Point-of-Care Testing Pays Off

APRIL 2014
Point-of-Care
Testing Pays Off
The Doctor’s Allergy Formula provides
ophthalmologists — for the first time — with
a comprehensive diagnostic system to identify
the root cause of ocular surface disease
through non-invasive allergy testing.
Sponsored by
FA C U LT Y
Jodi Luchs, MD
Jay S. Pepose, MD, PhD
Dr. Luchs is co-director of the department of
refractive surgery at the North Shore/Long
Island Jewish Health System and is assistant
clinical professor of ophthalmology at Hofstra
University School of Medicine. He is the
director of clinical research, and the director
of cornea/external disease at South Shore
Eye Care.
Dr. Pepose is director of the Pepose
Vision Institute and is a Professor of
Clinical Ophthalmology at the Washington
University School of Medicine, St. Louis,
Missouri.
Ranjan Malhotra, MD
William B. Trattler, MD
Dr. Malhotra is a partner at Ophthalmology
Associates/Cornea and Laser Vision Institute
specializing in cornea/external disease and
refractive surgery. Dr. Malhotra is a clinical
instructor at Washington University School
of Medicine and the Veteran’s Administration
Hospital in St. Louis.
Dr. Trattler specializes in refractive,
corneal and cataract eye surgery at the
Center For Excellence In Eye Care
in Miami.
Jai G. Parekh, MD, MBA
... with Howard J. Loff, MD
Dr. Parekh is the managing partner at BrarParekh Eye Associates, NJ, chief of cornea and
external diseases at St. Joseph’s HealthCare
System, NJ, and is clinical associate professor
of ophthalmology on the Cornea Service at
the New York Eye & Ear Infirmary, NY.
Chief Medical Officer, Doctor’s Allergy Formula
Board Certified Ophthalmologist
ASOPRS Fellowship Trained
Oculoplastic & Reconstructive Surgeon
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COPYRIGHT 2014, PENTAVISION LLC. ALL RIGHTS RESERVED.
2
Point-of-Care Testing Pays Off
The Doctor’s Allergy Formula provides ophthalmologists — for the first
time — with a comprehensive diagnostic system to identify the root cause
of ocular surface disease through non-invasive allergy testing.
c
cular
Surface Disease
(OSD) is one of the
(O
most
common pathm
ologies we encounter.
o
Approximately 50%
A
of patients with OSD
o
have
primary
or coexisting
h
i
ocular allergies.1 Allergies
affect approximately 60 million
Americans, of which 40%
(25 million) have allergies that
are ocular in nature.1-3
Proper diagnosis and management is paramount. Left untreated,
ocular allergies can significantly
affect a patient’s daily life and may
result in ocular surface damage.
Fortunately, new diagnostic tests
have been developed to
objectively diagnose and
more appropriately direct the
treatment of ocular allergies.
O
Why Do So Many Patients
Have Ocular Allergies?
Dr. Trattler: We all have busy
practices, both medically and
surgically. It’s a bit surprising how
often patients come to us with
symptoms and signs of ocular
allergies, whether as a primary or
secondary reason. Please share
your thoughts on why we see
so many patients with ocular
allergies in our practices.
Dr. Luchs: From a demographpatients quickly once we’ve deterics standpoint, allergies are serimined ocular allergies are present.
ous business. According to some
Dr. Parekh: Furthermore, as
sources, allergic disease affects
ophthalmologists, we’re poised
30% of the U.S. populato see allergy patients
tion.4 So, there are
throughout the year,
versus allergists
a large number of
ve
Allergies
aff
ect
who tend to see
people out there
w
patients only
with ocular allerapproximately 60 million during the
gies. Allergies
two big
are one of
Americans,
of
which
40%
allergy
the most
seasons:
common
(25 million) have allergies
pollen in
conditions
the spring
with which
and ragweed
patients presthat are ocular
in the fall. Alent. They are often a component
llergy has a huge
in nature.
overlap
with dry
of a patient’s other
ov
eye, blepharitis and
OSD manifestations,
contact lens overwear
such as blepharitis,
syndrome. We see many allergy
and complaints associated with
patients, and a good deal of them
dry eyes, such as grittiness, burncomplain of itch, foreign body sening and uncomfortable eyes.
sation, and red, watery, scratchy
Some patients also complain of
eyes. And it’s really important to
itching, or what began as itching
go through the differential diagand has progressed into irritanosis. Again, allergy can take many
tion and discomfort. Allergies, in
forms: perennial, seasonal, atopic
general, can affect patients’ lives
keratoconjunctivitis (AKC), vernal
in profound ways. For example,
keratoconjunctivitis (VKC) and
allergies can affect their ability to
giant papillary conjunctivitis
read, drive, perform work-related
(GPC).6 It’s our job to rule out other
activities and leisure activities, use
computers, wear contacts lenses
potential reasons for the sympand so on.5 So, it’s important that
toms, so we can arrive at a differential diagnosis of ocular allergy.
we make the diagnosis and treat
3
“We are seeing a paradigm shift in the way we’re
going to deliver ophthalmic care. We’re going to be
providing much more point-of-service testing.”
– Jay S. Pepose, MD, PhD
Types of Hypersensitivity
When you think about the four types of hypersensitivity, skin
testing falls into Type 1, the immediate IgE mediated hypersensitivity. Skin tests would be the classic form, the extreme form would be
anaphylaxis. For skin testing, you’re basing the response on histamine
release which causes small bumps, which are measured. We’re trying
to determine what the patient has been sensitized to, where they
have IgE present on mast cells or basophils that when triggered,
release histamines, leukotrienes and prostaglandins. Type 2 hypersensitivity is mediated through a cytotoxic antibody response. For
example, drug-induced hemolysis from penicillin would be a classical
example of cytotoxic hypersensitivity reaction. And then you have
Type 3, which is an immune complex disease, such as serum sickness.
Type 4 is a delayed-type hypersensitivity.
– Jay S. Pepose, MD, PhD
4
Dr. Malhotra: There’s a huge
Venn diagram of overlap between OSD with allergies, dry eye,
blepharitis and ocular rosacea. It’s
usually not just one disease, but
an overlap of multiple diseases.
It’s critical to remember that treatment of one could affect treatment of another. Many patients
are self-medicating or their primary care doctor may prescribe oral
allergy medications year-round,
which can make dry eyes worse.
So, addressing their allergies, or
lack of allergies, could sometimes
improve their symptoms. OSD can
routinely affect vision. It affects
our surgical outcomes with LASIK,
refractive and cataract surgery.
That’s why we often find that dissatisfied surgical patients have
ocular surface disease.
Dr. Luchs: Often, it’s not just
one ocular surface disease. There
can be several. And it’s important
to address what you think is primary, while not neglecting anything else that may be present.
Who’s Experiencing Ocular
Allergies?
Dr. Trattler: Are there any
groups of patients that are at
higher risk for experiencing ocular
allergies?
