WPE 2023 Treatment of Ocular Allergies Much More Than Itchy Eyes

4/19/2023
Treatment of Ocular
Allergies Much More Than
Itchy Eyes!
Emily Stephey, OD, FAAO
Assistant Professor
Southern California College of Optometry | Marshall B. Ketchum University
Martin J. Torres, PharmD, FCSHP

Director of Pharmacy | UC Irvine Medical Center
Adjunct Professor of Pharmacology
Southern California College of Optometry | Marshall B. Ketchum University
Western Pharmacy Exchange 2023 presented by
Disclosures/Conflicts of Interest
The speakers do not have any conflicts of interest

or financial disclosures to report.
Learning Objectives
• Describe the pathophysiology of the ocular inflammatory response
responsible for the manifestations of allergic eye disease.
• Compare the different medication classes and their mechanisms of
action utilized in the treatment of ocular allergic reactions.
• Differentiate between the indications, side effects, and contra-
indications for each medication class used to treat ocular allergies.
• Compare the OTC medications utilized to treat ocular allergies.
• Identify the Pharmacist’s role in medication education.
1
4/19/2023
Review of the Ocular Allergic Response

• Hypersensitivity or allergic reactions are inappropriate,
exaggerated immune responses to antigen(s) that result in
tissue damage.
• During an allergic response, mediators are released from mast

cells.
• Mediators are responsible for the inflammatory response and

include histamine, prostaglandins, leukotrienes, cytokines, and
eosinophil chemotactic factor.
1. Marwa K and Kondamudi N. StatPearls. 2022 Jan.
Type I Type II Type III Type IV

hypersensitivity hypersensitivity hypersensitivity hypersensitivity
• Mediated by IgE • Cytotoxic reaction • Mediated by • Delayed reaction
antibodies mediated by IgG immune complexes mediated by
or IgM antibodies cellular response
1. Marwa K and Kondamudi N. StatPearls.

2022 Jan.

• Type I hypersensitivity (IgE-mediated or humoral) reactions
⎻ Also known as immediate allergic response.
⎻ Occurs when antigens are reintroduced in persons who have
had a previous exposure.
⎻ When first exposed to an antigen, IgE antibodies are produced

that attach to mast cells and basophils which makes mast cells
more susceptible to rupture upon re-exposure to the same
antigen.
2. Chigbu DI. Cont Lens Anterior Eye. 2009 Feb.
2
4/19/2023
Retrieved August 8, 2022, from https://nhinnovations.ie/histamine-

intolerance/

⎻ When mast cells rupture or degranulate, large quantities of
inflammatory mediators are released which include histamine
(the main mediator in Type I allergic reactions),
prostaglandins, leukotrienes and eosinophil chemotactic factor.
⎻ Histamine activates H-1 receptors on blood vessels which

results in vasodilation, leakage of fluid due to increased
vascular permeability, and tissue swelling.

2022 Jan.

• Antigens that cross-link with
the IgE antibody on the mast
cells trigger the allergic
response.
Laurie Sorrenson. Making an Impact on Allergies. Optometric Management. 2008. Retrieved August 21, 2022, from
https://www.optometricmanagement.com/issues/2008/may-2008/making-an-impact-on-allergies
2. Chigbu DI. Cont Lens Anterior Eye. 2009

Feb.
3
4/19/2023

⎻ H-1 receptors are located in the heart, bronchial smooth
muscle, CNS, mucous membranes, and in the blood vessels of
the eye.
⎻ H-2 receptors are located in the gastric parietal cells (GI tract),
blood vessels, mast cells, blood vessels of the eye, bronchial
smooth muscles, the CNS, and in WBCs.

2022 Jan.

⎻ Type-I reactions commonly occur in hay fever, allergic
conjunctivitis, asthma, hymenoptera stings, and other
chemical and toxin sensitivities (e.g., drug allergies).

2022 Jan.

• The eye is a common site of
allergic responses/immune
reactions.
― Conjunctiva involved most
frequently.
― Lids and cornea may also be
affected.
Retrieved August 11, 2022, from https://pathofex.com/how-to-get-something-out-of-your-eye/
2. Chigbu DI. Cont Lens Anterior Eye. 2009 Feb.
4
4/19/2023

• In the eye, release of histamine causes …
― Swollen lids
― Red eyes
― Itchy eyes
― Watery eyes
― Chemosis
― Papillae Laurie Sorrenson. Making an Impact on Allergies. Optometric Management. 2008. Retrieved August 21, 2022
from https://www.optometricmanagement.com/issues/2008/may-2008/making-an-impact-on-allergies
2. Chigbu DI. Cont Lens Anterior Eye. 2009

Feb.
Retrieved August 10, 2022, from https://timroot.com/conjunctival-chemosis-from-eye-allergy-video/ Retrieved August 10, 2022, from https://laicare.net/tag/giant-papillary-conjunctivitis/

• Type IV Hypersensitivity (Cell-Mediated) Immune Response
⎻ A delayed hypersensitivity reaction involving T-lymphocytes.
⎻ After sensitization, the delayed response generally takes 24
hours, peaking at 48 to 72 hours.

