LEARNING METHOD AND MEDIUMThis educational activity consists of a case report and ten (10)study questions. The participant should, in order, read theLearning Objectives contained at the beginning of this activity,read the material, answer all questions in the post test, andcomplete the Activity Evaluation/Credit Request form. Toreceive credit for this activity, please follow the instructionsprovided below in the section titled To Obtain CE Credit. This educational activity should take a maximum of 1.0 hour to complete.

CONTENT SOURCEThis continuing education (CE) activity captures content froma roundtable discussion.

ACTIVITY DESCRIPTIONEye care providers face multiple challenges in diagnosingocular allergies and achieving patient satisfaction withtreatment. Studies show that ocular allergies are oftenunderdiagnosed and often not treated optimally. Recently, a group of experts convened to discuss their insights andapproaches for managing patients with ocular allergy. This CEactivity brings you highlights from these case discussions in a4-part series.

TARGET AUDIENCEThis educational activity is intended for optometrists.

LEARNING OBJECTIVESUpon completion of Part 4 of this 4-Part CE Case Series,participants will be better able to:• Conduct a thorough differential diagnosis to identifyallergic conjunctivitis and any comorbid conditions

• Choose appropriate medications based on disease severityto effectively control the early-phase and late-phaseresponses of ocular allergy

• Choose appropriate medications to provide effectivemaintenance control of ocular allergy

• Counsel patients on preemptive strategies and the role ofpharmacologic and nonpharmacologic interventions forallergy control

• Collaborate with colleagues in other specialty areas tooptimize the management of the patient with ocular allergy

ACCREDITATION DESIGNATION STATEMENTThis course is COPE approved for 1.0 hour of CE credit foroptometrists.

COPE Course ID: 40813-AS

DISCLOSURESLeonard Bielory, MD, had a financial agreement or affiliationduring the past year with the following commercial interests inthe form of Consultant: Allergan, Inc; Bausch + LombIncorporated; GlaxoSmithKline; Merck & Co, Inc; PharmacalResearch Laboratories, Inc; and Sanofi; Honoraria forpromotional, advertising or non-CE services received directlyfrom commercial interest or their Agents (eg, SpeakersBureaus): Allergan, Inc; Bausch + Lomb Incorporated; andMerck & Co, Inc; Contracted Research: Allergan, Inc; and EPA;Ownership Interest: STARx Tech; Other (Legal): Goodman LLC.

Milton Hom, OD, had a financial agreement or affiliationduring the past year with the following commercial interests in the form of Consultant: Allergan, Inc; Bausch + LombIncorporated; NicOx SA; SARcode Bioscience, Inc; andTearScience; Contracted Research: Abbott Medical Optics;Allergan, Inc; and Bausch + Lomb Incorporated.

Paul M. Karpecki, OD, had a financial agreement or affiliationduring the past year with the following commercial interests inthe form of Honoraria: Merck & Co, Inc; and OCULUS, Inc;Consultant: Abbott Medical Optics; Alcon, Inc; Allergan, Inc;Akorn, Incorporated; ArcticDX Inc; Bausch + LombIncorporated; Bio-Tissue, Inc; Bruder Healthcare Company; Carl Zeiss Meditec, Inc; Eyemaginations, Inc; FocusLaboratories, Inc; Hydrogel Vision Corporation; Konan Medical;Marco Ophthalmic; NicOX SA; OCuSOFT; Odyssey Medical, Inc;SARcode Bioscience, Inc; and ScienceBased Health; Contracted Research: Bausch + Lomb Incorporated; Fera Pharmaceuticals; and SARcode Bioscience, Inc; Ownership Interest: TearLab Corporation.

Jack Schaeffer, OD, had a financial agreement or affiliationduring the past year with the following commercial interests in the form of Consultant: Abbott Medical Optics; Alcon, Inc;Allergan, Inc; ArcticDX Inc; Aton Pharma, Inc; Bausch + LombIncorporated; Carl Zeiss Vision; CooperVision; EssilorLaboratories of America; HOYA; Optos; Optovue, Inc; SARcodeBioscience, Inc; TearScience; Valeant Ophthalmics; andVistakon Inc.

