Bringing ocular allergies into the spotlight

Allergy meeting confirms underdiagnosis of allergic conjunctivitis

papillae on the upper tarsal conjunctiva in a patient affected by VKC


A young boy with severe conjunctival redness, discharge, and mild limbal infiltrate. This is a typical appearance of vernal keratoconjunctivitis
Source: Andrea Leonardi, M.D.

Physicians at the American Academy of Allergy, Asthma, and Immunology Annual Meeting (AAAAI) this past spring confirmed that ocular allergies are underdiagnosed and have a strong connection to allergic rhinitis.
“Ocular allergy deserves attention on a grander, public health level to make the appropriate diagnosis and management and to decrease morbidity,” according to a poster on ocular allergy epidemiology from Sara H. Axelrod, M.D., M.P.H., resident in medicine, University of Medicine and Dentistry of New Jersey (UMDNJ), Newark, N.J. The poster reported that data from the National Health and Nutrition Examination Survey (NHANES) III found that 40% of the population in the survey reported at least one occurrence of ocular allergy symptoms. NHANES had a sample size of 20,010, with 59% answering questions relevant to allergy.
Ocular allergy is often ignored because “people don’t ask about the eye,” said Sergio Bonini, M.D., internist, Department of Medicine, Second University of Naples, Naples, Italy, leading a seminar on ocular allergy at the meeting.
“We joke that the eye is the upper part of the upper respiratory system, but the eye needs its own identity,” said Andrea Leonardi, M.D., Department of Neurosciences, Ophthalmology Unit, University of Padua, Padua, Italy, who co-led the ocular allergy seminar.
Another study at the AAAAI meeting, held in Washington, D.C., in March, estimated that about half of the $3.4 to $4.8 billion in annual direct costs for allergic rhinitis are actually attributed to ocular symptoms, reported lead investigator Donald E. Stull, Ph.D., United BioSource Corporation, London. Ocular allergy expenses also compose half of the $3.1 to $4.3 billion in annual indirect costs for allergic rhinitis, investigators added. The study likened the burden of ocular allergy symptoms to nasal congestion, as nearly half of the allergic rhinitis symptoms are caused by ocular allergy. “Given that 95% of the patients in this study had nasal congestion and ocular symptoms, focusing on the combination of these symptoms for understanding the burden of [allergic rhinitis] would be reasonable,” wrote Dr. Stull and investigators.

Ocular allergy and asthma

One study presented at the meeting tracked the prevalence of allergic conjunctivitis in asthmatic children and reported that physician registry of allergic conjunctivitis was found in 16% of the 1,549 patients studied, although 43.9% of patients actually complained of at least one symptom suggestive of ocular allergy. “Symptoms suggestive of ocular allergy were frequent in asthmatics though the diagnosis was underreported by physicians,” wrote lead study author Gabriele L. Westphal, University of Paraná, Curtiba, Brazil.
The same group of Brazilian investigators even proposed in a poster presentation that allergic conjunctivitis, rhinitis, and asthma may be part of the same disease. “As many as two thirds of asthmatic patients have symptoms of allergic rhinoconjunctivitis. This suggests there is a close relationship between allergic diseases and a reason to include conjunctivitis in the concept of ‘one airway disease,’” they wrote.

New drops

Some of the ocular allergy research presented at the meeting focused on the upcoming medication Bepreve (bepotastine ophthalmic solution, Ista Pharmaceuticals, Irvine, Calif.). Bepreve, a selective antagonist of the histamine receptor, aims to treat ocular itching associated with allergic conjunctivitis. Bepreve is already marketed in Japan by Mitsubishi Tanabe Pharma Corporation under the brand name Talion. Bepreve is undergoing a 10-month review by the U.S. Food and Drug Administration, with results expected in September, according to a press release from Ista.
Phase III studies with Bepreve have shown statistically significant reductions of ocular itching and improvement in nasal symptoms, according to Ista. At AAAAI, Thomas T. Macejko, M.D., Cincinnati, presented results that showed that Bepreve was statistically superior to placebo in 86 patients for the reduction of rhinorrhea, non-ocular symptoms, and tearing. Investigators used a Conjunctival Allergen Challenge (CAC) with Bepreve or placebo for up to eight hours after dosing.
Three subjects in the Bepreve group and seven subjects in the placebo group withdrew due to noncompliance; another two subjects in the Bepreve group withdrew because of unacceptable ocular itching and redness.
A second study with Bepreve, led by Gail L. Torkildsen, M.D., ORA Clinical Research & Development, North Andover, Mass., showed the drop’s clinical efficacy for the reduction of ocular itching in a CAC model of allergic conjunctivitis at 15 minutes and 8 and 16 hours.

SLIT, climate change and allergy

The 7,000 attendees at this year’s AAAAI meeting were briefed on a host of emerging treatment trends that also affect ocular allergy, including the use of sublingual immunotherapy, or SLIT. SLIT is a newer alternative to allergy shots during which patients receive their allergy solution orally under their tongue. Results continue to show generally good outcomes for SLIT, which is used more commonly in Europe, although some physicians remain skeptical about its safety and efficacy.
A number of presenters also addressed the effects of climate change on the rising rates of allergy. A study that tracked shifting ragweed trends in the New York City metropolitan area found that although the amount of ragweed pollen in the air on a given day during the ragweed season has decreased, the duration of the ragweed season is actually longer. This is likely due to climate change, said lead presenter Mark E. Weinstein, M.D., fellow, UMDNJ. “This could have a clinical impact, with the increased potential for allergic priming and symptomatic days,” Dr. Weinstein said.

Editors’ note: Ista Pharmaceuticals was involved with the studies of Bepreve. Schering-Plough (Kenilworth, N.J.) provided financial support for the study from Dr. Stull.
Drs. Bonini and Leonardi have financial interests with Alcon (Fort Worth, Texas) and Schering-Plough. The other physicians quoted do not have any related financial interests.

Contact information

Bonini: se.bonini@gmail.com
Leonardi: andrea.leonardi@unipd.it