Article Date: 8/1/2008

Create an Allergy-Ready Staff

Create an Allergy-Ready Staff

Educate your staff in these four areas to help you identify and appropriately treat allergy patients.

GLENN S. CORBIN, O.D., Reading, P a.

Allergic disease is the fifth leading chronic disease in the United States, among all ages, and the third common chronic disease among children younger than age 18, according to the American Academy of Allergy, Asthma & Immunology (AAAAI). In addition, a recent nationwide survey revealed that more than half (54%) of all U.S. citizens test positive to one or more allergens.1 Also, researchers believe that allergic rhinitis affects 20% of all adults and up to 40% of children.2 Further, roughly 50% of those who have nasal allergies said their ocular symptoms (red, watery and itchy eyes) were moderately to very bothersome, and 10% of these people reported that red, itching eyes were the most troublesome part of their allergies, according to HealthSTAR Communications' Allergies in America: A Landmark Survey of Nasal Allergy Sufferers, Executive Summary. (Visit: for additional information.)

Because these statistics reveal allergy as an epidemic that impacts one's quality of life, you, as a primary eyecare provider, should adopt an aggressive strategy toward identifying and treating allergic patients. This, in turn, will dispel many patients' belief that optometrists just prescribe spectacles and contact lenses and will bind patients to your practice not only for your allergy care, but for all their eyecare needs.

An "allergy-ready" staff (i.e. employees who start the patient education process regarding ocular allergy) is an essential component to identifying allergic patients for two reasons:

1. They are your eyes and ears, as patients see them first in the pre-testing area.

2. Your patients often view your employees as an extension of you and your abilities as an eyecare practitioner. Therefore, if your staff displays knowledge of allergy, your patients will know you have the education, skills and equipment to diagnose and treat allergy.

To make your staff "allergy ready," educate them in these four areas:

1. Ocular allergy causes

I've discovered that a Power-Point presentation and/or DVD that cover(s) the basics of seasonal and perennial allergic conjunctivitis and giant papillary conjunctivitis, among other ocular allergic reactions, are excellent educational tools. We know that these types of educational presentations have a positive impact on patients in understanding their disease, so we should expose our staff to the same level of education.

Also, consider sending or bringing your staff with you to optometric or ophthalmic trade shows, where they can attend continuing education courses on allergy.

Armed with this education, your staff will be able to ask and answer probing questions about allergy. Also, they'll be able to recognize its signs and symptoms, so they can make a note of it in the patient's medical record — passing the patient-education torch to you for the exam portion of the appointment.

An example of education the "allergy-ready" staff should possess: that genetics play a major role in allergy and, as such, information from patients regarding a family history of allergy is essential. For instance, if one parent has allergies, the risk of the child developing allergies is nearly 50%, according to the AAAAI.

The "allergy-ready" staff also uses this education to, for example, to counsel perennial allergy patients about the ways in which they can modify their environment to lessen the effect of allergens on their quality of life.

Consider sending your staff to optometric or ophthalmic trade shows, where they can attend continuing education courses on ocular allergy.

These suggestions:

► Use a vacuum with a high-efficiency particulate (HEPA) filter or double bag, since using standard or water-filtered vacuum cleaners stirs dust into the air.
► Remove wall-to-wall carpeting, if possible, as it's easier to rid dust mites from hardwood, laminate, tile and linoleum flooring.
► Regularly wash throw rugs in hot water or have them dry cleaned to rid dust mites.
► Regularly clean heating, ventilation and air conditioning (HVAC) ducts to eliminate dust mites and mold (another common allergen).
► Purchase allergen filters for the HVAC system to improve air quality.
► Encase mattresses, box springs and pillows in airtight, zippered plastic or special allergen-proof fabric covers to decrease the amount of dust mites.
► Cover comforters and pillows made of natural materials, such as down feathers or cotton, in allergy-proof encasings to minimize the presence of dust mites.
► Use a cleaning solution containing 5% bleach and a small amount of detergent on solid surfaces, that won't be damaged by bleach, to keep indoor molds and mildew at bay.
► If mildew is visible in carpeting or wallpaper, remove it from the house.
► Promptly repair and seal leaking roofs or pipes to keep indoor molds and mildew at bay.
► Never install carpeting on concrete or damp floors because of the increased risk of developing mold.
► Avoid storing clothes, papers or other items in damp areas because of the increased risk of developing mold.

2. Ocular allergy drugs

Have your staff read pharmaceutical company brochures regarding ocular allergy and the designated treatments, and consider scheduling educational meetings conducted by your pharmaceutical company representatives regarding treatment. Both types of education not only enable your staff to answer patient questions regarding treatment, but to initiate discussions with patients about the latest treatments. This, in turn, shows patients that you have the expertise and ability to prescribe ocular allergy medications — often prompting them to seek further information from you regarding a specific drug or drugs during the examination portion of their appointment. (See "Ocular Allergy Drops," below.)

Ocular Allergy Drops
An "allergy-ready" staff is familiar with the names, dosing and age of use of the available ocular allergy treatments.

