Comments: Even though OTC vasoconstrictors and antihistamines are popular, a recent article suggests that these drugs can cause rebound dilation of conjunctival vessels Chronic Drug Treatments Mast Cell Stabilizers Crolom (B & L)- cromolyn sodium 4% ophthalmic sol. Alomide (Alcon)- lodoxamide tromethanine.1% ophthalmic sol. Opticrom (Allergan)- cromolyn sodium 4% ophthalmic sol. Abrevia (Allergan)-FDA approval pending Almast (Santen)- pemirolast potassium 0.1% Alcoril ( Allergan)- nedocromil sodium 2% Qid for 1 week, then bid PRN Comments Mast cell stabilizers have no antihistamine or anti-inflammatory properties- no good for acute reactions, may take 1-2 weeks Excellent for long-term preventative and maintenance Excellent for preventative during seasonal or where anticipating exposure-i.e. (cats) Work by inhibiting the degranulation of mast cells, prevents release of histamine and other mediators Very safe for long-term treatment Most are initially approved for Vernal but also used in GPC, seasonal (hay fever) conjunctivitis and atopic keratoconjunctivitis. Oral Antihistamines If there is concurrent rhinitis and/or sinusitis OTC Benadryl (diphenhydramine) or Chlor- Trimeton (chlorheneramine): Drowsey!!! Claritin (loratadine 10mg) OTC qd /Claritin- D 12 & 24 (psuedoephedrine); Clarinex 5 mg qd Zyrtec (ceterizine 5 + 10mg) qd Allegra (fexofenadine 60 & 180mg) bid/ Allergra-D with psuedoephedine for decongestant Oral Allergy Medications Allegra fexofenadine 60 mg BID 180 mg QD Seasonal allergic rhinitis Allegra - D added pseudoephedrine for decongestant 60 mg BID Well tolerated, non-drowsy $60.00/month 1
Community Eye Care Center Jane Ann Grogg, O.D. 804 Monroe St., Bloomington, IN 47405 812-855-1671 Lic # 18002849B Allegra-D 60 mg Disp: # 60 Sig: i tab po bid Refill 3 Dispense as written Substitution permitted Oral Allergy Medications Zyrtec 10 mg Cetirizine Seasonal allergic rhinitis, perennial allergic rhinitis, chronic idiopathic urticaria i tab PO qhs Occasional drowsiness Cat. B Community Eye Care Center Jane Ann Grogg, O.D. 804 Monroe St., Bloomington, IN 47405 812-855-1671 Lic # 18002849B Zyrtec 10 mg Disp: # 30 Sig: i tab po qhs Refill 3 Dispense as written Substitution permitted Oral Allergy Medications Clarinex Desloratadine 5 mg qd Not available at this time with a decongestant Seasonal and perennial allergic rhinitis. Chronic idiopathic urticaria OTC Products: Loratadine Claritin Seasonal allergic rhinitis and idiopathic chronic urticaria 10 mg qd Claritin - D 24 decongestant added i tab daily Claritin - D 12 decongestant added i tab BID Claritin Reditabs Dissolve on tongue with or without water. Alavert 10 mg Loratadine cont. 2
OTC Products (not all inclusive) Benadryl Diphenhydramine 25-50 mg q 4-6 hrs DROWSEY!!!! Anticholinergic effects Glaucoma precaution Homeopathic Formulations Simelasan s eye drops #2 Other Treatment Modalities Cold Artificial Tears Air conditioner Moving to a colder climate Cold compresses Avoiding allergen CL s related allergies-switching to disposable lenses, decrease wearing time, enhance daily lens hygiene Topical cyclosporine: Restasis Mucolytic agent (Acetylcysteine 10%) Oral steroids Dosage varies widely For allergic responses, pulse therapy works well (60-80 mg x 3-4 days) Oral Steroids Contraindicated in patients with peptic ulcer disease, TB, active infection, psychosis, or pregnancy. Side effects: Hyperglycemia, hypokalemia, hypertension, peptic ulcer, Incr. IOP, cataract, PTC, mental status changes, osteoporosis, decreased wound healing fluid retention, other 3
Intranasal rhinitis agents Clinical indications: Isolated rhinitis symptoms, overwhelming nasal congestion Atrovent nasal spray Beconase AQ Flonase Nasacort AQ Rhinocort Nasalcrom OTC Mast cell stabilizer Cases 1. Mild itching, redness, & SCL intolerance. Mast cell stablizer?+/-antihistamine; steroids? Both? 2. 21 y/o just moved to IU in the Spring with moderate itching, mucous discharge & runny nose. Decongestant-antihistamine? Mast cell? Antihistamine alone, Antihist + mast cell, steroid? Oral antihist? 3. 8 y/o boy with severe itching x 1 month Steroids alone?, Antihist + mast cells? 4. 35 y/o with itching with near cats. Decongestant- antihist?, antihistamines?, Mast cells?, Mast cells + antihist.? Focal Points By the time patient reaches your office, the problem is most likely moderate. Look at the immediate needs & long-term goals when selecting treatment plan. Can you identify the offending allergen? Make sure to rule out dry eye- burning vs itching Be aggressive in treatment, try to eliminate, not just reduce symptoms Educate the patient! Don t forget about palliative treatment. Make sure you have the right diagnosis! Drug- induced Allergic Conjunctivitis A specific hypersensitivity reaction to an ophthalmic solution, ointment, cream or cosmetic used on the ocular surface or periorbital area Thimerosal preservative History is critical: important to review all medications, skin products, cosmetic & OTC meds Clinical Features Beefy red conjunctiva usually of lower conjunctiva and lid Punctate keratitis; greater inferior half Conjunctival scarring Contact dermatitis Contact Dermatitis Thickened, dry, scaly, erythematous, itchy eyelids Treatment Try to identify the causative agent and eliminate Cold compresses Preservative-free artificial tears FML ophthal Ung (or other steroid ophthalmic cream) Apply sparingly to affected area Bid x 5-7 days Consider oral antihistamine in moderate to severe cases For example Allegra Consider PO steroids in severe cases 4
Management Removal of offending agent is imperative Cold compresses Topical steroids or ointments (FML) maybe helpful Toxic Conjunctivitis OTC eye decongestants: ie vasoconstrictors Topical antibiotics: ie. Tobramycin/ gentamycin Glaucoma medications: ie: Alphagan Signs Diffuse conjunctival hyperemiarebound inflammation following D/C of vascoconstrictors Follicular conjunctivitis Blepharoconjunctivitis Management D/C of topical meds Symptoms may actually worsen initially Topical steroids may help 5
Mucous Fishing Syndrome Yes it is a real condition!!! Frequent history of dry eye or any condition which causes mucous production Patient traumatizes the conjunctiva & cornea while trying to remove the excessive mucous Vicious cycle of increase mucous Patient may deny Signs Adult with chronic mucous Isolated, well-circumscribed areas which stain heavily with rose bengal/lissamine green Over the caruncle, plica, nasal & inferior bulbar/ tarsal conjunctiva Management Patient education: D/C removing mucous Non- preserved tears At risk for secondary infection 6