Ocular Allergy by clarityeye

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									        Therapeutic in Ocular Allergy




   Virgilio Vinas, MD, MPH,
    PhD




        Ista Pharmaceutical-Virgilio Vinas, MD,
        MPH, PhD
                                                  1   11/10/2011
Vision Statement
     Annual growth 15%
     60-90 millions suffer
      Allergic conjunctivitis
     Pollinosis 95.2% with
      Seasonal Allergic
      Conjunctivitis
     20% with allergic
      rhinitis are
      Rhinoconjunctivitis
     6.6 million prescriptions
      for ocular allergy=$560
      millions
      in 2008



Ista Pharmaceutical-Virgilio Vinas, MD,
MPH, PhD
                                          2   11/10/2011
Allergic Eye Diseases
    IgE-mast cell
     mediated in Allergic
     Conjunctivitis
    Chronic mast cell
     activation
     eosinophil/T-
     lymphocyte mediate
    Allergens are
     antigens
    Immune System has
     exaggerate response
     to allergen

Ista Pharmaceutical-Virgilio Vinas, MD,
MPH, PhD
                                          3   11/10/2011
Allergic Eye Diseases
    Both parents are
     atopic their child has
     50% developing Type
     I Allergic Reactions
     with one parent is
     30%.
    Allergens may
     dissolve in the tears
     providing avenue for
     antigens exposure to
     surface ocular
     structures.
    Blinking and Flushing
     of tear film are
     protective
Ista Pharmaceutical-Virgilio Vinas, MD,
MPH, PhD
                                          4   11/10/2011
Allergic Eye Diseases




 Ista Pharmaceutical-Virgilio Vinas, MD,
 MPH, PhD
                                           5   11/10/2011
    Allergic Eye Diseases
    Type I Hypersensitivity Reaction: Binding Antigen+IgE to
     receptor FceRI= release chemical mediators from mast
     cells
     Basophils and Eosinophils have FceRI
    Type IV Hypersensitivity
     Reaction: Binding Antigen+IgE to effector T cells




    Ista Pharmaceutical-Virgilio Vinas, MD,
    MPH, PhD
                                              6          11/10/2011
Allergic Eye Diseases




Ista Pharmaceutical-Virgilio Vinas, MD,
MPH, PhD
                                          7   11/10/2011
Allergic Eye Diseases




Ista Pharmaceutical-Virgilio Vinas, MD,
MPH, PhD
                                          8   11/10/2011
Allergic Eye Diseases




Ista Pharmaceutical-Virgilio Vinas, MD,
MPH, PhD
                                          9   11/10/2011
    Allergic Eye Diseases




  Seasonal Allergic Conjunctivitis: Triggered
by the same allergens responsible for
seasonal allergic rhinitis-April/May Tree
Pollens-June/July Grass Pollens- July/August
Weed Pollens
 Perennial Allergic Conjunctivitis: Conjunctiva continual
   exposure year round allergens such as house dust mites
and spores as allergic rhinitis
 Symptoms: Itching, Watering, Redness of
conjunctiva

    Ista Pharmaceutical-Virgilio Vinas, MD,
    MPH, PhD
                                              10       11/10/2011
Allergic Eye Diseases
    Vernal Keratoconjunctivitis: Severe
     inflammatory disease intermittent or persistent
     begins before the age of 10 years improve at
     puberty (3-25 years old) more in warm
     climates. Sometimes genetic factors or
     allergens reaction, no personal history and
     negative skin test, males more frequently
     affected. Large “cobbles” inside upper eyelid
     and stickness
    Atopic Keratoconjunctivitis: Severe
     inflammatory disease sometimes due to true
     IgE-related allergy. Lifelong starting in young
     adulthood (30-50 years), history atopic disease
     (rhinitis, asthma). Associate with atopic
     eczema on face, eyelids, eye infection, damage
     to cornea, cataract
    Symptoms: Itching, soreness, redness
     watering,pain, blurred vision, light sensitive

    Ista Pharmaceutical-Virgilio Vinas, MD,
    MPH, PhD
                                                11     11/10/2011
Allergic Eye Diseases
     Giant Papillary Conjunctivitis:
      Damage caused by contact lens edges,
      eye prosthesis, post operative stitches,
      aggravated by allergy. Symptoms are
      large “cobbles” inside the upper eyelid.
      In contact lens users reflects the age
      of contact lens wearers. Rarely occurs
      in children or elderly




    Ista Pharmaceutical-Virgilio Vinas, MD,
    MPH, PhD
                                              12   11/10/2011
Diagnostic Tests in Ocular Allergy
     Schirmer test (mm)
           15.0±2.0
           15.0±5.0
     BUT (s)
            6.6±1.6
           3.4±2.4*
     Fluorescein score
      (points)
            0.5±0.5
           5.5±3.5*
     Rose-Bengal (points)
            0.1±0.5
           4.4±3.6*
     Conjunctival injection
      grade
            0.5±0.5
           2.5±0.5*
     Ista Pharmaceutical-Virgilio Vinas, MD,
     MPH, PhD
                                               13   11/10/2011
Therapeutic in Ocular Allergy