2022 Jan.
5
4/19/2023

• Goal of pharmacotherapy: to alleviate the signs and symptoms
of ocular allergy based on the pathophysiologic mechanisms of
allergy.
3. Trocme, S and Karan, K. Current Opin Allergy and Clinical Imm.

2002 Oct.
Ocular Allergy Conditions

(Hypersensivity Rxns)
• Type 1 Hypersensitivity Reactions
• Type 4 Hypersensitivity Reactions
Allergic conjunctivitis
• Type I hypersensitivity reaction
(Seasonal vs perennial)
• More common
• Less serious
Giant papillary • Type I + IV hypersensitivity reaction

conjunctivitis • Usually contact lens related
Vernal • Type I + IV hypersensitivity reaction

keratoconjunctivitis • More severe signs/symptoms
• Sight threatening if not treated
Atopic
• Type I + IV hypersensitivity reaction
keratoconjunctivitis • More severe signs/symptoms
• Sight threatening if not treated
3. Trocme, S and
Karan, K. Current
6
4/19/2023
Seasonal Allergic Conjunctivitis (SAC)

• Most common ocular allergy
― 20% of population affected
• Related to specific pollens that release during specific seasons

― Grass pollen in May/June and ragweed in Aug/Sept.

2002 Oct.
Seasonal Allergic Conjunctivitis (SAC)

• May also experience symptoms involving nose and throat
• To assist in diagnosis:
― Patient history
― Itching
― Papillae and/or chemosis
Retrieved August 10, 2022 from https://laicare.net/tag/giant-papillary-conjunctivitis/

2002 Oct.
Seasonal Allergic Conjunctivitis (SAC) -

OTC
• Topical mast cell stabilizers and antihistamines first-line treatment.
Ketotifen Olopatadine
2002 Oct.
7
4/19/2023
Perennial Allergic Conjunctivitis (PAC)

• Year-round allergic condition
― May involve indoor allergens and is triggered by animal
dander, dust mites, molds, etc.

2002 Oct.

― Patient history
― Itching
― Papillae and/or
chemosis
Retrieved August 10, 2022, from https://laicare.net/tag/giant-papillary-

conjunctivitis/

2002 Oct.

- OTC
• Topical mast cell stabilizers and antihistamines first-line treatment.
Ketotifen Olopatadine
3. Trocme, S and Karan, K. Current Opin Allergy and Clinical Imm. 2002 Oct.
8
4/19/2023
Giant Papillary Conjunctivitis (GPC)

― Commonly, patient has history of contact lens (CL) use.
• Corneal involvement rare

2002 Oct.

― Patient history
▪ H/O contact lens (CL) wear?
― Foreign body sensation
― Itching Kierstan Boyd. Giant Papillary Conjunctivitis. American Academy of Ophthalmology. 2022.
Retrieved August 21, 2022, from https://www.aao.org/eye-health/diseases/what-is-giant-
papillary-conjunctivitis
― Giant papillae on superior lid eversion

2002 Oct.

• Topical mast cell stabilizers and antihistamines first-line treatment
• Discontinuation of contact lens
― Lens hygiene
― Different replacement schedule?
• Short-term “mild” topical steroids if more severe, acute symptoms

2002 Oct.
9
4/19/2023
Vernal Keratoconjunctivitis (VKC)

• Type I + Type IV hypersensitivity reaction
― Can be asymmetric, seasonal recurrences (spring/summer)
― More common in males

▪ Children and teenagers
▪ Patients commonly “outgrow” VKC around 21 years of age
4. Kumar, S. Acta Ophthalmol.

