Seasonal allergies are a common trigger for dry eye flares

Short-term steroid use can alleviate patient discomfort.

In patients with dry eye disease (DED), seasonal allergies are likely to trigger an exacerbation or flare of their DED symptoms. These patients will often complain of runny or teary eyes, redness, itchiness, burning, a gritty sensation, as well as symptoms that affect the adjacent regions such as sinus tenderness and a stuffy, runny nose.

In my clinical experience, most have these allergy-induced dry eye flares during the spring and summer when pollen, the biggest inciting factor, is being dispersed by blooming flowers and trees. A complicating element is that patients often take oral antihistamines to treat their ocular symptoms which can lead to excessive drying and in turn, a worsening of underlying DED.

A dry eye flare is defined as an acute episode of worsening symptoms where inflammation has disrupted the homeostatic balance within the tear film. This acute worsening of symptoms can last from a few days to a couple weeks. Most commonly, a dry eye flare is caused by a trigger that activates a pro-inflammatory cascade on the ocular surface.1-4

Along with seasonal allergies, other triggers include perennial allergies such as pet dander, dust, and mould; excessive screen time; contact lens overwear; and vented air from heat or air conditioning.5-13

DED is a multifactorial condition with the two main pathways being a decrease of healthy tear production or increased tear evaporation from the ocular surface.1-4 If any one of a number of instigating factors is collectively added, there can be a heightened inflammatory response on the ocular surface which can affect both of the DED pathways leading to the exacerbation of DED.1-4

Dry eye flare: What to look for

When I educate patients about dry eye flares, I let them know that a flare is a symptomatic acute episode during a previously quiescent period. Many of my more severe dry eye patients will be on baseline therapy such as cyclosporine or lifitegrast (Xiidra; Novartis), and for the most part, their symptoms are well controlled. When there is a trigger such as seasonal allergies, it puts them into a pro-inflammatory state, and they develop a sudden onset of acute symptoms.

In other words, these patients are quite miserable. They will not say, "Doctor, I think I'm experiencing a dry eye flare," but they will say, "My medications don't seem to be working anymore. I'm getting these symptoms again." That is when I take the opportunity to educate them, reminding them that although there is no cure for DED, it is normal to experience fluctuations in symptoms, and we can manage it together with therapy. I say your seasonal allergies are pushing your eyes into overdrive or a pro-inflammatory state.

Subsequently, my next step would be to tell them that medication is needed to control this acute flare. Treatment with an approved fast-acting, low-dose topical steroid can provide rapid relief of symptoms—exactly what these patients are looking for.

How to treat

Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%; Kala Pharmaceuticals) is the first FDA approved corticosteroid for the short-term treatment of the signs and symptoms associated with DED. The drop has a novel formulation utilizing AMPPLIFY, Kala’s proprietary mucus-penetrating particle technology. Nanoparticles of ~300 nm in diameter are coated to facilitate their penetration through the mucus barrier. This controlled delivery system enables the drop to spread more uniformly across the ocular surface.

I like to use it in these patients because the quick onset of action means noticeable, rapid relief, plus they only need to use it for a short period of time—no more than 2 weeks. Those DED patients on chronic medication can continue while supplementing with Eysuvis. Patients should be educated that seasonal changes or other triggers mentioned earlier may cause them to have recurrent episodes of dry eye flares that need to be treated with a short course of a low-dose steroid.

As we know, many of us worry about intraocular pressure (IOP) elevation secondary to steroid use. I reassure patients that the drop has a favourable side effect profile, and because of its low concentration, I am comfortable with episodic dosing throughout the year. In fact, loteprednol etabonate ophthalmic suspension 0.25% was studied in more than 2,800 DED patients.14-16

The drop was well-tolerated and illustrated a low incidence of IOP increase similar to vehicle. In treatment and vehicle groups, respectively, 0.2% and 0% of subjects experienced a ≥10 mm Hg increase from baseline resulting in an IOP measurement of ≥21 mm Hg at any post-baseline visit up to 29 days.14-16 This IOP safety data provides me with a boost in confidence to prescribe Eysuvis in my DED patients.

For compliant patients who have a good understanding of their dry eye disease, I have them keep their loteprednol etabonate ophthalmic suspension 0.25% handy. I advise them to restart their medication for a short course when they notice a dry eye flare. It is normal for patients to experience multiple flares throughout the year. For some, it may be more or less frequent. These inflammatory spikes of acute exacerbation occur in about eight out of 10 dry eye patients, and about half of DED patients experience flares only without continuous symptoms between four to six times per year.17-20

Advising on antihistamine use and contact lens wear

A number of allergy patients will be taking oral antihistamines. If I see that they are having signs and symptoms of ocular surface disease, I will tell them to hold off on their oral antihistamine because they can worsen DED. Depending on the severity of their systemic allergy symptoms, I will talk to their allergy specialist to determine if they can switch to a nasal decongestant or other nonsystemic therapy. The best solution is always to avoid the allergy trigger and make other appropriate environmental and/or lifestyle changes.

I advise contact lens wearers to discontinue use when they are experiencing a dry eye flare. I prefer they not use eye drops with contact lenses to avoid problems such as build up, debris, or denaturing the lens material.

Plus, lens wear can add to or be a culprit of their dry eye flare due to the mechanical rubbing on their eyes and oxygen deprivation. While they take a contact lens holiday, they can also start a short course of Eysuvis to rapidly relieve their symptoms. They can then consider slowly going back into their contact lenses; however, I recommend decreasing wear time as much as possible and no more than 8 hours per day. We should always ensure patients are wearing lenses with optimal oxygen permeability with daily disposables as an ideal option.

Stay ahead of the game

For most of our DED patients it is not a matter of if, but when they will have an acute exacerbation of symptoms—dry eye flares. Fortunately, we have a fast-acting treatment to lessen their misery.

Dagny Zhu, MD
Dr Zhu is a cornea, cataract, and refractive surgeon, and Medical Director and Partner at NVISION Eye Centers in Rowland Heights, California.
Zhu acknowledged no financial interest in the products or companies mentioned.
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