During spring and fall, many of the 50 million Americans who suffer from allergic eye disease are gearing up to fight the battle once again. Our schedules are chock-full of patients needing our care for their allergies. The complaints of these patients are as varied as the weather; some complain of nuisance irritations, and some suffer with severe response that can accompany allergic eye disease.  We as primary eye care doctors should select appropriate treatments, lenses and care systems to minimize symptoms and keep our patients wear contact lenses comfortably from morning to night. 

Managing Allergies
Successful treatment of allergic eye disease hinges on problem solving, which includes a thorough history (ocular and systemic) and a complete ocular exam. It is especially important to fully understand the mechanism and consequence of ocular allergy and how it directly affects contact lens wear. By understanding the different types of allergies (and the available treatments), we can select the best possible treatment that will allow our patients to wear their lenses safely and effectively. Additionally, using various therapies to "quiet" the eye, using new contact lens materials and solutions, and employing various means to prevent recurrence are requisites for successful treatment.

Significant papillary conjunctivitis due to vernal changes.

Management depends upon properly staging the disease. Mild reactions respond well to cold compresses and preservative-free artificial tears such as Genteal and Refresh tears.  Many over-the-counter artificial tears such as Visine have preservatives.  Chronic use of them can induce chronic red eyes.  Prescription medicines such as Patanol, Elestat, Alrex can effectively treat ocular allergy at a quick pace and patients can continue to enjoy wearing contact lenses at the same time.  But in moderate to severe allergic reactions, the levels of histamine and other mediators are significantly elevated. In these cases, the ever-expanding line of ocular medications comes to the rescue.

In most severe ocular allergy cases, a prolonged break from lens wear is indicated. For others, it can be helpful to simply reduce wearing time and/or switch to daily disposables. Instruct patients not to rub their eyes; this avoids additional mechanically induced mediator release. Whenever possible, reducing environmental mediators is crucial to a successful outcome.

It is paramount to scrutinize the complete ocular surface when deciding to return the patient to lens wear. Once the patient returns to lens wear, medications that produce significant results with minimum dosing are ideal. Some eyedrop medicines can be used directly on contact lenses.  To ensure that patients properly comply when using medications, the drugs should be easy and convenient to use, safe for prolonged use, provide rapid and prolonged relief, and ideally prevent recurrence.

Allergic conjunctivitis in a patient with a reaction to tree pollen.

In the case of significant allergy where the signs and symptoms warrant more aggressive therapy, a combination step-up approach using a "soft" steroid in tandem with a mast cell stabilizer (or combination mast cell stabilizer/antihistamine) is well tolerated and effective in reducing the clinical ravages of allergic eye disease. Patients should be out of their lenses when using this approach but this should allow for a quicker return to lens wear after discontinuing the steroid. The mast cell stabilizer can be used as maintenance therapy while lens wear is initiated.

Lens Wear and Care
Several lens-related issues must be addressed to assure continued safe lens wear during flare-ups. It is important for patients to have a complete understanding of what they can expect with lens wear during allergy season, what can be done to help them, and how to minimize if not entirely avoid the problem. In addition to having the patient take a break from lens wear and providing relief to the ocular surface, practitioners must be relentless in educating their patients on lens maintenance, care and replacement.

Daily disposable lenses, now available in both spherical and toric powers, are ideal for patients who suffer from any form of allergic eye disease. Fortunately, patients are more likely to accept the cost of disposable lenses today. When lenses cannot be replaced on a daily basis, a solution regimen that minimizes lens deposition and has a reduced chance for additional adverse response is required. The oxidative systems remain in favor with practitioners for those patients who use frequent replacement lenses.

In addition to using daily disposables or frequently replaced lenses, gas permeable rigid lenses are another excellent option for patients with significant allergies if conjunctival trauma can be minimized. Gas permeable lenses are the mainstay of lens options for our patients with distorted corneas, as with keratoconus. Many of our keratoconus patients suffer from significant allergies, especially from April through October in our area. Pay careful attention to proper solution usage, adjunctive enzyme use, and lens edge design, especially as it addresses the palpebral conjunctiva. Using an alcohol-based cleaner and anti-allergy medications are key to providing adequate comfort for the extended wearing periods required for these patients. We will often employ a mast cell stabilizer or combination mast cell stabilizer/antihistamine during seasonal exacerbations.

Medical Treatment

Maintaining Lens Wear
Most of us are well-acquainted with the strategies we employ to minimize the cascade of events in allergic eye disease. But these familiar mantras are worth repeating, especially this time of year.
•	Proper patient education is key: advise patients not to rub their eyes.
•	Appropriate hiatus from lens wear is often mandatory.
•	Consider simple environmental modification; e.g., wash hair before bedtime (pollen collector), use air filters to minimize aero-allergens.
•	Topical agents are helpful in addressing insult to the ocular surface (includes frequent use of "chilled" artificial tears).
•	Frequent lens replacement (daily if possible), reduced wearing time and use of appropriate accoutrements are essential management components.
•	Be alert to potential masquerade syndromes.

When patients do not respond to seemingly appropriate therapy in a timely fashion, practitioners need to re-evaluate their diagnosis and treatment plan. First, rule out the masqueraders of ocular allergy: rosacea, medicamentosa, ocular surface infections (viral and bacterial), ocular pemphigoid and keratoconjunctivitis sicca.

Researchers are continuously making advances in medicines that provide better treatments to combat ocular allergies. In the near future, new sets of blocking antibodies and mediator binding agents will be available. Specifically, if we want to manage these patients successfully, it is crucial to choose the most effective and appropriate therapy, based on symptoms and severity of presentation.

With current new medicines, we can successfully treat ocular allergy and help our patients wear contact lenses comfortably all day along.  Contact lens wear can only exacerbate an already precarious situation. Addressing the underlying etiology of allergy with effective medicine treatment plus lens material and design of each patient, assuring that the ideal solution regimen is used and modulating the response of the ocular surface are key to keeping patients wear contact lenses successfully.