Two Diagnoses, One Approach
Two Diagnoses, One Approach
Allergic and bacterial conjunctivitis are very different, but consistent use of the medical practice model ensures the best outcomes for both diseases.
By Blair Lonsberry, MS, OD, M.Ed., FAAO
Eye redness and discomfort are common patient complaints resulting in patients seeking care. The underlying cause can vary from acute sight-threatening conditions (for example, angleclosure glaucoma and bacterial conjunctivitis) to chronic (allergies and meibomian gland dysfunction).
Is it Allergy or Infection?
While both allergic and bacterial conjunctivitis cause eye redness and discomfort, they present with some signs and symptoms that are unique to each condition and other symptoms that overlap. Allergies tend to affect both eyes simultaneously, whereas a bacterial infection typically begins in one eye and moves to the other. Bacterial conjunctivitis also can cause a purulent discharge and patients often report that their lids are stuck together in the morning.
Both allergy and bacterial conjunctivitis can result in a papillary response on the upper lid, which is visible during upper lid eversion on a slit lamp exam. Papilla also can be associated with contact lens wear. Certainly these problems can occur concurrently as contact lens-related discomfort and allergy exacerbate each other.
The key to diagnosing the true cause of red eyes is to combine the clinical findings with elements from a well-designed history questionnaire and discussion. Allergy patients experience itching, but we have to be careful about using this as a hallmark symptom because eyelids may itch due to lid diseases such as blepharitis. Allergy-related itching often occurs in conjunction with other allergy symptoms such as a runny nose, and itching typically affects the whole eye as opposed to just the lid margin, which would be more indicative of lid disease. Ocular allergy patients also may experience watery eyes and swelling.
Treating Bacterial Conjunctivitis
Once we've diagnosed bacterial conjunctivitis, the key is to begin treatment with an appropriate antimicrobial agent and impress upon patients the importance of compliance.
Bacterial conjunctivitis can cause permanent damage and impaired vision if it isn't treated quickly and appropriately. For example, Pseudomonas, if allowed to secure a "foothold" on the cornea due to corneal compromise, can result in perforation — sometimes in as little as 24 hours. We want to ensure a high concentration of a broad-spectrum antibiotic onto the eye. Patient compliance — taking medications in the appropriate manner — is often a challenge. Clinicians must take this into consideration when prescribing. If the same therapeutic result can be achieved with a medication requiring less frequent dosing, patient compliance is likely to be better.
Prescribing for Allergy
For patients suffering with allergic conjunctivitis, treatment and management isn't nearly as straightforward. There are two common forms of allergic conjunctivitis: seasonal and perennial. Seasonal allergy sufferers are classical allergy patients presenting with complaints in the spring or fall. Perennial allergy sufferers are those patients who are allergic to everyday allergens such as cats, dogs or dust mites. Perennial allergy sufferers also can experience seasonal flare-ups. Approximately 50% of the population suffers from allergies, and about 80% of those patients experience ocular complications, according to the 2003-2004 Gallup Study of Allergies.
When it comes to treatment, over-the-counter remedies and prescription medications are available. With the availability of OTC products, patients have the ability to self-diagnose and treat. OTC products are often seen as a more convenient and affordable option to patients. Patients suffering from seasonal allergies may need to receive treatment for a few months of the year or year-round if they have a perennial allergy, such as cat dander. Allergy patients may be taking an oral antihistamine, which often doesn't treat ocular complaints and can, in fact, compound ocular symptoms by increasing dryness.
Prescription medications not only treat symptoms by blocking the primary allergy mediator (histamine), but also can help prevent their development by stabilizing the mast cells, which are the storehouses for the histamine. Most prescription products currently on the market are both mast cell stabilizers and antihistamines. Over-the-counter drops may temporarily relieve itching or redness but patients generally need to take OTC drops 4-6 times per day, compared to using prescription drops once or twice a day. This convenience appeals to patients, who don't want to put in drops every few hours when symptoms return. Again, this is important because it increases compliance and thus the chance of achieving the best outcome.