DISCLOSURE ATTESTATIONEach of the contributing physicians listed above has attestedto the following:1. that the relationships/affiliations noted will not bias orotherwise influence his or her involvement in this activity;

2. that practice recommendations given relevant to thecompanies with whom he or she has relationships/affiliations will be supported by the best available evidenceor, absent evidence, will be consistent with generallyaccepted medical practice; and

3. that all reasonable clinical alternatives will be discussedwhen making practice recommendations.

PRODUCT USAGE IN ACCORDANCE WITH LABELING Please refer to the official prescribing information for each product for discussion of approved indications,contraindications, and warnings.

GRANTOR STATEMENTThis CE activity is supported through an unrestrictededucational grant from Bausch + Lomb Incorporated.

TO OBTAIN CE CREDITWe offer instant certificate processing and support Green CE.Please take this post test and evaluation online by going tohttp://tinyurl.com/eyeonallergycecase4. Upon passing, youwill receive your certificate immediately. You must answer 7out of 10 questions correctly in order to pass, and may takethe test up to 2 times. Upon registering and successfullycompleting the post test, your certificate will be madeavailable online and you can print it or file it. Please make sureyou take the online post test and evaluation on a device thathas printing capabilities. There are no fees for participating inand receiving CE credit for this activity.

DISCLAIMERThe views and opinions expressed in this educational activityare those of the faculty and do not necessarily represent the views of the State University of New York College ofOptometry, MedEdicus LLC, Bausch + Lomb Incorporated, or Optometric Management.

Strategies for Improving Ocular AllergyDiagnosis, Treatments, and Outcomes

CE Newsletter Series For Optometrists

With Online Testing and Instant CE Certificate

ORIGINAL RELEASE: MARCH 24, 2014EXPIRATION: MARCH 12, 2017

Faculty Milton Hom, OD, FAAO, FACAAI(Sc) (Course Director/Moderator)Private PracticeAzusa, California

Leonard Bielory, MDProfessorRutgers University Center of Environmental PredictionRobert Wood Johnson University HospitalDepartment of MedicineNew Brunswick, New JerseyPast Co-DirectorImmuno-ophthalmology ServiceRutgers University-New Jersey Medical SchoolNewark, New JerseyPrivate PracticeSpringfield, New Jersey

Paul M. Karpecki, OD, FAAO Clinical Director Corneal Services and Ocular Disease ResearchKoffler Vision GroupLexington, Kentucky

Jack Schaeffer, OD, FAAOPresident and Chief of Optometry Services Schaeffer Eye CenterBirmingham, Alabama

EYE ON ALLERGY™

CASE 4 in a Series of 4

Sponsored by the State University of New York College of Optometry

This continuing education activity is supported through an unrestrictededucational grant from Bausch + Lomb Incorporated.

This CE activity is copyrighted to MedEdicus LLC ©2014. All rights reserved.

Administrator:

This course is COPE approved for 1 credit.

COPE Course ID: 40813-AS

0 to 100; I use the cut-offs established for OSDI to categorize theresults of a TOSS questionnaire as normal, mild, moderate, or severe.This case patient’s score represents moderate severity.

Options for managing contact lens intolerance associated with AC are either lens-related strategies or pharmaceutical treatments. Theformer approach includes adding rewetting drops, changing the caresystem, or refitting the lens to put the patient into a daily disposablesystem3 or a lens of another material. This patient was using amultipurpose care solution for cleaning her lenses, and perhaps mayhave benefited from a switch to a hydrogen peroxide-based system.She had, however, used a peroxide-based system previously and wasdispleased by its complexity and because she experienced a dryingeffect. Lens refitting also was not a good solution for this patient,considering that she was in a customized multifocal lens system.

