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Many optometrists may not realize that proper management of ocular allergies and dry eye may have a financial impact on the contact lens aspect of their practice; according to one expert.
"[CL] sales are a key part of many optometry practices," Dr. Karpecki said. "When "[CL] wearers are suffering from significant allergies, they may 'take a break' by reducing their [CL] wearing time, or stopping it altogether. This break can become prolonged, and sometimes patients never go back to wearing their contacts. So it's very important for optometry to maintain comfort for these patients."
Allergies or dry eye?
Complicating the treatment is that many patients who suffer from allergies take oral antihistamines, which can have significant drying effects on the ocular surface. This dryness can enable the allergen to stay in the eye longer, as there are insufficient tears to wash it away. The presence of the allergen in the eye can then lead to a further immune response.
"Doctors need to look at the whole picture," Dr. Karpecki said. "Sometimes they see patients with systemic involvement, such as itchy palate and itchy throat, and respond by putting them on oral antihistamines only to find that they're exacerbating the primary problem, which is the allergic conjunctivitis and dry eyes."
Many allergy patients will also be self-medicating with over-the-counter ocular allergy drops, such as ketotifen fumarate ophthalmic solution (Zaditor, Novartis Ophthalmics: Alaway, Bausch & Lomb; Refresh Eye Itch, Allergan Inc.), before they visit the office. Such ocular allergy medications can have some muscarinic effects, although not nearly to the same extent as oral antihistamines.
"We really need to be aware of what these patients are already trying on their own," Dr. Karpecki said.
Successful allergy management
Dr. Karpecki recommends starting mild or moderate seasonal or perennial allergy patients with olopatadine hydrochloride (Patanol, Alcon Laboratories), epinastine hydrochloride (Elestat, Allergan, Inc.), or bepotastine besilate ophthalmic solution (Bepreve, ISTA Pharmaceuticals). "These agents aren't sedating, they have great effects on the mast cells-maybe even more so than a mast cell stabilizer alone-and they work very quickly," he says.
Some of the newer ocular allergy drops can also offer a degree of systemic relief, he added. "Bepotastine may prevent eosinophilic migrations and that might be beneficial. From what I'm seeing in my clinic, it seems to help with the systemic symptoms of allergies, such as itchy palate, rhinitis, and itchy throat.
"A small percentage of patients will actually taste the drop a little, so when I prescribe it I let hem know that," Dr. Karpecki said. "I tell them that this drop may also help with their sinus, throat, and nasal symptoms, and therefore they might taste some of the drop in the back of their throat. Furthermore, patients appreciate the cost savings they can enjoy by not having to buy oral medications in addition to topical ocular medications. It's a nice combination of cost savings and treatment benefits."
In patients who are still having allergy and dry eye symptoms, Dr. Karpecki often will recommend a nasal spray, such as azelastine hydrochloride (Astelin, Meda Pharmaceuticals Inc.), beclomethasone (Beconase, GlaxoSmithKline), or fluticasone propionate (Flonase, GlaxoSmithKline).