Article Date: 2/1/2012

Making the Case for Ocular Allergy
allergy

Making the Case for Ocular Allergy

Still not convinced that diagnosing and treating ocular allergy should be a priority? Here's something you may have overlooked.

Rob Murphy, Contributing Editor

Ask any optometrist to tell you how much of his/her practice revenue is comprised of contact lens services (not including products), and many will reply “roughly 10%,” says Gary Gerber, O.D., founder of The Power Practice, in Franklin Lakes, N.J.

“There's lots of room for improvement here from two sources: raising fees and fitting more patients,” he says.

Dr. Gerber adds that one could argue that this number is “woefully” low because optometrists aren't fitting patients who have ocular allergy, yet could still achieve successful wear.

It could also be argued that this number is far below what it should be because undiagnosed and untreated ocular allergy is playing a role in contact lens discontinuation. (Keep in mind that discomfort — including that which comes with unattended or mismanaged ocular allergy — ranks as the leading reason for contact lens dropout.1)

Given these two plausible arguments, optometrists should make identifying and effectively treating the condition a priority.

“Ocular allergy is a complex disease state. Yet it's easy for O.D.s [to diagnose and effectively treat] … In other words, it's what we do everyday, so while a complex entity, the differential diagnosis process is simple for us,” explains John Rumpakis, O.D., M.B.A., president and CEO of Practice Resource Management, Inc. in Lake Oswego, Ore. (See “Is it a Medical Office Visit?” below.)

Here are three ways you can make diagnosing and treating ocular allergy a priority, say ocular allergy experts.

1. Review the link

Brush up on how ocular allergy can negatively effect contact lens wear, and vice versa.

“ … If the contact lens-wearing patient has allergies, they tend to complain of itchy and watery eyes and lens awareness, due to lens movement stemming from the watery eyes,” explains Alan G. Kabat, O.D., an associate professor at Nova Southeastern University College of Optometry, in Ft. Lauderdale, Fla., and who has written and lectured extensively on the topic.

The patient who has ocular allergy may also complain of compromised vision, says Marc D. Myers, senior staff optometrist at the Coatesville (Pa.) Veterans Affairs Hospital. “Ocular allergy alters the tear film,” he explains. “Depending on the fit and movement of the lens, this tear film change can negatively affect the patient's vision.”

Something else to keep in mind: Many patients take systemic antihistamines, which are notorious for drying the ocular surface, says Paul M. Karpecki, O.D., corneal services and research director at Koffler Vision in Lexington, Ky. “These drugs make the eye vulnerable to discomfort and contact lens intolerance,” he says.

On the other hand, remember that contact lenses can exacerbate ocular allergy. This can result in hypoxia, microtrauma to the cornea, a reduced corneal metabolic rate, a decreased epithelial mitotic rate, a weakened epithelium, the compromised integrity of the intra-epithelial cellular tight junctions, increased corneal lactate, a thinning tear film (which hastens evaporative tear loss) and biofilm formation on the lens surface.2 This biofilm invites the accumulation of deposits, such as denatured proteins, mucins, calcium and lipids, which, in turn, can then attract bacteria as antigens bind to the lens' surface.

“In a sense, [a contact lens] is a toxin [to the ocular allergy patient], if you want to think of it like that,” says Robert M. Cole III, O.D., a private practitioner in Bridgeton, N.J., and a longtime professor at the Pennsylvania College of Optometry at Salus University, in Elkins Park, Pa. “ … You put a contact lens on that eye, in most cases it increases the [allergic] reaction.”

Is It a Medical Office Visit?
Properly diagnosing and treating ocular allergies not only enables you to generate revenue from medical office visits, but should all go well with treatment, provide a means for a potential dropout to continue wearing contact lenses or a spectacle wearer to become a contact lens wearer. But tread carefully with regard to your billing, as it may put you at risk for insurance fraud and a costly audit. To avoid this, follow these steps when deciding whether to bill an office visit as medically necessary:
1. Ascertain through a proper case history, while eliciting the chief complaint, why the patient has come to your office, without leading your patient.
2. Carefully record not only the patient history, but also all other diagnostic measures you perform.
3. Establish why the visit is medically necessary.
4. Translate what you have recorded in the medical record throughout the visit into an appropriate CPT code, use the appropriate ICD-9 code, and submit to the carrier or patient for payment.
Consider these two clinical scenarios, both equally plausible:
Patient presents for annual eye exam. A patient arrives at your practice and states that the primary reason for his visit is an annual eye exam. During the case history, you ask the patient whether he's experiencing any ocular problems, and the patient replies that his eyes “itch every now and then.” Can you bill this visit to the patient's medical insurance? The answer is “no,” says Dr. Rumpakis.
“The chief complaint is what determines how one bills an appointment,” he explains. “This patient's primary reason for the appointment was to get his eyes checked. It was only through probing and leading questions that the doctor discovered tentative ocular allergy symptoms.”
Patient presents with complaints of itching. A patient arrives at your practice complaining of itching OD. Upon further questioning, the patient explains his eye has also been red and that he's noted some “stringy” discharge. Can you bill this visit to the patient's medical insurance? The answer is “yes,” says Dr. Rumpakis.
Because the patient's chief complaint set the stage for a medically necessary office visit, you can bill it to the patient's medical insurance, he explains.
“The economic reward is nothing more than a by-product of providing the standard of care, meticulous record-keeping and appropriate translation [to a CPT code] of what the physician actually did,” he explains. Patient care always comes first, the medical record second, and then appropriate coding for what was recorded comes last.