Therefore, I chose to treat her with anti-allergy medication.Pharmaceutical treatment for contact lens intolerance associated withAC allows fitting with the best lens in terms of physical fit and opticalperformance, and it has been shown effective for improving the signsand symptoms of allergy along with lens comfort as measured byincreased wearing time and decreased use of rewetting agents.4-6

It seems to me that many optometrists more often choose the lens-related strategies rather than pharmaceutical treatments for allergy.What are your thoughts about that?

Dr Karpecki: I agree. I think what you’ve characterized reflects thefact that historically, optometrists have tended to segregate themselvesinto contact lens fitters or therapeutic prescribers. This type of divisionamong practitioners seems to be less common now, and a greateroverall appreciation for using medications to treat conditions thatunderlie contact lens intolerance seems to have emerged.

But it is still important to recognize that there are interactions betweencontact lens wear and AC because these interactions can influencemanagement decisions. Many factors can contribute to an allergicresponse in contact lens wearers—the material, the edge design, surfaceproperties, fitting characteristics, replacement cycle, patient compliancewith lens care.7 In addition, the lens can trap airborne allergens andtherefore prolong antigen exposure to the ocular surface. The lens alsoaccumulates lipids, proteins, and other compounds on its surface thatcan be antigenic or cause irritation, inciting inflammation.

To determine how much the contact lens itself is contributing to apatient’s problem, I evert the upper lid to assess the tarsal plate. If I seemore papillae, hyperemia, or chemosis than I would expect with AC, I recommend discontinuing contact lens wear. Sometimes, the tarsalplate appears normal, and then I find I can manage the AC successfullywith medications instilled before lens insertion and after lens removal,thus allowing the patient to continue with contact lens wear.

Dr Schaeffer: Buildup of deposits on the lens surface varies dependingon lens material, and so changing to a different lens material issomething to consider in patients with ocular allergy and complaints oflens discomfort. Note, though, that there is variability in the amount ofbuildup on the lens among patients wearing the same type of lens.

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Case from the files of Milton Hom, OD, FAAO, FACAAI(Sc)

This case discussion focuses on a common clinical problemencountered in patients seeking optometric care—contact lensintolerance associated with allergic conjunctivitis (AC). It highlightsconsiderations for differential diagnosis and approaches tomanagement based on the mutual goals of controlling AC symptomsand allowing comfortable contact lens wear.

CASEA 52-year-old woman fitted with a multifocal silicone hydrogel(comfilcon A) contact lens presents with a daily wearing time of 15hours, but complaining about recent onset of mild, end-of-the-daydiscomfort along with itchiness and redness during the day. She has a history of allergy to tree pollen and is taking a nonsedatingantihistamine, loratadine. Clinical examination shows papillarychanges and redness in the palpebral conjunctiva OU (Figures 1 and 2).Her Total Ocular Symptom Score (TOSS) is 26.

Dr Hom: According to her history and clinical findings, this patientwas diagnosed with contact lens intolerance related to AC. It isimportant to assess the severity of itch, redness, tearing, and swellingin patients with ocular allergy, and I like to use TOSS for that. TOSS isnot a validated questionnaire, but it is simple and quick to administer,and has been used in studies of nasal corticosteroids to determinetreatment effects on ocular symptoms.1,2 It asks patients to rate thefrequency of any ocular redness, watering, itching, and swelling duringthe past week using response choices of the following: All of the Time,Most of the Time, Half of the Time, Some of the Time, or None of theTime. The total score, which is calculated using the same method asthat used for the Ocular Surface Disease Index (OSDI), can range from

ALLERGIC CONJUNCTIVITIS IN A CONTACT LENS WEARER

Figure 1. Papillary changes OU seen with fluorescein staining.

Photos Courtesy of Milton Hom, OD

Figure 2. Redness of the palpebral conjunctiva seen OU.

