PART 1 OF A 3-PART SERIES
Ophthalmic Technician Continuing Education

Increasing Your Clinical Value:
Opportunities for Ophthalmic Technicians to Get Involved with Allergy Patients

By Jodi Luchs, MD, FACS, and Loraine Huemmer, COT, CRC

Faculty/Editorial Board:

Jodi Luchs, MD, FACS, and Loraine Huemmer, COT, CRC

Sponsors/Support:

Supported by an Independent Educational Grant from Allergan, Inc.

This course has been submitted to JCAHPO for consideration of CE credit.

This course is not sponsored by JCAHPO; only reviewed for compliance with JCAHPO standards and criteria and awarded continuing education credit accordingly; therefore, JCAHPO cannot predict the effectiveness of the program or assure its quality in substance and presentation.

Copyright 2012, Review of Ophthalmology^®. All rights reserved. The opinions expressed in this supplement to Review of Ophthalmology do not necessarily reflect the views, or imply endorsement, of the editor or publisher. Copyright 2012, Review of Ophthalmology. All rights reserved.

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One of the most common conditions that lead patients to make an ophthalmic appointment is a red, itchy eye. In fact, each year, more than 50 million Americans suffer from allergic diseases. Allergies are the sixth leading cause of chronic disease in the United States, with an estimated 20 percent of the general population suffering from allergic conjunctivitis.¹ Because the patient history can offer important clues to making a diagnosis, the role of the ophthalmic technician is an important one—and a well-trained tech is an invaluable asset to the clinician. Not only will this monograph provide a comprehensive review of this common condition, but it will also detail the care of the allergy patient, including the part of the ophthalmic technician in the process. First and foremost, a basic understanding of ocular allergies is crucial to any healthcare professional successfully managing allergy patients.

The 411 on Ocular Allergies

Interestingly, the prevalence of allergic disease in general has increased over the past several decades, likely due to a combination of environmental, cultural and technological factors. One hypothesis for this increase, known as the "hygiene hypothesis", suggests that early exposure to nonpathogenic microorganisms in childhood may promote immune system maturation and protect from the development of an allergy later on, whereas a lack of exposure in early life may disrupt normal development of regulatory immune activity and increase the risk of allergic disease.^2,3 Thus, according to this hypothesis, as our societies and cultures evolved and became cleaner—with the advance of industrialization and technology—the incidence of allergy increased.

Contrary to the statistic mentioned in the previous section, one study suggests that up to 40 percent of the population is currently affected by ocular allergies.⁴ In another study of 5,000 children with allergies, almost one-third of them had ocular-only symptoms.^5,6 Ocular allergy can affect patients' lives in multiple ways. It can limit where patients can go, take away the enjoyment of outdoor activities, affect work-related activities, leisure time activities, the ability to read or work on a computer, social functioning, and it can also make contact lens wear, which is very important to many patients, unpleasant or even impossible. Thus, this prevalent condition deserves our attention as eyecare professionals.

Many people who suffer from chronic allergies are often undiagnosed. Furthermore, many individuals who have chronic ocular allergies self-medicate their symp toms with over-the-counter (OTC) products, rather than seek medical attention. When OTC products no longer control their symptoms, these patients will then present to an eyecare professional for help. However, these patients generally don't walk in identifying themselves as ocular allergy patients. They may present with a variety of stories, clinical signs or symptoms, and it is up to the eyecare professional to sort out the underlying cause(s). Because ocular allergy shares many signs and symptoms with other ocular surface diseases and can present in a wide variety of ways, this task of identifying the cause is not always straightforward. To help make the task of correctly identifying ocular allergies easier, let's delve even deeper, with a look at the biologic and physical manifestations of this common condition.

Back to Basics

Allergic conjunctivitis is inflammation of the conjunctiva that is caused by an allergic reaction. Because the large majority of eye allergies involve the conjunctiva, the terms "ocular allergy," and "allergic conjunctivitis" are often used synonymously.

The pathophysiology of this common condition involves a type-1, IgE-mediated hypersensitivity response facilitated by the exposure of a sensitized mast cell in the conjunctiva to a particular antigen. Antigen in the air dissolves in the tear film and penetrates the conjunctiva, where it can bind to the antigen-specific IgE on the surface of mast cells. This binding triggers a cascade of intracellular events, including calcium influx and phosphorylations, leading to the release of pre-formed granules from the mast cell cytoplasm. These pre-formed granules contain pre-formed inflammatory mediators, the most notable of which is histamine.

At the same time, the mast cell is stimulated to produce other inflammatory mediators, including prostaglandins and other cytokines. Of all of the mediators produced and released by the mast cell, it is primarily the histamine that is responsible for the classic signs and symptoms of allergic conjunctivitis: itch, redness and swelling. Histamine binds to histamine receptors on nerve endings in the conjunctiva to produce an itching sensation. It also binds to the histamine receptors on the conjunctival vasculature to produce vasodilation and an increase in vascular permeability— producing redness and swelling (chemosis).