Dr. Malhotra: If patients have
poor, insufficient tear film or rapid
tear breakup time, it can exacerbate allergic symptoms. I always
think of it like a razor burn. You
have friction on your eyelid, you
don’t have adequate tear film and
you develop some bumps on the
inside of the eyelid from friction
and that can create papilla. There
are also chemical mediators
associated with the papilla. I think
patients like diagnostic tests, because they want to see objective
evidence to confirm our diagnosis.
Dr. Pepose: I don’t think we see
allergies in really young children,
up to age 2 or 3, as frequently
because they haven’t had long
enough to be sensitized. We see
vernal in the next age group,
4 to 12 years old, particularly in
boys, and it’s more common in
warm climates.7 But allergies can
occur in individuals across the
board, particularly in atopic
patients who are genetically
predisposed anyway. They have
eczema; they have asthma.
Dr. Malhotra: When you ask
patients if they have allergies,
approximately 80% to 90% of
them say ‘yes’ — even when no
one has formally diagnosed them.
Dr. Parekh: Ocular allergies can
go very much ignored. Patients
don’t just self-diagnose, they selftreat. They’re all using OTC antihistamines now, and if they have
dry eye, they’re actually exacerbating their symptomatology.
Dr. Trattler: Dr. Loff, could you
comment on what led you to
develop an objective way to
diagnose allergic conjunctivitis?
Dr. Loff: As a practicing ophthalmologist in Georgia, I was
one of the leading prescribers of
Patanol (olopatadine hydrochloride ophthalmic solution 0.1 %,
Alcon). I found it very frustrating
because I was evaluating patients
with OSD but I didn’t know exactly
what the underlying pathology
was, so I was forced to use a shotgun approach, recommending
various drops until the patient
found some relief. If symptoms did
improve with the drops, I knew
we were really just masking the
symptoms — not getting to the
root cause.
With that in mind, I worked
with some of the leading botanists
to develop specific, regionalized
allergy panels for each part of the
United States to determine the
most ocular-specific allergens,
which, for the first time, can truly
objectively quantify and qualify
the root cause of specific underlying ocular allergies.
With the Doctor’s Allergy
Formula (DAF) system, we’re finding that approximately 95% of
patients tested have a positive
maybe in some part of the country extending into the fall. Those
would be trees, and grasses, and
pollens — ragweed, for example,
would be a perfect example. That
might be temperature dependent,
too. It might be a seasonal thing.
If you have a warm season, you
might have a higher pollen count,
for example. In terms of perennial allergies, we’re talking about
household allergens, things you’re
exposed to all the time, such as
mites, dust and pet dander.
Dr. Trattler: How do vernal,
atopic, and GPC differ from
seasonal and allergic conjunctivitis?
“It certainly is exciting to have the ability — for the
first time — to determine the specific allergens that
are affecting our allergic conjunctivitis patients. ”
– Jai G. Parekh, MD, MBA
response to at least one allergen.
For the 5% of patients who don’t
respond, the test allows us to rule
out ocular allergies, so we can
focus on identifying other causes
of OSD. I look forward to hearing
everyone’s feedback and experience on their use of the system.
Types of Ocular Allergy
Dr. Trattler: Let’s discuss the
types of ocular allergic conditions,
including seasonal, perennial,
vernal, atopic and GPC.
Dr. Pepose: Sure. You think
of seasonal allergies as being
mostly in the spring and summer
Dr. Parekh: We tend to see GPC
in contact-lens wearers due to
the lens, the care solution or even
a foreign body.8,9 AKC occurs in
patients who have some form of
eczema or periocular dermatitis.
I think of AKC when I see ocular
allergy with skin findings, such as
dermatitis or eczema.
Dr. Pepose: Vernal conjunctivitis is more common in males by a
ratio of about 3 to 1 and often
occur in children ages 4 to 12.
Vernal conjunctivitis is also more
common in warm climates.7
Dr. Luchs: The main concern
about vernal and AKC, the least
common but potentially the most
5
FIGU RE 1
severe of the allergic diseases, are
the potentially sight-threatening
complications, such as shield
ulcers, and the potential for almost
a pemphigoid like migration of
the ocular surface in patients with
atopic keratoconjunctivitis — all
of which can be quite devastating. But I think what distinguishes
these two conditions from the
seasonal is that vernal and AKC are
really disorders of the immune system. They are defects within the
regulation of the T & B cells.9
The Inflammatory Cascade
Figure 1. The Doctor’s Allergy Formula test with “no needle/no shot” plastic applicator.
FIGU RE 2
Figure 2. The application of allergens to the forearm, using superficial scratch technique.
6
Dr. Pepose: The inflammatory
cascade starts with dendritic cells
presenting the allergen. The ocular
surface has different types of
antigen-presenting cells:
Langerhan cells and macrophages.
They’re going to present the
antigen to naïve T cells, which
then become activated and
become T-helper (TH) cells and
then the TH cells turn on B-cells
to produce the IgE, creating sensitization and IgE release.
The IgE is then bound by the
mast cells so the next time the
allergen is presented, you’ll now
have sensitized mast cells because
they have surface IgE and they’re
going to degranulate. The histamine is already preformed, so
there is an immediate release of
histamine and then you start to
turn on production of leukotrienes
and prostaglandins, which is part
of the arachidonic pathway. That’s
the next stage — the early stage.
The later stage would be
recruitment of other cells via
the release of cytokines, which
FIGU RE 3
any of suspect symptoms, then I’m
going to order allergy testing.
Allergy Triggers
Figure 3. Inflamed test sites after 15 minutes demonstrate an allergic response.
up-regulate adhesion molecules,
such as ICAM, and there is also the
release of neuropeptides. Eventually, you begin to see migration of
eosinophils and T-cells and macrophages. That’s when the chronic
stage of inflammation begins.
Dr. Luchs: To put it simply, for
sensitized individuals, there are
antigens in the air. They dissolve in
the tear film, where they can gain
access to the mast cells in the conjunctiva that have already been
coded with the antigen specific
IgE.11 The antigen binds to those
IgE receptors and the mast cell
causes degranulation. Histamine
releases as well as all those other
inflammatory mediators. Histamine binds to the nerve endings
of the conjunctiva, which causes
itching. It binds to the histamine
receptors in the vasculature of
the conjunctiva to produce vasodilation and increases in vascular
permeability, which cause redness
and swelling. That’s the basic triad
of the itch, the redness and the
swelling of the allergic response.
Dr. Malhotra: When I have an
ocular surface disease patient and
I’m trying to differentiate, I’m looking for chemosis and papilla. If I
see any chemosis or papilla and
Dr. Trattler: Let’s discuss how
allergy skin testing has affected
the way you evaluate and treat
patients.
Dr. Malhotra: Dr. Loff, when using Patanol, did you have patients
use it seasonally or year round?
Dr. Loff: Well, if we assumed
the issue was seasonal, I had them
use it during a specific season. But
again, without truly knowing what
a patient was allergic to, it was a
very frustrating process from my
perspective.
