Dry Eye

Treating allergies in patients with dry eye disease

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By Beeran Meghpara, MD

Ocular allergy and dry eye disease (DED) are 2 of the most common inflammatory ocular surface diseases, and the 2 conditions overlap, frequently occurring together. In the Dry Eye Workshop II (DEWS II) report, it was noted that allergic conjunctivitis is a common risk factor for DED,1 and other researchers have shown a direct correlation between seasonal allergens and dry eyes.2 Up to 40% of Americans report ocular symptoms consistent with allergic conjunctivitis,3 and almost half report that acute episodes significantly impair their quality of life.4

Write it Up
Patients often use over-the-counter antihistamine products to self-treat allergy symptoms. As part of the Food and Drug Administration (FDA)’s Rx to OTC switch process, various concentrations of olopatadine, including the popular Pazeo, are no longer available as prescription products. These agents, though effective in treating ocular itch, are known to block muscarinic receptors on the ocular surface, causing dryness that may exacerbate existing DED.5 For these patients, prescription cetirizine ophthalmic solution 0.24% (Zerviate; Eyevance Pharmaceuticals), is an excellent option. It is the first new topical antihistamine to be approved by the FDA in 10 years.

Cetirizine is the same active ingredient that is found in Zyrtec (Johnson & Johnson Consumer), the number one oral antihistamine allergy treatment recommended by allergists.6 It has the advantage of being a highly specific H1 receptor antagonist with no anti-muscarinic receptor activity. The drop contains Hydrella as its vehicle, a combination of glycerin and hydroxypropyl methylcellulose (HPMC), which are the same components that make artificial tear products soothing to the eye. Zerviate’s mean comfort score in the Phase 3 clinical trial was <1 at all time points (scale of 1 to 10 with 1 being very comfortable).7

Two phase 3 efficacy studies revealed strong anti-itch efficacy of Zerviate compared with vehicle.8 Zerviate was shown to have a rapid onset of action at 3 minutes following allergen exposure and was effective in patients with moderate and severe allergic conjunctivitis.9  All of the above benefits have made Zerviate my preferred method of treatment for patients with ocular itch.

Masks are Making Dry Eye Worse
Eye care specialists are increasingly recognizing an uptick in ocular irritation and dryness associated with the wearing of masks to help reduce the spread of COVID-19.10 Patients specifically note they feel air blowing up from their mask into their eyes. This adds another ocular surface challenge on top of the dryness that patients are already experiencing due to increased screen time and spending more time indoors necessitated by the ongoing pandemic.

According to a recent report in Ophthalmology and Therapy, this increase in symptoms is occurring in people who did not previously experience dry eye symptoms.10 The authors wrote that the longer masks are worn, the more likely the wearer is to have discomfort. Individuals newly reporting irritation have subjective symptoms as per the Ocular Surface Disease Index as well as objective signs such as a deterioration in corneal staining.

As we head into another allergy season—while masking and staying home—it is important that patients are treated appropriately for both conditions.

1. Gomes JAP, Azar DT, Baudouin C, et al. TFOS DEWS II iatrogenic report. Ocul Surf. 2017;15(3):511-538.

2. Kumar N, Feuer W, Lanza NL, Galor A. Seasonal variation in dry eye. Ophthalmology. 2015;122(8):1727-1729.

3. Singh K, Axelrod S, Bielory L. The epidemiology of ocular and nasal allergy in the United States, 1988-1994. J Allergy Clin Immunol. 2010;126:778 –783.

4. Palmares J, Delgado L, Cidade M, et al; Season Study Group. Allergic conjunctivitis: a national cross-sectional study of clinical characteristics and quality of life. Eur J Ophthalmol. 2010;20:257–264.

5. Liu H, Farley JM. Effects of first and second generation antihistamines on muscarinic induced mucus gland cell ion transport. BMC Pharmacol. 2005;5: 8. doi: 10.1186/1471-2210-5-8.

6. Johnson & Johnson Consumer Companies, I. Zyrtec The #1 Allergist Recommended Brand*, Available from: http://www.multivu.com/ assets/52078/documents/Zyrtec-fact-sheet-99-original.pdf. 2011.

7. Malhotra RP, Meier E, Torkildsen G, et al. Safety of cetirizine ophthalmic solution 0.24% for the treatment of allergic conjunctivitis in adult and pediatric subjects. Clin Ophthalmol. 2019;13:403-413.

8. Meier EJ, Torkildsen GL, Gomes PJ, Jasek MC. Phase III trials examining the efficacy of cetirizine ophthalmic solution 0.24% compared to vehicle for the treatment of allergic conjunctivitis in the Conjunctival Allergen Challenge model. Clin Ophthalmol. 2018;12:2617-2628. DOI: 10.2147/OPTH.S185835

9. Zerviate [package insert]. Fort Worth, TX: Eyevance Pharmaceuticals LLC; 2020.

10. Moshirfar M, West WB, Marx DP. Face Mask-Associated Ocular Irritation and Dryness. Ophthalmol Ther. 2020;9:397–400. https://doi.org/10.1007/s40123-020-00282-6.


Beeran Meghpara, MD, is Co-Director, Refractive Surgery, Wills Eye Hospital; [email protected]

Financial disclosure: Dompe, EyeVance Pharmaceuticals, Kala Pharmaceuticals, Sun Pharma


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