2009

― Patient history and demographics
― Itching
Retrieved August 8, 2022, from
― Giant papillae on superior lid https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Palpebral-vernal-

keratoconjunctivitis-VKC/index.htm
eversion
― Horner-Tranta’s dots
― Shield ulcer
4. Kumar, S. Acta Ophthalmol.
2009
Retrieved August 8, 2022, from https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Palpebral-vernal-

Retrieved August 8, 2022, from https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Vernal-

Keratoconjunctivitis-limbal.html
10
4/19/2023

• Tear histamine levels higher in these patients
• Potentially sight threatening if not treated properly
― Damage to the ocular surface corneal scarring vision loss
4. Kumar, S. Acta Ophthalmol. 2009

• Topical mast cell stabilizers and antihistamines first-line treatment
― Prior to start of allergy season
• Short-term topical steroids if more severe, acute symptoms

• If shield ulcer present…
― Topical antibiotic to prevent infection
― Topical cycloplegic to aid in comfort
4. Kumar, S. Acta Ophthalmol. 2009
5. Erdinest, N et al. Current Opin Allergy and Clinical Imm. 2019 Oct.
11
4/19/2023
Atopic Keratoconjunctivitis (AKC)

― Caused by predispositional, constitutional, or hereditary factors
instead of by acquired hypersensitivity to specific antigens.
― Usually, a family history or personal history of allergy, with

hay fever, asthma, eczema, or atopic dermatitis being
commonly identified.
― More common in males

▪ 20-50 years old
3. Trocme, S and Karan, K. Current Opin Allergy and Clinical Imm. 2002 Oct.

― Patient history and demographics
― Itching
― Thickened lid margins
― Papillae on superior lid eversion Retrieved August 8, 2022, from https://webeye.ophth.uiowa.edu/eyeforum/cases/167-
atopic-keratoconjunctivitis.htm
― Horner-Tranta’s dots
― Shield ulcer
2002 Oct.
Atopic Keratoconjunctivitis (VKC)
Retrieved August 8, 2022, from https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Palpebral-vernal-

Retrieved August 8, 2022, from https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Vernal-Keratoconjunctivitis-limbal.html
12
4/19/2023

• Potentially sight threatening if not treated properly
― Damage to the ocular surface corneal scarring vision loss
Retrieved August 8, 2022, from https://webeye.ophth.uiowa.edu/eyeforum/cases/167-atopic-keratoconjunctivitis.htm
3. Trocme S, Karan K. Current Opin Allergy and Clinical Imm. 2002 Oct.
Medication Classes for Ocular Allergies6-10

• Systemic Antihistamines
• Ocular Decongestants
• Ocular Antihistamines
• Ocular Mast Cell Stabilizers
• Ocular Dual Antihistamine/Mast Cell Stabilizers
• Ocular Steroids
• Ocular Non-Steroidal Anti-inflammatory Drugs

• Ocular Steroids
13
4/19/2023
Systemic Antihistamines6-10
• 1st Generation H1 Receptor Antagonists
⎻ Diphenhydramine (Benadryl®) (allergies, insomnia, and motion
sickness)
⎻ Dimenhydrinate (Dramamine®) (motion sickness)

⎻ Chlorpheniramine (Chlor-Trimeton®) (allergies, urticaria)
⎻ Meclizine (Bonine®) (motion sickness)
Systemic Antihistamines6-10
• 2nd Generation H1 Receptor Antagonists
⎻ Non-Sedating
▪ Loratadine (Claritin®, Alavert®) (allergies, conjunctivitis)
▪ Desloratadine (Clarinex®) (allergies, urticaria)
▪ Fexofenadine (Allegra®) (allergies, upper respiratory)
⎻ Less-Sedating
▪ Cetirizine (Zyrtec®) (allergies, conjunctivitis)
▪ Levocetirizine (Xyzal®) (allergies, urticaria)

• Ocular Steroids
14
4/19/2023
Decongestants
(Alpha-Adrenergic Agonists)6-12
• Indications
⎻ Relieve redness and discomfort of the eyes caused by minor eye
irritation.
• Mechanism of Action
⎻ Primary effect at ocular decongestant doses: local
vasoconstriction of the smooth muscles of the conjunctival arterioles
secondary to α-adrenergic receptor innervation.
Decongestants
⎻ Secondary effect, which is concentration and dose dependent:
mydriasis due to alpha-adrenergic effects on the iris radial muscle
causing contraction resulting in pupil dilation.
TISSUE FUNCTION REC
Pupillary dilator (radial) Contraction causes
α1
muscle in the iris. mydriasis.
Pupillary constrictor
Contraction causes miosis. M3
(sphincter) muscle in the iris.
Contraction adapts to short

Ciliary muscle range focus. Relaxation M3
adapts to long range focus.
Ciliary epithelium Produces aqueous humor. β2
Decongestants
• Contraindications
⎻ Narrow angle glaucoma
⎻ Anatomically narrow angle without glaucoma
⎻ Hypersensitivity
15
4/19/2023
Decongestants
• Warnings/Precautions
⎻ Overuse of all agents can cause rebound vasodilation and congestion of
the conjunctival arterioles with increased redness of the eyes.
⎻ Transient stinging and blurring after instillation
• Patient Information
⎻ Do not use > 48 hours without consulting an eye care professional.
⎻ Patients with glaucoma should not use these medications without the
advice of a doctor.
Decongestants (Alpha-Adrenergic Agonists)6-12

