The Top 10 Questions For Ocular Allergy Patients
A thorough interview provides the cornerstone for effective management.
By Robert Murphy, Contributing Editor
A time-honored tradition in medicine going back at least to the days of Hippocrates and his colleagues holds that the patient history ranks among your most resourceful diagnostic exercises. This is most clearly the case in instances calling for a meticulous differential diagnosis, in which carefully tailored questions may elicit answers that help guide the rest of the examination and rule out all but the most likely diagnosis.
It is likewise pivotal in the case of allergic conjunctivitis, not so much for differential diagnosis — the itching, redness and swelling that attend the condition are practically pathognomonic — but rather in guiding your management approach and patient education. The patient history for those with ocular allergy is especially useful in helping patients avoid excessive allergen exposure in the first place and thereby preventing the impetus for the allergic pathological cascade.
Key questions have to do with determining if possible the allergens to which a patient tends to be vulnerable, the seasons of the year or times of the day when allergic symptoms are worst, and critically, the nature of the patient's work and home environments. A key distinction divides the most troublesome allergens between those found outside and those commonly encountered indoors.
A thorough medication history is likewise critical — what worked well in the past, and what proved of little value? This clearly is helpful in selecting an effective treatment regimen. “You don't need to reinvent the wheel,” says private practitioner John D. Sheppard, MD, MMSc, who is also a professor of ophthalmology and clinical director of ocular pharmacology at the Eastern Virginia Medical School in Norfolk, Va. In other words, why experiment when you already know what treatment has brought symptomatic relief in previous allergic episodes?
In the discussion that follows, ophthalmologists with extensive experience in treating ocular allergy offer their suggestions on how to take a generative patient interview for those presenting with manifestations of allergic conjunctivitis or a history of prior flare-ups. Prevention remains a paramount goal, even as effective anti-allergy ocular medications may serve usefully either in a prophylactic or abortive capacity. The sidebar, “Allergy by Numbers: Pollen Counts,” offers tips on how patients can consult the Internet for updates and forecasts on pollen counts not only in their community, but also in places to which they may soon travel.
|A 12-Step Program for Allergy Patients|
|Ophthalmologists not only can help relieve an allergic conjunctivitis patient's symptoms through the use of effective anti-allergy eye drops and other medications. They can also offer useful advice on how to avoid or mitigate a flare-up through commonsense lifestyle changes and other practical measures.|
What follows are 12 tips that you may wish to recommend to patients:
1. Never rub your eyes. Unfortunately, the average adult touches their face up to 16 times per hour, and far more for those with allergies or for children.
2. Wash your hands regularly: thus when you actually do rub your eyes, you will not self-innoculate with allergens.
3. If your allergies are bad in the morning, check for down or feather pillows, and switch to allergy-free pillows.
4. During your worst allergy season, remain indoors with filtered air-conditioning to reduce antigen exposure.
5. If your allergies are limited to your eyes, use drops, not pills. If limited to your nose and sinuses, use nasal sprays, not pills.
6. Avoid over-the-counter remedies that “get the red out.” They invariably contain vasoconstrictors, chemicals that quickly induce dependence. Withdrawal will occur with a temporary worsening of the redness when stopping these medications. Not only that, chronic regular use is extremely bad for mucous membranes in the eye and the respiratory passages. These products have been “grandfathered” and would never be approved by the FDA under modern screening protocols.
7. Chill your drops to provide added comfort and efficacy: cool temperatures are a chemical-free vasoconstrictor.
8. Use cool compresses with a fluid-filled face mask to alleviate symptoms instead of rubbing.
9. Use your allergy eyedrops before visiting allergic places or working in the garden during allergy season, rather than waiting until the itching and redness begin.
10. Put your pet out of the house or at least out of your bedroom.
11. Know your own personal hypersensitivities and avoid contact accordingly, especially when local pollen counts are high.
12. Ask your doctor to try prescription Singulair tablets (montelukast, Merck), an excellent anti-allergy medication that is not an antihistamine and is completely nonsedating. It becomes generic in August.
|—John D. Sheppard, MD|
Top 10 Allergy-Related Questions
Physicians naturally have their own favorite approach to taking a history that elucidates the specific factors that initiate or exacerbate a patient's ocular allergy symptoms. Dr. Sheppard offers a useful list that can help you establish a basis for pertinent follow-up questions and, ultimately, recommend appropriate preventative or therapeutic measures. The items may lack the wit of David Letterman's signature top-10 lists, but allergy sufferers come to you for symptomatic, not comic, relief. The list is not exhaustive; you may wish to add one or two further questions of your own.