The release of histamine and other mediators also attracts other inflammatory cells into the conjunctiva such as eosinophils, neutrophils, macrophages, monocytes, lymphocytes and others. Once these cells arrive in the conjunctiva, they too become activated and secrete inflammatory mediators, which prolong and propagate the allergic inflammatory response. Thus, it is clear that allergic conjunctivitis is much more than merely itchy eyes and mast cells. It is a multicellular, allergic inflammatory cascade. Not surprisingly, treatment of the allergy patient requires a comprehensive approach. But before we get into the treatment of this condition, we should review the clinical signs and symptoms that are often associated with allergic conjunctivitis.

When It's More Than Just Allergy…

Two unique situations deserve a special mention: contact lens wearers with ocular allergy and patients who have co-existing dry eye and allergy. Contact lens wear and allergy. One-third (33 percent) of respondents to an online survey about eyes and allergies identified themselves as contact lens wearers and of these, 12 percent admit to having dropped out of their lenses because of allergies.7 Ocular allergy is a well-known cause of reduced contact lens wearing time and contact lens intolerance. Contact lenses can trap antigen in the tear film against the ocular surface, thereby precipitating or worsening ocular allergy symptoms. While contact lens wearers who also suffer from ocular allergies may come in complaining of itching, they may not volunteer information that they are increasing the frequency of rewetting drop use to enhance their comfort, or that they are taking their lenses out earlier. In fact, a survey by the Allergy and Asthma Foundation of America revealed that almost three-quarters of patients who wear contact lenses and suffer from ocular allergies use one of those strategies to cope with continued wear, while more than 40 percent stop wearing their lenses altogether during allergy season.7 Those behaviors are probably overlooked by many eyecare providers, but are important to elucidate because we can make a major impact on the quality of these patient's lives by effectively treating their ocular allergy.

Reduced contact lens comfort can have detrimental effects on work performance, impair enjoyment of leisure time, interfere with the ability to perform activities of daily living, and reduce self-perception of appearance if patients switch from contact lens to spectacle wear. Therefore, clinicians should not overlook the potential for effectively treating allergies, which are causing contact lens intolerance, in order to produce important secondary benefits for patients' lives. For allergy sufferers who want to remain in contact lenses, many physicians recommend the use of single-use contact lenses. Dry eye and allergy. Because many allergic conjunctivitis patients have some degree of dry eye, treating both conditions is often necessary in order to achieve an optimal outcome. The use of artificial tears can be very beneficial in these patients and thus should not be overlooked. In addition to relieving dry eye symptoms by lubricating the eye, they also reduce allergy symptoms by diluting or washing away antigens and inflammatory mediators from the tear film. Topical cyclosporine is also an effective treatment for patients with allergic conjunctivitis and dry eye disease. In addition to reducing ocular surface inflammation, improving tear production and stabilizing the tear film, this drug's immunomodulatory activity may have some therapeutic benefit in the allergic inflammatory cascade as well as the cycle of inflammation in dry eye disease.

 

Clinical Signs and Symptoms

The clinical signs of allergic conjunctivitis include conjunctival hyperemia, chemosis, lid edema and a stringy mucous discharge. That said, it is rare for patients to present to their ophthalmologist's office with these signs. Usually, by the time they have arrived in our offices, the acute redness and swelling have resolved, leaving a relatively white and quiet eye. Occasionally, a fine papillary reaction can be observed on the palpebral conjunctiva, which can help aid in the diagnosis. Thus, because a patient's appearance may be deceiving, it is crucial to take a complete history in order to ensure a proper diagnosis and treatment regimen.

The ophthalmic technician is often the first point of contact and the first history taker in the patient encounter; therefore, it is crucial that they have a high index of suspicion for allergy and ocular surface disease. Furthermore, it is critical that they ask the appropriate questions, thus allowing the physician to key in on the issue of allergy and treat appropriately.

As we are all aware, the hallmark symptom of ocular allergy is itch. However, many patients don't present to our offices simply complaining of itch, or with acute findings of red, swollen eyes. Sometimes, similar to what happens with their clinical signs, patients with ocular allergy start out with itch symptoms, which lead to rubbing and secondary redness and irritation. But often, their episode of itchiness and redness occurred days or weeks prior to their visit, and by the time they present to our offices, their eyes look relatively white and quiet upon presentation. And occasionally, some of these even forget about their prior episode of itch. They may present complaining about dry eyes, contact lens intolerance, difficulty working on a computer, episodic redness, etc.—all symptoms that may also suggest other ocular surface diseases such as dry eye or blepharitis.