Cost is often an issue when comparing prescription medications versus OTC products. However, when patients take OTC medications 4-6 times a day, with insufficient management of their condition, the cost "difference" is minimized or eliminated.
Contact lens wearers who have allergies have a very difficult time wearing their lenses during allergy season. The use of prescription medications is a crucial component to successful wear during these periods. I recommend moving these patients to a daily disposable contact lens schedule.
Handling Complex Allergy Cases
Aside from standard allergy cases, we see some patients who either have severe allergy symptoms or have a mix of concurrent ocular surface issues.
When patients' eyes are very inflamed and symptomatic, I will consider prescribing a steroid 3-4 times a day for 1 week and concurrently starting them on a topical prescription allergy drop. The steroid drop will help alleviate symptoms and reduce allergy signs quickly. Unfortunately, long-term use of topical steroids has complications, so they should only be used on a short-term basis for acute flare-ups.
Patients whose initial symptoms point to multiple problems or who only achieve partial relief from allergy treatments should be assessed for concurrent problems such as chronic dry eye. Once we treat the allergy, we can determine if a separate problem exists. Discomfort in the morning (grittiness and burning), and of course risk factors such as heavy computer use, point to dry eye. We discuss treatments that will provide relief and schedule follow-up visits to ensure those measures are working.
Teaching Patients Successfully
It's essential to educate patients about allergy and bacterial conjunctivitis and their treatments, particularly because patients must have proper expectations for treatment and understand the importance of their role in implementation.
Overall, for both bacterial conjunctivitis and allergy, my patient education goal is compliance, and I think we can improve compliance by explaining the disease and the treatment regimen. People hear what they want to hear, so I repeat the same message two or three times to be sure a patient understands the message. Before the patient leaves the office, I want to feel confident in the patient's ability to carry out the treatment and achieve the best possible outcome.
However, when educating patients about bacterial conjunctivitis and allergy, the approach and message are very different.
Prescribe in Winter; Fill in SpringIn addition to prescribing allergy medication for patients who are symptomatic, I also prescribe for patients who don't come in during allergy season. The vast majority of people with allergies have ocular symptoms, so if a patient says he has seasonal allergies, I write a prescription for him to fill when the time is right. I tell him that when his allergies are bothering him, he can fill the prescription without coming in to see me.
Of course, I go through the signs and symptoms of allergy eyes and explain that if there's no itching, or if problems occur outside of allergy season, then he needs to see me because it's not allergy.
Discussing a Dangerous Infection
Bacterial conjunctivitis is an acute disease with the potential for tremendous harm. I hate to scare patients, but sometimes I think it's necessary in order to convey the seriousness of the situation. Without proper treatment, bacterial conjunctivitis can cause blindness. I tell patients a case about a 70-year-old patient who came in complaining of eye pain and discharge. Upon examination, we noticed profuse discharge from his left eye. His vision was count fingers and after lavaging the eye, we noticed his cornea was completely opaque.
We began heavy topical antibiotic treatment and referred him to a corneal specialist. Cultures were taken and the organism was determined to be Pseudomonas. Unfortunately, the patient's cornea perforated the next day and he developed endophthalmitis and had to have his eye enucleated 2 days later. We often think of Pseudomonas as a concern in contact lens wearers, but it also can affect patients who have compromised corneas such as this patient with severe dry eye.
Clearly, the treatment goal for bacterial conjunctivitis is to cure the infection. I prescribe an effective treatment, but patients need to understand the seriousness of the infection and the potential consequences of not following the prescribed treatment. They need to fill the prescription, use it as prescribed and come back to see me in a few days.
