Allergies have been steadily increasing through the years
Lower rates of allergy when raised with farm animals
Lower rates with handwashing less than 3 times a day, bathing less frequent than every other day
Hayfever is rare in undeveloped countries (rural Africa)
What happened to the dirt eaters?
Allergy by the numbers (Alexander)
20% of the population affected
87% wake up tired
54% unable to concentrate
63% unable to play sports
1 in 5 feels MD does not take it seriously enough
Don’t let past history bias you, optometrists are usually the first to detect allergy
90% of allergy patients have ocular symptoms
Seasonal is not always springtime, seasonal can be in December or Fall.
Weather related: Cold and wet, pollen builds. Warm and dry, pollen is liberated
Size and penetration: 4 to 10 microns reaches lungs, 10 to 40 microns reaches nose and eyes. Over 40 microns, settles too quickly to remain airborne.
Hang time: 2 microns takes 6 hours to drop, 15 microns takes 15 min, 20 microns takes 4 min to drop from a 10 foot ceiling.
Sizes matters: tobacco 1 micron, smog 2 microns, cat allergens 2.5 microns, dust mite droppings 4 to 40 microns, molds 2 to 10 microns, ragweed 20 microns, grass 30 microns.
Over 20% of the pollen are smaller than 5 microns.
Pollen release times: Morning 730 am, Late morning 9 am, Afternoon, All day
Pollen counts
Seasonal map
Association with dry eyes: approximately 1/3 has primary tear film deficiency
Strategies are different for outdoor and indoor allergies
Indoor allergies are usually perennial allergies
Outdoor are usually seasonal and needs avoidance.
Home is the battleground: dust mites, animal dander and molds
Workplace = occupational allergy
Oral: Non-sedating antihistamines
Claritin, Zyrtec, Allegra, etc
Altered lacrimation reported as side effect in less than 5% of patients by manufacturers
But yet, 70 to 80% showed increased staining after Claritin treatment for 4 days (Welch, Ousler, Abelson; Cornea 2000; 19: (Suppl): S135)
Case Report: Bulbar staining and Flonase
The Cromolyn Story
Roger Altounyan (1922 to 1987) discoverer
Self experimentation: inhaled guinea pig hair to induce asthma
Could only test 2 compounds a week on himself
Took 670 compounds and nine years!
Levocabastine (Livostin): Most potent antihistamine, better than olopatadine
$49.40 5ml bottle
Nedocromil (Alocril) second generation mast cell stabilizer, late and early phase inhibition
$56.91 5ml bottle
Olopatadine (Patanol): “Combination” allergy med
Effective on tryptase/chymase (TC) containing mast cells located in skin and eyes.
Tests on human cells, not rodent cells.
Poor effectiveness on lungs, nose and small intestines.
Sometimes, TID is needed
Most expensive $58.38 5 ml bottle
qD Patenol
0.2% formulation (legacy formulation 0.1%)
good for 16 hours
Ketotifen fumarate (Zaditor) $48.96 5 ml bottle
Pemirolast (Alamast) mast cell stabilizer
Azelastine (Optivar) $53.22 6ml bottle
Emedatine (Emadine) H1 antagonist
Loteprednol: site specific steroids $38.03 5 ml (Alrex) $27.66 5ml (Lotemax)
New treatment: Epinastine
0.05% BID histamine H1 receptor antagonist mast cell stabilizer
Improved itch scores for seasonal allergic conjunctivitis
Off label use of cyclosporine
Anti-inflammatory and immunomodulating agent
Case Report: Cyclosporine and allergy
Nutritional intervention: Butterbur, Perilla 6000, stinging nettle, similium.
Case Report: Environmental triggers
Tags: allergies have, perennial allergies, “hygiene, steadily, allergies, hypothesis”