The most common forms of allergic conjunctivitis fall into two major categories: seasonal and perennial. Both are—by far—the most common presenting forms of ocular allergic disease, however, they are (fortunately) the least severe and generally don't produce sight-threatening sequelae.

Seasonal or Perennial?

Not sure if a patient is suffering from seasonal allergic conjunctivitis (SAC) or perennial allergic conjunctivitis (PAC)? Following is an explanation of the differences between the two forms.

SAC. This is the most common form of allergic conjunctivitis.⁵ Approximately 90 percent of all ocular allergy cases are seasonal and are linked to pollen-related allergies, according to Mark B. Abelson, MD, senior clinical scientist at Schepens Eye Research Center.⁸ Patients suffering from this form of allergic conjunctivitis present most commonly in the spring and/ or fall, although symptoms can last throughout the summer. Symptoms include itchy eyes and/or a burning sensation and are usually bilateral, though there may be asymmetric involvement. It is helpful to keep in mind that ocular symptoms are often accompanied by nasal and pharyngeal symptoms, such as a runny nose and scratchy throat. Clinical signs include watery discharge, white exudates that become stringy with chronicity, mild injection of the conjunctival surfaces with varied levels of conjunctival edema and papillary hypertrophy along the tarsal conjunctival surface.

Airborne pollens from trees, grasses and weeds are the most common allergens for this type of allergy. However, it is incorrect to conclude that these patients only experience symptoms for a few weeks out of the year. Consider, for example, the fact that one study, which surveyed 124 allergic conjunctivitis patients, found that 46 percent—almost half—of eye allergy patients are affected by two allergy seasons per year. Furthermore, 18.5 percent of these patients reported that a single allergy season lasts more than 3 months.^9,10 Another large survey demonstrated that ocular allergic symptoms were present in almost every month of the year—not only during peak spring or fall allergy season.⁴ Because the onset of SAC symptoms is seasonally related to specific circulating airborne allergens, it is important to consider the location and climate where the patient resides when assessing them. For example, mango pollen peaks in the air in December and January, whereas grass pollens are associated with increased ocular symptoms during the spring as well as during "Indian summer" in the fall. Considering these points, patients with SAC may experience ocular allergy symptoms throughout most of the year.

PAC. As the name suggests, PAC tends to produce year-round symptoms because the causative antigens are always present. Additionally, it is more likely than SAC to be associated with perennial rhinitis.⁵ The prevalence of PAC is considered a variant of SAC and is much lower than that of SAC.¹¹ And while symptoms of PAC are the same as those of SAC, they tend to be less severe.¹² Dust mites are the most common cause of this type of allergy, although pet dander—especially cat dander—is another common offending agent. Pet dander remains suspended in the air for extended periods of time, which allows it to settle on just about everything including carpets, furniture, clothing, etc., thereby producing chronic exposure and consequently, chronic symptoms for susceptible individuals. Interestingly, even patients suffering from PAC can experience seasonal worsening of their symptoms. Other antigens that can cause PAC include mold, cockroaches, dust, cosmetics, tobacco smoke and pollutants.

More severe forms of ocular allergic diseases include vernal keratoconjunctivitis and atopic keratoconjunctivitis, which are less common and can produce sight-threatening consequences in some patients. Also of importance, many patients with allergic conjunctivitis may also suffer from other ocular surface diseases such as blepharitis and dry eye.

Keep in Mind the Possibility of Co-existing Conditions

For example, the ocular surface inflammation created by allergic conjunctivitis may act as a trigger for the inflammatory cycle at the heart of the pathophysiology of dry eye.^14,15 Similarly, many patients with ocular allergies may take oral antihistamines for their ocular symptoms or associated nasal symptoms. However, these medications can often dry the eyes, thereby paradoxically worsening ocular allergy symptoms. Ultimately, as the dry eye symptoms worsen, so will the symptoms of ocular allergy. Why is this? Dry eye syndrome limits the eye's ability to flush antigens from the ocular surface, allowing them to become concentrated in the tear film, thereby increasing the potential for antigens to access mast cells in the conjunctiva. Furthermore, a compromised ocular surface, as is often demonstrated by the ocular surface staining pattern we see in patients with dry eyes, may allow antigens in the tear film to gain greater access to mast cells in the conjunctiva.

Blepharitis can also increase ocular allergy symptoms in several ways. Posterior blepharitis, which is associated with meibomian gland dysfunction, can result in an abnormal lipid layer of the tear film, which can interfere with the spreading of tears over the ocular surface and increased evaporative loss of the tear film, resulting in a concentration of dissolved antigen on the ocular surface. This, in turn, may result in an exacerbation of allergic signs and symptoms. Anterior blepharitis may produce itching of the lid margins often confused with allergy. Furthermore, both posterior and anterior blepharitis can produce red eyes, lid swelling and symptoms of burning, irritation and foreign body sensation often confused with ocular allergy.