"They're just allergies …"Mike, a 27-year-old, arrived at the practice for his 2-year exam. According to the responses on his questionnaire, the purpose of his visit is to update his eyeglass and contact lens prescriptions. He writes that he prefers contact lenses, but he wears eyeglasses as a backup. Mike confirms that he has allergies and checks the "Yes" boxes next to itching, redness and watery eyes. He lists his occupation as "graduate student."
Mike enters the exam room wearing eyeglasses. My initial examination confirms redness, chemosis, tearing and lid swelling. I ask Mike if his allergies are bothering him right now, and he shrugs, "This happens every spring." I check his chart and see that his last appointment was in summer.
Through our discussion, Mike says that yes, he does rub his eyes. He estimates that he wears eyeglasses instead of contact lenses for about 2 months of the year. He takes over-the-counter allergy medication occasionally.
Clearly, Mike is uncomfortable and stuck using eyeglasses instead of the contact lenses he prefers. He has under-reported his problem in the past. The task is to evaluate his problem, educate him about allergies and prescribe the best medication.
I tell Mike that we can control his ocular allergy symptoms and keep him in his contact lenses all year long. I prescribe an allergy medication and explain that it's more effective and convenient than over-the-counter drops. Because his ocular surface is inflamed from the allergies, and this may affect his vision, I need him to use the drops and come back in 2 weeks for his new eyeglasses and contact lenses. I tell him to wear eyeglasses until we meet again. I tell my staff to bill this as a medical visit and schedule Mike's next visit as a routine exam.
After 2 weeks, Mike returns with clearer, more comfortable eyes. He says he's able to read comfortably, and he's no longer distracted by itching or tempted to rub his eyes. I perform the refraction and prescribe eyeglasses and new, one-day replacement contact lenses, explaining to Mike that the new contact lenses will help prevent allergy symptoms.
Finally, I make sure Mike understands that allergy symptoms will resume as soon as he stops taking the medication, so he should continue taking it until the point that his spring allergies usually stop. He can check any weather website for a pollen count to be sure. Additionally, because Mike is a graduate student who does a great deal of reading and spends hours on the computer, I tell him to contact me if he has any additional discomfort with his eyes.
"Don't just live with it," I tell him. "We can fix it."
Mike's family isn't local and he doesn't work for a large company where he can spread the word about my allergy treatment. He is, however, part of a large patient base. If that patient base is 5,000, and 50% have some ocular allergy symptoms, then there's a significant opportunity to increase comfort and satisfaction and build that medical practice model by elevating the patient experience.
Educating Allergy Patients
With allergy, the patient discussion is much less scary, but it can be just as complicated. Patients need to understand that allergies don't go away. The treatment goal for allergy is to control the signs and symptoms.
Short term, we need to stop the itch and alleviate the redness. After a few weeks of relief, patients may be tempted to be lax with their medication, but if they don't stick to the regimen, their symptoms will return.
Patients with seasonal allergies need to get through a few months of the year. They can start their medication 2 weeks before allergy season begins to help prevent flare-ups.
We also need to educate allergy patients about practical matters such as prescription coverage. If their insurance doesn't cover a prescription allergy medication, I don't want them to experience sticker shock and decide not purchase it. I explain that neither prescription nor over-the-counter medications are cheap (OTC brands run upwards of $15 or $16 a bottle), but the OTC drug requires more frequent dosing and contains preservatives that may cause other problems.
Embodying the Medical Practice Model
When we think of bacterial conjunctivitis and allergy, their vast differences tend to stand out in our minds. That's because we're oriented toward diagnosis — emphasizing the differences between diseases so we can tell them apart. But from a practice model perspective, both of these diagnoses follow the same pattern: expert diagnosis, medical treatment and follow up. Not all red eyes are the same, but a consistent approach across diagnoses ensures the best outcomes.
Dr. Lonsberry is Clinic Director of the Portland Vision Center at Pacific University of Oregon College of Optometry. Email Dr. Lonsberry at email@example.com.
Optometric Management, Issue: August 2010