dr. Starr recommends initiating treatment a few weeks prior to the start of the fall or spring allergy seasons with a dual-acting mast cell stabilizer/antihistamine. In addition, these individuals are reminded about non-pharmacologic strategies for reducing allergen exposure, including wearing sunglasses and brimmed caps when outside, washing their clothes frequently, keeping windows closed, and leaving outerwear outside of the house.
Artificial tears are also a useful adjunct because they can flush the ocular surface of allergens and inflammatory mediators, and preservative-free preparations are preferred for patients needing frequent instillation.
Patients with dry eye and who have a history of developing exacerbations in the late fall and early winter coinciding with declining humidity indoors and outside are counseled about the use of humidifiers at home and in the workplace, keeping themselves hydrated, and healthy computer habits. Some patients may also find it useful to increase the frequency with which they are instilling artificial tears in addition to twice daily topical cyclosporine emulsion (Restasis, Allergan). However, Dr. Starr noted that the latter interventions are usually maintained year-round because dry eye is a chronic disease and it is important to try to optimize the ocular surface even in the absence of aggravating environmental factors.
While initiating pre-emptive measures according to a patient’s history of disease flares can help reduce the likelihood of an extreme exacerbation of dry eye and SAC, it is not a guarantee. Therefore, patients must also be instructed to call for an appointment if they are experiencing a severe flare that may be an indication for a short course of a topical corticosteroid to control surface inflammation.
Dr. Starr also noted that when managing patients with dry eye and ocular allergy, clinicians should keep in mind that each of these conditions may masquerade as the other or they may coexist, which may partly explain the frequent disconnect between signs and symptoms in ocular surface disorders.
“Traditionally, we think of allergy when patients have a chief complaint of ocular itching, and we think dry eye when a patient complains of grittiness or foreign body sensation,” Dr. Starr said.
However, he added, recent studies have shown a significant overlap of these symptoms with almost 58% of allergy patients with itch also complaining of dryness in a study by Hom et al. (Ann Allergy Asthma Immunol. 2012;108:163-166).
It is also important to remember that some medications used to treat allergy will secondarily cause or exacerbate eye dryness, with antihistamines being among the biggest culprits. New developments in point-of-care diagnostic tests are helping to overcome some of the diagnostic challenges, he said.
“Tests, such as one available for measuring tear osmolarity (TearLab, TearLab Corp.) and another for detecting adenovirus (AdenoPlus, Nicox), help me on a daily basis to distinguish between common causes of red eyes,” Dr. Starr said. “In the future, we will have other point-of-care diagnostics for identification of MMP-9, IgE, and other markers that will further help clinicians with the differential diagnosis of ocular surface disorders.”
Christopher E. Starr, MD
Dr. Starr is a consultant and speaker for Alcon Laboratories, Allergan, Bausch + Lomb, Merck, and TearLab Corp., and has done research for Allergan, Rapid Pathogen Screening, TearLab Corp.