PART 1 OF A 3-PART SERIES
Optometric Staff Continuing Education for ABO Credit

Increasing Your Clinical Value:
Opportunities for Optometric Staff to Get Involved with Allergy Patients

By Milton M. Hom, OD, FAAO and Melissa Quintana, Optometric Technician

Faculty/Editorial Board:

Milton M. Hom, OD, FAAO and Melissa Quintana, Optometric Technician

Credit Statement:

This course is approved for 1 hour of CE credit by the American Board of Opticianry. Course approval number SWJM253-1.

---

All across America, allergies seem to be on the increase. Season after season, pollen levels are at all-time highs. In fact, the 2010 spring season showed record-breaking levels and 2011 was even higher. Now, 2012 is shaping up to shatter even more records.¹

While our Southern California practice for the most part experiences mild weather year-round, even some of the most traditionally cold climates in the United States have not experienced a true winter this year. And of course, with milder temperatures, the plant life has been blooming year-round, exacerbating allergy season for many. We typically treat 20% of our patients for ocular allergies, which mirrors national reported averages.² In 2012, however, we have already treated more than 50% of our patients for allergy symptoms.

More than 50 million Americans already suffer from allergic diseases, and allergies are the sixth leading cause of chronic disease in the United States. Because the patient history can offer important clues to making a diagnosis, the role of the optometric staff is an important one—and a well-trained staff is an invaluable asset to the optometrist.

The Daily Journey of Pollen

What are the causes of ocular allergies? For the current scenario, weather is the number-one factor influencing pollen counts. Recently, the allergy seasons are getting longer and longer. They start earlier and end later. The climate changes have prolonged the season and propelled us to unprecedented pollen levels. Some have referred to this as "climate chaos." ¹ Carbon dioxide is another factor. The more of it is present, the more it fuels plant growth and more pollen is released.

Understanding the daily journey of pollen can help our patients avoid the worst times of the day when levels are at their highest. Pollen usually rises with heat and drops with cooler temperatures, which explains why our patients often suffer from allergy symptoms the most during commute hours. This goes hand in hand with the daily journey of pollen: as the earth heats up in the morning, the pollen rises and as the earth cools in the evening, the pollen falls.

Furthermore, mold and other pollens are common residents in car air conditioners and smog also makes pollen more potent. More traffic means more smog and exhaust, which once again leads back to commuting hours being a peak time for allergies.

The "hygiene hypothesis" offers a theory on why allergies have increased. Early exposure to allergens in childhood may promote immune system maturation and protect from the development of an allergy later on. On the flip side, lack of exposure in early life may disrupt normal development of immune activity and increase the risk of allergic disease.^3,4 According to this hypothesis, as our societies and cultures evolved and became cleaner, the incidence of allergy increased.

The Allergy Cascade Although not specifically part of the optometric staff's scope of responsibility and training, knowledge of the allergic cascade will aid in the understanding of the body's response to allergens in general. The allergy cascade can be a multi-faceted complex set of cause and reaction, setting off other allergens in the body. Patient perception of their allergies' interference with daily life activities, cosmetic appearance and overall quality of life is gaining importance. Our body's immune system is designed to constantly be on the lookout for intruders. It has the ability to distinguish between "self" and "non-self" (foreign substances such as inhaled ragweed) from which it will tirelessly work to protect us. An allergic response is the body's overreaction to some substance it believes to be a threat to the body. The substance is perceived as an attacker that threatens the bodily system, and the immune system will subsequently produce specific antibodies to combat this threat. An allergic cascade refers to the chain of events that takes place when an allergen triggers an allergic response. It is the unique sequence of chemical releases in the body that take place in response to an allergen. The end result of this chain is the release of histamines and other chemicals that bring on typical allergy symptoms. Individuals must first become sensitive to an allergen before an allergic reaction can take place. This process involves the immune system mistakenly perceiving an allergen again.

Quality of Life

Allergies have a tremendous impact on the quality of life of our patients. Ocular allergy can affect patients' lives in multiple ways. It can limit where they can go, take away the enjoyment of outdoor activities, affect work-related activities, leisure time activities, the ability to read or work on a computer, social functioning, and it can also make contact lens wear—which is very important to many patients— unpleasant or even impossible. Thus, this prevalent condition deserves our attention as eyecare professionals.

Patient appearance and well-being can be radically affected by allergies, as measured by one survey.⁵ Patients suffering from allergies experienced fatigue, frustration, irritability, embarrassment, helplessness, and felt less attractive. Their condition troubled them when reading, driving, going outdoors, sleeping, and concentrating on daily tasks. When the symptoms are severe, allergies can be debilitating.