Decongestant Concentration Duration of Action Rx Status
Phenylephrine 0.12% 0.5 – 1.5 hr Non-prescription
Imidazole Class Concentration Duration of Action Rx Status
Naphazoline 0.012% 3 – 6 hrs (QID Non-prescription

(multiple strengths) 0.025% max dose) Non-prescription
(combo products w/1st gen
0.03% Non-prescription
antihistamine)
0.1% Rx Only
4 – 6 hrs
Oxymetazoline 0.025% Non-prescription
(QID max dose)
1 – 6 hrs
Tetrahydrozoline 0.05% Non-prescription
(QID max dose)
Non-Imidazole Class Concentration Duration of Action Rx Status
6 – 8 hrs
Brimonidine (Lumify®) 0.025% Non-prescription
(QID max dose)
Decongestants
• Brimonidine tartrate 0.025% (Lumify®)
⎻ A selective alpha-2 receptor agonist which
reduces redness by constricting the venule,
and with minimal to no activity on the alpha-1
receptor (constriction of arterioles) has lower
risk of redness rebound of loss of efficacy.
⎻ Similar to higher concentration preparations

(0.1%, 0.15%, 0.2% solutions) used for IOP
reduction in glaucoma.
16
4/19/2023
Decongestants
(Alpha-Adrenergic Agonists)
Usage Pearls from Dr. Stephey
• Cause vasoconstriction … and potential

dilation of the pupil.
• If patient uses Visine (or an alternative)

unilaterally, can cause anisocoria.
⎻ Anisocoria: Pupil in one eye differs in
size compared to pupil of the other
eye.
14. Leonardi A et al. Allergy. 2019

Sept.
Decongestants
• Patients commonly use Visine (and their alternatives) to decrease

redness of the eyes.
⎻ Available OTC = widely available
⎻ Patients recognize the “brand name”
Decongestants
• Does NOT address why patient’s eyes are red in the first place
⎻ What’s the underlying cause?
⎻ Dryness? Allergies? Viral infection? Something else?
• Educate patients usage can lead to rebound redness
17
4/19/2023
Decongestants
• Upneeq® (Oxymetazoline HCl 0.1%)

⎻ Indicated for the treatment of
acquired blepharoptosis or ptosis.
⎻ FDA approved July 2020. Retrieved August 1, 2022, from

https://www.clinevada.com/2021/10/20/before-and-after-upneeq-
eye-drop/
Decongestants
NDA
212520
Page 4

• Ocular Steroids
18
4/19/2023
Ocular Antihistamines6-12
• Indications
⎻ Relief of symptoms of allergic conjunctivitis.
⎻ May be used alone or in combination with a decongestant to
relieve ocular irritation or congestion in the treatment of allergic
or inflammatory ocular conditions.
⎻ Ocular antihistamines are considered second generation
antihistamines.
⎻ Selectively block the action of histamine on H-1 histamine
receptors, which reduces the effects of histamine, and do not
block other receptors.
• ADEs/Cautions
⎻ Headache (11%); <5%: blurred vision, burning or stinging on
instillation, tearing, dry eyes, corneal infiltrates/staining, etc.
• Patient Information
⎻ Advise patients not to wear contact lens if their eye is red.
⎻ Should not be used to treat contact lens-related irritation.
⎻ The preservative, BZAK, may be absorbed by soft contact
lenses. Wait 10 minutes after instillation.
ADE = adverse drug effect
19
4/19/2023
• Emedastine difumarate ophthalmic solution 0.05% (Emadine®)
⎻ The only pure ocular antihistamine.
⎻ Dosage: 1 drop in the affected eye(s) up to 4 times a day.
FDA Approved: 12/97

• Ocular Steroids
Ocular Mast Cell Stabilizers6-12

• Indications
⎻ Pure mast cell stabilizers are used for vernal conjunctivitis,
vernal keratoconjunctivitis, vernal keratitis, and seasonal
conjunctivitis.
20
4/19/2023

⎻ Stabilize mast cells by inhibiting the degranulation of
sensitized mast cells after exposure to specific antigens.
⎻ This prevents the release of histamine and other mediators

involved in allergic reactions.
⎻ These drugs have no intrinsic vasoconstrictor, antihistaminic

or anti-inflammatory activity.

