Article Date: 7/1/2011

Establish an Ocular Allergy Practice
allergy

Establish an Ocular Allergy Practice

Treating this widespread problem can enable you to treat other ocular diseases.

Frank Celia, Contributing Editor

For the most part, allergy in the United States is considered a systemic problem and is treated accordingly: Patients who suspect they suffer from allergies usually first visit their family practitioner, who may refer them to an allergist. These patients often end up taking an oral systemic medication, and treatment frequently ends there.

Although allergy also affects the eyes, systemic antihistamines are partially effective at alleviating ocular symptoms (e.g. itching and redness), and they have also been shown to contribute to secondary dry eye problems.1-3 In addition, allergists and general practitioners tend to lack slit lamps, which can provide more information regarding ocular health. Further, optometrists have the ability to both identify and manage ocular surface problems.

In addition, treating ocular allergy represents a low-risk, low-overhead strategy for enhancing your practice's medical profile. “It makes a statement to patients,” says Glenn S. Corbin, O.D., of Wyomissing, PA. “They think that if this doctor can prescribe an eye drop that they have to go to the pharmacy to fill, they assume that if they have other problems you are going to be able to help them as well. Ocular allergy patients are a fairly easy way to make an entrée into more medical treatment.”

Since the public generally fails to associate optometry with the treatment of ocular allergy symptoms and with no imminent plans for a national campaign to rectify this oversight, each optometric practice must build its own allergy practice pretty much from the ground up. What follows is advice from those who've done just that.

Networking with allergists

Most thriving optometric practices have solid working relationships with local general practitioners and family physicians. To establish an ocular allergy practice, it's essential you seek and network with allergists in your area as well, says John L. Schachet, O.D., who's in private practice at Eyecare Consultants Vision Source, in Englewood, Colo. Dr. Schachet says that when he was starting out in practice, he made it a policy to contact a different local healthcare practitioner once a week and take him or her to lunch to provide education on his various diagnostic and management abilities.

“Whenever a profession overlapped with vision care, I thought it would definitely be beneficial for me to get to know some of these individuals [as doing so would lead to referrals and practice growth]…,” he explains. “I found the allergists were very open to referrals.”

The reason: Dr. Schachet says he explained to them that he had both the education and devices to identify and manage ocular surface problems. (While allergists may have headlamps or loops, nothing in their offices can match the stereoscopic view of a slit lamp.) In addition, Dr. Schachet says he told the allergists with whom he met that he had the education and proper equipment to monitor patients' intraocular pressure. (As allergists are aware that some allergy medications can cause the pupil to dilate and prompt angle-closure attacks in patients who have very narrow angles or undiagnosed angle-closure glaucoma, this skill was of particular interest.) Further, Dr. Schachet says he mentioned that referrals would be a two-way street, as he would need to refer patients to an allergist when he noted systemic disease—something not under his management jurisdiction.

Dr. Schachet says his allergy patients grew to such large numbers, that he eventually added an allergist to his practice. A friend of Dr. Schachet for more than 30 years, Gary L. Niemann, M.D., set up his practice under the same roof four years ago. In addition to lowered overhead of shared staff, the doctors say the two practices enjoy a symbiotic referral relationship.

Specifically, when ocular patients demonstrate systemic problems, Dr. Niemann can be consulted. When Dr. Niemann has a question about a drug's IOP-elevating potential, Dr. Schachet is only a corridor away.

Online marketing

The days of attracting patients through the Yellow Pages and local print newspapers are long gone. A majority of patients now seek services via the Internet. In fact, almost 60% of all U.S. adults have looked online for information regarding health topics, such as specific disease or treatment, according to a recent survey.4 Further, this same survey revealed that 11% of adults have consulted online rankings or reviews of doctors or other providers. The bottom line: If you're not online, you don't exist. So, if you don't already have a practice web site, get cracking, say those interviewed. (Visit www.optomeric.com/article.aspx?article=104604 for more information.)

Steven J. Gradowski, O.D., who practices privately in Omaha and sees ocular allergy patients, says he's currently in the process of increasing his practice's online presence to attract more of these, among other types of patients. The reason: Several new patients have presented for care after seeing his practice included on websites dedicated to keratoconus and corneal refractive therapy.

“Our discussions with the ‘younger’ members of our staff seem to lean toward Facebook as a vehicle to reach out to our desired patients—younger families and college types,” he notes. “Facebook offers a way to provide updated info on various new treatments for eye problems, new products and patient education.” He adds that he's also exploring ways to use Linkedin to communicate and network on a business level.

Dr. Schachet agrees that social media is a beneficial platform, as it has created profitable opportunities to stay in touch with existing patients and reach new ones. (See “Social Media Options,” below).

A caveat: While the financial bar for involvement in social media is lower than that of traditional marketing, it requires more labor on your part to do it right. Specifically, providing content for a social networking account will probably take about 10-to-15 hours of work a week, say the experts. As a result, you should probably put one employee in charge of its coordination, Dr. Schachet says.