Identification of allergy patients begins with a patient history, which is the key diagnostic tool for detecting ocular allergies, often making it possible for clinicians to diagnose allergic conjunctivitis even before examining the patient.

All Hands on Deck

In today's fast-paced world, ophthalmic medical personnel (OMPs, i.e., certified ophthalmic technicians, certified ophthalmic assistants, certified ophthalmic medical technologists and those working toward certification while employed in an ophthalmological office) play an important role in providing data that are important to the physician in order to provide the appropriate level of care and treatment to patients. Securing a history takes skill and requires a team effort between the OMPs and the physician.

The role of the ophthalmic technician will vary a bit with the attitudes and instructions of the supervising eye doctor. It is always advisable to know how in-depth your physician wants the history and workup. It is best to develop a systematic method of questioning and to perform the history in a friendly yet professional manner. If a patient has confidence in you and trusts you, then you will be able to obtain more information from them.

When ocular allergies are involved, the accuracy, consistency and efficiency of the ophthalmic technician becomes extremely important. The patient's presenting symptoms are an important aspect of the history and invariably include some degree of itch—usually ocular itch or periocular itch, or both.

The Allergy Cascade Although not specifically part of the ophthalmic technician's scope of responsibility and training, knowledge of the allergic cascade will aid in the understanding of the body's response to allergens in general. The allergy cascade can be a multi-faceted complex set of cause and reaction, setting off other allergens in the body. Patient perception of their allergies' interference with daily life activities, cosmetic appearance and overall quality of life is gaining importance. Keeping pace with this emphasis, there are now tools such as questionnaires with which to measure quality of life. Many present clinical research projects are including specifically designed quality-of-life questionnaires in their studies to better understand the psyche of the patients involved and the effect on lifestyle. Our body's immune system is designed to constantly be on the lookout for intruders. It has the ability to distinguish between "self" and "non-self" (foreign substances such as inhaled ragweed) from which it will tirelessly work to protect us. An allergic response is the body's overreaction to some substance it believes to be a threat to the body. The substance is perceived as an attacker that threatens the bodily system, and the immune system will subsequently produce specific antibodies to combat this threat. An allergic cascade refers to the chain of events that takes place when an allergen triggers an allergic response. It is the unique sequence of chemical releases in the body that take place in response to an allergen. The end result of this chain is the release of histamines and other chemicals that bring on typical allergy symptoms. Individuals may first become sensitive to an allergen before an allergic reaction can take place. This process involves the immune system mistakenly perceiving an allergen again. Links in the chain that make up an allergic cascade include: Proteins in the allergen, which are mistakenly recognized as threatening. The production of specialized antibodies to deal with this perceived threat. The antibodies attach to mast cells containing chemicals, one of which is histamines. The more severe the allergy, the more mast cells there are in the eye.13 The histamines circulate in the body, causing allergic reaction symptoms. Symptoms can affect eyes, nose, lungs, throat, skin and digestive tract.13 When inhaled, the same allergen that produces allergic conjunctivitis can cause nasal symptoms. If it goes into the lower airway, the patient can get lung symptoms. The physician will decide what specifically to target with treatment. The target depends on the type of allergy the patient is suffering from and the severity (mild, moderate or severe) of that allergic condition.

Other common symptoms include burning, tearing, sensitivity to light or a gritty or foreign body sensation. Physical examination and slit lamp exam are, of course, also important for ruling out other causes of the patient's symptoms, including dry eyes, blepharitis, rosacea and medication toxicity. The physician will be interested in known allergens or exposures, including pets, as well as the frequency, severity and duration of the patient's symptoms. The patient history should also include the presence of any associated systemic allergic conditions such as asthma, allergic rhinitis or eczema.

A family history of allergies is also important to note because it is a significant risk factor for the development of ocular allergies. The history should also include the efficacy of any previous medical treatments the patient has used, including OTC formulations. These pieces of information only take a moment to collect, but are crucial in helping the physician distinguish patients who have occasional allergy symptoms from those with more chronic long-term and recurrent disease. Many physicians find that it is also helpful to include some degree of the severity of the itch.¹⁶ Some even use the patient's own words in quotes, such as "I could not stop rubbing" or "I wanted to rub my eyes out" versus " they itch occasionally".