Dr. Malhotra: With the results
of an objective allergy test, you
know when patients most need
medication, so they don’t have
to use it year round, which potentially saves patients money.
Also, you can better help patients
avoid their triggers. For example,
if a patient is allergic to feathers,
have him get rid of down comforters and feather pillows. I have
several patients who had chronic
atopic lid disease. Allergy testing
revealed that they were allergic to
feathers or dust mites. Once they
know and can avoid the offending
allergen, they’re essentially cured
and can stop taking medications.
Dr. Parekh: Behavioral modification is very tough to institute if
you don’t know what a patient is
allergic to.
Dr. Luchs: It’s really eye opening to think about the number of
patients we see who answer ‘yes’
when you ask if they have allergies, yet they have no idea what
7
“The test streamlines patient care because in one
seating, in potentially one or two visits, patients can
get their ocular surface complaints sorted out. ”
– Jodi Luchs, MD
they’re allergic to and they’ve
never undergone allergy testing.
Dr. Malhotra: The majority of
the testing panel given by allergists is for food allergies. It’s not
for the most common ocular allergies. So, some patients have been
told they don’t have allergies, but
it’s because the test wasn’t
specific to their allergen. And
that’s another big advantage of
Doctor’s Allergy Formula testing
— the regionalized panel of this
ocular specific allergy test.
Dr. Loff: I agree. One reason
I created the test is because I
found it frustrating when I sent
patients to an allergist and they
were tested for the wrong things
— allergies to medications, foods
and insect bites. Patients are fearful about needles and shots. It’s
a very uncomfortable process.
This also drove me to develop an
ocular-specific program that was
noninvasive, without any shots or
needles. It is very simple for any
ophthalmic practice to implement
this test in the office.
Increased Testing
in Eye Care
Dr. Pepose: I think we’re see-
ing a paradigm shift in the way
ophthalmic care is delivered. We’re
going to be providing more point-
8
of-service testing. We already have
tear osmolarity. We have new
tests such as MMP9. We’re going
to have IgE testing as part of an
initial screen for allergies, so we’ll
become more like internists in
some ways. But instead of using
blood for analysis, we’re going to
use tears. This profile is going to
orient us in a certain direction.
Additionally, one of the missing
components has been skin testing to get some specificity and we
now have the ability, with sublingual immunotherapy, to actually
treat these patients without shots.
We’re going to practice evidencebased medicine as a new standard
of care. And I think that’s good for
everyone.
Dr. Trattler: It certainly is exciting to have the ability, for the first
time, to determine the specific
allergens that are affecting our
allergic conjunctivitis patients.
Dr. Luchs: It takes some skill
and a bit of art to determine
what’s going on with some
patients. And that’s where a pointof-care test is ideally suited to help
guide our diagnoses and treatment recommendations. Allergy
skin testing can be very helpful in
sorting out what contribution
allergy is causing to a patient’s
OSD or whether it’s contributing
to their ocular surface complaints.
Dr. Malhotra: We know that dry
eye patients also may have allergic
conjunctivitis and that the two
are not mutually exclusive. With
allergy skin testing, we can start
to delineate the underlying
pathology, and tests for lactoferrin, MMP-9 or IgE may also be
developed.12
Dr. Trattler: Being able to test
for a specific allergen allows us to
direct our therapy and treatment
recommendations. It’s interesting
that many patients believe they
know what they’re allergic to, but
test results often surprise them.
For example, we have a technician in our office who thought she
was allergic to dogs. Based on our
testing she’s not, so now she can
interact with dogs without fear of
an allergic reaction.
“ If you ask patients if they have allergies,
approximately 80% to 90% of them
will say ‘yes’ — even if no one has formally
diagnosed them.
– Ranjan Malhotra, MD
”
Efficient Testing
Dr. Pepose: In terms of efficiency, one of the nice things about
this test is that we don’t have to
perform it ourselves. A nurse practitioner, physician’s assistant or
other office tech often can handle
this step. Then you receive the results and provide the counseling.
Dr. Luchs: I’ve begun to integrate it into my protocol for anyone with ocular surface disease
to help determine what, if any,
contribution there is to allergy. It
may reveal that the patient does
in fact have an allergy and that it’s
playing a major role in their ocular
surface disease.
Dr. Parekh: Proprietary testing with Doctor’s Allergy Formula works well because it’s
noninvasive — no needle or shot
is required. I haven’t had a single
patient resist the workup. If during
my workup, the patient has hyperactive airway disease, rhinitis or
eczema, I refer him to an allergist
for a further work-up. I’ve found
that in some parts of the country
that allergists are quick to rush
these patients to immunotherapy
when often, all they have is localized ocular disease.
Dr. Pepose: I’ve found that only
a small percentage of patients,
maybe only 5%, are electing to
go through sublingual immunotherapy to create tolerance to the
allergen — although it’s certainly
more appealing for them not to
have any shots. And the skin test
itself is not a shot, it’s just a plastic
roller, rolling to scratch the skin, so
it’s not invasive.
Dr. Parekh: If testing indicates
it’s simply an ocular allergy, I can
change the therapeutic regimen,
Exacerbating Behaviors
Dr. Trattler: Dr. Pepose, can you discuss the “hygiene hypothesis”?
Dr. Pepose: Yes, it’s a hypothesis that’s been around for a long
time. It was based on clinical observations that on average, there
were less allergies in people with larger families and also those who
grew up on a farm rather than in the city.1 The hypothesis was that
in the large families, you’d get more exposure to infectious diseases
than in small families. In the same sense, as countries became more
developed, there was better hygiene. This lack of exposure to normal
commensal microbes didn’t dampen one’s immune response and induce tolerance, which normally would occur because these microbes
were around so much. I think that’s the general hypothesis.
Dr. Trattler: One important topic to mention is keratoconus, as
this condition is associated to ocular allergies. Patients often are eye
rubbers and underlying allergies can lead to the development and
exacerbation of keratoconus.
Dr. Malhotra: Plus people who have obstructed sleep apnea often
have dry eye. Almost every single one of my patients that come in
with keratoconus has allergy testing, and it’s something that I address.
Even if you crosslink them, you need to address their ocular surface.
As you know, keratoconus is associated with ocular allergies, and you
want to keep patients from rubbing their eyes because even if you
crosslink them, it could still develop into a progressive disease. So, I
think that addressing that component is important and finding out if
they’re allergic to something that’s avoidable is extremely important.
1. Brooks C, Pearce N, Douwes J. The hygiene hypothesis in allergy and asthma: an update. Curr Opin Allergy Clin
Immunol. 2013;13:70-77.
9
“As an ophthalmologist, I was frustrated with
the shotgun approach utilized in subjectively
diagnosing ocular allergies. This motivated me
to develop a specific ocular-oriented program
that was noninvasive — without shots or needles
— that was also very simple for any ophthalmic
practice to use in their office.