In fact, at his practice he says he's designated one staff member to update his practice's social media accounts. These accounts include Facebook, Twitter, Yelp, Multiply, Diigo, Wordpress, Posterous and Tumblr, among others. In addition, Dr. Schachet says he contracts with a marketing firm in Colorado Springs, Colo. to make sure the content is up to par, balancing the fine line between authenticity and delivering a practical marketing message. To achieve the right mix of authenticity, fun and practicality, many experts suggest hiring an outside consultant to help set up and maintain social media accounts. Additionally, although social media is not as youth dominated as its reputation might suggest (the average Facebook member's age is 37, after all), it might not hurt to seek input from some of your young employees on its look and content to keep it fresh, says Dr. Schachet.

Although his practice's Facebook effort (www.facebook.com/EyeCareConsultants?sk=wall&filter=) is less than a year old, Dr. Schachet says a number of patients have already responded.

“When we first started, it [the popularity of the site] built quickly,” he says. “It has brought in some business we wouldn't have had otherwise.”

Keeping your eyes peeled

Be vigilant about identifying those who have undiagnosed allergies, those interviewed say. It is estimated that about a third of allergic rhinitis patients do not know they have the condition.5

Patients who have allergies, though don't know it, often blame their symptoms on a “recurrent cold” that occurs around the same time every year, says Dr. Corbin. “One of the critical ways to build an allergy practice is to ask the right questions,” he advises. “Ask if the patient ever experiences bouts of itching, redness and tearing. And ask them year round because you may be seeing them off-season, and they feel great.”

In addition, those who complain of ocular issues and have allergies will exhibit a papillary conjunctival reaction that is not always present in patients who have dry eye, those interviewed say. “With allergies, the patient will complain of profound itching,” says Dr. Corbin. “You can have some level of itching with dry eye, but its hallmarks are more the foreign body sensation, grittiness, discomfort and reflex tearing. And usually with allergy, there is more redness in the eye.”

In addition, these patients' lower lids may reveal dark half circles. This swelling and discoloration is indicative of allergy, say those interviewed.

Dr. Schachet says that the “allergic salute” tips him off that a child has allergies. Specifically, the “allergic salute” is when a child uses the palm of his hand to rub his nose up and down. You may even notice a crease in the child's skin under the bridge of his nose from chronic rubbing, he says. “I can't tell you how many times I've walked into the exam room and seen this [both the salute and crease],” notes Dr. Schachet. “Then I look over at the mother and ask how long her child has had allergies, and it comes as a complete shock to her.”

Educating patients

When patients present for their annual exam, let them know you have the ability to handle ocular conditions outside the realm of refractive vision care by asking them to provide both their vision and medical insurance, says Dr. Gradowski.

“Patients very often ask us what we need their medical insurance for,” he says “Then we explain that if we find any pre-existing or new medically related eye condition, we can file it under their general medical insurance.”

In addition, inquire about the current drugs patients are taking, and include the question: “Are you taking any over-the-counter (OTC) drugs, and if so, for what?” Those interviewed say this question will get many patients to divulge that they are taking OTC drugs to manage their ocular allergy symptoms, and you can use this answer as a means of educating them that you have prescription rights and can, therefore, prescribe something easier to use, more effective or safe. (See “Prescription Ocular Allergy Drugs,” below.)

Also, keep in mind that many of these patients and those patients being treated for systemic allergies are at risk for concomitant dry eye, as several OTC drugs contain preservatives that put patients at risk for this condition.

As a result, during the patient exam, be on the lookout for any signs of ocular dryness, via slit lamp exam, say those interviewed.

Dr. Schachet says it's paramount to get the message out that you have the ability to treat ocular allergy. “I think that is more important than anything else in building an allergy practice,” he says, “because you're not going to get to first base otherwise.”

The general consensus seems to be that treating ocular allergy presents less of a challenge than getting patients to understand that you can do it. But if you're willing to invest some time, forethought and creativity, it can be done. OM

Social Media Options
Though Facebook and Twitter garner the most attention, here are examples of other social networking websites that can also help to raise the online profile of your allergy practice:
www.yelp.com: This site features business reviews and has been helpful in recruiting new patients for some practices.
www.foursquare.com: A location-based social media site, it allows users to “check in” at their favorite destinations, including outdoor venues like golf courses and parks.
www.linkedin.com: Similar to Facebook, this site is popular among business professionals.
www.tumblr.com: This site hosts blogs (i.e. web logs) that put a great emphasis on photos and videos rather than text.
www.flickr.com: This site specializes in posting and sharing digital photographs.

In response to the rise in popularity of social media, companies have sprung up to help users coordinate the multiple components of their online presence:
www.SocialOomph.com: This site can schedule and send “tweets” (i.e. Twitter postings), as well as coordinate other social media.
www.HootSuite.com: A kind of digital “dashboard” that encompasses multiple social networks, this site allows users to monitor and post to different sites simultaneously.
www.postling.com: This site links up your social medical accounts, allowing you to manage them all in one place.

