The Centers for Disease Control and Prevention (CDC) estimates that 45 million American adults wear contact lenses.1 As eyecare practitioners, our responsibility, care, and level of expertise do not stop at the prescribing of these lenses. It is our responsibility to also manage any potential adverse effects that could arise from or during their use.
It is suggested that allergic conjunctivitis affects roughly 40% of the population.2 This could equate to nearly 18 million contact lens wearers in the United States alone who are experiencing these symptoms.
Contact lenses can be a fantastic and convenient form of vision correction for patients as well as a very good source of revenue for an eyecare practice. Therefore, it can be beneficial on multiple faces to reduce contact lens dropout as much as possible. The comfort of contact lenses is one of the primary causes of lens discontinuation among patients, so this article looks to address this by reducing complications and discomfort from ocular allergies.
Allergic conjunctivitis can be separated into four main subgroups. Although there may be overlap in the signs present and the symptoms expressed by patients, they have different causative mechanisms and it is important to distinguish between them in order to accurately diagnose and treat our patients.
Seasonal or perennial allergic conjunctivitis
Seasonal and perennial allergic conjunctivitis cases typically ease and worsen depending on the time of year and their causative agents. Seasonal conjunctivitis usually occurs in the spring or summer months and can be brought on by pollen, grass, trees, hayfever, etc.
Conversely, perennial allergies can be experienced year round or can be worse during cooler months like autumn or winter and can be due to dust mites, pet dander, and other agents that we are around more when we are inside our homes.2
Allergies of this nature are brought on by a type 1 hypersensitivity reaction. In this process, after exposure to the triggering antigen, there is a rapid or immediate reaction of mast cell degranulation and histamine being released by an immunoglobulin E (IgE)-mediated process.
Patients presenting with this form of allergic conjunctivitis typically report bilateral, itchy, watery eyes. There may be serous or mucous discharge, chemosis, and hyperemia of the conjunctiva, edematous lids, and papillae present on the palpebral conjunctiva.3 Again, reports of these symptoms might vary with time of year due to their relapsing and cyclical nature.
Managing seasonal or perennial conjunctivitis
Patients experiencing seasonal or perennial conjunctivitis can benefit from topical and/or oral anti-allergy medications. Treatments that include antihistamines and mast cell stabilization components can be quite beneficial at calming the symptoms quickly and providing longer relief than antihistamines alone.
Drops in this combination category might include Lastacaft, Payday, Alaway, or Zaditor. If oral medication is recommended, it is important to remember the sedative side effects attributed to some older-generation formulations like Benadryl. Opting for newer formulas like Claritin, Allegra, or Zyrtec may have better drowsiness profiles.
Vernal keratoconjunctivitis (VKC)
The mechanism of VKC is poorly understood at this time, but it is believed to involve some components of the type 1 hypersensitivity reaction process discussed earlier.2 It is hypothesized that a combination of environment, genetics, and irritant allergens produce the condition.
Sufferers of VKC tend to be younger (teenage) males, and it is more common in warmer environments. Complaints are usually bilateral and may include thick, string-like discharge, and concurrent or previous atopy, asthma, or dermatitis. Conjunctival papillae are noted more superiorly in this condition and the limbus or cornea may become involved as chronicity and severity increases.
Corneal involvement may be seen by a sterile corneal “shield” ulcer superiorly or Horner-Trantas dots along the superior limbus, along with superficial punctate keratitis (SPK).3 Cases of VKC should be treated with a frequent topical steroid such as loteprednol, prednisolone, or dexamethasone to calm the initial storm of inflammation present.
Treating VKC in contact lens patients
Depending on the severity and signs present, some practitioners may also include antibiotic therapy if there is corneal involvement or cycloplegia to improve patient comfort and outcomes. Contact lens wear should also be discontinued during a VKC flare, and some patients may have already ceased use, as lens wear can be very uncomfortable during these episodes.
Allergy medications may also be considered in these patients to allow for longer-term maintenance and minimize the risk of relapses. Drops like the previously mentioned antihistamine/mast cell stabilizers of Lastacaft, Payday, Alaway, or Zaditor can allow good coverage of allergen control for VKC patients following resolution of the flare, and are typically dosed once or twice a day, depending on the formulation.
Atopic keratoconjunctivitis (AKC)
Similar to VKC, AKC has a mechanism of inflammation that is not fully understood today, but also has type 1 hypersensitivity processes. AKC can be affected by atopy (a genetic tendency to be affected by allergic conditions), a person’s environment, and genetics. AKC patients tend to be older, middle-aged male individuals, contrasting the common demographic associated with VKC.
