Article Date: 2/1/2010

Nasal Effects of Ocular Allergy Medications

Nasal Effects of Ocular Allergy Medications

Learn about the action of antihistamine/mast-cell stabilizing eye drops and how they may improve your management of patients who have allergies.

Optometric Management Staff

It's certainly no surprise to optometrists that ocular allergy is a common condition.1 In particular, in most practices, a day seldom goes by without one or more patients presenting with a chief complaint of symptoms related to seasonal or perennial allergic conjunctivitis. Using the currently available gold-standard prescription antihistamine/mast-cell stabilizing eye drops, doctors can provide fast and effective relief from such symptoms as itchy, red eyes.

Some, however, prefer to look beyond the eyes and also talk with patients about other allergy symptoms they may have. When they do, they find that ocular and nasal allergy symptoms often occur together.1-3

According to Paul M. Karpecki, O.D., F.A.A.O., Lexington, Ky., it's important to know if patients have allergy symptoms other than ocular so he can ensure they receive the most complete care. “The classic dilemma for optometrists is that patients with rhinitis, itchy palate, etc., are typically prescribed oral antihistamines, which are known to dry the eyes, actually exacerbating the primary complaint,” he says.


Can drops do double duty?

The recent FDA approval of a new antihistamine/mast-cell stabilizing eye drop has renewed interest in the previously explored concept that this class of medications may alleviate not only ocular but also nasal symptoms. “Being able to address nasal symptoms with an eye drop instead of an oral medication with its accompanying drying effects would be advantageous,” Dr. Karpecki says.

“ For severe nasal symptoms, however, nothing works better than a nasal medication. For severe ocular symptoms, nothing works better than an eye drop. ”

Alan G. Kabat, O.D.

The effects of the new medication, bepotastine besilate ophthalmic solution 1.5% (Bepreve, Ista Pharmaceuticals, Inc., Irvine, Calif.), on nasal symptoms were assessed as a secondary endpoint in two phase III, 7-week, masked, randomized, placebo-controlled clinical studies that led to its approval by the FDA for the treatment of itching associated with allergic conjunctivitis. Both studies — one single-site and one multi-site (n=157) — used the conjunctival allergen challenge (CAC) model of allergic conjunctivitis. Total nonocular composite symptom score (TNSS) was evaluated for each patient. The TNSS was defined as the sum of nasal congestion, rhinorrhea, nasal pruritis and ear and/or palate itching.

The consolidated results from the two studies have not been published yet, but according to Ista, bepotastine demonstrated a 77% reduction from baseline in TNSS within 7 minutes after dosing (clinical and statistical significance vs. placebo [P ≤ 0.001]). In addition, bepotastine demonstrated an 82% reduction from baseline in TNSS at 8 hours after dosing (clinical and statistical significance vs. placebo [P ≤ 0.001]).

Earlier studies

Data on nasal effects are available for two previously approved antihistamine/mast-cell stabilizing drops, as well. The nasal effects of olopatadine HCl ophthalmic solution 0.2% (Pata-day, Alcon Laboratories, Inc., Fort Worth, Texas) were evaluated in two randomized, placebo-controlled, double-masked, hybrid environmental studies.4

The two studies had a combined enrollment of 500 patients with histories of seasonal allergic conjunctivitis or rhinoconjunctivitis. One of the studies was conducted over 10 weeks in the spring. The other was conducted over 12 weeks in the fall. In both studies, patients assessed their ocular signs and symptoms. In addition, patients in the spring study reported the frequency of their nasal symptoms, and patients in the fall study reported the frequency and severity of their nasal symptoms. Each day during the studies, ragweed (fall study) or grass (spring study) pollen counts were obtained from each investigative center. Slope analyses were performed on the nasal symptom assessments by pollen count.

When To Refer

Warner Carr, M.D., an allergist practicing in Mission Viejo, Calif., recommends that eyecare specialists refer patients to an allergist whenever there is a strong suspicion of allergy.
“Allergy is a systemic disease,” he says. “When it is affecting the eye, it is also likely to be affecting the nose, lungs and skin. Allergy also worsens other diseases and conditions, such as migraine and sleep apnea. If a patient's itchy, red, watery eyes improve with topical treatment, allergic conjunctivitis may just be the tip of the iceberg.”
Allergists work with eye doctors to address the systemic nature of allergy and maximize the ocular treatments that have been prescribed. They perform specialized testing to identify allergy triggers, help patients formulate allergen avoidance strategies and provide immunotherapy when necessary.
“Working together to optimize symptom control, we can improve patients' quality of life and productivity and address the huge economic burden associated with allergy,” Dr. Carr says.
Dr. Carr refers his patients with ocular allergy to an eyecare specialist whenever he is concerned about their vision. “For example, a patient who is not responding to topical drops and environmental control needs to be seen by an eye doctor,” he says.
Signs of sight-threatening allergic eye diseases, such as vernal or atopic keratoconjunctivitis or giant papillary conjunctivitis also prompt a referral. Dr. Carr also refers patients to an eye specialist when he sees a potential need for the use of topical ocular corticosteroids or suspects a serious eye infection, or when patients have ocular pain or asymmetric eye redness.