• Cromolyn (generic)
• Lodoxamide (Alomide®)
• Nedocromil (Alocril®)
• Pemirolast (Alamast®)

• Cromolyn sodium ophthalmic solution 4% (generic)
⎻ Indications: vernal keratoconjunctivitis, vernal conjunctivitis, and
vernal keratitis.
⎻ Dosage: 1-2 drops in each eye 4-6 times/day.
⎻ Onset of Action/Duration: Response to treatment may be seen

within a few days; treatment for up to 6 weeks is often required.
⎻ ADRs/Warnings/Cautions: The most commonly reported adverse

effect is transient ocular stinging or burning on instillation.
21
4/19/2023

• Lodoxamide tromethamine 0.1% ophthalmic solution (Alomide®)
⎻ Indications: vernal keratoconjunctivitis, vernal conjunctivitis, and
vernal keratitis.
⎻ Dosage: 1-2 drops in each eye 4 times/day for up to 3 months.

⎻ Non-FDA approved: allergic conjunctivitis
⎻ ADRs/Warnings/Cautions: ~15%: transient stinging, burning,
and discomfort on instillation.

• Nedocromil sodium ophthalmic solution 2 % (Alocril®)
⎻ Indications: allergic conjunctivitis
⎻ Dosage: 1-2 drops in each eye 2 times/day.
⎻ Onset of Action/Duration: Onset of action is within ~ 15 minutes
which is faster than other mast cell stabilizers.
⎻ ADRs/Warnings/Cautions: The most commonly reported

adverse drug effect is headache (~40%).

• Pemirolast potassium 0.1% ophthalmic solution (Alamast®)
⎻ Dosage: 1-2 drops in each eye 4 times/day.
⎻ Onset of Action/Duration: Symptomatic response (e.g.,
decreased itching) may be evident within a few days following
initiation, but frequently requires up to 4 weeks of therapy.
⎻ ADRs/Warnings/Cautions: 10-25%: headache, rhinitis, and

cold/flu symptoms.
22
4/19/2023

• Ocular Steroids
Ocular Dual Antihistamine/Mast Cell

Stabilizers11-12
• Indications
⎻ Itching of the eye associated with allergic conjunctivitis.

Stabilizers11-12
⎻ Block the effect of histamine on H-1 receptors and stabilize
sensitized mast cells after exposure to specific antigens by
inhibiting their degranulation (e.g., release of allergic mediators).
⎻ The ability to prevent the release of allergic mediators from mast

cells is referred to as a mast cell stabilizer effect.
⎻ This second class of ocular antihistamines is named dual

antihistamine/mast cell stabilizers.
23
4/19/2023

Stabilizers11-12
• Azelastine (generic)
• Alcaftadine (Lastacaft®)
• Epinastine (Elestat® discontinued, generic)
• Ketotifen OTC
Opportunity for
• Olopatadine OTC (Pataday®) patient counseling
• Bepotastine (Bepreve®)

Stabilizers11-12
• Azelastine HCl ophthalmic solution 0.05% (generic)
⎻ Dosage: 1 drop in affected eye(s) 2 times/day.
⎻ Onset of Action/Duration: 3 minutes/8 hours.
⎻ ADRs/Warnings/Cautions: Temporary burning and stinging after

instillation (~30%), bitter taste (~10%), headaches (~15%), etc.

Stabilizers11-12
• Alcaftadine ophthalmic solution 0.25% (Lastacaft®)
⎻ Dosage: 1 drop in each eye 1 time/day.
⎻ Onset of Action/Duration: 15 minutes/24 hours.
⎻ ADRs/Warnings/Cautions: <4%: eye irritation/redness,

burning/stinging on instillation, eye itching, and <3%:
nasopharyngitis, and headache.
24
4/19/2023

Stabilizers11-12
• Epinastine HCl ophthalmic solution 0.05% (generic)
⎻ Dosage: 1 drop into each eye 2 times/day.
⎻ Onset of Action/Duration: 3-5 minutes/8 hours.
⎻ ADRs/Warnings/Cautions: 1-10%: Burning sensation in the eye,

hyperemia, itching, URI/cold symptoms (10%), and 1-3%: headache,
rhinitis, sinusitis, cough, pharyngitis.

Stabilizers11-12
• Ketotifen fumarate ophthalmic solution 0.025% (OTC) (Alaway®,
Zaditor®, etc.)
⎻ Dosage: 1 drop in the affected eye(s) 2 times/day.
⎻ Onset of Action/Duration: within minutes/up to 12 hours.
⎻ ADRs/Warnings/Cautions: Headache (≤10% to ≤25%); Conjunctival

injection (≤10% to ≤25%); Rhinitis (≤10% to ≤25%); <5%: Local allergic
reaction, stinging and burning, etc.