These patients usually exhibit bilateral, mucous discharge or tearing, palpebral conjunctival papillae superiorly or inferiorly, and have a high concurrence of atopy or dermatitis conditions (more than 90% of affected individuals).2
AKC patients may also have signs of previous corneal complications, including:3
- Corneal neovascularization
- Corneal scarring
- SPK
- Keratoconus progression/development
Patients experiencing AKC may require management with a topical steroid drop like loteprednol or prednisolone. As atopic individuals may be more likely to experience allergic reactions and episodes, onboarding an allergy medication can be beneficial for them as well.
Many of these patients may already be using these medications orally due to their predisposed higher potential for allergies, so ensuring good coverage of antihistamine and mast cell stabilizers is helpful in managing their condition.
Giant papillary conjunctivitis (GPC)
The previously mentioned conditions may arise during contact lens wear, but they are not necessarily a reaction to the lens itself. Conversely, GPC, while not a classic allergy, is a response to mechanical contact with an irritant or allergen. This commonly comes in the form of a contact lens or a loose ocular suture. The chronic rubbing of the eyelids against the article causes an inflammatory reaction that concentrates in the area of irritation.3
Classically, large papillae can be seen on the superior tarsal conjunctiva with upper lid eversion. A pseudo-ptosis may also be present if the papillae are of significant size. If the GPC is caused by a loose suture, this area of papillary reaction may be more concentrated rather than diffuse across the whole palpebral conjunctiva, as is commonly the case with contact lens-induced cases.
Patients who wear reusable soft lenses like continuous or extended wear modality lenses may be more prone to experiencing GPC symptoms. Allergens can more readily adhere to these types of lenses if they are not cleaned properly or removed as frequently as recommended.
Patients suffering from GPC may complain of itchy, painful eyes, more with blinking or in the presence of an irritant, such as during contact lens wear, along with mucous discharge. This can lead secondarily to contact lens movement, awareness, or altogether intolerance. Depending on the causative agent, these symptoms may be unilateral or bilateral.
Managing GPC in contact lens patients
In these cases, lens wear may need to be discontinued for a period of time if it is the inciting agent. Patients with GPC may benefit from topical steroid management for a couple of weeks.
As the drop is tapered or discontinued, they should be observed for relapse of their signs and symptoms. For this reason, it can be beneficial to use a soft steroid as it may need to be used for a longer period of time, and patients may need to be tapered slowly.
If a loose suture is found to be the causative agent, its removal might be considered. However, depending on the reason for the suture, it may need to remain in place. In this situation, the ends of the suture can be trimmed to be as least bothersome as possible.
Further, proper hydration of the ocular surface may aid in less contact with the suture and the eyelids. There can also be other options to reduce the interaction of the lids and suture, but they will vary depending on the location of the suture and the reason for its presence.
Gaining a thorough understanding of allergies and contact lens intolerance
As listed above, some of the symptoms attributed to these conditions may be mild such as conjunctival hyperemia, tearing, or ocular irritation. However, if left unaddressed, these issues can progress to more visually inhibiting conditions such as scarring or ulceration. Beyond sight alone, these conditions affect our patient’s quality of life, ocular comfort, and contact lens performance.
With the cyclical nature of some types of allergic conjunctivitis, some patients may not report to our offices with these symptoms, especially if they are attributing them more to their seasonal allergies. It’s important that we understand these conditions well and know the correct questions that may elicit a response from someone who has been suffering in silence.
Asking contact lens patients the right questions about intolerance
Asking patients about eye rubbing can indicate areas of irritation that may be occurring. Careful examination of the eyelids, upper and lower, as well as bulbar and palpebral conjunctiva, can be very helpful in identifying inflammation.
Vital dyes such as sodium fluorescein and lissamine green can help distinguish areas of inflammation such as SPK, subtle papillae, eyelid inflammation, and more. Remember, especially in AKC, there can be high degrees of concurrent conditions such as asthma, atopic dermatitis, and systemic allergies.
It can be helpful to question patients about their contact lens comfort and performance during different times of the year as well as lens stability during wear, especially in cases of GPC. Discussion over current contact lens wear and hygiene habits might prove helpful in diagnosing a case of ocular allergies, but can also lend insight into areas to address during treatment or prevention.
Further considerations for contact lens patients with discomfort
If reusable contact lenses are being worn by a patient, allergens can be more prone to stick to the lens especially if they are not being effectively cleaned daily. For this reason, daily disposable lenses can show improved comfort for patients experiencing any type of ocular allergies.4
Certain preservatives in ophthalmic drops and solutions can cause ocular surface irritation and inflammation.4 Preservative-free options can be very helpful in these cases to remove a contributing factor to these reactions. There are a variety of reputable and safe artificial tear options over the counter for lubrication, as well as Clear Care Plus hydrogen peroxide contact lens solution for the cleaning of lenses.