Clinical Signs and Symptoms

The clinical signs of allergic conjunctivitis include conjunctival hyperemia (Figures 1 and 2), chemosis, lid edema and a stringy mucous discharge. That said, it is rare for patients to present to their optometrist's practice with these signs. Usually, by the time they have arrived in our offices, the acute swelling has resolved, leaving a relatively white and quiet eye. Occasionally, a fine papillary reaction can be observed on the palpebral conjunctiva, which can help aid in the diagnosis. Thus, because a patient's appearance may be deceiving, it is crucial to take a complete history to ensure a proper diagnosis and treatment regimen.

The optometric staff is often the first point of contact and the first history taker in the patient encounter; therefore, it is crucial that they have a high index of suspicion for allergy and ocular surface disease. Furthermore, it is critical that they ask the appropriate questions to allow the optometrist to key in on the issue of allergy and treat appropriately.

As we are all aware, the hallmark symptom of ocular allergy is itch. However, many patients don't present to our offices simply complaining of itch, or with acute findings of red, swollen eyes. Sometimes, similar to what happens with their clinical signs, patients with ocular allergy start out with itch symptoms, which lead to rubbing and secondary redness and irritation. But often, their episode of itchiness and redness occurred days or weeks prior to their visit, and by the time they present to our offices, their eyes look relatively white and quiet upon presentation. And occasionally, some patients even forget about their prior episode of itch. They may present complaining about dry eyes, contact lens intolerance, difficulty working on a computer, episodic redness, etc.—all symptoms that may also suggest other ocular surface diseases such as dry eye or blepharitis.

All Hands on Deck

Managing allergy patients takes a team effort in clinical practice. There is no way a doctor alone can dispense the needed education about allergy. Optometric staff form an invaluable part of the team approach.

The role of the optometric staff will vary a bit with the attitudes and instructions of the supervising eye doctor. It is always advisable to know how in-depth your doctor wants the history and workup. It is best to develop a systematic method of questioning and to perform the history in a friendly yet professional manner. If a patient has confidence in you and trusts you, then you will be able to obtain more information from them.

When ocular allergies are involved, the accuracy, consistency and efficiency of the optometric staff becomes extremely important. The patient's presenting symptoms are an important aspect of the history and invariably include some degree of itch—usually ocular itch or periocular (around the eyes) itch, or both. Other common symptoms include burning, tearing, sensitivity to light, or a gritty or foreign body sensation. Physical examination and slit lamp exam are, of course, also important for ruling out other causes of the patient's symptoms, including dry eyes, blepharitis, rosacea and medication toxicity. The optometrist will be interested in known allergens or exposures, including pets, as well as the frequency, severity and duration of the patient's symptoms. The patient history should also include the presence of any associated systemic allergic conditions such as asthma, allergic rhinitis or eczema.

A family history of allergies is also important to note because it is a significant risk factor for the development of ocular allergies. The history should also include the efficacy of any previous medical treatments the patient has used, including over-the-counter (OTC) formulations. These pieces of information only take a moment to collect, but are crucial in helping the doctor distinguish patients who have occasional allergy symptoms from those with more chronic long-term and recurrent disease. Many doctors find that it is also helpful to include some degree of the severity of the itch.⁶ Some even use the patient's own words in quotes, such as "I could not stop rubbing" or "I wanted to rub my eyes out" versus "they itch occasionally".

When inquiring with a patient about allergies, one question commonly asked is, "Do you have any allergies?" Unfortunately, the patient has no idea they have allergies. Many times, the eye doctor and staff are the first to diagnose allergies. Breaking the question down into categories, you can elicit more clues to whether allergies are present. In general, specific types of allergic responses should be inquired about such as:

• Do you have any allergy to prescription or OTC medications?
• Do you have any allergies to food, tape, latex, animals or any general substances?
• Do you have any seasonal allergies, or allergies that persist throughout the year?
• Do you use any OTC allergy medications? (This question is extremely important because the patient may be masking signs of an allergy through the use of these medications.)
• Do you have problems using eye drops? (This question will help evaluate how compliant the patient will be during the course of treatment and assists the doctor in determining whether the patient will do better trying a once-a-day drop approach versus drops throughout the day.)

Any positive response should concisely document the type of allergen, the reaction the patient suffers, when it occurs and how long it lasts. It is important not to interpret for the patient. The interpretation of history and symptoms is the domain of the optometrist, who assembles all information gathered from the history and the medical exam to develop a diagnosis and treatment plan. Some allergies can be genetic, such as those to cow's milk or animals, while others, such as poison ivy or a wasp sting, are not. Some doctors may want their staff to question patients regarding family allergies in general.