     Management

      General measures:
      - do not to rub the eyes. Eye rubbing causes mechanical mast
      cell degranulation.
      - artificial tears several times a day
      - allergen avoidance
      - topical antihistamine eye drops
      - cool compresses
      -avoidance of contact lenses use -- allergens adhere to contact
      lens surfaces

 Ista Pharmaceutical-Virgilio Vinas, MD,
 MPH, PhD
                                               14              11/10/2011
Therapeutic in Ocular Allergy
             Dry Eye or tear insufficiency
              (Schimer’s Test) : punctate-
              keratopathy, reduced tear break-up
              time (BUT)
           Oral antihistamines reduce tear film
              (anticholinergic)
           Punctal plugs
            Allergen Avoidance
           SAC
           -Limit outdoor exposure-Air
              conditioning-Car and home
              windows closed
           PAC
           -Replacement old pillows or covers
              mattresses- Washing of beddings-
              Reducing humidity-Home
              vacuuming and ducting-Remove
              animals from home-Remove
              reservoirs of dust:carpets-curtains-
              drapes-
 Ista Pharmaceutical-Virgilio Vinas, MD,
 MPH, PhD
                                                 15   11/10/2011
Therapeutic in Ocular Allergy




 Ista Pharmaceutical-Virgilio Vinas, MD,
 MPH, PhD
                                           16   11/10/2011
Therapeutic in Ocular Allergy
    IgE (which are located on
     mast cells in the tissues
     and basophils in the blood)
    When an allergen is
     encountered, it binds to
     IgE, which excessively
     activates the mast cells or
     basophils, leading them to
     release massive amounts
     of histamines.
    Antihistamine refers to H1
     receptor: located through
     the body eye conjunctiva
     vascular endothelial cell,
     immediate effect increased
     vascular permeability or
     inflammation

    Ista Pharmaceutical-Virgilio Vinas, MD,
    MPH, PhD
                                              17   11/10/2011
Therapeutic in Ocular Allergy
     Types and dosages of antiallergic eye
      drops

 Chemical mediator release inhibitory eye drops
    (devoid of antihistaminic activity)
     Sodium cromoglycate (Intal®) 4 times a day
     Amlexanox (Elics®) 4 times a day
     Pemirolast (Alegysal ®) 2 times a day
     Tranilast (Rizaben®/Tramelas®) 4 times a day
     Ibudilast (Ketas®/Ibinal ®) 4 times a day
     Acitazanolast hydrate (Zeperin®) 4 times a day


 Histamine H1 receptor antagonists (having
     antihistaminic activity)
     Ketotifen fumarate (Zaditen®) 4 times a day
     Levocabastine hydrochloride (Livostin®) 4 times a
      day
     Olopatadine hydrochloride (Patanol®) 4 times a day




 Ista Pharmaceutical-Virgilio Vinas, MD,
 MPH, PhD
                                                           18   11/10/2011
Therapeutic in Ocular Allergy
    Topical antihistamines in allergic conjunctivitis

    Drug       Dose        Other actions     Comparative
                                              studies
Azelastine   /12 h     Inhibits leukotrienes, < olopatadine
                      reduces ICAM-
           expression. Dual action
Levocabastine /6 h                            < emedastine
                                   < olopatadine
Emedastine               /12 h                            >
    evocabastine

Olopatadine                         Dual action: antiH1     >
    epinastine
           0.01% /12 h + mast cell stabilizer
                                   > evocabastine
           0.02% /24 h                          > ketotifen
                                   > azelastine
Epinastine /12 h         Dual action: antiH1
           + mast cell stabilizer < olopatadine
Ketotifen /12 h.       Dual action: antiH1
                       + mast cell stabilizer < olopatadine


    Ista Pharmaceutical-Virgilio Vinas, MD,
    MPH, PhD
                                                                19   11/10/2011
Therapeutic in Ocular Allergy
  Bepreve ™ (bepotastine besilate
   opthalmic solution) 1.5%
Is a non-sedating, highly selective
   antagonist of H1 receptor+ mast cell
   stabilizer+eosinophils suppressor into
   inflamed tissue .
Compound’s primary mechanisms of
   action is effective against ocular
   itching in 15 min or less. BID dosing.
   Long acting 8 hours. Relieve nasal
   symptoms
Bepostatine use since 2000 in Japan as
   TALION systemic drug for allergic
   rhinitis-urticaria-pruritus
Adverse reactions in 25% subjects was a
   mild taste following instillation
    Ista Pharmaceutical-Virgilio Vinas, MD,
    MPH, PhD
                                              20   11/10/2011
Therapeutic in Ocular Allergy
      “Time to Onset and Duration of Action of the
       Anihistamine Bepotastine Besilate Ophthalmic
       Solutions 1.0% and 1.5% in Allergic Conjunctivitis: A
       Phase III, Single-Center, Prospective, Randomized,
       Double-Masked, Placebo-Controlled, Conjunctival
       Allergen Challenge Assessment in Adults and
       Children”
       Mark B Abelson, MD, CM, FRCSC, Gail L Torkildsen, MD, Jon I
       Williams, PhD, James A Gow, BSc (Med), MD, Paul J Gomes,
       MS and Timothy R McNamara, Bepostatine Besilate
       Ophthalmic Solutions Clinical Study Group.
       The study enrolled 861 individuals of whom
       15% (127 subjects) were pediatric subjects
       10-17 years, ramdomized to receive Bepreve
       (22.5%) or placebo (20%) twice daily,
       following test drop installation for each eye at
       study visit 2 (one week of dosing) and visit 3
       (three weeks of dosing). Overall comfort for
       the treatment of ocular itching and
       conjunctival hyperemia was graded using a
       quantitative scale named Conjunctival Allergen
       Change (CAC)


