Oct 2016

CONTINUED FROM P16
References
1. O’Brien, P, and Louis, C. “Dry eye: diagnosis and current
treatment strateg ies.” C urrent allergy and asthma
reports 4.4 (2004):314319.
2. “New Data on Contact Lens Dropouts: An International
Perspective.” Rumpakis, J. 2016. < https://www.
reviewofoptometry.com/article/newdataoncontactlensdrop
outsaninternationalperspective
3. Research in dry eye: report of the Research Subcommittee
of the International Dry Eye WorkShop (2007). Ocul Surf.
2007Apr;5(2):17993.
4. Pritchard N, Fonn D, Brazeau D. Discontinuation of
contact lens wear: a survey. Int Contact Lens Clin. 1999
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5. Weed K, Fonn D, Potvin R. Discontinuation of contact lens
wear. Optom Vis Sci. 1993;70(12, suppl.):140.
6. Richdale K, Sinnott LT, Skadahl E, Nichols JJ. Frequency of
and factors associated with contact lens dissatisfaction
and discontinuation. Cornea. 2007;26(2):16874.
7. Craig, JP et al. “The TFOS International Workshop on
Contact Lens Discomfort: Report of the Contact Lens
Interactions With the Tear Film Subcommittee Report on
Interactions With Tear Film.” Investigative ophthalmology
& visual science 54.11 (2013): TFOS123TFOS156.
8. Nichols, JJ et al. “The TFOS International Workshop on
Contact Lens Discomfort: Executive SummaryExecutive
Summary.” Investigative ophthalmology & visual science
54.11 (2013): TFOS7TFOS13.
9. Nichols, JJ, and Sinnott, L. “Tear film, contact lens, and
patient related factors associated with contact lens–
related dry eye.”Investigative ophthalmology & visual
science 47.4 (2006): 13191328.
10. Cox, S and Nichols J. Contact Lens Dry Eye: Neurotrophic
Disease or MGD? Contact Lens Spectrum, Volume: 31 ,
Issue: July 2016, page(s): 3235
11. Korb, D.R., Greiner, J.V., Herman, J.P., Hebert, E.,
Finnemore, V.M., Exford, J.M., Glonek, T., Olson, M.C., 2002.
Lidwiper epitheliopathy and dryeye symptoms in contact
lens wearers. CLAO J. 28, 211216.
12. Efron N , Brennan NA , Morgan PB , Wilson T Lid wiper
epitheliopathy. Prog Retin Eye Res. 2016 Jul;53:14074.
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13. Coles, C.M.L., Brennan, N.A., 2012. Coefficient of friction
and soft contact lens comfort. Optom. Vis. Sci. 88.
Eabstract 125603.
14. Jones, L. Editorial: Hydrogel contact lens materials: Dead
and buried or about to rise again? Contact Lens Update.
October 7 2013. http://www.contactlensupdate.com/
15. http://www.gpli.info/labconsultantmaterialstreatments/
16. Carracedo, Gonzalo et al. Effect of overnight
orthokeratology on conjunctival goblet cells. Contact Lens
and Anterior Eye,Volume 39 , Issue 4 , 266 269
17. Agranat JS, Kitos NR, Jacobs DS. “Prosthetic replacement
of the ocular surface ecosystem: impact at 5 years.” Br J
Ophthalmol 2016; 100 :11711175
*Alex Petty is a New Zealand optometrist based in Tauranga with
a particular interest and knowledge in speciality contact lenses,
ortho-k and myopia control.
Dry eyes and allergy: a common association?
BY DR ADAM WATSON*
Dry eye and allergy problems are usually
considered as separate entities and, if
there is consideration given to both, it
is usually in terms of differential diagnosis: “is
this a dry eye or an allergy problem causing the
patient’s symptoms?”
But the two may co-exist and there may be a
causative relationship between the two in many
cases.
Dry eye problems are common, affecting up to
15% of people over 50 with a greater proportion
of women affected. Ocular surface allergy is
also common with around 20% of people having
some degree of seasonal or perennial allergic
conjunctivitis. When both are present, a tailored
management strategy that takes both into
account is desirable.
