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Anterior Segment Ocular Allergy Topical Corticosteroids and Antihistamines—Mast Cell Stabilizers for the Treatment of Allergic Conjunctivitis Lan Gong, MD, PhD 1 and Michael S Blaiss, MD 2 1. EYE and ENT Hospital of Fudan University, Shanghai, China; 2. University of Tennessee Health Science Center, Memphis, Tennessee, US Abstract The most common ocular manifestation of allergy, allergic conjunctivitis (AC), is the result of a hypersensitivity response occurring after exposure of the ocular surface to airborne antigens. Treatment options for AC comprise antihistamines, mast cell stabilizers, dual-acting mast cell stabilizer-antihistamines, corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and combinations thereof. Despite clinical evidence to support the use of antihistamines, such as levocabastine, antihistamines are unable to mitigate all symptoms of AC because histamine is not the only mediator released during the allergic inflammatory response and has no direct effect on inflammatory cells involved in clinical symptoms. Dual-acting mast cell stabilizer-antihistamines, such as bepotastine, alcafatidine, epinastine, ketotifen, and olopatadine, have a broader effect than antihistamines alone. Corticosteroids inhibit the entire inflammatory cascade and therefore offer the most complete option for AC, although their use has been limited due to concerns about increased intraocular pressure (IOP) and the potential for cataract formation with extended use. Loteprednol etabonate (LE) has a decreased effect on IOP and cannot form Schiff base intermediates with lens protein, which is considered a first step in cataractogenesis. The efficacy and safety of LE in the treatment of seasonal AC (SAC) has been demonstrated in clinical trials. Keywords Mast cell stabilizer, ocular allergy, seasonal allergic conjunctivitis, antihistamine, corticosteroid Disclosure: Lan Gong, MD, PhD has no conflicts of interest to declare and Michael S Blaiss, MD, is a consultant for B&L and Allergan and a speaker for B&L, Allergan, and Alcon. Aknowledgements: Editorial assistance was provided by James Gilbart at Touch Medical Media. Received: May 30, 2013 Accepted: July 15, 2013 Citation: US Ophthalmic Review, 2013;6(2):78–85 Correspondence: Lan Gong, MD, PhD, 83 Fenyang Road, Shanghai, 200031, People’s Republic of China. E: Support: The publication of this article was supported by Bausch + Lomb. The views and opinions expressed are those of the authors and not necessarily those of Bausch + Lomb. Medical writing was provided in part by Cactus Communications. Ocular allergy is one of the most frequently encountered conditions in clinical eye care—epidemiologic reports have shown that it affects up to 60 million US citizens. 1 The eye, being continually exposed to the external environment, is a common site of allergic inflammation. The classic clinical signs of this inflammation are seen in the conjunctiva. Allergic conjunctivitis (AC) manifests as a immunoglobulin E (IgE) hypersensitivity reaction that occurs when the ocular surface is exposed to external antigens. 2–4 These antigens include airborne pollen, animal dander, and other environmental antigens. 3,5 Even though these environmental antigens are not always threats to the ocular surface, they elicit an inappropriate adaptive immune response in some individuals, leading to this hypersensitivity reaction. 3,6,7 Ocular allergy comprises clinically distinct forms, ranging from the milder, relatively benign variants such as seasonal and perennial AC (SAC and PAC, respectively) to the more serious sight-threatening variants, such as vernal and atopic keratoconjunctivitis (VKC and AKC, respectively). Of these types, 78 SAC and PAC are the most common and together represent 95  % of all ocular allergy cases in the US. 8 Both SAC and PAC develop as a result of an immediate type 1 IgE hypersensitivity response. 6 Signs and symptoms associated with these types of conjunctivitis include ocular and periocular pruritus, redness, chemosis, watery discharge, burning, stinging, and photophobia. The main goal of treatment is to reduce inflammation early and to minimize further ocular surface irritation and discomfort. 9,10 SAC is most commonly caused due to exposure to pollens from grasses, trees, ragweed, or other seasonal plants. It therefore tends to occur frequently in spring and autumn, which are seasons associated with higher levels of these airborne allergens. 11 While the most obvious solution would be avoidance of the causative agents, this may not always be practical. The most commonly used nonpharmacologic interventions include cold compresses, lubrication, such as artificial tears, and the daily disposal of contact lenses in patients who are wearers. 12 Saline eye drops have been described as effective in reducing signs and symptoms in 30–35 % of cases. 13,14 © Tou ch ME d ica l ME d ia 2013