”
– Howard J. Loff, MD
and the patient can work on
behavioral modification, use a
HEPA filter, avoid pollen, dander or
whatever it may be, and return in
a few months for follow up.
I’ve been performing this test
for several months and the results
are quite impressive. Patients
return 1 month after we’ve done
the test, hopefully having made
some of the recommended
changes and I would say 80% feel
better. Immunotherapy isn’t the
only solution for these patients,
and it’s certainly not first-line
therapy.
low, it’s important to have EpiPens
or other medications, such as
Benadryl (diphenhydramine) and
oral sublingual antihistamines, on
hand to help mitigate any kind
of reaction. There have been a
couple of reports of localized
reactions on the skin, but nothing
systemic.13
Dr. Loff: As Dr. Luchs mentioned, the Doctor’s Allergy
Formula test is specific for environmental allergens that most people
are exposed to regularly. There’s
never been a reported serious
adverse or anaphylactic reaction
with any of the allergens tested
with our system.
Potential Risks
Dr. Trattler: Is there anything to
consider before patients undergo
this test?
Dr. Luchs: There’s a very small
risk of anaphylactic reaction to an
antigen, but the antigens being
evaluated are environmental, so
they’re things most people are
exposed to in everyday life. Thus,
the likelihood of an anaphylactic
reaction is extremely remote.13
Dr. Parekh: Though the risk is
10
Pre-Testing Protocol
Dr. Trattler: What’s your protocol for patients prior to testing?
Dr. Pepose: I give patients a list
of medications they should avoid
prior to testing. They have to stop
nasal and topical ocular antihistamines 48 hours in advance. For
oral antihistamines and some
antidepressants and sleep medications that have antihistamine
effects, patients are instructed to
stop taking them 5 days before
the test.
Dr. Parekh: We take the
patients in the examination area,
which is the allergy room now,
and my technician performs the
test. The patients go back to the
waiting room and watch television for 15 minutes, then return to
the room and have the test read.
I review the results and counsel
the patient before he leaves. We’ve
streamlined the testing process so
it takes only 35 minutes total.
We actually earmark a couple
of sessions throughout the month
as sessions for allergy testing.
The whole office is turned into
an ocular allergy practice and the
turnaround time is terrific. The
patients come in for testing and
then counseling from me. I usually
tell them to avoid certain behaviors or activities that put them in
contact with allergens, and
then we follow up in a month
to see exactly how things are
progressing. Not one patient, and
we have tested several hundred
patients in our practice, has been
resistant to undergoing this test.
Not one.
Dr. Pepose: Because the allergens are applied using a plastic
applicator, patients have a very
different response than if we’d
approach them with a needle or
tuberculin syringe.
Dr. Malhotra: Some patients
think they have to be tested
when their allergies are acutely
occurring. So it’s important they
understand they can be tested
any time because we’re exposing them to an allergen to which
they’ve already been sensitized.
Dr. Loff: It’s also important to
note the histamine control. Many
doctors find that if the histamine
response is minimal (less than
4 mm), patients respond better to
steroids as the primary option in
lieu of antihistamines. For those
patients who have a moderate (4
to 6mm) or exacerbated response,
it’s better to recommend antihistamines because they’re more likely
to respond to those. So, the test,
used in conjunction with the histamine response, can help direct
which pharmacotherapy would be
best for a specific patient.
Conclusion
Dr. Parekh: Finally, I’d like to
mention that Doctor’s Allergy
Formula testing uses a multidisciplinary diagnostic code, so it’s
not a lab test. We’re not the first
practitioners to do this. Allergists,
dermatologists, even some primary care doctors are doing this so
we’re actually late to the game.
Dr. Luchs: This test streamlines
caring for our patients because in
one or two visits, they can have
their ocular surface complaints
sorted out in one location — from
allergy to dry eye to blepharitis
— rather than self-medicating,
seeing an allergist, seeing their
primary care physician doctor for
red eye and possibly getting an
antibiotic. When ocular allergies
are the main problem, we can
handle their medical care.
Dr. Parekh: This test is apropos
for the healthcare climate we’re
in because it is truly point-of-care
testing. And when so many other
tests don’t pay enough but yet we
feel we owe it to our patients, Doctor’s Allergy Formula testing actually fits really well in the model of
how best to take care of patients.
REFERENCES
1. Singh K, Bielory L. Epidemiology of ocular allergy symptoms in United States
adults (1988-1994). American College of Allergy, Asthma & Immunology Annual Meeting; Nov 9-15, 2006; Philadelphia, PA. Abstract 34.
2. Austin JB, Kaur B, Anderson HR, et al. Hay fever, eczema, and wheeze: a
nationwide UK study (ISAAC, international study of asthma and allergies in
childhood). Arch Dis Child. 1999;81:225-230.
3. Nathan RA, Meltzer EO, Seiner JC, Storms W. Prevalence of allergic rhinitis in
the United States. J Allergy Clin Immunol. 1997;99:S808-S814.
4. Bielory L. Allergic and immunologic disorders of the eye. Part II: ocular allergy. J Allergy Clin Immunol 2000;106(6):1019-1032.
5. Miljanovic B, Dana R, Sullivan DA, Schaumberg DA. Impact of dry eye syndrome on vision-related quality of life. Am J Ophthalmol. 2007;143:409-415.
6. McGill JI, Holgate ST, Church MK, Anderson DF, Bacon A. Allergic eye disease
mechanisms. Br J Ophthalmol 1998;82(10):1203-1214.
7. Bonini S, Coassin M, Aronni S, Lambiase A. Vernal keratoconjunctivitis. Eye
(Lond.) 2004;18:345-351.
8. Spring TF. Reaction to hydrophilic lenses. Med J Aust. 1974;23:449-450.
9. Kari O, Saari KM. Diagnostics and new developments in the treatment of
ocular allergies. Curr Allergy Asthma Rep. 2012;12:232-239.
10. Bielory L. Allergic and immunologic disorders of the eye. Part I: immunology
of the eye. J Allergy Clin Immunol. 2000;106:805-816.
11. Bacon AS, Ahluwalia P, Irani AM, et al. Tear and conjunctival changes during
the allergen-induced early- and late-phase responses. J Allergy Clin Immunol
2000;106(5):948-954.
12. Luchs J. How new tests help sort out OSD. Ophthalmology Management. June
2013.
13. Liccardi G, D’Amato G, Canonica GW, Salzillo A, Piccolo A, Passalacqua G.
Systemic reactions from skin testing: literature review. J Investig Allergol Clin
Immunol. 2006;16:75-78.
11
The company that brought ocular
allergy testing to Ophthalmology.
Founded by Ophthalmologists
for Ophthalmologists.
IN-OFFICE
OCULAR ALLERGY
TESTING
ENHANCING
PATIENT CARE
• Test for underlying cause of Ocular Surface Disease
• Your trained tech performs and reads test site
• Test for 60 regional, ocular-specific allergens
• First line for Ocular Surface Disease Testing
• FDA-approved, in-office testing
• Covered by all major medical insurance
• No needles. No shots.