Photos Courtesy of Milton Hom, OD

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Other possible contributors to a patient’s complaints also should betaken into account. Of particular importance is dry eye, because, byitself, it can cause contact lens intolerance. In addition, dry eye isworsened by contact lens wear, and so can exacerbate allergy byinterfering with flushing of antigens from the ocular surface. Dry eyeis likely a comorbid issue in this patient, considering her age and heruse of an oral antihistamine.

Poor compliance with lens care or lens replacement regimens isanother factor that worsens problems with allergic reactions, again byallowing increased buildup of deposits on the lens surface; this is animportant concern, considering data showing that the majority ofpatients do not follow the instructions they are given.8,9 I do think,however, that use of generic lens care products is one of the leadingcauses for intolerance among soft contact lens wearers. The genericproducts are rarely the same formulation as the recommended caresolution, and their use may result in solution/lens interactions.Therefore, my first strategy in addressing contact lens intoleranceassociated with AC is to have patients start with a fresh lens, and then I insist they use the care system I recommend. I reevaluate themafter 2 weeks to determine if they have improved with this simpleintervention that can spare them from pharmaceutical treatment.

Because the use of daily disposable lenses naturally eliminates problemscaused by lens deposits and poor hygiene, they are clearly preferred forpatients with AC. Now we have new daily multifocal lenses. While theremay not be a daily disposable option for a particular multifocalplatform, patients in multifocal lenses can still replace their lenses morefrequently. A patient in a 30-day lens can be told to change lensesweekly, or at least every other week.

Dr Karpecki: I also prefer a daily disposable contact lens for patientswith allergies, although in my experience there is also a 1-week lensthat seems to be very well tolerated. Affordability may also be an issuein how frequently patients change lenses, so it is nice to have a coupleof options like this.

Dr Hom: While there are several effective antihistamine/mast cellstabilizers available, for this patient I prefer bepotastine over othersbecause I think when a patient is suffering with a lot of discomfort fromallergy, a twice-daily agent can give better coverage against allergenexposure throughout the day than a once-daily medication. Resultsfrom a randomized, observer-masked, crossover study conducted inpatients with AC during peak fall allergy season are consistent with myimpression.10 And, the twice-daily regimen still allows convenient dosingwhen the lens is not in the eye. I prescribed bepotastine besilate, 1.5%,twice daily for her, with instructions to instill 1 drop in the morning, 10 to 15 minutes prior to lens insertion, and the second drop after sheremoved her lenses at the end of the wearing time.

Dr Karpecki: I agree that bepotastine besilate, 1.5%, is an excellentcombination antihistamine/mast cell stabilizer for treating AC,regardless of severity, although there are times when I will select otheragents from this category. For example, in a woman of childbearingage, I typically prefer alcaftadine, which is the only antihistamine/mast cell stabilizer assigned a Pregnancy Category B rating.11 Whenpatients have had good success with a particular agent, I typicallyrecommend they continue using the same medication during the

following allergy season. I also ask patients if they have to use morethan 1 drop per day to control their allergy symptoms. If they answerno, I am comfortable using the once-a-day medications, alcaftadine orolopatadine, 0.2%. However, if they say they have days on which theyneed an extra drop to control symptoms, I may consider switching tobepotastine, which is dosed twice daily.

Dr Schaeffer: When using an antihistamine/mast cell stabilizer inpatients wearing a contact lens, the main concern relates to increasedexposure to preservatives.

Contact lens patients must understand that they should not beinstilling medications while wearing their lenses. I have found that itis helpful, however, for patients to place a drop of one of the newlipid-based artificial tear products into the bowl of the lens just priorto insertion. This is an off-label recommendation. I also recommendthey remove the lens during the day, clean it, and place a drop of thelipid-based tears into the bowl of the lens before putting it back in theeye. This technique increases lens comfort.