When inquiring with a patient about allergies, one question not to ask is "Do you have any allergies?". It is too general a question. Instead, by breaking the question down into categories, you can elicit are more accurate responses. In general, specific types of allergic responses should be inquired about such as:

• Do you have any allergy to medication, either prescriptions or over-the-counter?
• Do you have any allergies to food, tape, latex, animals or any general substances?
• Do you have any seasonal al lergies, or do you have allergies throughout the year?
• Do you use any over-the-counter allergy medications? (This question is extremely important because the patient may be masking signs of an allergy through the use of these medications.)
• Do you have problems using eye drops? (This question will help evaluate how compliant the patient will be during the course of treatment and assists the physician in determining whether the patient will do better trying a once-a-day drop approach versus drops throughout the day.)

Any positive response should concisely document the type of allergen, the reaction the patient suffers, when it occurs and how long it lasts. It is important not to interpret for the patient. The interpretation of history and symptoms is the domain of the physician who assembles all information gathered from the history and the ophthalmic exam to develop a diagnosis and treatment plan. Some allergies can be genetic, such as those to cow's milk or animal dander, while others, such as poison ivy or a wasp sting, are not. Some physicians may want their technicians to question patients regarding family allergies in general.

When gathering information for the physician, ophthalmic technician can also incorporate specific questions such as:

• Do you ever suffer from red eyes, itchy eyes, watery eyes or swollen eyelids?
• Do you use OTC eye drops to treat red, itchy, watery eyes or swollen eyelids?
• Do you take any oral allergy medications?

Always remember to note the frequency of use of any affirmative answers to the above, as well as when the last dose was taken if presently in use.

A thorough history is the foundation for the examination and diagnosis of patients, as well as their successful treatment. Once a good history is obtained, the ophthalmologist can direct the examination with greater purpose and take it to the next level with regard to history, symptoms and level of discomfort. Here, the next logical step in the management of a patient with allergic conjunctivitis is the determination of a treatment plan. While ophthalmic technicians are not directly involved in this area, it is still of great benefit for us to possess knowledge about what therapies patients are using in the event that any issues arise.

Treating Ocular Allergy with Success

Because patients have access to an array of OTC medications, it is important for ophthalmic technicians to bring this into their history taking and to record self-medication attempts for the doctor. Some medications may mask symptoms, while others may become addictive and cause a rebound effect when the patient attempts to discontinue the use of the medication. It is also important to note how compliant the patient is when treatments are attempted. Topical ophthalmic products for the treatment of ocular allergies at the disposal of the physician include artificial tears, vasoconstrictor/antihistamines, antihistamines, mast cell stabilizers, mast cell stabilizers/antihistamines, NSAIDs, and steroids. Side effects of topical steroids may make the physician reluctant to prescribe these medications. Side effects can include some or all of the following: increase of intraocular pressure, cataract formation or exacerbation of cataracts, and worsening of ocular infections such as viral or fungal keratitis.¹⁸

Initial treatment strategies flow directly from the patient's presenting history. The long-term management of chronic allergy patients often involves a combined approach, including medical therapy for the ocular disease along with co-management with an allergist to better identify the underlying causative allergens and to help manage any associated systemic findings. However, these patients must also be educated about their allergic disease. It is essential to teach them about the difference between instant gratification and long-term control of their symptoms. Because many of these patients self-medicate their symptoms, they must be educated that while these products may produce instant relief of their itch, their long-term use can produce chronic symptoms that may prove difficult to clear up until the underlying allergic process is controlled. Again, co-management with an allergist can be helpful when attempting to discuss with patients how to change their current patterns of exposure to allergen and self-medication.

Brush Up On Your Reporting Skills

The importance of taking a careful history in ocular allergy patients is clear. Doing so can help us gain insight into the presence of underlying allergy, as well other ocular surface diseases. Introduce yourself while escorting the patient to the examination lane. Explain to the patient that the physician has asked you to obtain information and measurements to assist them with the patient's eye exam. Some patients are extremely nervous, and a smile can go a long way to make them more comfortable with the process. For us it may just be a job and we may participate in many exams each day, but to the patient, it's their eyes. While performing a work-up, the ophthalmic tech becomes a reporter focusing on the patient, just as a newspaper reporter will develop their stories by filling in the "who, what, where, when, how and why". We already know "who" the patient is, and can leave the "why" for the physician to focus on as a diagnosis and treatment. History questions can fill in the "what" (the chief complaint), "where" (the complaint or symptom and the location), the "when" (the start of the complaint) and finally, the "how" (how long the complaint lasts). It's extremely helpful—and often necessary—for us to report on the "who, what, where, when, how and why" of each patient that sets foot in the exam room. Obviously the "who" is the patient, and the "why" can be left up to the physician. But the rest—the "what, where, when and how"—will need filling in. What. The chief complaint (CC) tells us why the patient has come in for an exam. It is an essential part of every chart note, significantly affecting coding and reimbursement. According to the 1997 Documentation Guidelines for Evaluation and Management Services, "the CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter usually stated in the patient's words". Whenever necessary, the ophthalmic technician can use the patient's exact words in quotes. It is also important to note whether or not the complaint is unilateral or bilateral. Family history may hold a clue to the source of their allergy, as well as their work situation (factory allergens, etc.) or environment (new construction, job change, new pet, new detergent, and move to a new section of the country). Where, when and how. The history of present illness (HPI) is related directly to the chief complaint and delves further into it. Evaluation and Management (E/M) guidelines define it as "a chronological description of the development of the patient's present

