CORNEA EWAP MARCH 2024 31 fertilization,” he said. In the ICON paper, 2 which explored the diagnosis and management of allergic conjunctivitis, the authors described a “predominance of self - management [that] increases the risk of suboptimal therapy that leads to recurrent exacerbations and the potential development of more chronic conditions that can lead to corneal complications and interference with the visual axis.” The authors wrote that “successful management includes overcoming the challenges of underdiagnosis and even misdiagnosis by a better understanding of the subtleties of an in - depth patient history, ophthalmologic examination techniques, and diagnostic procedures, which are of paramount importance in making an accurate diagnosis of [ocular allergy].” They advocated for “appropriate cross - referral between specialists (allergists and eyecare specialists).” Whether it’s an allergist or ophthalmologist first seeing the patient experiencing ocular symptoms, Dr. Bielory pointed to Figure 2 in the ICON paper, which leads the physician through an algorithm of the different assessments to be done by the allergist and/or ophthalmologist, followed by diagnoses and severity - based treatment. Dr. Akpek detailed her process when she has a patient with known ocular surface disease or symptoms of discomfort and blurred vision. “I do a thorough symptoms evaluation, past medical history, medication history, and review of the system with particular attention to underlying collagen vascular, inflammatory, or allergic diseases, which might be comorbid issues. When a patient is asked about their symptoms, they usually complain of multiple symptoms that could be confusing. That’s when I ask them about the most bothersome symptom,” she said. “Patients with allergy usually complain of itching, although some patients describe it as stinging. Exam findings are also important. Presence of upper tarsal conjunctival papillae is an important finding, but in some severe chronic cases, such as atopic or vernal keratoconjunctivitis, these might not be present and replaced with scarring.” From a treatment standpoint, Dr. Bielory said he thinks most physicians follow the same consensus, going “from lubricants/antihistamines to multiple action agents. If that doesn’t work, you go to immunomodulators, steroids, cyclosporine, and immunotherapy,” he said. Dr. Bielory said there are studies that show patients can be exposed to 10 –100 times more allergens if they’re on the appropriate immunotherapy. Dr. Akpek said due to the overlap that can occur among the different types of allergic conjunctivitis and sometimes diseases changing from one form to another (such as seasonal allergic conjunctivitis turning into perennial), she thinks it’s best to determine the chronicity and the changes on the ocular surface to determine severity. “Treatment should be tailored according to chronicity and severity of the physicianmeasured clinical signs,” Dr. Akpek said. “For acute seasonal allergic conjunctivitis, mast cell stabilizer plus antihistamine medications would be helpful. But any chronic allergy should be treated with anti - IL - 2 medications, such as tacrolimus or cyclosporine. Steroids should be avoided as much as possible.” In terms of new options for ocular allergy treatment, Verkazia (cyclosporine ophthalmic emulsion, Santen) was approved in 2021, and also in 2021, Dextenza (dexamethasone ophthalmic insert, Ocular Therapeutix) received approval for ocular allergy as an additional indication. Johnson & Johnson Vision received approval for the first drug-eluting contact lens — ACUVUE Theravision with Ketotifen — in 2022 for treatment of allergic conjunctivitis along with vision correction. Dr. Bielory regularly reviews advances in therapeutics for ocular allergy. 3 He said there is still a large unmet need to serve patients who experience allergic conjunctivitis. Among several active areas of research, Dr. Bielory pointed to a 2022 paper about immunobiologicals and ocular surface disease, which concluded that immunobiologicals can provide “a more directed therapeutic approach to ocular inflammatory disorders” and another recent paper that looked at type 2 cytokine pathways that have impacts on both the skin and the ocular surface, which could help lead areas for immunomodulatory intervention. As an allergist, Dr. Bielory said his advice to his colleagues in ophthalmology is to think more holistically when they see signs of ocular allergy, recommending to the patient that an allergist get involved if the eye is not the only organ system being affected. As a lesson learned, Dr. Akpek said that as ophthalmologists treat meibomian gland dysfunction and dry eye, they should not forget about allergy. She also noted that ASCRS recommends the minimal exam to include flipping of the upper lids to look for papillary changes. EWAP continued on page 42
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