Doing the best possible job for patients with ocular allergies involves a careful ferreting out of symptoms and selecting the most effective treatments based on the severity of the disease and the effectiveness of the medications.
When faced with diagnosing a presenting patient, Dr. Luchs noted that many patients with mild ocular allergies do not often volunteer symptoms that might suggest an allergic process.
Mild ocular symptoms
"Do the patients have itchy eyes? Do they have signs associated with ocular surface disease, such as dry eyes, ocular burning, irritation, or redness? Based on the answers, clinicians can then delve into the appropriate additional questions," he said. "Ophthalmologists must maintain a high index of suspicion for allergies and other ocular surface diseases."
Much overlap exists among allergies, dry eye syndrome, and blepharitis and the symptoms of these disorders, he noted.
"It is important to look for these disorders, ask the right questions, and do the right diagnostic testing to zero in on the diagnosis," he said.
Patients with mild symptoms may not voluntarily complain of anything, or may complain of occasional ocular itching, discharge, and redness that may or may not affect their daily activities.
For these patients, a plain antihistamine can work well. However, all the modern prescription allergy drugs are combination products that include an antihistamine and a mast cell stabilizer and are excellent solutions for patients.
Some over-the-counter (OTC) products that contain ketotifen are also excellent solutions, according to Dr. Luchs.
"We have plenty of good drugs to choose from," he said.
Additionally, in milder cases, patients can even do very well simply with the use of an artificial tear formulation to wash out antigens from the eyes.
Moderate ocular symptoms
For patients with moderate symptoms, the newest drug that has been introduced is alcaftadine ophthalmic solution 0.25% (Lastacaft, Allergan). One advantage associated with use of this combination antihistamine/mast cell stabilizer is that only once-daily instillation is required, Dr. Luchs noted.
"This provides very good efficacy for controlling ocular allergies with once-daily dosing," he said.
Olopatadine hydrochloride ophthalmic solution 0.2% (Pataday, Alcon Laboratories) is an older antihistamine/mast cell stabilizer also used once daily to control symptoms of allergy.
Choosing which of the two drugs to prescribe is based on clinical experience, he noted. Though Dr. Luchs believes that both of these once-daily products are excellent choices for controlling ocular allergies, in his practice, the therapeutic effects of olopatadine do not last quite as long as those of alcaftadine.
"Most patients find alcaftadine effective when used once daily," he said. Both drugs provide rapid onset of relief of allergy symptoms.
When patients have moderate symptoms of allergy, their daily functioning, such as work-related, leisure activities, and the ability to wear contact lenses, begins to be affected.
"These are the patients that we are more motivated to treat," Dr. Luchs said. "A less-frequent dosing schedule can provide several advantages for these patients.
"Importantly, they can instill the drug in the morning and not get rebound symptoms throughout the day, which may otherwise interfere with functioning," he said. "For contact lens wearers, the occurrence of rebound symptoms requires patients to remove the lenses, instill the medication, and disinfect the lenses before reinserting them. A drug that provides long symptom control is optimal."
He also likes bepotastine besilate ophthalmic solution 1.5% (Bepreve, ISTA Pharmaceuticals) and epinastine.
"Both of these are very effective drugs for relieving ocular itching, however, they are dosed twice daily," he said.
The OTC ketotifen products also work well for patients with moderate allergies, he noted.
"These are the only OTC medications that I like for my [patients with ocular allergy]," Dr. Luchs said. "The other OTC medications that are available, such as Visine (Johnson & Johnson) andOpcon-A (Bausch + Lomb), are combination antihistamine and redness-relief drops that have some appeal in the marketplace because they provide instant relief of itching and redness. However, some patients can develop a dependence on these products because of the rebound effect after the redness is relieved."