Patients seeking freedom from glasses can enjoy the cosmetic benefits, increased comfort, and visual improvements contact lenses afford them. But for patients with allergies and allergic eye disease, contact lens wear can be difficult, and some patients may think they have no other option but to return to spectacles permanently. These patients may be particularly susceptible to itching, irritation, and overall discomfort that they may associate with contact lens wear. In fact, these effects can stem from a number of factors, including the environment, lens hygiene practices, and even medications they use to manage systemic allergies.
As primary care eye physicians, optometrists have a unique opportunity to investigate the patient’s experience with allergies and contact lens wear and, potentially, uncover prevention or treatment options that address the individual’s needs. Optometrists do not always need to recommend discontinuing lens use to achieve those optimal patient outcomes.
Managing allergic symptoms requires a careful history, diagnostic acumen, and appropriate treatment strategies. Using this guidance, clinicians can re-establish a comfortable wearing experience and preserve the benefits contact lenses bring their patients.
Distinguish From 5 Types of Itch
Identifying individuals with allergic eye disease is critical, even when they are not presenting with symptoms at the time of their visit. Obtaining a comprehensive medical history is imperative since patients often neglect to report allergic symptoms when they are asymptomatic during the visit. Once the clinical history has been completed and the patient is ready to head into the exam lane, optometrists can begin to look for cues that allergic eye disease may present a quality of life concern.
Itching is often a hallmark sign of allergic eye disease, but it is not exclusive to ocular allergies. There are 4 types of itching that correlate with specific ocular abnormalities. It is important to identify itching patterns and question patients as to their symptomatology to discriminate between allergic conjunctivitis and other potential ocular conditions.
The first type of itching a patient may demonstrate is closing their eyes and itching along their eyelids. This type of itching likely does not indicate allergic conjunctivitis. Rather, it is likely a dermatitis response that can be treated by identifying the irritant and removing it. Prescribing a topical corticosteroid cream or ointment and having the patient apply it directly to the affected area will likely provide relief.1
The second type of itching involves an individual rubbing their fingernail along their lash margins. This is typically a symptom of blepharitis. Careful examination of the lid margin may reveal hyperemia, altered meibum production, lid notching, and collarettes at the base of the eyelashes.2
The third type of itching a patient may exhibit involves pulling down the lower eyelid and scratching the lower fornix. This condition is known as mucus fishing syndrome. This type of itch does not indicate allergic conjunctivitis, and clinicians must instruct their patients to cease this behavior .3 A short course of corticosteroid drops may provide these patients with symptomatic relief.
The fourth type of itch involves an individual digging in the corner of their eye (nasal canthal region) with either a finger or a knuckle rub. When a patient demonstrates this behavior and complains of symptoms concentrated in the nasal canthal region, allergic conjunctivitis is a likely culprit. More severe forms of seasonal allergic conjunctivitis may be accompanied by chemosis, ocular hyperemia, lid swelling, and a prominent epiphora response — all of which result from excessive histamine released onto the ocular surface from mast cells.4
There is a fifth type of itching that is very difficult to associate with any one condition. Patients will close their eyes and with a fist or open hand they will rub their whole eye with a fist or open hand. There’s a long list of differential diagnosis including several ocular surface conditions that may potentially cause this itching response.
Identify Allergic Conjunctivitis Culprits
Basic observations can lend support to a clinician’s suspicion of allergic conjunctivitis. A detailed ophthalmic examination can help optometrists confirm these suspicions, provide a specific clinical diagnosis, and identify potential culprits.
Giant papillary conjunctivitis (GPC) is a form of chronic allergic conjunctivitis that can often occur in contact lens wearers. It involves an inflammatory reaction on the superior palpebral conjunctiva secondary to excessive deposits on the contact lenses. In this condition large papillae form on the superior tarsal plate due to friction caused by the eyelid moving over the contact lens (Figure 1).5
Individuals with GPC frequently complain of contact lens discomfort, excessive mucus, unstable or blurred vision, and a sensation of excessive lens movement. This excessive movement is the result of altered blink dynamics caused by papillae on the tarsal plate. Everting the upper lid on every single contact lens wearer during slit lamp evaluation can help clinicians rule out the presence of GPC.
Patients with vernal keratoconjunctivitis (VKC) can present with large papillae on the superior tarsal plate, often referred to as cobblestone papillae. This chronic form of allergic disease is frequently seen in younger men. Patients with VKC often have a substantial ocular inflammatory response and experience difficulty wearing contact lenses. Shield ulcers may accompany this chronic inflammation along with trantas dots, which are small inflammatory islands located in the limbal region of the cornea that can be seen in the earlier stages of the disease.6
Review Contact Lens Hygiene
Seasonal allergic conjunctivitis can present a unique set of challenges for the patient and practitioner and necessitate changes in contact lens behavior. One of the best treatment strategies involves fitting contact lenses that are disposed of more frequently — ideally, daily disposable contact lenses. Patients refit with daily disposable lenses often demonstrate improved allergic eye symptoms.7 Daily disposable lenses remove allergens that bind themselves to the lens surface when they are disposed of at the end of the day and are minimally affected by the patient’s hygiene habits or lens cleaning solution efficacy.