Join the 750+ Ophthalmologists utilizing our system
www.drsallergy.com
1 (8 00) 8 1 7-3 00 6
Visit Us at ASCRS 2014
BOOTH #703
September 2014
Point-of-Care Testing
for
Ocular
Allergies
With Doctor’s Allergy Formula,
ophthalmologists can improve diagnosis,
treatment decisions and outcomes —
without disrupting the flow of the clinic.
Sponsored by
1
FACULTY
MITCHELL A. JACKSON, MD
Dr. Jackson is the founder/medical director of
Jacksoneye, Lake Villa, IL, and is a clinical assistant
at the University of Chicago Hospitals.
JODI LUCHS, MD
Dr. Luchs is co-director of the department of refractive
surgery at the North Shore/Long Island Jewish
Health System and is assistant clinical professor of
ophthalmology at Hofstra University School of Medicine.
He is the director of clinical research, and the director of
cornea/external disease at South Shore Eye Care.
JAI G. PAREKH, MD, MBA
Dr. Parekh is the managing partner at Brar-Parekh Eye
Associates, NJ, chief of cornea and external diseases at
St. Joseph’s HealthCare System, NJ, and is clinical
associate professor of ophthalmology on the cornea
service at the New York Eye & Ear Infirmary of Mt. Sinai/
The Icahn School of Medicine at Mt. Sinai.
JAY S. PEPOSE, MD, PHD
Dr. Pepose is director of the Pepose Vision Institute
and a professor of clinical ophthalmology at the
Washington University School of Medicine,
St. Louis, MO.
JOHN D. SHEPPARD, MD, MMSC
Dr. Sheppard is president of Virginia Eye Consultants and
the ophthalmology program director and clinical director
of the Thomas R. Lee Center of Ocular Pharmacology at
Eastern Virginia Medical School.
ROBERT J. WEINSTOCK, MD
Dr. Weinstock is the director of cataract and refractive
services at the Eye Institute of West Florida and the
Weinstock Laser Eye Center and the surgical director of
the Largo Ambulatory Surgery Center. He also is an
associate clinical professor of ophthalmology at the
University of South Florida in Tampa.
EDITORIAL STAFF
CHIEF MEDICAL EDITOR,
Ophthalmology Management
Larry E. Patterson, MD
EDITORIAL DIRECTOR
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… WITH HOWARD J. LOFF, MD
Dr. Loff is chief medical officer for Doctor’s Allergy
Formula, a board-certified ophthalmologist and ASOPRS
fellowship-trained oculoplastic and reconstructive
surgeon.
Ophthalmology Management is
published by PentaVision LLC.
Copyright 2014, PentaVision LLC.
All Rights Reserved.
Point-of-Care Testing
for
Ocular
Allergies
With Doctor’s Allergy Formula,
ophthalmologists can improve diagnosis,
treatment decisions and outcomes —
without disrupting the flow of the clinic.
Doctor’s Allergy Formula is a noninvasive, no-needle proprietary allergy testing modality
that is administered by a technician in the ophthalmologist’s exam room. The testing
system is designed to objectively diagnose the source of ocular allergies to help the
physician determine the most appropriate treatment. Doctor’s Allergy Formula utilizes a
panel of 60 allergens that are specific to each region of the country, which enables
assessment of ocular allergies in the context of associated ocular surface disease. The test
is approved by the FDA and covered by Medicare and all major medical insurance.
In Doctor’s Allergy Formula Part I,1 published in April, a panel of leading ophthalmologists discussed the science of ocular allergies and ocular surface disease, the inflammatory cascade, allergy demographics and how testing helps doctors determine an
appropriate treatment strategy for each patient.
Here, in Part II, the panel discusses how to seamlessly integrate Doctor’s Allergy
Formula into the practice and how the test can guide and improve treatment decisions.
A GOOD FIT IN ANY PRACTICE
ROBERT J. WEINSTOCK, MD: We’ve
been using Doctor’s Allergy Formula for
approximately 6 months and I’ve learned a
great deal about integrating it into a practice.
As many of us would agree, designating a
person, or specific technicians, to be trained
— with the help of the Doctor’s Allergy Formula team — to administer the test is a smart
place to start. Also, having the doctor present
in the building is paramount, especially in the
beginning, and having the doctor spend time
with the patient to explain the results is
important.
What have you found to be crucial in integrating this testing into your practice?
JOHN D. SHEPPARD, MD, MMSC: It’s
amazing how prevalent allergy is, and how
often it is overlooked as one of the “big three”
of ocular surface disease: dry eye, meibomian
3
gland disease and allergy. Allergy is an integral part in the pathogenesis of so many of
my patients’ problems. I need to be aware of
that so I can prioritize my therapeutic
approach. Not only do I have to recognize the
condition, I have to decide whether allergy is
a significant contributor to a patient’s problems. For the first time, Doctor’s Allergy Formula gives me an objective way to do that.
However, I also must be able to take advantage of this test without interrupting or slowing
patient flow in the clinic. I’ve accomplished this
thanks to a single strategy: Our entire practice is
on board. From schedulers to staff at the checkout desk, everyone knows about the test and how
we use it. We’ve added it to our checkout sheet
alongside the LipiFlow consultation and the
various products, such as cold masks and nutraceuticals, that we offer for ocular surface disease.
Every Wednesday afternoon, we have a dedicated clinic, which is run by an LPN and one of
my chief technicians and supervised by our
optometrists. No one is in the retina clinic that
day, so we have dedicated office space for administering the test. The optometrists make a report
on the charts of the patients who are tested so
the next time I see them, I have the results. The
data is waiting for me, along with a tear osmolarity test result, the visual acuity, and so on, so I
can make a diagnosis.
None of this absorbs my time, I have an
income stream, and I’m addressing not only
ocular problems but also systemic problems for
patients who also may have eczema, asthma,
rhinitis or sinusitis. I’m doing it in my office,
which is convenient and familiar for them, thus
more comfortable than sending them to an
allergist’s office. The test is totally integrated
into the practice, takes no extra time for me
and provides me with an additional chance to
deliver state-of-the-art care.
JODI LUCHS, MD: A strategy we use in our
4
practice is to bring patients back strictly for
allergy testing subsequent to their initial
consultation or regular exam. Practice flow
isn’t interrupted on that initial day, and when
I see patients at the next visit, a technician
has already performed the test. I review the
results with the patients, who often feel I’m
providing a great deal of specialized attention
to their ocular surface disease and allergies
in an effort to tailor a therapeutic plan specifically for them.
JAI G. PAREKH, MD, MBA: You can choose
how you want to incorporate Doctor’s Allergy
Formula into your practice. In our mindset,
ocular surface disease is very important; therefore, we think just like other tests such as visual
fields and OCT scans, this test deserves its own
session. I’m in the building when the allergy
test is performed because, technically, we’re
administering an antigen that can cause an
adverse response. Along with me, we have on
hand EpiPens and Benadryl.