Dr Karpecki: Because of the potential for a reservoir effect, in theinterest of safety, I strongly prefer that patients who are using topicalophthalmic medications wear a daily disposable lens. This is particularlytrue for patients using corticosteroids because of concerns about IOPelevation and infectious keratitis. In a study evaluating treatment ofgiant papillary conjunctivitis, an IOP elevation �10 mm Hg developedin 7% of patients who used loteprednol, 0.5%, 4 times daily for 6weeks while continuing to wear their contact lenses12; this was a muchhigher rate than the 1% rate associated with this ester-based steroidwhen used in patients not wearing soft contact lenses.13 No cases ofinfectious keratitis were reported in the patients using loteprednolwhile continuing contact lens wear, but we should be concerned withthe possibility of infectious keratitis occurring.

Dr Hom: Dr. Bielory, are there any particular issues to consider aboutcontact lens wear in patients with atopic disease?

Dr Bielory: There are no clear data on whether atopic patients aremore prone to develop giant papillary conjunctivitis with contact lenswear, but it is clear that processes affecting the ocular surface,including AC, are more difficult to manage in atopic patients.14

Dr Hom: The patient we are discussing returned 2 months afterstarting bepotastine. She reported achieving improved comfort and a1-hour increase in her daily wearing time for several weeks. Twoweeks prior to the follow-up visit, however, her itchiness worsenedand she had to reduce her wearing time to just 12 hours. Now, shescored a 36 on TOSS, and I noted that the onset of her flare coincidedwith an increase in tree pollen counts.

I chose to treat her flare-ups with loteprednol etabonate, 0.2%, andinstructed her to use the medication twice daily, before putting hercontacts in and after removing them. This formulation of loteprednol isthe only topical corticosteroid specifically indicated for seasonal allergicconjunctivitis management, and while it has a good safety profile interms of risk for IOP elevation, IOP monitoring is still important.

The patient returned 1 week later. Her symptoms were alleviated,redness reduced, and her wearing time was 15 hours. IOP was stable,

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and she was instructed to continue the steroid and to return in 1week. At her next visit, her symptoms had subsided (tree pollen countshad fallen) and she was told to remain on bepotastine; to startloteprednol, 0.2%, if she flared; and to return in 6 months.

Dr Bielory: Patients with recurrent seasonal allergic conjunctivitiswho develop a significant flare with rising pollen counts should beassessed by an allergist to determine if they are candidates forimmunotherapy. Immunotherapy is not a cure, but it downregulatesthe immune response so that patients need less medication for allergyrelief. It takes approximately 6 to 12 months for patients to benefitfrom immunotherapy, but if they start the treatment during theirallergy season, they will be better at the next year’s season.15

Dr Hom: I think optometrists are not referring AC patients for allergytesting and immunotherapy as much as they should be. I tell mypatients that immunotherapy can make them feel a lot better, andwhile it will not eliminate their symptoms altogether, it will reducetheir need for medication, along with the cost and compliance issuesthat accompany medication use.

Let us discuss, briefly, rush immunotherapy.

Dr Bielory: Rush immunotherapy is a method for accelerating thedesensitization process so that injections of increasing doses ofallergen are given over a period of hours rather than months.Compared with standard immunotherapy, rush immunotherapy isassociated with faster onset of benefit, but it has an increased risk ofsystemic reactions.15

Dr Schaeffer: I think contact lens patients wearing monthlyreplacement lenses are better served if we begin managing theirdiscomfort related to allergy by increasing lens replacement frequency.If they change from a monthly to a weekly replacement schedule, theyreduce the amount of antigen in the eye 4-fold, and I think that is amore economical approach than initiating treatment with expensivemedications or immunotherapy.

Dr Bielory: I agree with you, but if you ask patients to discontinuetheir lens wear completely, you are likely to encounter more resistance.

Dr Hom: Allergic conjunctivitis is a common problem and a commoncause for intolerance and dropout in contact lens wearers.16 Carefulhistory and evaluation are important to establish the diagnosis becauseAC shares overlapping symptoms with other, possibly comorbid,conditions. Medical management of AC can be safe and effective forreducing contact lens intolerance. Decisions should be individualized;lens-related strategies and referral to an allergist deserve appropriateattention because such steps may optimize patient care.