1. What are you specifically allergic to: pollens, pets, mold, dust, chemicals, foods?
This question mostly has to do with prevention. If you know what you're allergic to, you can either try to avoid it, or else initiate prophylactic treatment.
Let's say your worst antigen is pollen causing seasonal allergic conjunctivitis. “If you know you're going to be outside, at a picnic or a soccer game, you may want to use your anti-allergy eye drops before you leave home, give it time to work, and prevent the allergy cascade from starting, rather than retroactively treat an inflamed eye,” says Cynthia Matossian, MD, a private practice ophthalmologist in Mercer County, NJ, and Bucks County, Pa., and an adjunct clinical assistant instructor in ophthalmology at Temple University.
Then there are the ever-present allergens responsible for perennial allergic conjunctivitis. No one wants to jettison a beloved pet, yet cats are especially troublesome. “Cat dander is the stickiest antigen on the planet,” Dr. Sheppard says. “Cat dander gets all over the house just by foot traffic.” His own solution for his cat: outside.
Dust is a notorious perennial culprit, and it's practically everywhere. Here, the chief problem has to do with a dust mite's digestive droppings. “The dust mite has a simple gut,” says Peter D'Arienzo, MD, a private practitioner in Manhasset, NY, and a clinical assistant professor at New York Medical College. “They eat skin, so they need certain enzymes called proteases to break it down in the stomach. These enzymes are so strong they actually persist in the fecal contents. In the droppings, it's the proteases that cause sensitization of the allergic reaction.”
2. What time of the year are your allergies the worst?
This question, pertaining chiefly to seasonal allergy, likewise lends itself to preventative measures. “Seasonal allergic conjunctivitis is more commonly related to pollen exposure,” Dr. D'Arienzo says. “So if they have more itching in March, April or May, they can be sensitive to tree pollen. If the symptoms are worse in June and July, it could be a sensitivity to grass pollen. If their itching is worse in September and October, it could be ragweed.”
Patients who are aware of their worst allergy season can prepare by starting on anti-allergy eye drops before the most troubling months arrive, and thereby prevent an allergic cascade.
3. Are your allergies bad upon awakening in the morning?
“That tells me they have down or feathers in their pillows, or there's something in the bedroom,” Dr. Sheppard says. He recommends instead widely available allergy-free foam pillows. “You have to look at the labels, because some people have down pillows and don't even know about it.”
If a pet enjoys indoor privileges, at least keep it out of the bedroom, especially at night. Patients should wash their bedding frequently in very hot water to rid it of allergens; otherwise, they're inhaling some degree of dust or other antigens all night, especially from the pillow. Patients who report significant symptoms after vacuuming their carpets may benefit from using a vacuum cleaner with a HEPA filter to decrease dust levels, Dr. Matossian says.
Those who have been outside for long stretches should shower before bedtime to wash away antigens. Frequent and thorough hand-washing throughout the day is also important; then, if the patient happens to touch or rub the eye, there is less risk of self-innoculating. Hand-washing is particularly important for children, who love to get dirty and hate to follow instructions about eye rubbing.
4. Have you had antigen skin testing to determine specific hypersensitivities?
Many patients know intuitively by experience which antigens cause the most trouble. Yet, there's no more precise way to identify a patient's worst allergens than by an antigen skin test, typically performed by an allergist. Here again, the point of this question centers on prevention. Simpler RAST testing of a blood sample may also offer clues to specific hypersensitivities.
5. Do allergies limit you at work or in your avocations?
Here you get into livelihood and lifestyle, which can get tricky. People who like their jobs and are skilled at them will not wish to quit because of allergies. Both indoor and outdoor occupations may be troublesome. Poorly ventilated air-conditioning or heating ducts can disseminate dust throughout an office. Likewise, landscapers and other outdoor workers remain vulnerable to nature's antigenic ravages.
These inescapable perennial and seasonal allergy sources may likewise call for preventative treatment with an anti-allergy eye drop.
6. What eye drops or oral medications are you taking?
Medication history is a critical task usually relegated to a staff member. Many patients self-medicate with vasoconstricting decongestants such as Visine A, Clear Eyes or Naphcon A. These may “get the red out,” but because they contain weak antihistaminic properties, they fail to address the underlying problem.