The physical and historical presentations may have overlap or even co-exist, but differentiating them allows for more accurate and effective treatment. If an allergen can be identified or is known to have caused the issue, avoiding that can be of high priority. In contact lens-related cases, wear may need to be discontinued until symptoms resolve or improve.
Provide contact lens patients with long-term solutions
As we discussed, while only one of the previous conditions can be a direct result of contact lens use (i.e., GPC), all of them may be present in patients who are contact lens wearers. It’s therefore helpful to not only know the recommended treatment path, but how to concurrently manage their lens use.
In most of the above cases, contact lens use should be discontinued or may not even be tolerated by the patient during the active phase of their reaction. If/when lens wear is restarted, it can be helpful to discuss daily disposable contact lenses, if possible, to attempt to reduce the build-up of allergens on the lenses.4
If reusable modality lenses are being utilized, proper lens wear, care, cleaning, and hygiene are important to revisit. Solutions such as Clear Care Plus offer a preservative-free contact lens solution for those in active flares or patients who are more prone to these conditions.
If the topical drops that are recommended or prescribed are not contact lens compatible, the lenses should be removed prior to instillation, and patients should wait a few minutes to reinsert them. For patients using topical allergy eyedrops once or twice a day, it can be convenient to do them before and/or after wearing their contacts so they don’t have to remove them during the day to apply the drops.
To download a cheat sheet for patients with step-by-step instructions on how to insert and remove contact lenses and general hygiene tips, check out Contact Lens Care for Patients with Take-Home Instructions!
Treatment recommendations for contact lens patients with ocular allergies
Regardless of which of the above conditions a patient is suffering from, patients should be educated to avoid the causative allergen(s) if possible. They should also be discouraged from rubbing their eyes, which causes further mast cell degranulation and worsening symptoms.
If allergens are suspected to be accumulating in or on the eyelids and lashes, removing and cleaning this buildup is another area to manage. Wipes, foams, or sprays offer simple, convenient ways to break up this debris and remove it from near the ocular surface.
Solutions such as OcuSoft, Optase, Peeq, and Tear Restore have a variety of products in this area and they can be performed when patients brush their teeth or wash their face as good timelines to clean their eyelids.
Applying cool compresses and artificial tears frequently during the day may help alleviate ocular discomfort. In some of the cases discussed, over-the-counter (OTC) mast cell stabilizers, antihistamines, or combination therapies may be beneficial, such as Pataday, Lastacaft, Alaway, Zaditor, and more. In more severe cases, short-term topical NSAID or steroid treatment may be considered, such as loteprednol or prednisolone drops, for example.
Tips for prescribing oral allergy medications for ocular allergies
Oral medications remain an option for systemic treatment or very severe signs and symptoms, but again, remember to consider the sedative effects of the various generations if recommending these to patients as older versions may have higher risks of causing drowsiness.
As with all prescriptions, careful attention should be paid to the safety profile of the medication with regard to the patient's age, side effects, etc. Some of the previously mentioned medications may have separate formulations for children, such as Children’s Claritin and Children’s Xyzal. Others, such as Pataday or Alaway have age recommendations of older than 2 or 3 years old for their usage.
The risk of systemic absorption of topical eye drops is thought to be quite low, though many ocular steroids, as well as other drop classes, carry a category C rating for pregnancy and breastfeeding risk complications. This means that there is typically insufficient data to definitively say there is little/no risk from its use as it pertains to pregnant or nursing mothers and their children.
New topical therapies for ocular allergies
One newer interesting option of managing ocular allergies and irritation has come in the form of Optase Allegro. This new preservative-free eye drop from Optase is not a medication drop like those mentioned before, but rather uses its ingredients—ectoin and hydroxyethyl cellulose—to create a water barrier on the tear film. This works to minimize allergen penetration to the ocular surface and minimize discomfort as well as soothe present irritation.
Again, this drop is not directly impacting the mast cells, histamine, or other inflammatory components, but offers a unique option for patients of all ages as well as those who are pregnant, nursing, or contact lens users. This drop also can be applied over contact lenses which can be helpful in patients who are able to wear their lenses concurrently.
Conclusion
It seems like more and more I hear people stating their runny noses, coughs, and watery eyes are from allergies. While this can sometimes be the case, it is important to remember that this is not a catch-all term for the symptoms we experience or see in clinic.
As we’ve discussed and seen, there can be a lot of overlap between the different forms of ocular allergic reactions that may occur. As eyecare providers we can help distinguish the signs and symptoms for our patients. Through this, we can offer tailored treatments to ease their discomfort, help them better understand their own eyes, and keep them comfortable in contact lenses for a long time.
The views and opinions expressed in this article belong to the author themself and do not necessarily reflect those of their associated groups or organizations.