Stabilizers11-12
• Ketotifen fumarate ophthalmic solution 0.025% (OTC) (Alaway®, Zaditor®, etc.)
FDA Approved: 7/99
Contains BZAK
Solution (Alaway Ophthalmic) Solution (Zaditor Ophthalmic) Solution (Ketotifen Fumarate Ophthalmic)
0.025% (10 mL): $1.04/ml 0.025% (5 mL): $1.95/ml 0.025% (5 mL): $2.44 - $2.70/ml
25
4/19/2023

Stabilizers11-12
• Olopatadine HCl ophthalmic solution OTC (Pataday®)
⎻ Dosage: 1 drop into each affected eye either once daily or twice daily
depending on concentration.
⎻ Onset of Action/Duration: within minutes.
⎻ ADRs/Warnings/Cautions: ≤5%: Headache, burning, stinging, itching,

conjunctivitis, eyelid edema, eye pain, foreign body sensation, keratitis,
etc.

Stabilizers11-12
⎻ 0.1% solution (Pataday Twice Daily Relief®): 1 drop 2x/daily.
⎻ 0.2% solution (Pataday Once Daily Relief®): 1 drop 1x daily.
⎻ 0.7% solution (Pataday Once Daily Relief Extra Strength®): 1 drop

1x/daily.
Note: 1) Patanol® 0.1% solution and Pazeo® 0.7% solution were discontinued. 2) Alcon secured the rights to switch prescription
products using the active ingredient olopatadine to OTC as part of its separation from Novartis in April 2019.

Stabilizers11-12
26
4/19/2023

Stabilizers11-12
• Bepotastine besilate ophthalmic solution 1.5% (Bepreve®)
⎻ Dosage: 1 drop into the affected eye(s) 2 times/day.
⎻ Onset of Action/Duration: Within 3 minutes/up to 16 hours.
⎻ ADRs/Warnings/Cautions: Dysgeusia (25%) – Mild taste sensation

after instillation; 2%-5%: eye irritation, nasopharyngitis, and headache.

Stabilizers
• Treatment algorithm (see next slide)
• Encourage patient adherence to treatment.

― OTC vs Rx
― Least amount of drops per day
Treatment Algorithm for Ocular Allergies

• If history of seasonal allergies with symptoms during

particular season but patient asymptomatic…
― MC stabilizer prior to allergy season
• If mild symptoms…
― MC stabilizer/antihistamine combo (OTC or Rx)
• If severe symptoms…
― Add short term ophthalmic steroids to MC
stabilizer/antihistamine
Sept.
27
4/19/2023
Medication Classes for Ocular

Allergies6-10
• Ocular Steroids
Ocular Steroids6-12
• Indications
⎻ Steroid-responsive ocular inflammatory conditions.
⎻ Postoperative inflammation/pain.
⎻ Seasonal allergic conjunctivitis.
▪ Loteprednol etabonate 0.2% ophthalmic suspension
(Alrex®)
⮚ Instill 1 drop into affected eye(s) 4 times daily.
Ocular Steroids6-12
⎻ Decrease inflammation by suppression of normal immune
response: decrease mast cell, basophil, neutrophil
degranulation; decrease production of inflammatory mediators;
reduce capillary permeability.
⎻ Ocular corticosteroids differ in their ability to suppress

inflammation which corresponds to their relative anti-
inflammatory efficacy.
28
4/19/2023
Ocular Steroids6-12
⎻ The effectiveness of ocular steroids in suppressing
inflammation is also due to differences in being able to
penetrate the cornea, which consists of both hydrophobic
(lipid) and hydrophilic (aqueous) layers.
Ocular Steroids6-12
Relative Topical Potency &
Medication
Clinical Efficacy
Fluorometholone alcohol (FML®)* (suspension)
Least
Rimexolone (Vexol®)* (suspension)
Fluorometholone acetate (Flarex®) (suspension)
Dexamethasone sodium phosphate (solution)
Loteprednol etabonate (Lotemax®, Alrex®)* (suspension)
Prednisolone sodium phosphate (solution)
Dexamethasone acetate (Maxidex®)** (suspension)
Prednisolone acetate (Pred Forte®)** (suspension)

Most
Difluprednate (Durezol®)** (emulsion)
Notes: In general Acetate > Alcohol; Acetate > Phosphate; * = “soft” steroids; ** = “hard” steroids
Abstracted From: Chak G. Topical Corticosteroid and NSAID Therapies for Ocular Inflammation_ Cataract and Refractive Surgery Today_Oct_Nov_2014; Donnenfeldt E.Topical
Corticosteroids: Making Sense of the Options_Topics in Ocular Anti-inflammatories_Oct.2013; http://www.aao.org/eyenet/article/savvy-steroid-use.
Ocular Steroids
• Patient education important, risk of…

― Elevated intraocular pressure (IOP) – “steroid responders”
― Steroid induced glaucoma
― Cataract formation
▪ Posterior subcapsular cataract
― Corneal thinning
• Encourages patient not to self-treat in future
Sept.
29
4/19/2023
Ocular Steroids
• Taper schedule
• Know your comparative potency