However, some patients may not be candidates for daily disposable contact lenses — particularly those wearing specialty lenses such as corneal gas permeable lenses (GPs), scleral lenses, hybrid lenses or custom soft lenses. When contraindications for daily disposable lens wear prevent a clinician from refitting lenses, a change in cleaning regimen may help to alleviate allergic conjunctivitis symptoms. Solutions limited in preservatives and potential allergic agents, such as hydrogen peroxide disinfection systems, may reduce allergic symptoms in these patients.
Apply Over-The-Counter Topical Treatments
Optometrists have a plethora of treatment options designed to treat allergic eye disease and make contact lens wear more tolerable. Some are available over the counter and others are only available with a prescription. Over the last several years, new options that were once only available with a prescription are now available over the counter.
Olopatadine, which was once only available with a prescription, is now available over the counter. This a topical antihistamine with a mast cell stabilizing effect is available in 3 concentrations: 0.1%, 0.2%, 0.7%.8 Olopatadine 0.1% (blue label) is dosed twice a day, Olopatadine 0.2% (red label) is dosed once a day,and Olopatadine 0.7% (green label) is dosed once a day. When prescribing drops for the ocular surface, clinicians must instruct patients to refrain from inserting contact lenses for approximately 15 minutes after drop instillation.
Alcaftadine 0.25% ophthalmic solution has also recently become available as an over-the-counter eye drop. It demonstrates both antihistamine and mast cell stabilizing properties and is approved for once a day use.9
Ketotifen is a contemporary anti-allergic eye drop that has been available over the counter for a long time and has been available under several trade names. The drop’s antihistamine and mast cell stabilizing effects provide relief for patients with allergic conjunctivitis.10,11 Recently, a preservative free formulation became available over the counter.
Prescribe Medications or Corticosteroids
Prescription-strength solutions may sometimes be more suitable for treating patients with allergic conjunctivitis. Cetirizine 0.024% has recently become available with a prescription and approved for twice a day dosing.12
Clinicians may also prescribe corticosteroids. And frequently, these drugs are prescribed off-label. There are several ophthalmic corticosteroids that reduce inflammatory sequelae for individuals who have flares of seasonal allergic conjunctivitis that are not adequately controlled with topical antihistamines and mast cell stabilizers. Oftentimes, these medications are used for short periods of time at a high dosing frequency to mitigate the inflammation as quickly as possible. Active agents that can reduce inflammation accompanying allergic eye disease include fluorometholone, loteprednol and prednisolone (Figure 2). When steroid use is indicated, contact lens wearers must abstain from lens use for a period of time due to the frequency of dosing that is required.
Individuals with GPC require corticosteroids as part of their treatment regimen, administered more frequently throughout the day to sequester the inflammation. While corticosteroids can control inflammation and provide relief, they also have the potential to create adverse side effects, creating the need for other treatments. Research shows that corticosteroid use can increase intraocular pressure, creating a potential risk for glaucoma and the development of posterior subcapsular cataracts.14, 15
The frequency of cyclosporine 0.1% has shown promise as an alternative to corticosteroids and has demonstrated the ability to improve quality of life in patients with VKC.15
Keep Apprised of Options in the Pipeline
New medications and devices are constantly manufactured and evaluated through clinical trials to determine their efficacy in treating various diseases. Two recently approved treatment options show promise in alleviating allergic conjunctivitis symptoms.
A new class of pharmaceuticals known as reactive aldehyde species (RASP) inhibitors demonstrate the ability to reduce the inflammatory response in eyes with allergic conjunctivitis. These drugs treat inflammation associated with allergic conjunctivitis through a non-corticosteroid pathway and reduce ocular itching, tearing and redness associated with allergic conjunctivitis.24,25
Recently, the first drug-eluting contact lens, an etafilcon A lens with ketotifen, received approval from the US Food and Drug Administration (FDA). Clinical trials have demonstrated the lens’s ability to reduce itching compared with lenses that do not dispense medication.18 Despite FDA approval, it is currently unavailable in the US. This novel contact lens design may play a critical role in reducing allergic conjunctivitis symptomatology in both contact lens wearers and individuals with emmetropia seeking alternative solutions.
Educate The Patient
Optometrists can improve patients’ odds of maintaining a successful relationship with contact lenses by providing an education on how some systemic drugs affect the ocular surface. Without appropriate clinical guidance, patients may attempt inappropriate self treatments with over-the-counter products.
Patients will often seek treatments independently, usually with oral antihistamines, decongestants, or a combination. It’s incumbent upon primary eye care physicians to explain that these options often reduce the tear film volume, and create a more challenging microenvironment for contact lens wear.19,20
With this knowledge, patients may be able to adjust their expectations and make better informed choices.
Optometrists must recommend appropriate contact lenses, solutions, and other therapeutics to enable patients with allergic conjunctivitis to wear their contact lenses comfortably. By understanding the clinical tools at their disposal and leveraging them to optimize patient wearing experience, clinicians can maintain comfort for their patients who wear contact lenses and treat inflammatory responses associated with allergic eye disease.