2. Provide patient education

Make your patients aware of the existence of ocular allergy and your ability to both diagnose and effectively treat it, says Art Epstein, O.D., a prolific author and peripatetic lecturer based in Phoenix. For example, he says he has staff place an “Allergy Survey” sticky note on the normal patient intake form. This note includes three questions for which the patient is to check “Yes” or “No”: (1) “Do you EVER suffer from red eyes, itchy eyes, watery eyes or swollen eyelids?” (2) “Do you ever use an over-the-counter eye drop (i.e. VISINE A, VISINE AC, OPCON A, etc.) to treat red eyes, itchy eyes, watery eyes or swollen lids?” (3) “Do you take oral medication like CLARITIN, ALLEGRA or ZYRTEC for your allergies?”

“The nice thing about [using the sticky note] is that it brings attention to the seriousness of allergy, while also identifying allergy patients who might otherwise think that they either do not have allergies or are effectively treating it with OTC medications, which are often suboptimal,” he explains.

He adds that should the patient answer “yes” to any of the aforementioned “sticky note” questions, he always personally discusses the answer with the patient to reinforce the importance of proper management as well as the fact that ocular allergy is an area of personal expertise.

“Many of these patients confuse dry eye and allergy, and many have either one or the other or both,” he says. “So this gives me an opportunity to discuss both and address any questions, so the patient knows I can and want to meet his needs.” (See “The Arsenal for Ocular Allergy.”) The Asthma and Allergy Foundation of America in conjunction with Vistakon, offers a free educational brochure called Eye Health and Allergies, which you can place in your reception room. You can access the brochure at www.aafa.org/eye allergies.

Practitioners who don't provide such patient education will find one or more of their contact lens patients dropping out of wear, says Dr. Kabat.

“Many of these patients are self-medicating with over-the-counter artificial tears — which don't completely alleviate the problem — because they don't know ocular allergy exists or that their practitioner can diagnose and treat it,” he explains. “Ultimately, many of these patients conclude on their own that they just can't wear lenses and simply drop out, never to return to the practice.”

