Therapeutics

Patients may not be aware of symptoms Detecting Ocular Allergy

Technicians must develop their sleuthing skills to help patients find relief.

René Luthe, Contributing Editor

With spring nearly here, eye care practices can expect a burst of appointments related to seasonal conjunctivitis. Once trees and flowers come alive again, patients will be eager for relief from itchy eyes and runny noses. In addition to hay fever, pet dander, cigarette smoke, feathers and dust mites also wreak havoc on the ocular surface. To help patients find relief, ophthalmic support staff need to be proactive in uncovering clues and piecing them together.

Consider SPEED

At May Eye Care Center, Hanover, Pa., every patient 18 and older receives the SPEED (Standard Patient Evaluation of Eye Dryness) questionnaire, according to Lori Bathurst, COA, ABOC. Comprised of only four questions, it examines the frequency and severity of dry eye-type symptoms such as sensations of grittiness or burning, or watery eyes. It also examines the occurrence of symptoms at the moment, as well as over the past 72 hours and past three months. A number is associated with each answer; the technician totals the score and depending how high it is, passes it on to the doctor.

“Our doctors look at it and determine whether they want to try medication, or perhaps allergy testing,” Ms. Bathurst explains.

Bowden Eye Associates, Jacksonville, Fla., uses an adaptation of the SPEED questionnaire, though the practice doesn’t ask the patient to complete a paper test. According to clinical supervisor Keri Barkey, COA, each technician asks the questions of the patient orally while doing the work-up. It’s critical that support staff are consistent to uphold their role in detecting ocular allergy, she says. “It has absolutely made a difference in the number of allergy patients we diagnose and treat.”

The technician records the patient’s responses for the doctor, and questions further about the history of the complaint.

See something, say something

Even if the practice chooses not to use a formal questionnaire, technicians should seize the initiative in looking for signs of allergy. Erin Comen, COA, of Katzen Eye Group, reports that while techs there don’t go by a set paper guideline to detect allergy, they are expected to be proactive in their interactions with patients. “If we have a patient in the chair and his eyes are red, well, he may not be complaining, but patients don’t always put two and two together to figure it’s allergies.” It’s up to the technician to prompt them.

For example, a patient may “wonder why their eyes are so tired and dry,” after returning from Las Vegas, where smoking is permitted indoors, Ms. Comen says. “Or, people who get a new pet, or start dating someone who has a pet, wonder why they are suddenly experiencing these issues.”

In these instances, the technician may help the patients to realize the cause of their problem.

Documentation is key

Whichever way practices choose to go in addressing the issue with patients, these veterans agree on the importance of being thorough in your questioning and documentation. Often, Ms. Comen notes, clues that allergies may be a problem emerge when questioning patients on their medication history. “You hear about all the specific meds they are on for a seasonal allergy or a cold or a sinus issue, and that way you can kind of pick up on it.”

“We gather as much information as we can to make it easier for the doctors, so they don’t have to ask another 50 questions of the patient,” explains Ms. Bathurst.

Ocular surface-dedicated

Some practices have an allergy/dry eye-dedicated position between the technician and the doctor to ensure that relevant patients are well served. “Dry eye counselors” handle many patient education-related duties at Bowden Eye, Ms. Barkey reports. “They really streamline our practice’s care of those patients, getting them to either allergy testing (the scratch test) or treatment for dry eyes,” she says.

The patient sees the dry eye counselor before the doctor is brought in. Sessions typically run eight to 10 minutes, during which the counselor may perform the relevant testing, and discuss how the patient can avoid potential irritants. The dry eye counselor also informs the patient what the doctor will discuss and the testing and therapies he may prescribe. In terms of a return on investment in personnel, “our dry eye counselors have paid for their positions here 10 times over,” Ms. Barkey says.

Rx relief

When the doctor diagnoses an ocular allergy, several prescription options are available to relieve the itch (see also “Prescription Drugs Indicated for Relief of Ocular Allergies”):

■ Antihistamine/mast cell stabilizers. These first-line therapies deliver the relief of antihistamine plus the extended duration of action of a mast cell stabilizer. Mast cells can release the inflammatory mediators in the eye, so stabilizing them inhibits a pathway of inflammation involved in ocular allergies. Topical antihistamine/mast cell stabilizers do not have the drying effect of oral antihistamines and some offer once-a-day dosing.

■ Nonsteroidal anti-inflammatories. Topical NSAIDs are not commonly used for the relief of ocular allergy symptoms. The duration of action and dosing varies.

■ Steroids. Typically reserved for more severe cases of allergy, steroids are effective in fighting ocular inflammation.

However, due to serious side effects, such as cataract and glaucoma, steroids are used strictly on a short-term basis.

On-site testing

Both May Eye Care and Bowden Eye Associates perform on-site allergy testing with the scratch, or prick, test. The technician or dry eye counselor lightly scratches the patient’s skin on the forearm with a disposable plastic device coated with a selection of antigens. These are antigens that are specific to the region, and specific to eye-related problems; the practice tests for 60 antigens at one visit. After 15 minutes, redness or swelling indicates that the patient is allergic to that antigen. The technician measures the reaction and delivers the results to the doctor, who discusses them with the patient.

Ms. Bathurst explains that this approach saves the doctors time while saving the patient from making a second appointment to learn test results.

Should the results of the test indicate a chronic problem, or a reaction to multiple antigens, May Eye Care utilizes an immunoglobulin serum based on research done at Johns Hopkins University and tailored to the specific needs of each patient.

When the serum arrives, Ms. Bathurst schedules the patient for an office visit where she instructs the patient on how to use the serum, and cautions the patient not to expect results too quickly. The patient returns in another three months for a checkup with the doctor.

Keep asking

Whatever model a practice chooses to use to diagnose allergy, the technician’s role is crucial. “The big thing,” in detecting allergy, according to Ms. Comen, “is knowing that your patients don’t always know.” OP