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    Exploring off-label, investigational approaches for allergic conjunctivitis

    Conventional treatments may give way to therapies with new mechanisms of action

    The combination of the newer antihistamine/mast cell stabilizer ophthalmic medications with artificial tears-along with instructions about the avoidance of culprit allergens and eye rubbing-will control signs and symptoms of seasonal and perennial allergic conjunctivitis (SAC/PAC) in most patients.

    While the addition of a topical corticosteroid can be helpful for patients with a severe ocular allergy manifestation, there are other strategies ophthalmologists may consider to manage those more-challenging cases, said Michael B. Raizman, MD.

    In terms of proper management of SAC/PAC, Dr. Raizman suggested referring patients to an allergist for possible immunotherapy, which is now administered by either the sublingual route or by injection.

    “Desensitization has been around for a long time, but the sublingual approach is generally preferred by patients,” said Dr. Raizman, Ophthalmic Consultants of Boston; associate professor of ophthalmology, Tufts University School of Medicine; and director of the cornea and cataract dervice, New England Eye Center, Boston.

    No solid data

    While desensitization has shown to be effective for many of the allergens that cause SAC and PAC, he added, there is not solid clinical trial data on its efficacy for controlling specific ocular signs and symptoms.

    “My personal experience is the effects are modest, but it may be helpful for patients with severe SAC and PAC,” he said.

    Acting through calcineurin inhibition which may lead directly to mast cell stabilization, topical cyclosporine can also be an effective treatment for severe SAC/PAC and useful as a steroid-sparing agent.

    However, the benefit may require dosing cyclosporine 0.05% emulsion (Restasis, Allergan) three or four times daily or use of a compounded preparation containing up to 0.5% of the active ingredient.

    Tacrolimus, another calcineurin inhibitor, is available as an ophthalmic product outside of the United States. In addition, topical pimecrolimus may be available in the future, Dr. Raizman noted.

    A different mechanism of action

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