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A salve for sore eyes.

The Problem

A 36-year-old female with seasonal allergies presents with a several-week history of worsening symptoms. Her allergic symptoms are more severe in the spring and are characterized by eye irritation, sneezing, rhinorrhea, and an itchy palate. Her eye symptoms have been particularly severe at night. She has a cat with which she is unwilling to part. She denies wheezing and cough. She has been on fexofenadine for several years and was recently started on a nasal steroid and artificial tears in an attempt to control her eye symptoms. With regard to her eyes, she denies a.m. mattering, sick contacts, foreign body sensation, vision changes, or eye pain. On examination she has conjunctival injection, eyelid swelling, and clear copious eye secretions. Neither the nasal steroid nor artificial tears has improved the patient's symptoms, and she is wondering if additional therapies exist that would provide relief You wonder if an ocular therapy would be better than the nasal steroid.

The Question

In patients with allergic eye symptoms, is topical eye therapy more effective than nasal steroids?

The Search

You go to PubMed (www.pubmed.gov) and search "allergic conjunctivitis AND drug therapy." You limit to randomized controlled trials.

Our Critique

The study capitalizes on a rigorous laboratory technique for elicitation of allergic ocular symptoms. The authors concluded that fluticasone was not as effective as artificial tears for the reduction of itching, redness, and chemosis. As the authors discuss, the optimal trial design would have been a head-to-head comparison between olopatadine and fluticasone with the incorporation of a double-dummy design with eye drop patients receiving saline nasal sprays and nasal spray patients receiving saline eye drops. The lack of control for the subjects receiving nasal preparations may have enhanced the perceived benefit of ocular medications. In the clinical setting, the cost of olopatadine may be a significant barrier to the use of this medication (5-mL bottle costs $100).

Clinical Decision

You discuss with the patient the findings from the study and suggest that she may benefit from this medication. You prescribe the medication. She calls you several weeks later to tell you that her symptoms are 70% better and that she still has the cat.

The Evidence

Rosenwasser LJ, et al. A comparison of olopatadine 0.2% ophthalmic solution versus fluticasone furoate nasal spray for the treatment of allergic conjunctivitis. Allergy Asthma Proc. 2008;29:644-53.

* Design and setting: Randomized, placebo-controlled, parallel clinical trial conducted in a single center in North Andover, Mass.

* Patients: Potential subjects were eligible for enrollment if they were younger than age 18 years and had a history of allergic conjunctivitis; had a positive skin test to cat hair/dander, grasses, ragweed, or trees; had normal visual acuity; were willing to avoid wearing contact lenses for 3 days before and during the study; and were willing to refrain from using disallowed medications. Potential subjects were excluded if they had allergies to any of the study medications, had ocular or systemic diseases; had used systemic or ocular antihistamines, vasoconstrictor drugs, decongestants, immunotherapies, monamine oxidase inhibitors, artificial tears, lid scrubs, mass cell stabilizers, prostaglandins, or ocular nonsteroidal anti-inflammatory drugs within 7 days of study initiation; had used inhaled, ocular, topical, or systemic corticosteroids within 2 weeks or depocorticosteroids within 45 days of study initiation

* Intervention: Enrollment was based upon the conjunctival allergen challenge (CAC) test involving the instillation of allergen into the eyes. Itching, redness, chemosis, mucus discharge, and eyelid swelling were assessed at 7, 15, and 20 minutes. Subjects were randomized to fluticasone furoate nasal spray; olopatadine 0.2%; artificial tears; or saline nasal spray

* Outcomes: A trained technician applied the medication and the CAC was performed bilaterally (visit 3). Subjects were given study medication and dosing diaries for 6 days. On the seventh day (visit 4), the allergen was in stilled and the CAC was repeated.

* Results: Olopatadine demonstrated significantly greater reductions in ocular itching over the other groups at all time points except for the 7-minute time point, compared to artificial tears at visits 3 and 4. For ocular redness, olopatadine was statistically superior to fluticasone at all visit 3 post-CAC time points. Olopatadine was statistically superior to fluticasone at all visit 3 and 4 post-CAC time points for chemosis and tearing and for lid swelling at all visit 4 post-CAC time points. Fluticasone did not demonstrate differences, compared with placebo nasal spray, at any time point. All treatments were safe and well tolerated.

BY JON O. EBBERT, M.D., AND ERIC G. TANGALOS, M.D.

Dr. EBBERT and DR. TANGALOS are with the Mayo Clinic in Rochester, Minn. They report having no conflicts of interest. To respond to this column or suggest topics for consideration, write to Dr. Ebbert and Dr. Tangalos at our editorial offices or e-mail them at imnews@elsevier.com.
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Title Annotation:MINDFUL PRACTICE
Author:Ebbert, Jon O.; Tangalos, Eric G.
Publication:Internal Medicine News
Geographic Code:1USA
Date:Aug 1, 2010
Words:798
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