Joseph Allen (00:00): So this allergy season has been bad. In fact, allergy severity has been higher across the United States this season, likely because of things like climate change. As things heat up, the kind of spring season is prolonged and this allows for plants to release their allergens for longer periods. Now we all see signs of allergies during eye exams. In fact, where I practice, I see papillary reactions on a vast majority of my patients, even people who are asymptomatic for allergy symptoms. But it is sometimes difficult to discern the difference between signs and symptoms of eye allergies versus that of dry eye syndrome. So today we're going to be reviewing the different types of eye allergy kind of signs and symptoms, the diagnoses, and then of course treatment options, even discussing some lesser kind of known helpful tips and strategies for management.

(01:01): So I'm sure you remember from school, but allergies are a type 1 hypersensitivity reaction mediated by IgE antibodies. So if somebody has exposure to an antigen like tree pollen, for example, it lands on somebody's eyelid or their conjunctiva, if they have antibodies for it, then mast cells will degranulate, releasing not only histamine, but also leukotrienes, prostaglandins, cytokines, tryptase, as well as other factors. And all of these drive the signs and symptoms that we typically associate with allergic responses, right? The redness, the itching, the tearing, mucus discharge, and even chemosis. And from an examination standpoint, this can have a wide range, right? Somebody can present with an acute-like chemosis, very whole eye reaction in just one eye because they introduced a substance to just that one eye, to somebody having just kind of mild papillary reaction in both eyes due to seasonal allergies. You can see vernal keratoconjunctivitis due to somebody's perennial allergies to even for the unfortunate view atopic conjunctivitis where the conjunctiva may appear kind of 360 deep-red sort of reaction.

(02:16): But by far, the type of eye allergies I see the most are that of seasonal allergic conjunctivitis, right? Patients come in, there's a light papillary reaction on the conj and the patient also has symptoms of itchy eyes and red watery eyes. However, I do also note that there are times when patients will have not only allergic responses but also dry eye or they'll have patients that have pretty moderate to severe dry eye who happen to also have a papillary reaction on their conj. From my personal just anecdotal experience, I find that patients who do have more moderate to severe dry eye issues, signs and symptoms who have that papillary reaction, they tend to have a reduced lacrimal lake and I've done testing on enough patients to notice again in my anecdotal experience that these patients tend to be at higher risk or more often have a confirmed diagnosis of some autoimmune disease such as Sjogren's syndrome.

(03:20): I’d love your feedback on that one. If you yourself have patients who have Sjogren's syndrome or some other type of known aqueous muco-aqueous deficiency, if you tend to see more papular reactions in those patients. But the point I'm making here is that yes, they can present simultaneously and sometimes you have to use your clinical judgment to determine, is this allergy, is it both, or is it more of, "Hey, there's significant dry eye and something is causing more of this irritant appearing conj". Now, of course, management of these mild-to-moderate allergies, whether they be seasonal or perennial, can be managed either conservatively or we can be more aggressive with it. On the conservative side, typically using preservative-free artificial tears several times a day as that will help flush any sort of allergens from the ocular surface or again, cold compresses, that'll help constrict blood vessels, reducing puffiness and irritation to the eyelids.

(04:18): Now, of course, the next steps for symptomatic relief, which I find a lot of eye doctors are going this route beyond even the conservative treatments is prescribing an eye drop antihistamine and mast cell stabilizer combo. But of course, when things do get rough, practitioners often do reach for the topical steroids to bring that reaction swiftly back down. In my personal and just clinical experience, I find just hitting VKC hard with steroids to get things under control is kind of the best strategy. Again, just what's worked really well for me. And as people respond to those topical steroids or signs and symptoms come down, not only are they happy, but then I feel good and I can start to taper down the use of that steroid while concomitantly having them using more topical antihistamine mast cell stabilizer combos and I also usually start them on some form of topical cyclosporine even while they're starting to use the steroids.

(05:20): Because topical cyclosporine has been shown to reduce inflammation not only in the tear film, but on the ocular surface by inhibiting T-cell activation and class 2 histocompatibility antigens as well as reducing eosinophil counts in the tear film. Of course, with long periods of steroid use, we do need to have frequent follow-ups just to check eye pressure and also just educating patients that with not only topical steroids but oral steroids that patient may have a higher risk toward cataract development or again, IOP issues. Now, if a patient also has other types of allergy symptoms beyond just itchy eyes, then they may consider taking oral antihistamines to help with this. However, historically, oral antihistamines have carried that concern that although they help with your allergy symptoms, they may dry out the whole body and make symptoms of dry eyes worse. But either way, I think it's still always a good idea if patients are taking an oral antihistamine to let them know that it may dry out their eyes more and just be maybe more precautious and recommend using a preservative-free artificial tears at least maybe twice a day, especially during that harsh allergy season.

(06:33): And then beyond, of course, medical treatments, just lifestyle adjustments and certain tips can help our patients as well. Big one is, of course, trying to avoid whatever their allergen is, which can sometimes be easier said than done, but for example, cleaning the house more regularly to remove any sort of dust, mold, pollen that could be in the house, pet dander is a big one. Also, even like cockroaches, scary enough, are known to be an allergen. But from here, let me just say, "Hey, thank you so much for being here. Hope you enjoyed today's episode. Let me know your thoughts in treatment of management of different allergic disease." Otherwise, keep an eye on it. We'll see you in that next one. Peace.