When gathering information for the optometrist, staff can also incorporate specific questions such as:

• Do you ever suffer from red eyes, itchy eyes, watery eyes or swollen eyelids?
• Do you use OTC eye drops to treat red, itchy, watery eyes or swollen eyelids?
• Do you take any oral allergy medications?

Always remember to note the frequency of use of any affirmative answers to the above, as well as when the last dose was taken if presently in use.

A thorough history is the foundation for the examination and diagnosis of patients, as well as their successful treatment. Once a good history is obtained, the optometrist can direct the examination with greater purpose and take it to the next level with regard to history, symptoms and level of discomfort. Here, the next logical step in the management of a patient with allergic conjunctivitis is the determination of a treatment plan. While optometric staff are not directly involved in this area, it is still of great benefit for us to possess knowledge about what therapies patients are using in the event that any issues arise.

When It's More Than Just Allergy... Two unique situations deserve a special mention: contact lens wearers with ocular allergy and patients who have co-existing dry eye and allergy. Contact lens wear and allergy. One-third (33%) of respondents to an online survey about eyes and allergies identified themselves as contact lens wearers and of these, 12% admit to having dropped out of their lenses because of allergies.7 Ocular allergy is a well-known cause of reduced contact lens wearing time and contact lens intolerance. Contact lenses can trap antigen in the tear film against the ocular surface, thereby precipitating or worsening ocular allergy symptoms. While contact lens wearers who also suffer from ocular allergies may come in complaining of itching, they may not volunteer information that they are increasing the frequency of rewetting drop use to enhance their comfort, or that they are taking their lenses out earlier. In fact, a survey by the Allergy and Asthma Foundation of America revealed that almost three-quarters of patients who wear contact lenses and suffer from ocular allergies use one of those strategies to cope with continued wear, while more than 40% stop wearing their lenses altogether during allergy season.7 Those behaviors are probably overlooked by many eyecare providers, but are important to elucidate because we can make a major impact on the quality of these patient's lives by effectively treating their ocular allergy. Dry eye and allergy. Because many allergic conjunctivitis patients have some degree of dry eye, treating both conditions is often necessary in order to achieve an optimal outcome. We did a study showing that more than 40% of the patients have both allergic conjunctivitis and dry eyes.8 The use of artificial tears can be very beneficial in these patients and thus should not be overlooked. In addition to relieving dry eye symptoms by lubricating the eye, they also reduce allergy symptoms by diluting or washing away antigens and inflammatory mediators from the tear film. Topical cyclosporine is also an effective treatment for patients with dry eye disease. In addition to reducing ocular surface inflammation, improving tear production and stabilizing the tear film, this drug's immunomodulatory activity may have some therapeutic benefit in the allergic inflammatory cascade as well as the cycle of inflammation in dry eye disease.

Treating Ocular Allergy with Success

Many people who suffer from chronic allergies are often undiagnosed and they tend to self-medicate their symptoms with OTC products, rather than seek medical attention. When OTC products no longer control their symptoms, these patients will then present to an eyecare professional for help. However, they generally don't walk in identifying themselves as ocular allergy patients, so it's up to the eyecare professional to sort out the underlying cause(s).

Because patients have access to an array of OTC medications, it is important for optometric staff to bring this into their history taking and to record self-medication attempts for the doctor, as some medications may mask symptoms. It is also important to note how compliant the patient is when treatments are attempted.

Key elements in the patient history may provide crucial information about lifestyle modifications, which may greatly benefit our patients. It is important to remind patients to minimize their exposure to the allergens that trigger their symptoms whenever possible. Aside from making lifestyle changes—be they temporary or permanent—patients may also find relief from non-pharmacological treatments and/or medical therapy.

The doctor may call upon his staff to educate a patient regarding the mode of treatment that he has decided to use for this particular person. Some aspects of the treatment, such as use of cold compresses, instillation of drops, and keeping an allergy diary, might be delegated to a trained employee.

After the Diagnosis

The optometric staff's work really begins once all the symptoms have been presented to the optometrist, the ocular exam has been performed and a diagnosis of ocular allergy has been made. The optometrist may have a really good idea of the allergy cause and what will cure it, or may just be targeting allergy as the diagnosis. We may be called upon to do some or all of the following:

• Ensure patient understanding. Should a medication be prescribed, it is our job to make sure the patient understands the directions. Frequency of use, when to use, how to instill into the eyes, side effects to report to the optometrist, as well as when to call if the medication is not working are part of making sure the patient understands their treatment plan. It's also important to communicate to the patient that their non-compliance will complicate their care and that use of OTC medications can mask symptoms or work against a prescribed medication. Have them check with the doctor before taking any OTC allergy medication. If you have a forgetful patient, help them with a plan of action to remember their medication use, such as posting a chart on the refrigerator and checking off when the medication is used. With your doctor's approval, watch them instill an artificial tear to make sure they have an effective instillation technique.
  
