Use this grading scale to fine-tune your diagnosis and treatment plan.
Allergic eye disease is perhaps the best example of a condition that requires keen observation of the signs and symptoms of inflammation to determine the most effective treatment option. The attached grid is designed to help you make appropriate decisions when faced with this complex condition.
In this article, I'll provide a brief overview of my therapeutic approach.
Gauge the Inflammatory Response
Allergy patients with few or no signs of inflammation are best served with a combination antihistamine/mast cell stabilizer, such as epinastine HCl ophthalmic solution 0.05% (Elestat), azelastine HCl ophthalmic solution 0.05% (Optivar), olopatadine HCl (Patanol) or ketotifen fumarate ophthalmic solution 0.025% (Zaditor).
When I see moderate signs of inflammation, such as conjunctival injection, chemosis, erythema and lid edema, I turn to a steroid with allergic eye disease indications, such as loteprednol. etabonate 0.2% (Alrex). Often, I'll start a patient on loteprednol q.i.d. and 1 to 2 weeks later, I'll prescribe a combination antihistamine/mast cell stabilizer.
Address the Cascade
If we look at the inflammatory components of allergic eye disease and the mechanism of action of the various medications, we see that steroids affect all the components of the cascade. Synthesis involves prostaglandins, cytokines and leukotrienes, all of which can be controlled only by a medication that affects the arachidonic pathway. Late-phase involves inflammatory mediators, which then recycle the process again. Only a steroid medication can affect all these components in all phases of the allergic cascade.
Besides signs, the severity of a patient's symptoms also factors into the therapy I choose, and I'll consider a steroid medication for patients with moderate to severe symptoms. I consider all of the following complaints at least moderate in nature:
* Inability to sleep
* Inability to work
* Inability to read
* Inability to drive
* Inability to participate in normal life activities.
When you question patients about their allergy symptoms and their ability to engage in activities of daily living, you'll be astounded by how many tell you they're having these problems.
The final situation in which a steroid drop, such as loteprednol, is most effective is when patients are in the synthesis mode or if they've had allergy symptoms for a week or longer.
Pocket Guide for Clinicians
Looking for signs of inflammation, such as redness, chemosis and edema, as well as moderate symptoms or duration of the allergic condition will aid clinicians in effective allergic eye disease management. Use the attached treatment grid as another guide in therapeutic management.
BY PAUL M. KARPECKI, O.P., F.A.A.Q.
Kansas City, Mo.
Dr. Karpecki is director of research for Moyes Eye Clinic in Kansas City, Mo. A noted educator and author, he lectures on new technology, surgical advances and therapeutics. He is a paid consultant to Bausch & Lomb.
Copyright Boucher Communications, Inc. Aug 2005
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