illness from the first sign and/or symptom or from the previous encounter to the present." HPI may be reported using one or more of the following elements: location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms. Subjective symptoms relate to how the patient actually feels (e.g., pain and nausea) and are not observable by another. Objective symptoms (e.g., redness or swelling) are observable by another. Two Medicare carriers, Palmetto GBA and Noridian, have determined that "ancillary staff may question the patient regarding the CC, but that does not meet criteria for documentation of the HPI. Information gathered may be used as preliminary information but needs to be confirmed and completed by the physician."17 The ophthalmic tech and the physician need to work as a team to accomplish this aspect of the history. In keeping with Medicare instructions, "a medical assistant or technician may take the chief complaint and note it but only the physician may perform the HPI." By providing details in the history portion of a workup, the ophthalmic technician makes it easy for the physician to review the information for accuracy and provide an arena for the doctor to discuss the issue with the patient to direct the conversation toward a diagnosis and a treatment plan. Ask patients to describe their symptoms. When do they occur? When are their symptoms worse? Is there anything that can make it better? Is there anything that makes it worse? Are there pets in the home? What type of work does the patient do? Where do they work? Where do they spend most of their time? What are their hobbies? It is also important to ask about a family history of allergy because when both parents have allergies, their children have a greater than 50 percent chance of having an allergy as well.2 We also need to ask patients about exposure to dusts, pollutants, vapors or other occupational exposures. Additionally, it is important to ask about symptoms of ocular surface disease in general, such as dry eyes, irritation, burning, foreign body sensation, tearing or contact lens intolerance. Patients may not report these symptoms because they may not consider them "abnormal" for them, yet they may have a significant functional impact on their lives. Many patients will admit that they thought these symptoms were "normal for age" or that they have simply "learned to deal" with them. Thus, a positive review of symptoms should prompt additional questions regarding specific allergy symptoms such as itch, as well as many of the factors mentioned above.

 

Key elements in the patient history may provide crucial information about lifestyle modifications, which may greatly benefit our patients. For example, we may counsel patients to try to avoid outdoor activities when pollen counts are high, drying clothes outside on the clothesline, driving with the car windows open during allergy season, having the household pet enter or sleep in the bedroom, and to close windows in the house. It is important to remind patients to minimize their exposure to the allergens that trigger their symptoms whenever possible. Aside from making lifestyle changes—be they temporary or permanent—patients may also find relief from a variety of products.

Non-pharmacological treatments. Options such as artificial tears and cool compresses are helpful, especially in milder cases, for relief of itch and swelling. The use of artificial tears can be very beneficial in these patients, and should not be overlooked. In addition to relieving dry eye symptoms by lubricating the eye, artificial tears also reduce allergy symptoms by diluting or washing away antigens and inflammatory mediators in from the tear film.

Medical therapy. When conservative non-pharmacological measures prove insufficient, medical therapy is indicated. Typically, topical therapy is more effective than systemic therapy with oral antihistamines for treating ocular symptoms. Topical therapy, unlike systemic therapies, is also less likely to produce ocular surface drying, which might paradoxically worsen allergy symptoms. When systemic therapy is indicated (e.g., when the patient exhibits nasal allergy symptoms), it may be necessary to counteract ocular surface drying with artificial tears and ointments.

Historically, several different classes of topical medication have been used to treat the symptoms of allergic conjunctivitis. OTC topi cal antihistamine/vasoconstrictor preparations are certainly effective in relieving redness, swelling and itching, but these drugs have no significant effect on the underlying allergic inflammatory cascade. Additionally, they are only useful for short-term relief; long-term use can be associated with the rebound phenomenon, where withdrawal can lead to more severe symptoms or even ocular surface toxicity.

First-generation mast cell stabilizers, such as lodoxamide tro-methamine 0.1% (Alomide, Alcon Laboratories, Inc.) and cromolyn sodium 4% (Crolom, Bausch + Lomb, Opticrom, Allergan Pharmaceuticals), are effective in stabilizing mast cells from releasing their preformed cytoplasmic granules, which contain histamine. However, these first-generation medications often require dosing four to six times daily and complete stabilization of the mast cells can take several weeks. In general, these agents are no longer routinely used or available.

