Allergy

Allergy is a modern pandemic. Incredibly, nearly 1 in 2 or 3 people seem to suffer from some form of allergy these days.

 

No one seems quite sure why it has become quite so common. Perhaps it is something to do with more hygienic clean living standards which prevail. There is certainly a genetic basis.

 

Do you suffer with allergic rhino-conjunctivitis?

Do you have atopy - the allergy trio of eczema, asthma and hayfever?

Or does it run in the family?

 

Well, if you do - you have my sympathy. No one needs painfully sore streaming red eyes at work or during the exam season.

 

Here is my suggested approach to help.

 

The diagnosis of allergy is usually easy and already clearly established; but it is not always so obvious especially if mild.

 

The symptom list is a classic.

 

Eyes which are itchy, rubbed frequently, and twitchily blinking excessively are very common. As allergy worsens, patients are likely to experience fluctuating vision, redness, photosensitivity, and stringy mucoid discharge. Quite often, but not always, the nose will be suffering too, runny and sneezy in abundance.

 

It is important to establish whether there is any seasonal variability or flare-ups observed when exposed to certain 'things' - as these are the clues to the likely allergens. It is usual for there to be several: house dust mite, various different pollens, mold spores, animal dander are the commonest. Formal allergy skin prick tests can be undertaken where there is doubt.

 

What medicines have been tried already? Probably antihistamines such as cetirizine, may be a nasal spray and cromoglycate eye drops. If you have read this far it is likely they aren’t working well enough.

 

The purpose of any medical consultation is to confirm an accurate diagnosis, and by examination determine the exact disease severity. It is equally important then to empower patients with knowledge about the condition so as to take back control.

 

A good baseline to assist simple monitoring is to start a personal subjective discomfort score, out of ten: 10/10 would be horrendous, 1-2/10 mild, and 0/10 as the eyes should be, the target, perfectly comfortable.

 

A step-wise therapeutic ladder should be adopted.

 

In mild ocular allergy, I recommend either preservative free artificial tears (mechanical flush and comfort restorer, eg Xailin Fresh), or preservative free Catacrom x4/day both eyes (mast cell stabiliser, attempts to prevents histamine release). For more moderate disease activity, useful also for busy patients, we now have - new to the market - preservative free Ketofall (mast cell stabiliser and anti-histamine double action) which is needed just twice a day. Note the preference for preservative free, which is important on an already sensitised and sore eye.

 

If this isn’t quite enough, and exacerbations break through, when these are predicted to be short (eg very high pollen count in the summer), then the next best step is to have a reserve of preservative free steroid eye drops on hand to be used in short bursts. Softacort (mild) would be first defence in line, Dexafree (strong) second guard in more severe cases. They will work quickly and effectively, and may be used anything from a couple of times per day, most usually 4 times per day, but even hourly if needed. Aim for short courses of no more than a few weeks; occasionally longer ccourses are required for severe or corneal ulceration involving disease. The all abiding rule with steroids is this: if they are needed, an ophthalmic check-up is required to ensure there are no side effects (raised eye pressure can occur in around 20% and undetected could cause glaucoma; cataract is much rarer).

 

Nasal steroid spray (eg Avamys) can be a really useful addition. Not only does it dampen the nose symptoms, but by doing so somehow relieves the eyes in tandem (and with no ocular side effect risk).

 

A simple thing to try is the barrier approach of Vaseline at night to eye lids and smear around nostrils. Some relief may had in applying cold compresses.

 

I would recommend supplementing the diet with local honey if you have seasonal pollen-type allergy, and at some point try a month of dairy free if allergy is perennially present, persisting all through the year.  House dust mite reduction strategies are also important with regular hoovering (HEPA filters, eg Dyson) and steam cleaning (eg Polti).

 

Youngsters may stand a fair chance to out-grow immunological hypersensitivity over the years towards puberty. Sadly, adults can often expect to suffer for decades before also sometimes eventually seeing a natural wane.

 

For allergy which is at its most severe - requiring regular or prolonged steroids, substantially reducing quality of life - then I have no hesitation to recommend topical ointment cyclosporine 0.2% twice daily. It works really well, and side effects are rare in my experience. Note this medicine is quite expensive (~£70 per month); and the quirk, that this preparation was originally produced for canine use, but since has happily transferred over for humans many year ago.

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If the eyelid skin is eczematous, dry, cracked or fissured, a similar ointment medicine called  Protopic 0.03% is to be called upon.

 

There are but 3 last big guns, fortunately rarely required, and all subject to being undertaken under the expert auspices of an immunologist: Immunotherapy, second-line immunosuppressants and biologics. The former is a desensitisation programme undertaken over 3 years whereby grass pollen is taken either sublingually under the tongue or as a subcutaneous injection. The latter represent traditional and newer agent targeted powerful immunosuppressant therapies.