A couple of days per month, we devote four
or five hours and schedule six to eight patients
per hour to have the test done by two technicians. During that time, I complete some dictation, perform some minor plastics procedures
or see post-op cataract patients. When the
allergy-tested patients are ready for me, I
spend about 5 minutes with each, explaining
the results and adjusting their treatments as
needed. I see them again in 4 to 6 weeks to
assess how they’re doing. It’s a nice, relatively
quiet day for me, and it’s rich with information.
We’ve tested about 600 patients and have had
zero resistance to this protocol.
MITCHELL A. JACKSON, MD: We have
two doctors and four technicians in our practice, and we’ve taken a similar approach. We
created an allergy/ocular surface clinic. We
also have a glaucoma testing clinic and a cataract advanced diagnostics clinic. In our
electronic health records system, we’ve created all of these different tabs, including one
for Doctor’s Allergy Formula. When I want a
patient to undergo the test, I use the tab to
note this. He or she returns on allergy/ocular
surface clinic day, which we schedule once a
week. My associate and I alternate weeks.
On my week, I sit with each patient and
review their findings, which are always useful.
Armed with the data, I may be able to eliminate
eye-drying allergy medicines they don’t need.
“
ALLERGY IS AN
INTEGRAL PART
IN THE PATHOGENESIS
OF SO MANY OF MY
PATIENTS’ PROBLEMS.
I NEED TO BE AWARE
OF THAT SO I CAN
PRIORITIZE MY
THERAPEUTIC
APPROACH.
”
—John D. Sheppard, MD, MMSC
Or I may learn what specific time of year to
treat their allergic response. I can also tell them
that the objective results support a preauthorization for allergy medication if they need it.
JAY S. PEPOSE, MD, PHD: We use more of
a hybrid model because I find that patients
seem to fall into one of two groups. One group
knows they have allergies, but don’t know what
they’re allergic to. Many of them don’t want to
come back for testing, so we offer them the test
on the spot, unless they’ve been taking anti­
histamines. They’re often grateful to finally
learn what sets off their allergic response.
The other group consists of patients who
are the diagnostic dilemmas. They come in with
the overlapping symptoms of itching, burning
and foreign body sensation. For them, we’ve
created a combined intake form that includes
allergy and dry eye. We explain that they need
to discontinue antihistamines for 5 days, so we
can have them return for a combined allergy/
dry eye evaluation. At that visit, they undergo a
complete ocular surface disease workup, performed by one of our optometrists. The allergy
test data goes to an ophthalmologist who has a
follow-up visit for counseling.
DR. WEINSTOCK: Sometimes when we’re
seeing patients, we’re focused on their main
reason for seeing us, such as cataracts or a
retinal problem. To help keep a broader focus,
we’ve trained our technicians to talk to
patients about whether they have itchy,
watery, red, uncomfortable eyes. When they
do, the tech flags the intake form with a red
sticker. That alerts me to delve into that subject, along with any other ocular findings when
I’m with patients. I tell them we have a great
test that helps us find the cause and best treatment for their symptoms.
DR. LUCHS: We’re able to see from the
explanations that Doctor’s Allergy Formula
can be implemented into a busy practice in
different ways. Some practices segment
their time into specific disease subcategories and bring patients back for testing on
those days. Others have integrated the testing into the regular visit. Still others have
created a hybrid of the two, and all of the
methods are working well.
IN-OFFICE DIAGNOSTICS
ENABLE HIGH-QUALITY CARE
HOWARD J. LOFF, MD: What percentage
of patients who say they’re allergic to something truly are?
5
DR. PEPOSE: I wouldn’t say 100%, but a
very high percentage.
DR. JACKSON: In my experience, many
people who say they have allergies do, but
don’t know whether they’re seasonal or
perennial. That makes a big difference
because people are self-treating with medicines that are aggravating their condition
when they really need to use a treatment in
only the spring or fall. It’s significant when I
can tell them we’ll treat their dry eye yearround, but they only need allergy treatment
seasonally.
DR. LUCHS: All of us have integrated into
our practices the latest diagnostic and therapeutic advances in order to deliver state-ofthe-art care, and this new allergy diagnostic
test should be no exception. It represents
exactly how we want to manage patients with
ocular surface disease complaints. We utilize
all of the available tools to help us sort out
what’s going on so we can make the appropriate therapeutic choices.
DR. PAREKH: This kind of test is commensurate with comprehensive medicine as it
relates to, for example, lipids. If a patient is
told he has high cholesterol, what does that
mean? Well, today, triglycerides, LDL, HDL,
LDL/HDL ratio, all of these components are
measured. I’ve tested about 600 patients
with Doctor’s Allergy Formula, and I would
feel remiss had I not tested them. This tool
provides me with so much useful information; I would be upset to have it taken away
from me at this point.
DR. SHEPPARD: All of the new point-ofcare tests, such as LipiView, tear osmolarity,
InflammaDry and Doctor’s Allergy Formula,
enhance one another, and this segment will
continue to grow.
DR. PEPOSE: Yes, and if a patient has high
tear osmolarity and corneal staining, it
GETTING THE WORD OUT
JODI LUCHS, MD: In our waiting room, I’ve placed a flier that says if you have itchy, burning or
red eyes, you might have ocular allergies, and we now have a simple test that can help make
the diagnosis. Of course, as a corneal specialist, I’m especially aware of ocular surface diseases,
but the other subspecialists in the practice may sometimes be less focused on these issues.
The direct-to-patient marketing/information piece has prompted many patients to express
interest to their doctors about the test. The doctor then issues an allergy consult, the patient
comes to see me, gets the workup done, and then returns to that referring doctor within the
practice. The flier has been very effective for bringing patients to the allergy testing.
MITCHELL A. JACKSON, MD: All of our staff members and technicians now wear big buttons that say “Ask me what I’m allergic to” or “Tell me what your allergies are.” The button
motivates patients to engage in a discussion about allergies. Then, we let them know we
can perform a test to identify their allergen.
JOHN D. SHEPPARD, MD, MMSC: Internal marketing is the best marketing by far in terms
of informing and educating patients and return on investment. We can market to patients,
but it’s crucial to successfully market to the staff and doctors as well. We have 12 doctors
and three offices, and we have concentrated on motivating everyone to play a part in
everything from increasing premium IOL conversions to referring patients for LipiFlow
treatments, and now getting the word to patients about allergy testing.
6
doesn’t mean he doesn’t also have ocular
allergies, and both need to be treated.
DR. SHEPPARD: Another advantage of
having quantitative analysis is it helps recruit
patients as their own advocates. When I tell
patients they have superficial punctate keratopathy, they have no idea what I’m talking
about and may or may not take the drug I prescribe for them. On the other hand, if I tell
them they react positively to three specific
antigens, their tear osmolarity number is X,
and they need to avoid a certain exposure and
use this treatment, they tend to become my
ally. Next time I see them, their tear osmolarity score is lower, they no longer have that elm
tree in their front yard, their eyes itch less and
are less red. We all know that with chronic
conditions, compliance is the biggest enemy of
therapeutic success. When we make patients
their own advocates, we improve our ability to
help them.