Topical antihistamines, such as levocabastine hydrochloride 0.05% (Livostin, Novartis Ophthalmics) or emedastine difumarate 0.05% (Emadine, Alcon Laboratories, Inc.), can be effective in blocking histamine receptors on immune cells, and relieving itch symptoms. However, like the first-generation mast cell stabilizers, these drugs require multiple dosing during the course of a day and tolerance can develop to these drugs, making them less effective over time.

Topical nonsteroidal anti-inflammatory drugs such as ketoro-lac tromethamine 0.5% solution (Acular, Allergan) can also be effective for relieving symptoms of itch, but these drugs are often associated with significant burning and stinging side effects, which can adversely affect patient compliance with therapy.

The biggest problem with all of the above-mentioned classes of drugs is that they only treat the symptoms of allergic conjunctivitis. However, as described above, allergic conjunctivitis is much more than just itchy eyes; it's a multi-cellular disease. And although mast cells certainly play an important role in eliciting the immediate signs and symptoms of allergic conjunctivitis (e.g., the immediate itching, redness and swelling), other cell types, including eosinophils, neutrophils and macrophages, are involved in the allergic inflammatory cascade. All of these cells secrete many inflammatory mediators, which propagate this allergic response. Therefore, treatment of allergic conjunctivitis with a drug that blocks only one particular cell type or mediator involved in this process may increase the likelihood of breakthrough symptoms due to the short- and long-term effects of all of the cells and mediators not inhibited by that drug. That said, the treatment of ocular allergy with medication that has an effect on multiple aspects of this cascade may prove more effective.

Newer medications have an effect on multiple cells and mediators involved in the entire allergic pathway, so they may be likely to provide more comprehensive relief than the older drugs. The most frequently prescribed agents fall into the category of dual-action antihistamine/mast cell stabilizers. This class of medication includes olopatadine HCl 0.1% (Pata-nol, Alcon Pharmaceuticals) and olopatadine HCl 0.2% (Pataday, Alcon Pharmaceuticals), ketotifen fumarate 0.025% (Zaditor, Novar-tis), azelastine HCl 0.05% (Optivar, Meda Pharmaceuticals), epinastine HCl 0.05% (Elestat, Allergan Pharmaceuticals), bepotastine besilate 1.5% (Bepreve, ISTA Pharmaceuticals) and alcaftadine 0.25% (Lasta-caft, Allergan Pharmaceuticals).

These agents also have effects on other cells involved in the allergic cascade, most notably eosinophils. Furthermore, these agents are dosed twice daily, or in the case of olopatadine or alcaftadine, once daily, which can significantly improve compliance with these drugs, compared to the older-generation agents. Chronic use of these multi-action medications for our patients suffering from chronic or perennial allergies provides both relief of symptoms as well as long-term control of the underlying allergic process while preventing new symptoms from arising. They are therefore effective therapy both before and during an allergic reaction.

More severe cases of allergic conjunctivitis may require the addition of a topical corticosteroid to control the process. In these cases, a low-dose steroid, such as loteprednol etabonate 0.2% (Alrex, Bausch + Lomb) is often effective, although selected cases may require more potent topical steroids, such as loteprednol etabonate 0.5% (Lotemax, Bausch + Lomb) or prednisolone acetate 1.0% (Pred Forte, Allergan Pharmaceuticals). In such cases, it is essential to ensure that the diagnosis is correct, and that there is no sign of any ocular infectious process. Furthermore, steroids should be used with caution in patients with recent contact lens use due to the increased risk of infection. The use of topical steroids always carries the risk of classical steroid-related adverse events, including a rise in intraocu-lar pressure and cataract formation. Accordingly, when topical steroids are used in these cases, it us usually for a short term—usually 1 to 2 weeks—to get the acute inflammation under control and provide relief. Once the patient's clinical status improved, these agents can be rapidly tapered and the patient can be maintained on one of the combination antihistamine/mast cell stabilizers mentioned above.

To get the maximum benefit from these therapies, patients with chronic allergy need require consistent periodic monitoring. In addition to following patients on steroids to ensure that they are responding appropriately to the drug, physicians also need to encourage patients to continue taking their longer-term medications. Most antihistamine/mast cell stabilizing drugs perform best when used consistently; however, patients with chronic allergy tend to become noncompliant when symptoms ameliorate unless they are reminded of the importance of taking these drops regularly.

The physician may call upon his technician to educate a patient regarding the mode of treatment that he has decided to use for this particular person. Some aspects of the treatment, such as use of cold compresses, instillation of drops, punctal occlusion, and keeping an allergy diary, might be delegated to a trained employee.

