Filling in the Gaps: Emerging Management Strategies for Allergic Conjunctivitis

Data from new survey reveal eye care specialists use numerous approaches to reduce patients’ allergy symptoms.

By William Christie, MD

In the absence of practice guidelines for the management of allergic conjunctivitis (AC), there are no universally accepted treatment strategies. The lack of consensus around this vastly prevalent condition, as it affects about 40% of the population, is compounded by the fact that symptoms overlap with and can be similar to dry eye and allergic rhinitis which complicates diagnosis and management.^1-4

When it comes to managing AC, another confounding factor is that the condition is often initially managed by primary care physicians versus eye care specialists which can lead to a wide variation in approaches.

Prescribing Patterns
My colleagues and I participated in a study using an online, qualitative survey to understand current prescribing patterns and to identify existing gaps in treating allergic conjunctivitis.⁵ Participants included 48 ophthalmologists (mean age 50, 62% men/36% women, and a mean of 20 years in practice) and 44 optometrists (mean age 48, 60% men/40% women, mean of 15 years in practice) who are anterior segment specialists. Of note, these eye care practitioners were from different practice types—including private practice and academic and a range of geographic locations, with a variety of different community settings.

The survey found that the top 3 treatments these eye care practitioners choose first are dual-activity agents (mast cell stabilizer [MCS] plus antihistamine [AH]; 34.5%), artificial tears (29.3%), and cool compresses (16.1%). The preferred combination agent is olopatadine 0.2% (Pataday; Alcon), now available over the counter. For almost all the respondents (97%), symptom severity dictates when they decide to use steroids—70% treat with steroids in moderate AC and the other 27% use the agents for severe symptoms.

Combination Treatments
Half of the respondents use steroids in combination with dual-activity agents, 35% along with artificial tears, and 16% with oral AH. The other half prefer loteprednol etabonate over other steroids, 27% choose fluorometholone, and 17% prednisolone. The top 2 concerns around steroid use are IOP increases and misuse/abuse of drop; ophthalmologists were more concerned with the former and optometrists the latter. Ophthalmologists said they believe 35% of their patients’ misuse steroids and optometrists believe that percentage to be 28%.

 The greatest limitations of AC topical therapy according to the survey respondents are noncompliance with eyedrop regimens (18.8%) and short duration of action (15.5%). Risk of steroid-related side effects, rebound inflammation (13.1%) and failure to treat late-phase allergic reaction associated with antihistamines (10%) were also limitations.

Newest Option: Steroid-eluting Insert
In 2021, the FDA granted approval to Ocular Therapeutix Inc for Dextenza (dexamethasone ophthalmic insert 0.4 mg) to treat ocular itching associated with AC. It is the first such physician-administered intracanalicular insert that delivers a preservative-free drug with a tapered release of medication over a 30-day course.⁶

The approval was based on the results of 3 randomized, multicenter, vehicle-controlled studies that included 255 patients with a positive history of ocular allergies and positive skin test reaction to perennial and seasonal allergens.⁷ The dexamethasone insert was associated with lower mean ocular itching scores versus vehicle at all time points throughout the study duration of up to 30 days. In terms of safety, just 3.2% of patients experienced a transient elevation of IOP which was not in any way severe and quickly resolved when the insert was either flushed out or allowed to finish its course of treatment.⁷

Need for Dropless Pharmaceuticals
The findings from this survey emphasize the need for sustained-release steroid therapies that take patient adherence out of the medication equation and show how such technology could be easily and conveniently used in combination with other popular therapies.

William C. Christie, MD, is the sole owner and President/CEO of Scott & Christie Eyecare Associates, an Eyesouth affiliate practice, Cranberry Township, Pennsylvania. He may be reached at [email protected]. Dr Christie is a consultant to Ocular Therapeutix

Reference

1. Kimchi N, Bielory L. The allergic eye: recommendations about pharmacotherapy and recent therapeutic agents. Curr Opin Allergy Clin Immunol. 2020;20:414–420. DOI:10.1097/ACI.0000000000000669.
2. Bielory L, Delgado L, Katelaris CH, et al. ICON: Diagnosis and management of allergic conjunctivitis. Ann Allergy Asthma Immunol. 2020;124(2):118-134. doi: 10.1016/j.anai.2019.11.014.
3. Leonardi A, Modugno RL, Salami E. Allergy and Dry Eye Disease. Ocul Immunol Inflamm. 2021;5:1-9. doi: 10.1080/09273948.2020.1841804.
4. Hom MM, Nguyen AL, Bielory L. Allergic conjunctivitis and dry eye syndrome. Ann Allergy Asthma Immunol. 2012;108(3):163-6. doi: 10.1016/j.anai.2012.01.006.
5. Christie W, et al. Real-world Allergic Conjunctivitis Treatment Patterns of Eye Care Providers. Paper presented at: ASCRS Annual Meeting; April 22-26, 2022; Washington, DC.
6. Ocular Therapeutix™ announces FDA approval of supplemental New Drug Application (sNDA) for DEXTENZA® (dexamethasone ophthalmic insert) 0.4 mg for intracanalicular use for the treatment of ocular itching associated with allergic conjunctivitis. October 11,2021. https://tinyurl.com/yfkp48je. Accessed May 16, 2022.
7. Rubin JM, et al. Pooled analysis evaluating efficacy and safety of an intracanalicular dexamethasone insert for the treatment of allergic conjunctivitis. Paper presented at: ASCRS Annual Meeting; July 23-27, 2021; Las Vegas.