  Ista Pharmaceutical-Virgilio Vinas, MD,
  MPH, PhD
                                                                     21   11/10/2011
 Therapeutic in Ocular Allergy
Topical antihistamines – preferably those
with established dual action – are very effective in treating
    allergic conjunctivitis, and outperform other groups of
    drugs such as mast cell stabilizers or topical NSAIDs.
   Treatment for SAC should be started 2 weeks prior to
    the onset of season which cases symptoms: tree
    pollens in the spring, grass pollens in the summer, and
    weed pollens in the late summer and fall
   The onset of action of mast cell stabilizers is slow (5-14
    days) and the dosing is QID (inconvenient). Cromolyn
    cannot be used for acute symptoms
   All antihistamines dry the ocular surface due to their
    atropine-like effect which decreases tear production of
    the lacrimal glands peak serum levels 0.5-3 hours
   NSAIDs block the cyclooxygenase and inhibit the
    conversion of arachidonic acid to prostaglandins and
    thromboxanes not recommended for allergic
    conjunctivitis. Only Ketorolac approved for itching due
    to Atopic Conjunctivitis
   Steroids only Loteprednol (0.2%-Alrex, 0.5% Lotemax)

       Ista Pharmaceutical-Virgilio Vinas, MD,
       MPH, PhD
                                                            22   11/10/2011
Diagnostic Codes and Billing for Ocular
Allergy Management
                                          Diagnostic Codes
                                          
   •    Chronic allergic conjunctivitis: 372.14
   •    Acute allergic conjunctivitis: 372.05
   •    Vernal conjunctivitis:                372.13
   •    Allergic dermatitis of eyelid: 373.32

   •    Itching eyes: 379.99
   •    Hyperemia: 372.71
                                 Billing and Coding

   •        Initial Visit:
                              *Ophthalmic codes: 92004/92014       (BCBS 07: $170/$125)

                             *E&M codes: 99204/99214            (BCBS 07: $172/$103)

   • Subsequent Visits: Dx as previous

         *E&M codes:                                          99212 (BCBS 07: $49)
                                                               99213 (BCBS 07: $66)



    Ista Pharmaceutical-Virgilio Vinas, MD,
    MPH, PhD
                                                                  23                  11/10/2011
References for Therapeutic in Ocular Allergy

    Ciprandi G, Cosentino C, Milanese M, Tosca MA. Rapid anti-inflammatory action of
     azelastine eyedrops for ongoing allergic reactions. Ann Allergy Asthma Immunol 2003
     Apr;90(4):434-8.

     belson M. 2000 Year in Review: Pharmaceuticals—Anti-allergics. Rev Opthalmol 2000
     Nov:7(11):57-58.
    Allergic conjunctivitis. M Reza Dana, MD, MPH, MSc, UpToDate, 16.2, 8/2008.
     Chapter 88 – Allergic and Immunologic Diseases of the Eye. Neal P. Barney, Frank M.
     Graziano. Adkinson: Middleton's Allergy: Principles and Practice, 6th ed.
     Allergic Conjunctivitis. Presentation Materials. World Allergy Organization.
     Pediatric Ocular Inflammation. Immunology and Allergy Clinic of North America. Volume
     28, Issue 1, Pages 169-188 (February 2008).
     Chapter 146 – Ocular Allergies. Mark Boguniewicz Donald Y.M. Leung. Kliegman: Nelson
     Textbook of Pediatrics, 18th ed.
     Ocular Allergies. Ask the Expert. AAAAI.
     Allergic Conjunctivitis. Ask the Expert. AAAAI.
     Allergic conjunctivitis. Handbook of Ocular Disease Management.
     Ocular Allergy. Curr Opin Allergy Clin Immunol. 2007; 7(5):424-428. Medscape. Medscape
     The Pathophysiology of Ocular Allergy: Current Thinking. C Stephen Foster. Allergy,
     Volume 50 Issue s21, Pages 6 - 9, 2007.
     Online Continuing Education: Ocular Allergy. University of Indiana.
     Conjunctivitis, Allergic. Parag A Majmudar, MD. eMedicine.
     Allergic rhinoconjunctivitis and differential diagnosis of the red eye. Granet, David. Allergy
     and Asthma Proceedings, Volume 29, Number 6, 11/12 2008 , pp. 565-574(10).



     Ista Pharmaceutical-Virgilio Vinas, MD,
     MPH, PhD
                                                                 24                   11/10/2011

								
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