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At some point in each of our lives, we will likely deal with an allergy: foods, medication, environmental, or otherwise. Allergies continue to change

throughout our lives, as we grow out of some and into others. When we con-sider our patients’ ocular complaints, it is important to keep allergies in mind as a cause or contributing factor.

In diagnosing and treating our patients, allergy testing is a helpful tool that often gets overlooked. Until recently, few allergy testing options were available for in-office use by primary eye care providers, but that is changing. This can be a boon for our practices and for our patients with ocular allergies.

TURNING TO TESTINGA good patient history is vital in

diagnosing and treating patients, but

often we must turn to testing to aid us. There are multiple reasons to con-sider allergy testing. The most obvious is a patient presenting with ocular signs and symptoms of allergies: itchy, watery, painful, swollen, red, or burn-ing eyes.1,2

Ocular allergy includes disorders affecting the eyelid and conjunctiva: seasonal and perennial allergic con-junctivitis, contact blepharocon-junctivitis, and vernal and atopic keratoconjunctivitis.1 Typically the cause is either environmental allergy or a reaction to a topical agent (an ocular medication, a preservative, or a component of makeup). Some allergic reactions are mediated by immuno-globulin E and others are not.

Allergy testing can help us to under-stand what our patients may be allergic to and advise them regarding how to eliminate or decrease their exposure.

Testing can also help to indicate if the patient may benefit from more aggres-sive treatment, such as injections.

CONCOMITANT CONDITIONSAnother time to consider allergy

testing is in the management of patients with dry eye. It is important to remember that the signs and symptoms of allergies and dryness overlap.1 Both can coexist, exacer-bating the symptoms of each other. Patients who think that they may have allergies, even though they don’t, may add to their dry eye symptoms by self-medicating with systemic anti-histamines that they do not need.

Environmental allergies and food allergies should be considered in patients with chronic inflammatory

THE ROLE OF ALLERGY TESTING IN EYE CARE

In-office testing options are now available. BY CECELIA KOETTING, OD, FAAO

Figure 1. The liquid allergens come in closed individual vials from which small amounts are placed into separate wells within the testing tray. The plastic disposable applicator tips are then placed into the wells to obtain the correct amount utilized in testing.

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problems. Food allergies and sensitivi-ties can induce or worsen inflamma-tion within the body. Typically a food elimination diet or allergy testing can aid in diagnosing these problems. Patients with inflammatory bowel dis-ease (IBD), which includes ulcerative colitis and Crohn disease, can experi-ence ocular manifestations including episcleritis, scleritis, iritis, and dry eye disease (DED).3,4 In one study assess-ing the association of IBD with DED, 22% of patients with IBD had DED, whereas only 11% of control patients without IBD had DED.3,4

ALLERGY TESTING OPTIONSFew options for allergy testing are

available to the primary eye care provider; among them are skin prick testing and serum-specific IgE testing. Until recently the only other option was to refer patients to an allergist. At present, testing for food allergies and full panels of environmental aller-gens are still only available through an allergist. But there now exist two options for testing for environmental allergens that can be performed in our own offices.

One is Doctor’s Rx Allergy Formula (Bausch + Lomb). This FDA-approved diagnostic test was developed by an ophthalmologist and purchased in 2015 by Bausch + Lomb.5 It offers 39 separate panels developed for differ-ent regions of the United States. Each

panel tests for 58 different allergens along with two controls (Figure 1).5 The test is administered in approxi-mately 3 minutes with plastic dispos-able skin-prick applicators; no needles or shots are needed (Figures 2 and 3). After 15 minutes, the patient’s results can be read, and the allergens that are identified can be discussed with the patient (Figure 4). Most insurance plans reimburse for this test.

Another in-office allergy testing option is offered by AllerFocus. Again, this test assesses for 58 aller-gens along with two controls. This FDA-approved skin-prick test takes approximately 10 to 15 minutes to administer.6 The company also offers customized sublingual immunother-apy based on each patient’s allergen testing results.6

BEFORE TESTINGBefore office allergy testing is con-

ducted, the patient should be given a list of medications and supplements to discontinue in order for the test to be valid. This will typically include antihistamines, sleep aids, nasal ste-roid sprays, selective serotonin reup-take inhibitors, some antacids, and other medications.7 Most of these should be stopped approximately 3 to 7 days before testing. For patients who have been taking daily oral anti-histamines chronically for more than

1 year, these should be stopped more than 2 weeks before testing.7

KNOW YOUR ENEMIESIn this age of continually changing

and improving medical technology, it is important to know what is avail-able and how to incorporate it into our clinics. Allergy testing can be a valuable tool in many cases. Once allergens have been identified or ruled out, we are better equipped to make medical and lifestyle recommenda-tions to help our patients. n

1. Leonardi A, Bogacka E, Fauquert JL, et al. Ocular allergy: recognizing and diagnosing hypersensitivity disorders of the ocular surface. Allergy. 2012;67:1327-1337.2. Leonardi A, Doan S, Fauquert JL, et al. Diagnostic tools in ocular allergy. Allergy. 2017;72(10):1485-1498. 3. Felekis T, Katsanos K, Kitsanou M, et al. Spectrum and frequency of ophthalmologic manifestations in patients with inflammatory bowel disease: a prospective single center study. Inflamm Bowel Dis. 2009;15(1):29-34.4. Troncoso LL, Biancardi AL, de Moraes HV Jr, Zaltman C. Ophthalmic manifestations in patients with inflammatory bowel disease: A review. World J Gastroenterol. 2017;23(32):5836-5848. 5. Doctor’s Rx Allergy Formula: Ocular Allergy Diagnostic System. Bausch + Lomb. www.bausch.com/ecp/our-products/diagnostics/ocular-allergy-diagnostic-system. Accessed February 6, 2020.6. About Us. Allerfocus. www.allerfocus.com. Accessed February 6, 2020.7. Medications to avoid before allergy skin testing. In: Clinical Care Statements. American Academy of Otolaryngic Allergy. January 2015. www.aaoallergy.org/wp-content/uploads/2017/05/2015.Clinical-Care-Statements-Bro.web_.pdf. Accessed February 6, 2020.

CECELIA KOETTING, OD, FAAOn Referral Optometric Care and Externship

Program Coordinator, Virginia Eye Consultants, Norfolk, Virginia

n ckoetting@vec2020.comn Financial disclosure: None

Figure 3. Meanwhile, the tips of the plastic applicators can rest in the liquid allergens. Divide the forearm into four sections using a marker to help delineate where to place each applicator.

Figure 2. Typically the test is applied to the patient’s forearm and bicep. Prepare the patient’s skin by cleaning with alcohol pads and allowing the surface to dry.

Figure 4. After the allergens have been on the patient’s skin for the appropriate time, the arms are read for reaction size. These results are documented on the form to keep track of which allergens the patient had a response to and whether the test was considered valid.