According to the published results, in the spring study, relative to placebo, olopatadine significantly reduced the frequency of pollen effects on sneezing (P = .0017) and runny nose (P = .0031). In the fall study, relative to placebo, olopatadine significantly reduced the frequency of pollen effects on sneezing (P = .0355) and itchy nose (P = .0032) and reduced the severity of pollen effects on sneezing (P = .0451), itchy nose (P = .0178) and runny nose (P = .0327).

The nasal effects of epinastine HCl ophthalmic solution 0.05% (Elestat, Allergan Inc., Irvine, Calif., and Inspire Pharmaceuticals Inc., Durham, N.C.) were assessed within a single-center, randomized, single-dose, paired-eye, double-masked observational study.5 Patients with a history of ocular allergy to cats, positive skin-prick test and itching score ≥ 2 were placed in a cat exposure room (0-4 scale for ocular itching, ocular burning, tearing, nasal itching and rhinorrhea). The room contained levels of airborne Fel dl cat allergen comparable to those of cat-containing homes. Signs and symptoms of allergic conjunctivitis were recorded after 30 minutes of exposure. A drop of epinastine was instilled in one eye, and symptoms were assessed at various time points. After 60 minutes, epinastine-treated eyes showed significant decreases in nasal itching (P = .006) and rhinorrhea (P = .043).

An intriguing question

“Whenever one medication can take care of multiple symptoms, it's more cost-effective and convenient for patients.”

— Michael S. Blaiss, M.D.

Whether ocular allergy medications can also effectively treat nasal symptoms is an intriguing question for allergists, too. As Warner Carr, M.D., Mission Viejo, Calif., explains, “State-of-the-art in allergic rhinitis treatment right now is that if a steroid or antihistamine nasal spray fails to adequately relieve symptoms, we prescribe a second spray. We have many studies looking at the combination of antihistamine and steroid sprays, but we wonder how patients might fare if we could prescribe just one nasal spray in conjunction with an eye drop. With some of these new molecules for ocular use, perhaps better than we think.”

Michael S. Blaiss, M.D., an allergist in Memphis, Tenn., prescribes ocular antihistamine/mast-cell stabilizers for patients being treated for nasal symptoms who are still experiencing significant eye symptoms. “Whenever one medication can take care of multiple symptoms, it's more cost-effective and convenient for patients,” he says. “We know eye drops will drip into the nasolacrimal duct, but for significant nasal allergies this would not be a very efficacious treatment.”

Dr. Blaiss points out that a large body of evidence indicates the reverse to be true — that steroid nasal sprays have a positive effect on ocular symptoms.6 “Even so,” he says, “for severe eye symptoms, nasal steroids alone are likely not enough either. It really depends on the severity of the patient's problems.”

Targeting therapies

For Alan G. Kabat, O.D., F.A.A.O., Fort Lauderdale, Fla., the issue really boils down to targeted therapy. "Studies have suggested a secondary effect on nasal symptoms from the multiaction ophthalmic drugs, but my stance is we should look where the primary symptoms are," Dr. Kabat says. "If patients can get multi-symptom relief, that's an added bonus. For severe nasal symptoms, however, nothing works better than a nasal medication. For severe ocular symptoms, nothing works better than an eye drop. I am inclined to treat patients' red eyes, itchy eyes, etc., and refer them to an allergist for help with other symptoms.” OM

  1. Nathan RA, Meltzer EO, Seiner JC, Storms W. Prevalence of allergic rhinitis in the United States. J Allergy Clin Immunol. 1997;99:S808-S814.
  2. Kosrirukvongs P, Visitsunthorn N, Vichyanond P, Bunnag C. Allergic conjunctivitis. Asian Pac J Allergy Immunol. 2001;19:237-244.
  3. Schulman, Ronca and Bucuvalas, Inc. (SRBI). Allergies in America: A Landmark Survey of Nasal Allergy Sufferers. Available at Accessed Jan. 5, 2010.
  4. Abelson MB, Gomes PJ, Vogelson CT, et al. Effects of a new formulation of olopatadine ophthalmic solution on nasal symptoms relative to placebo in two studies involving subjects with allergic conjunctivitis or rhinoconjunctivitis. Curr Med Res Opin. 2005;21:683-691.
  5. Monson BK, Rothman JA, Raizman MB. Efficacy of epinastine ophthalmic solution for post-exposure treatment of signs and symptoms of allergic conjunctivitis in cat-sensitive subjects. Poster P254. Presented at: Annual Meeting of the American College of Allergy, Asthma, and Immunology, Nov. 12-17, 2004, Boston, MA.
  6. Origlieri C, Bielory L. Intranasal corticosteroids: do they improve ocular allergy? Curr Allergy Asthma Rep. 2009;9:304-310.

Optometric Management, Issue: February 2010