After the Diagnosis

The ophthalmic technician's work really begins once all the symptoms have been presented to the ophthalmologist, the ocular exam has been performed and a diagnosis of ocular allergy has been made. The clinician may have a really good idea of the allergy cause and what will cure it, or may just be targeting allergy as the diagnosis. At this point, the value of a well-trained technician comes into the picture. We may be called upon to do some or all of the following:

Ensure patient understanding. Should a medication be prescribed, it is our job to make sure the patient understands the directions. Frequency of use, when to use, how to instill into the eyes, side effects to report to the ophthalmologist, as well as when to call if the medication is not working are part of making sure the patient understands their treatment plan. It's also important to communicate to the patient that their non-compliance will complicate their care and that use of OTC medications can mask symptoms or work against a prescribed medication. Have them check with the doctor before taking any OTC allergy medication. If you have a forgetful patient, help them with a plan of action to remember their medication use, such as posting a chart on the refrigerator and checking off when the medication is used. With your physician's approval, watch them instill an artificial tear to make sure they have an effective instillation technique.

Follow up. If necessary, your ophthalmologist may ask that you call the patient in a few days to make sure they are following directions or to determine whether they need to be seen again in the event treatment plan is not effective. Tell the patient you will be calling, and ascertain they understand that if not compliant with their treatment plan/ medications they may not get the relief that their physician is expecting. It may also be helpful to make sure they understand sometimes finding the right combination of medications to help them may take work, and possibly different medications or combinations of meds. The answer is not always a quick fix or a sure thing.

Introduce the patient to the allergy diary. Sometimes an allergy diary is called for and you can assist the ophthalmologist by helping the patient to understand not only how to keep one, but the need for this aide. There is even an iPhone app that patients can be referred to, iPollenCount, which allows patients to electronically keep a diary of their allergy symptoms and correlates them with the daily pollen counts. Patients can then e-mail this information to their doctor. It is helpful for the tech to explain to the patient that if the allergy trigger can be discovered, it can either be avoided or medicated as soon as possible once exposed. Explain that by recording the date and time of their allergic reaction and backtracking; where you were, what you did, what you ate or touched, times and places, are always helpful in discovering the trigger, especially when a pattern is noticed. If the trigger cannot be avoided, at least the patient can be prepared to deal with the allergy before it becomes severe.

From initial questions to signs and symptoms, keep in mind that the most important thing to the patient is that they get relief. And to achieve that goal, it takes knowledge and work—both on the part of the patient's eyecare physicians and the ophthalmic technician.

Final Thoughts

To summarize the information presented here, practitioners need to remain alert for patients' year-round allergies to allergens such as cat dander, mold and dust, as well as vernal keratoconjunctivitis (VKC), atopic keratoconjunctivitis (AKC), and drug-related allergic reactions. Itching is the absolute hallmark of ocular allergies.

Signs and symptoms can be the key to determining the allergen. Some patients will report that their allergies produce significant suffering and that they have a severe effect on their lifestyle. On the other hand, another patient will become so acclimated to their allergy symptoms that they accept their discomfort as a normal or almost normal state of life. The many OTC preparations available to our patients make it easy for them to self-treat their symptoms. Dependency upon drops that whiten the eye and have a rebound effect can complicate a history and a treatment plan.

A careful conversational method of performing an ophthalmic history will help the tech record a patients' symptoms and level of discomfort. Then, with the aid of a clear and concise history, a physician can often narrow down a diagnosis even before examining the patient. Usually, if it itches, it's an allergy, if it burns and stings it's dry eye or blepharitis, and if it's crusty and sticky in the morning, it's bacterial. However, this is not universal, and there is a significant overlap of these symptoms across all of these ocular surface diseases. Redness alone can signify several different problems. Proper gathering of information by the technician can give the physician the key to unlock the diagnosis that will lead to the ultimate goal: a happy patient who has their ocular allergies under control, is once again comfortable, and experiencing an improvement in their quality of life. Happy patients lead to successful practices, and word of mouth referrals to the practice!

The front desk of the office may be the first personal contact with the office that a patient experiences, but the technician is the most personal as the point of contact before the physician. Professional and confident interactions between the technician and the patient assist the clinician in the medical care of the patient. By working with our physicians, continuing our education, harnessing our strengths and communicating clearly with physicians, can we enhance our care of our patients. A history that is complete, concise and thorough is the basic step in providing care for patients and directs the remainder of the office exam. It also assists the clinician in determining a modality of treatment that will be effective for each patient as an individual.

Dr. Luchs is Co-Director, Department of Refractive Surgery, North Shore/Long Island Jewish Health System and Assistant Clinical Professor of Ophthalmology at Hofstra University School of Medicine. He is also Director of Clinical Research and Director of Cornea/External Disease at South Shore Eye Care, LLP in Wantagh, NY.

Ms. Huemmer is Clinical Research Manager at South Shore Eye Care, LLP in Wantagh, NY.

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