  
• Follow up. If necessary, your optometrist may ask that you call the patient in a few days to make sure they are following directions or to determine whether they need to be seen again in the event the treatment plan is not effective. Tell the patient you will be calling them, and ascertain whether they understand that if not compliant with their treatment plan/medications, they may not get the relief that their doctor is expecting. It may also be helpful to make sure they understand that sometimes finding the right combination of medications to help them may take work, and possibly different medications or combinations of medications. The answer is not always a quick fix or a sure thing.
  
  
• Introduce the patient to the allergy diary. Sometimes an allergy diary is called for and you can assist the optometrist by helping the patient to understand not only how to keep one, but the need for this aid. There is even an iPhone app that patients can be referred to, iPollenCount, which allows patients to electronically keep a diary of their allergy symptoms and correlates them with the daily pollen counts. Patients can then e-mail this information to their doctor. It is helpful for the staff to explain to the patient that once the allergy trigger is discovered, it can either be avoided or medicated as soon as possible. Explain that recording the date and time of their allergic reaction and backtracking (where they were, what they did, what they ate or touched, times and places) is always helpful in discovering the trigger, especially when a pattern is noticed. If the trigger cannot be avoided, at least the patient can be prepared to deal with the allergy before it becomes severe.

From initial questions to signs and symptoms, keep in mind that the most important thing to the patient is that they get relief. And to achieve that goal, it takes knowledge and work—both on the part of the patient's eyecare practitioners and the optometric staff.

Final Thoughts

Depending on where you practice geographically, patients will be exposed to different types of allergens specific to your region at various times of the year. Practitioners also need to remain alert for patients' year-round allergies to allergens such as cat dander, mold and dust, as well as vernal keratoconjunctivitis, atopic keratoconjunctivitis, and drug-related allergic reactions. Itching is the absolute hallmark of ocular allergies. Usually, if it itches, it's an allergy. If it burns and stings, it's dry eye or blepharitis. And if it's crusty and sticky in the morning, it's bacterial. However, this is not universal, and there is a significant overlap of these symptoms across all of these ocular surface diseases. Redness alone can signify several different problems. Proper gathering of information by the staff can give the doctor the key to unlock the diagnosis that will lead to the ultimate goal: a happy patient. Happy patients lead to word-of-mouth referrals and successful practices.

Professional and confident interactions between the staff and the patient assist the clinician in the medical care of the patient. By working with our doctors, continuing our education, harnessing our strengths and communicating clearly with doctors, can we enhance our care of our patients. A history that is complete, concise and thorough is the basic step in providing care for patients and directs the remainder of the office exam. It also assists the clinician in determining a modality of treatment that will be effective for each patient as an individual.

Dr. Hom practices in Azusa, Calif.

Ms. Quintana is Research Study Coordinator and Optometric Technician for Dr. Hom. She has worked on more than 20 clinical studies.

References

1. Main E. Spring 2012 could be worstever for allergies. ABC News. 2012 Mar 17. Available at: http://abcnews.go.com/Health/AllergiesSeasonal/spring-2012-worst-allergies/story?id=15930328#.T5gJPO3Zx60 (Accessed May 2012).
2. BSM Consulting. Clinical Course: History Taking: Building the Foundation. 2008.
3. Risk Factors for Allergic Conjunctivitis. Virtualcancercentre.com. Available at: http://www.virtualcancercentre.com/diseases.asp?did=766#Risk_Factors. (Accessed December 9, 2010).
4. Bielory L. Allergic conjunctivitis and the impact of allergic rhinitis. Curr Allergy Asthma Rep. 2010;10(2):122-134.
5. Alexander M, Berger W, Buchholz P. et.al. The reliability, validity, and preliminary responsiveness of the Eye Allergy Patient Impact Questionnaire (EAPIQ). Health Qual Life Outcomes. 2005 Oct 31;3:67.
6. Luchs J. Ocular Allergic Diseases: Managing Chronic "Repeater" Allergy Patients. Ocular Surgery News. October 18, 2002.
7. AAFA. Eye Allergy Survey Results. Available at: www.aafa.org/display.cfm?id=7&sub=100&cont= 688. (Accessed April 2012).
8. Hom MM. Nguyen AL. Bielory L. Allergic conjunctivitis and dry eye syndrome. Annals of Allergy Asthma and Immunology. 2012;108(3):163-6.