- Chisholm SAM, Couch SM, Custer PL. Etiology and management of allergic eyelid dermatitis. Ophthalmic Plast Reconstr Surg. 2017;33(4):248-250. doi:10.1097/IOP.0000000000000723
- Bernardes TF, Bonfioli AA. Blepharitis. Semin Ophthalmol. 2010;25(3):79-83 doi:10.3109/08820538.2010.488562
- Chiew RLJ, Au Eong DTM, Au Eong KG. Mucus fishing syndrome. BMJ Case Rep. 2022;15(4):e249188. doi:10.1136/bcr-2022-249188
- Bielory L, Delgado L, Katelaris CH, Leonardi A, Rosario N, Vichyanoud P. ICON: diagnosis and management of allergic conjunctivitis. Ann Allergy Asthma Immunol. 2020;124(2):118-134. doi:10.1016/j.anai.2019.11.014
- Kenny SE, Tye CB, Johnson DA, Kheirkhah A. Giant papillary conjunctivitis: a review. Ocul Surf. 2020;18(3):396-402. doi:10.1016/j.jtos.2020.03.007
- Singhal D, Sahay P, Maharana PK, Raj N, Sharma N, Titiyal JS. Vernal Keratoconjunctivitis. Surv Ophthalmol. 2019;64(3):289-311. doi:10.1016/j.survophthal.2018.12.001
- Hayes VY, Schnider C, Veys J. An evaluation of 1-day disposable contact lens wear in a population of allergy sufferers. Cont Lens Anterior Eye. 2003;26(2):85-93. doi:10.1016/S1367-0484(03)00019-5
- Leonardi A, Quintieri L. Olopatadine: a drug for allergic conjunctivitis targeting the mast cell. Expert Opin Pharmacother. 2010;11(6):969-81. doi:10.1517/14656561003694643
- Namdar R, Valdez C. Alcaftadine: a topical antihistamine for use in allergic conjunctivitis. Drugs Today (Barc). 2011;47(12):883-90. doi:10.1358/dot.2011.47.12.1709243
- Meloto CB, Ingelmo P, Perez EV, et al. Mast cell stabilizer ketotifen fumarate reverses inflammatory but not neuropathic-induced mechanical pain in mice. Pain Rep. 2021;6(2):e902. doi:10.1097/PR9.0000000000000902
- Mark B Abelson et al. Efficacy of ketotifen fumarate 0.025% ophthalmic solution compared with placebo in the conjunctival allergen challenge model. Arch Ophthalmol. 2003;121(5):626-30. doi:10.1001/archopht.121.5.626
- Malhotra RP, Meier E, Torkildsen G, Gomes PJ, Jasek MC. Safety of cetirizine ophthalmic solution 0.24% for the treatment of allergic conjunctivitis in adult and pediatric subjects. Clin Ophthalmol. 2019;13:403-413. doi:10.2147/OPTH.S186092
- Tripathi RC, Parapuram SK, Tripathi BJ, Zhong Y, Chalam KY. Corticosteroids and glaucoma risk. Drugs Aging. 1999;15(6):439-450. doi:10.2165/00002512-199915060-00004
- Jobling AI, Augusteyn RC. What causes steroid cataracts? A review of steroid-induced posterior subcapsular cataracts. Clin Exp Optom. 2002;85(2):61-75. doi:10.1111/j.1444-0938.2002.tb03011.x
- Leonardi A, Doan S, Amrane M, et al. A randomized, controlled trial of cyclosporine A cationic emulsion in pediatric vernal keratoconjunctivitis: the VEKTIS study. Ophthalmology. 2019;126(5):671-681. doi:10.1016/j.ophtha.2018.12.027
- Clark D, Cavanagh B, Shields AL, Karpecki P, Sheppard J, Brady TC. Clinically relevant activity of the novel RASP inhibitor reproxalap in allergic conjunctivitis: the phase 3 ALLEVIATE trial. Am J Ophthalmol. 2021;230:60-67. doi:10.1016/j.ajo.2021.04.023
- Clark D, Salapatek AM, Sheppard JD, Brady TC. Reproxalap improves signs and symptoms of allergic conjunctivitis in an allergen chamber: a real-world model of allergen exposure. Clin Ophthalmol. 2022;16:15-23. doi:10.2147/OPTH.S345324
- Pall B, Gomes P, Yi F, Torkildsen G. Management of ocular allergy itch with an antihistamine-releasing contact lens. Cornea. 2019;38(6):713-717. doi:10.1097/ICO.0000000000001911
- Foutch BK, Sandberg KA , Bennett ES, Naeger LL. Effects of oral antihistamines on tear volume, tear stability, and intraocular pressure. Vision (Basel). 2020;4(2):32. doi:10.3390/vision4020032
- Askeroglu U, Alleyne B, Guyuron B. Pharmaceutical and herbal products that may contribute to dry eyes. Plast Reconstr Surg. 2013;131(1):159-167. doi:10.1097/PRS.0b013e318272a00e