Sept.
Medication Classes for Ocular

Allergies6-10
• Ocular Steroids
Ocular Non-Steroidal Anti-inflammatory

Drugs6-12
• Indications
⎻ Maintenance of pupillary dilation during surgery (inhibition of
intraoperative miosis).
⎻ Reduction of post-operative inflammation, pain, and photophobia

after cataract extraction surgery, argon laser trabeculoplasty, and
photoreactive procedures.
⎻ Treatment of non-surgically induced inflammatory conditions such

as allergic conjunctivitis and cystoid macular edema (CME).
30
4/19/2023
Ocular Non-Steroidal Antiinflammatory

Drugs6-12
⎻ Inhibition of cyclooxygenase (COX-1 and COX-2) which leads to a
decrease in the production of prostaglandins.
⎻ NSAIDs differ from steroids in mechanism of action and their effects

are much more narrow in scope in terms of their disruption of the anti-
inflammatory cascade.
Ocular Non-Steroidal Antiinflammatory

Drugs6-12
• Bromfenac (Prolensa®, Bromday®, generic)
• Diclofenac (generic)
• Flurbiprofen (generic)
• Ketorolac (Acular® and generic; Acular LS® and generic; Acuvail®)
• Nepafenac (Ilevro®, Nevanac®)
Ocular Non-Steroidal Anti-inflammatory

Drugs6-12
• Similar indications in treatment of ocular allergies as steroids

― Short-term solution
― Better option if contraindication to topical steroids
• Not a typical “go-to”

Sept.
31
4/19/2023
Reference List
1. Marwa K, Kondamudi NP. Type IV Hypersensitivity Reaction. [Updated 2022 Mar 12]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK562228/
2. Chigbu DI. The pathophysiology of ocular allergy: a review. Cont Lens Anterior Eye. 2009 Feb;32(1):3-15;
quiz 43-4. doi: 10.1016/j.clae.2008.07.003. Epub 2008 Sep 19. PMID: 18805042.
3. Trocme, Stefan D.; Sra, Karan K.. Spectrum of ocular allergy. Current Opinion in Allergy and Clinical
Immunology: October 2002 - Volume 2 - Issue 5 - p 423-427
4. Kumar S. Vernal keratoconjunctivitis: a major review. Acta Ophthalmol. 2009 Mar;87(2):133-47. doi:
10.1111/j.1755-3768.2008.01347.x. Epub 2008 Sep 11. PMID: 18786127.
5. Erdinest, Nira; Ben-Eli, Hadasa,b; Solomon, Abrahama. Topical tacrolimus for allergic eye diseases.
Current Opinion in Allergy and Clinical Immunology: October 2019 - Volume 19 - Issue 5 - p 535-543.
6. Kimchi N, Bielory L. The allergic eye: recommendations about pharmacotherapy and recent
therapeutic agents. Current Opinion in Allergy and Clinical Immunology. 2020;20(4),414-420.
7. Dupuis, P, Prokopich C, Hynes A, Kim H. A contemporary look at allergic conjunctivitis. Allergy Asthma
Clin Immunol. 2020;16(5).

Sept.
Reference List
8. Ventocilla M, Dahl A. Allergic Conjunctivitis. https://emedicine.medscape.com/article/1191467-
overview. Updated: Jul 07, 2022.
9. American Academy of Ophthalmology Preferred Practice Pattern Cornea/External Disease Committee.
Conjunctivitis Preferred Practice Pattern 2018. https://www.aao.org/preferred-practice-
pattern/conjunctivitis-ppp-2018.
10. Bielory L, Delgado L, Katelaris CH, et al. ICON Diagnosis and management of allergic conjunctivitis.
Annals of Allergy, Asthma, & Immunology. 2020;124(2),118-134.
11. https://online-lexi-com.
12. https://www-micromedexsolutions-com.
13. https://www.lumifydrops.com/
14. Leonardi A, Silva D, Perez Formigo D, Bozkurt B, Sharma V, Allegri P, Rondon C, Calder V, Ryan D,
Kowalski ML, Delgado L, Doan S, Fauquert JL. Management of ocular allergy. Allergy. 2019
Sep;74(9):1611-1630. doi: 10.1111/all.13786. Epub 2019 Jun 24. PMID: 30887530.