The Arsenal for Ocular Allergy
Thanks to highly efficacious topical medicines, you can provide effective treatment for ocular allergy, which, in most cases, will allow your patients to continue wearing contact lenses and enable you to successfully fit some ocular allergy spectacle wearers in contact lenses. Supportive measures, such as lubricating drops and cold compresses, can provide further comfort. Also, a switch in lens modality to a daily disposable is an ideal way to mitigate the troubling effects of ocular allergies, say those interviewed.
Topical antihistamine/mast cell stabilizers. These multi-action compounds affect numerous mediators of the ocular allergic response.3 Specifically, they block histamine receptors; inhibit mast cell degranulation, vasodilation and vascular permeability; and mitigate inflammation by inhibiting the recruitment and activation of eosinophils and other immune cells.3 These prescription agents: alcaftadine 0.25% (Lastacaft, Allergan), azelastine hydrochloride 0.05% (Optivar, Meda Pharmaceuticals), bepotastine besilate 1.5% (Bepreve, ISTA Pharmaceuticals), epinastine HCL 0.05% (Elestat, Allergan) and olopatadine hydrochloride 0.2% (Pataday, Alcon).
Single-acting mast cell stabilizers. These include cromolyn sodium 4% (Crolom, Bausch + Lomb), cromolyn sodium 4% (Opticrom, Allergan) emedastine difumarate 0.05% (Emadine, Alcon), lodoxamide tromethamine 0.1% (Alomide, Alcon) and nedocromil sodium 2% (Alocril, Allergan).
These topical antihistamine/mast cell stabilizers start to work within minutes to hours, bringing almost instant relief to a patient who presents with significant itching, eye watering and irritation, says Dr. Myers.
“You can tell the patient, ‘You can go out and cut the grass. By the time you start to cut the grass, you're going to get some relief.’”
If your patient is prone to seasonal or perennial allergic conjunctivitis year after year, it's reasonable to prescribe a topical antihistamine/mast cell stabilizer as a prophylactic measure in advance of their most daunting allergy season, say those interviewed.
Topical steroids. In the face of severe inflammation attending ocular allergy in contact lens wearers, it may be appropriate to prescribe a topical steroid for a week to two, say those interviewed. Topical steroids have been shown effective in quieting the inflammatory allergic response, especially when it's associated with the late-phase pathological cascade. Some physicians have used loteprednol 0.2% (Alrex, Bausch + Lomb), which is specifically FDA-approved for the treatment of ocular allergy, loteprednol 0.5% (Lotemax, Bausch + Lomb) and prednisolone acetate (Pred Forte, various manufacturers), the latter of which is prescribed for severe inflammation of the eye.
“If you've got lid edema and you've got a lot more than just an intolerance to the lens, if a patient comes off the street with a severe allergy, I'll go right to Pred Forte,” Dr. Cole says. “Otherwise, if it's an allergy patient, I always like those [ester] steroids … ”
Supportive therapies. Any of a wide array of non-preserved lubricating drops may help to bolster the tear film, as they ease discomfort and irritation.
“These drops can increase the volume of tears and help to flush away any allergens that may be dissolved in the tear film,” Dr. Kabat explains.“They may help to wash off the substrate of the contact lens and clear it. These drops increase the capacity of the eye to rid itself of excess debris. They're not going to do much for the response that's already been triggered. But they are adjunctively somewhat helpful.”
And don't forget cold compresses — a supportive therapy as old as the hills. While underutilized, it's an affordable and effective way to quell a symptomatic flare-up, say those interviewed.
“If the patient's having symptoms during the day, and he doesn't have drops, he can go to a restroom, wet a paper towel with cold water, and hold that over his eyelids for five minutes for relief,” Dr. Cole says. “It can really quiet down inflammation, and it can lessen the itching. You get vasoconstriction and just a shrinkage of the tissue that's secreting and causing the edema in many cases. During the acute stage, for symptomatic relief, it can help the patient to be able to continue wearing their lens.”
Daily disposables. If a contact lens acts as a substrate for the build-up not only of allergens but also of pro-inflammatory mediators and other debris in contact lens wearers prone to ocular allergies, it stands to reason that frequent replacement may be the best way to go, say those interviewed.
“[Ocular allergy] is a wonderful opportunity to try a one-day modality,” Dr. Cole says. “Because you're eliminating any of the chemicals in the disinfectant solution. With allergies, you tend to get more mucus production. With more mucus, you tend to get a greater chance of depositing on the lens. And the older the lens, the greater likelihood it's going to deposit.”
Hydrogen peroxide cleaning system. With a peroxide-based lens cleaning system, “you don't have to worry about chemical sensitivity,” Dr. Kabat says, echoing the view of numerous other doctors. This is an especially critical choice for patients who have a history of hypersensitivity to lens-care solutions.
In addition, advise your patients who opt for a long contact lens-replacement schedule to clean their lenses by mechanically rubbing them, say those interviewed. Multipurpose solutions have largely obviated the need to rub one's lenses clean. That said, given the build-up of allergens and pro-inflammatory chemicals in the face of ocular allergy, the mechanical scrubbing of the lenses often makes a significant difference.

3. Be on the lookout

An estimated 120 million Americans suffer from ocular allergies, and of these, upwards of 95% are prone to seasonal or perennial allergic conjunctivitis.3 In the meantime, upwards of 40 million Americans wear contact lenses.4 It stands to reason there would be significant overlap between the two populations.

Also, the prevalence of allergies overall — and allergic conjunctivitis in particular — is thought to be growing.4 The reason:

“I think the whole air quality in general is not as good as it was a number of years ago,” says Dr. Cole III.

He adds that when noxious emissions from cars, factories and other mechanical sources, such as inadequately maintained heating and air conditioning systems, combine with environmental allergenic culprits, such as pollens, grasses, dust, pet dander, etc. the patient is hit with a “double whammy” of triggers.

The argument full circle

Because ocular allergy may be hindering the profitability of your contact lens practice, you should make identifying and treating it a priority. The three aforementioned tips give you an excellent chance of accomplishing this. And, in the process of following these tips, you'll likely not only prevent some contact lens drop-out, but also identify spectacle-wearing ocular allergy patients who have always desired contact lens wear, yet always resisted inquiring about it, incorrectly thinking it wasn't possible. OM

1. Rumpakis J. New Data on Contact Lens Dropouts: An International Perspective. More than one in six of your contact lens patients will discontinue lens wear, a new study finds. That's a big chunk of your bottom line. www.revoptom.com/content/d/contact_lenses___and___solutions/c/18929/ (Accessed 1/13/12')
2. Lemp MA. Contact lenses and allergy. Curr Opin Allergy Clin Immunol. 2008 Oct;8(5):457-60.
3. Kabat AG, Granet DB, Amin D, Tort MJ, Blaiss MS. Evaluation of olopatadine 0.2% in the complete prevention of ocular itching in the conjunctival allergen model. Clin Optom 2011 Jul;(3):57-62.
4. Nichols KK, Morris S, Gaddie IB, Evans D. Epinastine 0.05% ophthalmic solution in contact-lens wearing subjects with a history of allergic conjunctivitis. Eye Contact Lens 2009 Jan;35(1):26-31.

Mr. Murphy is a freelance writer based in the Philadelphia area. He has spent several years reporting on the eyecare field. E-mail him at rmurphy2000@verizon.net. Or send comments to optometricmanagement.com.


Optometric Management, Volume: 47 , Issue: February 2012, page(s): 33 - 39