DR. JACKSON: When you have objective
data, self-motivation to continue therapy and
compliance definitely improve.
DR. WEINSTOCK: Does anyone have any
thoughts about administrating the allergy
test for kids?
DR. SHEPPARD: Some of the most difficult
patients to deal with are children because
they really don’t understand. If we can at
least recruit the parents to help with some of
the behavior modifications, therapies are
likely to be more successful. I practiced pediatrics for 5 years after medical school in the
Navy. This type of test is more successful in
children than the traditional pin prick testing.
There’s no increased risk of anaphylactic
response, but the immunogenic response in a
child is much more vigorous than in an adult.
We’ve tested several kids and they’ve done
very well. They benefit from a lifelong
approach of preventive care to arrest a clini-
JOHN D. SHEPPARD, MD, MMSC: We’ve created an atmosphere of friendly competition within
the practice. We’re all aware that ophthalmologists tend to be highly competitive. They were
valedictorians in high school, got into good colleges and got admitted to medical school,
where they were in the top 5% of their class. Otherwise, they wouldn’t be ophthalmologists.
That competition button just doesn’t turn off, and we use that to our advantage. We keep
track of retail sales, premium IOL conversions, LipiFlow referrals and allergy testing referrals.
At our meetings and our 5-minute daily morning staff huddle, we acknowledge who the leaders are. We may also highlight a member of the technical staff who’s doing a great job at the
allergy clinic, or referring patients, coming up with new ways to market or bringing mom or
dad in for a cataract evaluation. The internal motivation is really important. For those who
haven’t thought outside the box to get new services up and running, it’s easy to overlook.
JAI G. PAREKH, MD, MBA: Now that we’re using Doctor’s Allergy Formula and discussing
ocular allergies with our patients, they really appreciate the targeted treatment and helpful information we give them about behavior modification. Most modification can be
accomplished quickly, e.g., getting a HEPA filter at Walmart, keeping the door shut when
the landscapers are around. A couple minutes of conversation reinforces the doctor-­
patient relationship. I can’t tell you how many patients have referred other patients to
me for a variety of issues because they’ve seen me more in this interaction.
7
cally significant disease before it can become
advanced and cause damage, which contributes to an improved quality of life over many
decades.
DR. PAREKH: We’ve tested kids as young as
seven or eight. Also, we test every keratoconus patient in our clinic because nighttime
itching and aggressive scratching can exacerbate the cornea and astigmatism, which can
push someone into a state of full-fledged
keratoconus. We’re testing all of our contact
lens patients who have a history of giant papillary conjunctivitis (GPC), too. In some
cases, what I thought was GPC wasn’t; it was
pollen allergy. The contact lens itself can be a
reservoir for the allergen.
DR. WEINSTOCK: Doctor’s Allergy Formula is reimbursable through medical insurance and Medicare, which is very helpful to
the patient. However, copays can be a burden. Is it important to have this discussion
with patients up front?
DR. JACKSON: This is one of the reasons
we don’t test on the spot. We schedule it for
a different day and then alert our coding and
billing folks. We have two people who are
dedicated to pre-authorizations and finding
out whether there is a deductible or copay
because we don’t want any hidden surprises
for our patients. Due diligence ahead of time
means our patients know their costs ahead
of time. More than 90% of the patients
agree to have the test. For some, I have to
explain why I think it’s really important they
have the test even if they have to pay $50 or
$100 out of pocket. It’s important to have
that discussion, especially in this health
insurance climate.
DR. LOFF: You can approach the issue from
a cost-containment perspective, too.
DR. WEINSTOCK: That’s a good point.
Having the test may end up saving them
8
money in the long run if we learn they’re
spending on drops they don’t need or only
need at certain times of the year.
DR. PAREKH: Many of these patients are
pretty uncomfortable, eyes constantly itching
and/or red, so when we give them a diagnosis, they’re thrilled. I’ve had zero push-back
with this test.
DR. LUCHS: Nor have I. Whether patients
have the test on the spot or come back to
have it done, they’re very happy and grateful
to have the results. They get a sense that even
if they have to pay something, they’re getting
something in return. They can actually take
that piece of paper and see they’ve gained
knowledge. Doctor’s Allergy Formula is one
of the few new initiatives for which I’ve seen
nothing but acceptance.
TESTING GUIDES — AND
SOMETIMES CORRECTS —
TREATMENT DECISIONS
DR. WEINSTOCK: Can you share a case
that illustrates how treatment was dictated
or different than expected based on Doctor’s
Allergy Formula?
DR. SHEPPARD: We looked closely at our
first group of Doctor’s Allergy Formula
patients. Our selection criterion for testing
was a doctor’s suspicion of ocular allergies.
That meant virtually all of them had used
some form of topical antihistamine or steroid, which aren’t inexpensive medications.
Out of our first 40 patients, 15 had no
­reaction to the test panel. They had no
pathophysiologic reason to be using antihistamines. That surprised me. Because of the
variety of presentations and phenotypes
among our patients, we truly need some
assistance in categorizing the primary instigator of their problems, be it type 2 sensitivity, meibomian gland dysfunction,
hypersecretion, neurotropic disease or a
combination of factors.
DR. LUCHS: One of my patients who originally presented with all of the symptoms
that are so difficult to differentiate — itching, foreign body sensation, burning — we
had been treating for ocular allergy. His
Doctor’s Allergy Formula results were negative, suggesting that either we’re completely
missing the antigen, which I doubt, or
allergy really isn’t a component of his ocular
surface disease. When I know the latter with
any patient, I can focus on the other aspects
“
IN MY EXPERIENCE,
MANY PEOPLE
WHO SAY THEY HAVE
ALLERGIES DO,
BUT DON’T KNOW
WHETHER THEY’RE
SEASONAL OR
PERENNIAL.
”
­—Mitchell A. Jackson, MD
of ocular surface disease, dry eye and/or
blepharitis. A tighter focus usually leads to
better relief of the symptomatology. Consider, too, that a patient who has dry eye
may not have adequate ocular surface lubrication to flush out antigens or irritants that
get into the tear film. That may produce a
local response that creates their symptoms,
but they don’t rise to the level of skin-test
-positive allergy. We treat their dry eye and
they get better.
DR. SHEPPARD: Many of our patients use
oral antihistamines, which can be purchased
over the counter. In many cases, they’re over-
medicated and making their dry eye worse. If
I can prove they’re not allergic, I can take
that out of the equation. When these patients
are convinced to stop taking the oral antihistamines and don’t subsequently get worse,
they see they don’t need to take those drying,
sedating medications.