References 1. Maspero JF, Walters RD, Wu W, Philpot EE, Naclerio RM, Fokkens WJ. Anintegrated analysis of the efficacy of fluticasone furoate nasal spray onindividual nasal and ocular symptoms of seasonal allergic rhinitis. AllergyAsthma Proc. 2010;31(6):483-492.

2. Bielory L. Ocular symptom reduction in patients with seasonal allergicrhinitis treated with the intranasal corticosteroid mometasone furoate. Ann Allergy Asthma Immunol. 2008;100(3):272-279.

3. Hayes VY, Schnider CM, Veys J. An evaluation of 1-day disposable contactlens wear in a population of allergy sufferers. Cont Lens Anterior Eye.2003;26(2)85-93.

4. Hom MM. Allergic conjunctivitis and contact lenses: use of bepotastinebesilate. Eastern Allergy Conference; May 31-June 3, 2012; Palm Beach, FL.

5. Nichols KK, Morris S, Gaddie IB, Evans D. Epinastine 0.05% ophthalmicsolution in contact lens-wearing subjects with a history of allergicconjunctivitis. Eye Contact Lens. 2009;35(1):26-31.

6. Brodsky M, Berger WE, Butrus S, Epstein AB, Irkec M. Evaluation of comfortusing olopatadine hydrochloride 0.1% ophthalmic solution in the treatmentof allergic conjunctivitis in contact lens wearers compared to placebo usingthe conjunctival allergen-challenge model. Eye Contact Lens. 2003;29(2):113-116.

7. Donshik PC, Contact lens chemistry and giant papillary conjunctivitis. Eye Contact Lens. 2003;29(1 suppl):S37-S39.

8. Robertson DM, Cavanagh HD. Non-compliance with contact lens wear and care practices: a comparative analysis. Optom Vis Sci. 2011;88(12):1402-1408.

9. Hickson-Curran S, Chalmers RL, Riley C. Patient attitudes and behaviorregarding hygiene and replacement of soft contact lenses and storagecases. Cont Lens Anterior Eye. 2011;34(5):207-215.

10. McCabe CF, McCabe SE. Comparative efficacy of bepotastine besilate 1.5% ophthalmic solution versus olopatadine hydrochloride 0.2%ophthalmic solution evaluated by patient preference. Clin Ophthalmol.2012;6:1731-1738.

11. LASTACAFT [package insert]. Irvine, CA: Allergan, Inc; 2011. 12. Friedlaender MH, Howes J. A double masked, placebo-controlled evaluation

of the efficacy and safety of loteprednol etabonate in the treatment ofgiant papillary conjunctivitis. The Loteprednol Etabonate Giant PapillaryConjunctivitis Study Group I. Am J Ophthalmol. 1997;123(4):455-464.

13. Comstock TL, Decory HH. Advances in corticosteroid therapy for ocularinflammation: loteprednol etabonate. Int J Inflam. 2012;2012:789623.[Epub 2012 Mar 28]

14. Bielory B, Bielory L. Atopic dermatitis and keratoconjunctivitis. ImmunolAllergy Clin North Am. 2010;30(3):323-336.

15. Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practiceparameter third update. J Allergy Clin Immunol. 2011;127(1 suppl):S1-S55.

16. Kumar P, Elston R, Black D, Gilhotra S, DeGuzman N, Cambre K. Allergicrhinoconjunctivitis and contact lens intolerance. CLAO J. 1991;17(1):31-34.

TO OBTAIN COPE CREDIT ONLINE AND INSTANT CERTIFICATE

To obtain COPE CE Credit for this activity, read the material in its entirety and consult referenced sources as necessary. We offer instant certificate processing and support Green CE. Please take this post test and evaluation online by going tohttp://tinyurl.com/eyeonallergycecase4. Upon passing, you will receive your certificate immediately. You must score 70% or higher to receive credit for this activity, and may take the test up to 2 times.