Antihistamine/mast-cell stabilizer:
■ Azelastine hydrochloride ophthalmic solution 0.05% (Optivar, Meda Pharmaceuticals) Dosing: b.i.d. Age of Use: 3 yrs.+
■ Epinastine hydrochloride ophthalmic solution 0.05% (Elestat, Allergan) Dosing: b.i.d. Age of Use: 3 yrs.+
■ Olopatadine hydrochloride ophthalmic solution 0.2% (Pataday, Alcon) Dosing: q.d. Age of Use: 3 yrs.+
■ Olopatadine hydrochloride ophthalmic solution 0.1% (Patanol, Alcon) Dosing: b.i.d. Age of Use: 3 yrs.+

Topical corticosteroid:
■ fluoromethalone ophthalmic suspension (FML, Allergan) Dosing: q.i.d. Age of Use: 2 yrs.+
■ loteprednol etabonate ophthalmic suspension 0.2% (Alrex, Bausch & Lomb) Dosing: q.i.d. Age of Use: "safety and effectiveness not established in pediatric patients."
■ loteprednol etabonate ophthalmic suspension 0.5% (Lotemax, Bausch & Lomb) Dosing: q.i.d. Age of Use: "safety and effectiveness not established in pediatric patients."

Mast Cell Stabilizer:
■ Nedocromil sodium ophthalmic solution 2% (Alocril, Allergan) Dosing: q.i.d. Age of Use: 3 yrs.+
■ Pemirolast potassium ophthalmic solution 0.1% (Alamast, Vistakon Pharmaceuticals) Dosing: q.i.d. Age of Use: 3 yrs.+

■ ketotifen fumarate ophthalmic solution (Alaway, Bausch & Lomb) Dosing: b.i.d. Age of Use: 3 yrs.+
■ ketotifen fumarate ophthalmic solution (Zaditor, Novartis, Ophthalmics) Dosing: b.i.d. Age of Use: 3 yrs.+
■ ketotifen fumarate (Refresh Eye Itch Relief, Allergan) Dosing: b.i.d. Age of Use: 3 yrs.+

In addition, this staff education shows patients that you can prescribe medications for other ocular issues, such as glaucoma or age-related macular degeneration, should they or a family member develop these diseases.

Further, provide education regarding the adverse events of allergy medications, so your staff can educate your patients about these issues and let you know of any suspicions they may have regarding a patient's signs and symptoms during the pre-exam.

An "allergy-ready" staff is aware that:

► topical vasoconstrictors can provide rapid relief, especially for ocular redness; however the relief is often short-lived, and overuse may lead to rebound hyperemia and irritation.3 In addition, these drugs may place narrow-angle glaucoma patients at increased risk for pupillary block, as they cause pupil dilation. Also, this class of allergy medication may exacerbate systemic hypertension by constricting arteries and increasing blood pressure.
► chronic preserved ocular allergy drop use can cause dry eye. Benzalkonium chloride (BAC or BAK) is the typical culprit.4,5
► oral antihistamines, including prescription formulations, may worsen existing dry eye issues that often complicate allergy symptoms with various forms of tear film dysfunction or conjunctival hyperreactivity.6
► topical mast cell stabilizers are effective, though they generally have a slow onset of action.4
► severe seasonal ocular allergy symptoms, such as corneal necrosis (shield ulcers), among other damaging inflammatory changes may warrant the temporary use of topical corticosteroids. Long-term use, however, puts the patient at risk for ocular adverse effects, such as cataract formation and glaucoma.3

3. Allergy patient history

If your staff conducts the patient history portion of the exam, Educate them that the question: "do you suffer from allergies," isn't enough to identify allergy patients, unless the patient is experiencing allergic signs and/or symptoms at the time of his appointment. Why?

1. Because the signs and symptoms of allergy often aren't constant, many undiagnosed allergy patients either infer that their occasional runny nose and watery, itchy eyes are a normal part of the biological process or that they've simply experienced a bout with the common cold.
2. They become accustomed to their allergy signs and symptoms, never giving them a second thought.

The "allergy-ready" staff knows this, and uses this information as well as the education they've acquired regarding ocular allergy causes and ocular allergy medications to ask both the contact-lens wearing and non-contact lens wearing patient the following specific questions:

► "Do your parents or other family members have allergies?"
► "Do you ever throughout the course of the year suffer from periods of itching, redness, tearing or lid swelling?"

(By using the phrase "throughout the course of the year," your staff alerts the patient to really think back to any point in which he may have experienced these allergy signs and symptoms.)

► "Do you take any over-the-counter (OTC) allergy eye drops or oral allergy medication during the year?"

(Typically, patients fail to list OTC medications on patient history forms because they're not prescription medications, and thus, in their mind, unimportant to mention. When your staff makes a point to verbally ask this question and explains why they've asked it — using the education they've obtained on the adverse effects of both oral and topical allergy medications — patients are quick to volunteer this information, and they often cease their "self-prescribing" practices.)

4. Eyelid eversion

An "allergy-ready" staff knows how to perform eyelid eversion to give the O.D. a heads up regarding palpebral conjunctival changes, such as papillae or follicle formation, which are the hallmark of ocular allergy, such as giant papillary conjunctivitis (GPC). This skill not only separates your staff from the staff's of other neighborhood optometric practices — encouraging patient referrals — but, again, reveals to patients that ocular allergy is your jurisdiction.

By providing my staff with the four aforementioned areas of education, they've helped me to show patients that I'm the go-to O.D. for allergy, among other ocular issues. This has created patient loyalty and several referrals. Patient satisfaction is certainly nothing to sneeze at. OM

References furnished upon request.

Dr. Corbin practices in Reading, Pa. and is an adjunct faculty member at the Pennsylvania College of Optometry at Salus University. He's also a consulting staff member at HealthSouth Reading Rehabilitation Hospital. E-mail him at

Optometric Management, Issue: August 2008