Using Intranasal Corticosteroids for Ocular Allergy
There appears to be a link between rhinitis and ocular allergy symptoms. In fact, the medical literature shows that when rhinitis is treated with an intranasal (INS) corticosteroid, in many cases, ocular problems vanish as well.
As a result of this finding, in 2007 the FDA allowed one nasal allergy drug, fluticasone furoate (Veramyst, GlaxoSmithKline) to include in its package insert: “Veramyst may also help red, itchy and watery eyes in adults and teenagers with seasonal allergic rhinitis.”
“…Optometrists can track a patient's intraocular pressure, so there's no reason they can't prescribe nasal corticosteroids,” says Leonard Bielory, M.D., director of the STARx Allergy and Asthma and Allergy Center, Medicine, Pediatrics and Ophthalmology and at the Center of Environmental Prediction, Rutgers University.
Although a great deal of academic interest surrounds INS therapy, rank and file optometrists have been slow to adopt their use in a meaningful way. This is because general consensus holds that topical ocular agents provide faster and more complete relief of symptoms than INS therapy.6
“I do believe there are some patients whose ocular allergies would probably benefit from a nasal steroid, but the majority don't,” says Dr. Schachet. “The truth is when you talk about treating ocular allergies, the most effective treatment is almost always a direct drop.”
“For patients suffering a combined form of allergic rhinoconjunctivitis, INS can be useful,” says Dr. Bielory. “The use of topical steroids for garden variety ocular allergy of the conjunctival surface is probably the most effective treatment regimen one has in the armamentarium due to its direct effect. But the use of intranasal steroids on the nasal surface appears to have a secondary effect, as it decreases the neural stimulation vs. a direct steroid aspect of the conjunctival surface.”

Prescription Ocular Allergy Drugs
► Alcaftadine 0.25% (Lastacaft, Allergan) Age of use: two years +, Dosing: q.d.
► Azelastine hydrochloride 0.05% (Optivar, Meda) Age of use: three years +, Dosing: b.i.d.
► Bepotastine besilate 1.5% (Bepreve, ISTA Pharmaceuticals) Age of use: two years, + Dosing: b.i.d.
► Cromolyn sodium 4% (Opticrom, Allergan) Age of use: four years +, Dosing: q.i.d.
► Emedastine difumarate 0.05% (Emadine, Meda) Age of use: three years +, Dosing: q.i.d.
► Epinastine HCI 0.05% (Elestat, Allergan) Age of use: three years +, Dosing: b.i.d.
► Lodoxamide tromethamine 0.1% (Alomide, Alcon) Age of use: two years +, Dosing: q.i.d.
► Loteprednol etabonate 0.2% (Alrex, Bausch + Lomb) Age of use: Safety and effectiveness in children has not been established. Dosing q.i.d.
► Loteprednol etabonate 0.5% (Lotemax, Bausch + Lomb) Age of use: Safety and effectiveness in pediatric patients have not been established. Dosing: q.i.d.
► Nedocromil sodium 2% (Alocril, Allergan) Age of use: three years +, Dosing: b.i.d.
► Olopatadine hydrochloride 0.2% (Pataday, Alcon) Age of use: two years +, Dosing: q.d.
► Olopatadine hydrochloride 0.1% (Patanol, Alcon) Age of use: three years +, Dosing: b.i.d.
► Pemirolast potassium 0.1% (Alamast, Vistakon Pharmaceuticals, LLC) Age of use: three years +, Dosing: q.i.d.

* Be sure to check these drugs for their individual preservative amounts.

1. Spangler DL, Abelson MB, Ober A, Gomes PJ. Randomized, double-masked comparison of olopatadine ophthalmic solution, mometasone furoate monohydrate nasal spray, and fexofenadine hydrochloride tablets using the conjunctival and nasal allergen challenge models. Clin Ther. 2003 Aug;25(8): 2245-2267.
2. Abelson MB, Welch DL. An evaluation of onset and duration of action of Patanol (olopatadine hydrochloride ophthalmic solution 0.1%) compared to Claritin (loratadine 10 mg) tablets in acute allergic conjunctivitis in the conjunctival allergen challenge model. Acta Ophthalmol Scand Suppl. 2000;(230): 60-63.
3. Ouslter GW, Workman DA, Torkildsen GL. An open-label, investigator masked, crossover study of the ocular drying effects of two antihistamines, topical epinastine and systemic loratadine, in adult volunteers with seasonal allergic conjunctivitis. Clin Ther 2007 Apr;29(4): 611-616.
4. Pew Internet and American Life Project. Fox S. The Social Life of Health Information, 2011. http://pewinternet.org/Reports/2011/Social-Life-of-Health-Info/Summary-of-Findings/Section-2.aspx
5. Stewart MG. Identification and management of undiagnosed allergic rhinitis in adults and children. Clin Exp Allergy 2008;38(5):751-760.
6. Rosenwasser LJ, Mahr T, Abelson MB, 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 Nov-Dec;29(6): 644-653.

Mr. Celia is a freelance healthcare writer based in the Philadelphia area.


Optometric Management, Issue: July 2011