DR. LUCHS: Another good example of the
benefits of Doctor’s Allergy Formula is the
patient who comes in saying he always wakes
in the morning with swollen eyes, so he takes
an oral antihistamine. He’s noticing his
symptoms in the morning so that’s when he
takes the pill. When we perform the allergy
test, we find he’s actually allergic to dust
mites or feather pillows. We instruct him to
get rid of the pillows, get dust-mite resistant
bedding, or wash the bedding in hot water,
and, low and behold, his symptoms go away.
He’d been taking a pill in the morning for a
symptom that was developing overnight,
which of course was to no avail.
DR. PEPOSE: The positive predictive value
of the Doctor’s Allergy Formula test is very
high, but we should be cautious in how we
interpret a negative test and how we relate
that to the patient, because we’re not testing
for thousands of antigens. We’re testing for
60. It’s important to explain to patients they
don’t seem to have a systemic response to
these 60 antigens, but we can’t say with
100% certainty that they aren’t allergic to
anything or that they don’t have a local ocular
immune response that hasn’t reached the
point of systemic immunity. I’m sure there
are groups of patients like that. So I think we
have to be cautious in the way we interpret a
negative test where there is great specificity
in the positive.
DR. WEINSTOCK: So perhaps in some cases
you may get a negative allergy test, but based
on the strong clinical signs and symptoms, you
9
may still consider treating for ocular allergy?
Certainly you wouldn’t treat systemically if the
patient isn’t reacting to the test.
DR. PEPOSE: Right, because we’re not
really doing a local provocative test here. As
more diagnostics become available, such as
for IgE, chymase or tryptase, we’re going to
become more like internists. We’re going to
have a tear profile, and it may turn out we
learn more about those patients who do have
a local immune response vs. a systemic
immune response.
DR. LUCHS: The scenarios in which we’re
using a test like this aren’t cut-and-dried.
They’re not just positive or negative and
that’s it. We still need to be clinicians and
rely on our clinical acumen to decide
whether another component of allergy is
playing a role for an individual patient and
whether we need to treat it. Doctor’s
Allergy Formula is an additional data point
we can add to our diagnostic algorithm.
DR. SHEPPARD: There may be some
gaps in the testing. Obviously we’re
advanced in this science but we do have
farther to go. For instance, food allergens
aren’t included in the panel, and they’re very
difficult to test with cutaneous hypersensitivity analysis. One test that would be very
valuable to me would be one that determines whether a patient is reacting to the
benzalkonium chloride (BAK) in a medication or to the medication itself. As the science progresses further, I’m certain we’ll
have access through Doctor’s Allergy Formula to analyze these most important panels. In addition, maybe we need a secondary
panel for the patients whose results don’t
look as we expect them to look on the first
pass with the first 60 antigens.
DR. LOFF: The company has been
researching and developing tests for preser-
10
vatives, such as BAK and Polyquad, and
should hopefully have them commercially
available in the next few months.
AN ASSET FOR THE OR IN
ADDITION TO THE CLINIC
DR. WEINSTOCK: In a high volume surgical practice, how are you able to identify
patients who need allergy testing in light of
the fact that many of them are surgical
patients?
“
IT WAS A PARADIGM
SHIFT FOR ME TO
UNDERSTAND THE
VALUE OF POINTOF-CARE ALLERGY
TESTING IN MY
PRACTICE.
”
­—Robert J. Weinstock, MD
DR. PAREKH: I think the reason we’ve been
so successful with this is that we require
every patient to complete an allergy/ocular
surface disease intake form. I’m not eager to
defer a patient who is ready to schedule for
surgery, but I want to be sure whether I
should pre-treat someone who has severe
ocular surface disease before proceeding
with a procedure. I need to be confident that
the biometry will be accurate. A tear osmolality test and corneal staining are part of our
routine pre-testing for every cataract patient
for this reason.
DR. SHEPPARD: The surgery-related
algorithm for allergy is going to change just
as it has for dry eye. In past years, it was
anathema to delay cataract surgery even if
the patient had dry eye. Doctors are stepping back from that because of premium
IOLs. We looked at our own data 2 years
ago and virtually all of our unhappy multifocal lens patients had ocular surface disease.
What has happened is we’ve reduced the
number of cases in which we choose a multifocal lens, from approximately 15% to
about 9%. The 9% are happy, and it’s a
much happier environment for the doctors
and staff as well. So why should we treat
ocular allergy any differently?
For refractive surgery, the Boorstein article from 2003 clearly shows that oral anti­
histamines protect atopic patients from
diffuse lamellar keratitis after LASIK. Therefore, allergies should be a key component of
the pre-LASIK screening. Consider this as
well: The highest concentration of mast cells
in the eye, and therefore in the body, is in the
choroid, not the conjunctiva, and those cells
are very highly reactive in atopic patients. I’m
following a cohort of atopic patients in which I
expect to find a significant statistical difference in the incidence of at least anatomical
cystoid macular edema (CME) with routine
cataract surgery. In my cohort of patients who
have had skin testing, those with atopy test
positive for 28 to 32 antigens, whereas my
average reactors have 3 to 7 antigens. About a
half to three-fourths of my patients don’t react
to anything on the test panel. So we have
almost a tri-modal distribution. The folks with
the rubbery, leathery, lids and the puffy eyes
and the keratoconus and asthma and the
eczema are reacting to everything. They
clearly need sublingual immunotherapy, and
we can postpone their cataract surgery until
the ocular surface is under control. I treat
them aggressively for CME prevention, too,
and I give them a bolus of intravitreal corticosteroid at the time of cataract surgery. This is
a small group of patients, but a relatively large
group in a practice like ours where we see a
great deal of cornea patients.
THE VALUE OF
ALLERGY TESTING FOR
OPHTHALMOLOGY PRACTICE
DR. WEINSTOCK: I have little doubt that
Doctor’s Allergy Formula will become a
standard part of ophthalmology practices.
When I first heard about it, it seemed a
little out of the box to use skin testing
because it’s not something we learned in
residency or have had much, if any, training
or experience with. We had done other
seemingly tangential things in our practice
in the past, such as integrate hearing services, and some worked and some did not. I
tend to be skeptical.
However, when all the physicians in my
practice — the retina specialists, the glaucoma
specialists — discovered how valuable the
allergy testing was in making decisions about
topical therapies, they began showing up to
have themselves tested and ordering testing
for their own patients. That made me realize
how completely germane to ophthalmology
this is, especially in an ocular surface disease
clinic, a dry eye clinic and an allergic conjunctivitis clinic. It really is integral and makes me
wonder why we haven’t been doing this all
along. It was a paradigm shift for me to understand the value of point-of-care allergy testing
in my practice. I’m certainly glad I came to the
realization.
REFERENCES
1. Point-of-Care Testing Pays Off. O
­ phthalmology
Management, Volume: 18; Issue: April 2014;
pages s1-12.
2. Boorstein SM, Henk HJ, Elner VM. Atopy: a
patient-specific risk factor for diffuse lamellar
keratitis. Ophthalmology. 2003;110(1):131-7.
11
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