Symptom overlap
The symptoms of dry eye include burning,
stinging, tired eyes and grittiness sensation.
Vision may be variably affected by ocular surface
disturbance and poor tear film quality. Allergy also
frequently causes burning, stinging and irritated
sensations, while vision may be variably affected
by mucus production and tear film abnormalities.
A cardinal symptom of allergy, however, is
itching of the eyes due to histamine release
– itching is very suggestive of an allergic
component to the ocular surface disease.
Dry eye and allergy association – evidence
Inflammation has been recognised as a key
component of dry eye disease. More than likely
this has multifactorial causation including
tear film instability, hyperosmolarity of the
tear film and meibomian gland related factors.
Inflammation is also the underlying cause of
ocular surface allergy symptoms and signs –
type I hypersensitivity, in the case of seasonal or
perennial allergic conjunctivitis; type IV cellmediated
response in vernal and atopic disease.
Studies in children with both type I and
type IV (vernal) allergic disease have shown a
significantly decreased tear breakup time leading
to variable dry eye symptoms.
In atopic keratoconjunctivitis, the earlier age
of onset is associated with poorer Schirmer and
Rose Bengal scores, presumably as a result of the
more prolonged inflammation worsening ocular
surface damage and inducing dryness.
Among other risk factors including age,
rheumatoid arthritis and depression, the
presence of any allergy, asthma and eczema
(atopy) were significantly associated with dry eye
disease in a large study of female twins in the
UK. Additionally, in a study of 689 adults using
a validated questionnaire, most patients with
symptoms consistent with allergic conjunctivitis
(57%) also had dry eyes.
Management suggestions
When combined allergy and dry eye disease is
suspected, treatment should ideally address
both conditions. However, there is probably
room to rationalise the approach to simplify
what otherwise can be a veritable onslaught of
intervention.
Since both conditions involve inflammation
of the ocular surface, rational therapy includes
treatment or prevention of inflammation as
part of the approach. This may be helpful in
stabilising the tear film, thereby assisting in the
management of dry eye. Therefore, an initial
strategy may be the use of olopatadine (Patanol)
eye drops twice daily for their mast cell stabilising
and anti-histamine effect; and the addition
of a (preservative-free) lubricant drop to help
augment the tear film and to flush away ocular
surface allergens
Reviewing this after a couple of weeks will tell
you whether you’re on the right track. If the itching
and inflammation have improved, but dry eye
symptoms are still a feature, incorporating more
frequent preservative-free lubrication, eyelid
therapy including heat treatment, doxycycline
or azithromycin, and possibly punctal plug
placement may be appropriate.
If inflammation is a more prominent feature,
then a tapering course of a topical steroid
(fluorometholone or non-preserved prednisolone
or methylprednisolone) while continuing
olopatadine may be a useful strategy to optimise
the ocular surface. Again, attention to meibomian
gland dysfunction (MGD) may be an important
component of treatment.
Other modalities such as intense pulsed
light (IPL) therapy may play a part. More
severe allergic inflammation (vernal or atopic
keratoconjunctivitis) can be effectively treated
with topical cyclosporine or tacrolimus that often
help the dry eye problems as well.
In summary, dry eye and allergic eye conditions
are likely often present in combination, with
the link between them being ocular surface
inflammation. Control of the inflammation is an
important first step in managing both.
References:
DEWS Report. Ocular Surface. 2007;5:65-204
Chen et al. High incidence of dry eye…Acta
Ophthalmologica. May 2016 (epub)
Villani et al. Dry eye in vernal keratoconjunctivitis.
Medicine(Baltimore). 2015;94:e1648
Hon et al. Allergic conjunctivitis and dry eye syndrome. Ann
Allergy Asthma Immunol. 2012;108:163-6
Vehof et al. Prevalence and risk factors of dry eye disease…
Br J Ophthalmol. 2014;98:1712-7
Onguchi et al. The impact of the onset time of AKC on the
tear function… Am J Ophthalmol. 2006;141:569-71
* Dr Adam Watson works at Eye Institute in Auckland. He has
subspecialist interests in ocular surface disease, cataract,
corneal and refractive surgery and oculoplastic surgery.
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October 2016
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