Drops such as Visine A can also lead to physical dependence and potential adverse events if used long enough. “They contain vasoconstrictors, chemicals that quickly induce dependence,” Dr. Sheppard says. “Your blood vessels become dependent on those vasoconstrictors, so it's extremely difficult weaning people off such a powerful chemical dependence. Withdrawal will occur with temporary worsening of the redness. Chronic, regular use is extremely bad for mucous membranes in the eye and the respiratory passages. These products have been ‘grandfathered,’ and would never be approved by the FDA under modern protocols.”
Then there's the case of oral medications. For one thing, if the patient's symptoms are limited to the eye, it's a matter of overkill. “It's like using a cannon to kill an ant,” Dr. Matossian says. Oral antihistamines are also notorious for drying the eye, which can worsen allergic conjunctivitis through multiple mechanisms.
7. What eye drops or oral medications have worked well for you in the past?
This gets back to Dr. Sheppard's advice not to reinvent the wheel. Go with what has been known to work in the past.
8. What eye drops or oral medications have not worked well for you in the past?
The flip side of question 7, this one basically says, why repeat past failures?
9. Have you changed medications, detergents, cleaners, make-up, cologne or diet recently?
This question pertains to both a type I IgE-mediated immediate hypersensitivity, as well as a type IV delayed response in the form of contact dermatitis. This can manifest in the lids and periocular facial tissue as an erythematous, excoriated, often hyperpigmented “mask,” and therefore requires attention from a vigilant ophthalmologist.
10. Do you have pets, and where do they stay in the house? Do they sleep in your bed?
If your patient is allergic to animal dander, the best step may be to keep the pet outdoors as much as possible. At the very least, patients should keep the animal out of the bedroom, and especially avoid welcoming it as a bedmate.
Absent from this list, yet highly germane to the matter at hand, is another key factor: contact lens wear. It's well-known that contact lenses can exacerbate ocular allergy through multiple mechanisms. Here, the best step may be to recommend daily wear disposables. “The more frequently you replace the lenses, the better,” Dr. D'Arienzo says. “Put it in in the morning, and at the end of the day, throw it out. The pollen can accumulate in the lens, so this way, they're not exposing themselves.”
|Allergy by Numbers: Pollen Counts|
Numerous websites offer daily updates on pollen counts according to ZIP code, providing allergy sufferers with alerts about the antigen load in their community and elsewhere in the United States. One of the best is www.pollen.com. Simply type in your ZIP code or that of your destination, and you get a wealth of data regarding pollen counts and other allergy-related conditions, both for the present day and over the next several days, not unlike a weather forecast.|
“It gives you an amazing amount of information regarding the different allergens, their concentrations, and severity,” says Cynthia Matossian, MD. “There are bar graphs that clearly outline what's going on. There's one option that compares city 1 with city 2, or ZIP code 1 with ZIP code 2.
A free smart-phone allergy-alert application makes this information easily accessible no matter where you go. “It gives you an in-depth easy-to-follow synopsis of allergy triggers,” Dr. Matossian says. “They track allergy conditions like pollen counts, asthma, cold and cough, and UV sensitivity.”
Patients with severe hypersensitivity to certain pollens or other antigens may wish to consult such websites, and if necessary, perhaps adjust their schedule or plans accordingly. A golfer, for example, may wish to postpone a round to later in the week if the pollen count is sky-high on the day of the scheduled game. Someone traveling out of town can check the data pertaining to their destination, and perhaps prepare by starting on an anti-allergy drop before arriving.
For a broader educational resource, Dr. Matossian also recommends the American Academy of Allergy, Asthma, and Immunology website. “It's easy to navigate; you don't have to be a physician to find your way around the website,” Dr. Matossian says. “It's clear, very well organized. And I think that is a good source for patients if they want to learn more about their allergy.” Clearly, a well-informed allergy patient will be better prepared to take the necessary measures to mitigate their suffering and get on with their life.
Q&A Can Save the Day
It's well worth your while to sit down with an allergy patient and gain a specific sense of the nature of their allergic condition. Not only does it help tailor a treatment regimen commensurate with the case at hand, but it also sets the stage for useful patient education on how to minimize antigen exposure. (See sidebar, “A 12-Step Program for Allergy Patients.”)
The patient interview also provides useful diagnostic data which you can pass along to an allergist if a referral is indicated. Bear in mind that the patient history in cases of ocular allergy may be the most important part of your evaluation, and therefore calls for diligent and thorough attention. OM