Sept.
Test Questions
1. Which medication class is considered first-line treatment for
seasonal allergic conjunctivitis (SAC) and perennial allergic
conjunctivitis (PAC)?
a. Ocular Decongestants
b. Mast Cell Stabilizers
c. Dual Mast Cell Stabilizers/Antihistamines
d. Ocular Antihistamines

Sept.
32
4/19/2023
Test Questions
2. Which of the ocular allergy conditions are sight threatening if not
treated?
a. Seasonal Allergic Conjunctivitis (SAC)
b. Vernal Keratoconjunctivitis (VKC)
c. Perennial Allergic Conjunctivitis (PAC)
d. Atopic Keratoconjunctivitis (AKC)

Sept.
Test Questions
3. Select which medication is considered a selective alpha-2
receptor agonist indicated to reduce redness and in higher
concentrations is indicated for the treatment of glaucoma?
a. Brimonidine tartrate 0.025% (Lumify®)
b. Oxymetazoline HCl 0.1% (Upneeq®)
c. Nedocromil sodium ophthalmic solution 2% (Alocril®)
d. Olopatadine HCl ophthalmic solution OTC

Sept.
Test Questions
4. Which ocular steroid is indicated for seasonal allergic
conjunctivitis (SAC)?
a. Difluprednate (Durezol®)
b. Prednisolone acetate (Pred Forte®)
c. Dexamethasone acetate (Maxidex®)
d. Loteprednol etabonate 0.2% ophthalmic suspension (Alrex®)

Sept.
33

WPE 2023 Treatment of Ocular Allergies Much More Than Itchy Eyes

Uploaded by

Copyright:

Available Formats

You might also like

WPE 2023 Treatment of Ocular Allergies Much More Than Itchy Eyes

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

WPE 2023 Treatment of Ocular Allergies Much More Than Itchy Eyes

Uploaded by

Copyright:

Available Formats

4/19/2023

Martin J. Torres, PharmD, FCSHP

Western Pharmacy Exchange 2023 presented by

The speakers do not have any conflicts of interest

Western Pharmacy Exchange 2023 presented by

Western Pharmacy Exchange 2023 presented by

Review of the Ocular Allergic Response

• During an allergic response, mediators are released from mast

• Mediators are responsible for the inflammatory response and

1. Marwa K and Kondamudi N. StatPearls. 2022 Jan.

Western Pharmacy Exchange 2023 presented by

Review of the Ocular Allergic Response

Type I Type II Type III Type IV

1. Marwa K and Kondamudi N. StatPearls.

Review of the Ocular Allergic Response

⎻ When first exposed to an antigen, IgE antibodies are produced

Western Pharmacy Exchange 2023 presented by

Review of the Ocular Allergic Response

Retrieved August 8, 2022, from https://nhinnovations.ie/histamine-

Review of the Ocular Allergic Response

⎻ Histamine activates H-1 receptors on blood vessels which

1. Marwa K and Kondamudi N. StatPearls.

Review of the Ocular Allergic Response

2. Chigbu DI. Cont Lens Anterior Eye. 2009

Review of the Ocular Allergic Response

1. Marwa K and Kondamudi N. StatPearls.

Review of the Ocular Allergic Response

1. Marwa K and Kondamudi N. StatPearls.

Review of the Ocular Allergic Response

Retrieved August 11, 2022, from https://pathofex.com/how-to-get-something-out-of-your-eye/

2. Chigbu DI. Cont Lens Anterior Eye. 2009 Feb.

Western Pharmacy Exchange 2023 presented by

Review of the Ocular Allergic Response

2. Chigbu DI. Cont Lens Anterior Eye. 2009

Review of the Ocular Allergic Response

Western Pharmacy Exchange 2023 presented by

Review of the Ocular Allergic Response

1. Marwa K and Kondamudi N. StatPearls.

Review of the Ocular Allergic Response

3. Trocme, S and Karan, K. Current Opin Allergy and Clinical Imm.

Western Pharmacy Exchange 2023 presented by

Ocular Allergy Conditions

Western Pharmacy Exchange 2023 presented by

Giant papillary • Type I + IV hypersensitivity reaction

Vernal • Type I + IV hypersensitivity reaction

Seasonal Allergic Conjunctivitis (SAC)

• Related to specific pollens that release during specific seasons

3. Trocme, S and Karan, K. Current Opin Allergy and Clinical Imm.

Western Pharmacy Exchange 2023 presented by

Seasonal Allergic Conjunctivitis (SAC)

Retrieved August 10, 2022 from https://laicare.net/tag/giant-papillary-conjunctivitis/

3. Trocme, S and Karan, K. Current Opin Allergy and Clinical Imm.

Western Pharmacy Exchange 2023 presented by

Seasonal Allergic Conjunctivitis (SAC) -

Western Pharmacy Exchange 2023 presented by

Perennial Allergic Conjunctivitis (PAC)

3. Trocme, S and Karan, K. Current Opin Allergy and Clinical Imm.