Over the counter drops not relieving your itching, watering, redness, and swelling? A prescription strength drop is much more effective at knocking out moderate to severe allergies.  For contact lens wearers, OTC drops and their frequent dosing schedules are just not practical.  A once daily prescription strength drop will be much more effective for these patients, and less disruptive of their daily routines.  Here's a breakdown of the available ophthalmic drops; how often to dose them, and what, if any, side effects to expect.


TOP OF THE LINE ANTI-HISTAMINES
PATADAY: Fast relief, good medical coverage so the copay tends to be reasonable
Dosage: 1 x Day
Side Effects: None commonly reported.  Do not use on top of contact lenses.
Also available is the weaker concentration Patanol, that is dosed 2 x daily instead of once daily.


LASTACAFT: Fast relief, studies show that patient's get relief within 5-10 minutes of dosing
Dosage: 1 x Day
Side Effects: None commonly reported.  Do not use on top of contact lenses.


BEPREVE: Fast relief, can also give some minor nasal symptom relief as it drains down the back of your throat from the eye.
Dosage: 2 x Day
Side Effects: Can have a metallic after taste in some patients.
This drop comes in a much larger bottle than the prior 2, so it offers some financial advantage.  For milder symptoms, it can be used just once daily.



GENERIC ANTI-HISTAMINES: Prescription strength, but budget friendly.  These are older drops that are still effective, but need more frequent dosing than above.

EPINASTINE HCL: Also known as ELESTAT
Dosage: 2 x Day

AZELASTINE: Also known as OPTIVAR
Dosage: 2 x Day


SOFT STEROIDS: For patients suffering from severe allergic reactions with marked chemosis (swelling), you can't beat a steroid.  This is really effective for patients with a contact lens induced allergy like Giant Papillary Conjunctivitis.

If the eyelids look like this, you might want to use a steroid for faster resolution of this follicular reaction

ALREX: Loteprednol 0.2%
Dosage: Anywhere from four to once daily.  I typically dose twice daily unless the allergy reaction is very severe and I think four times a day is necessary.
Instructions:  SHAKE WELL.  This is a suspension, so you need to shake several times to adequately mix the medication into solution.
I typically keep patients on this drop for 2 weeks to 1 month, but in lower doses it is safe for longer term use.

FML or LOTEMAX OINTMENT: 
Dosage: 1 to 2 times daily
Lotemax has a higher safety profile, but FML ointment is still a low strength steroid.  Neither are generic, and an FML ointment Rx can have a copay as high as $60.  For really chronic follicular reactions, the contact time of an ointment can truly make a difference.  Obviously, like all the drops listed in this post, do not insert when wearing contact lenses.

Allergy season is in full swing, so many of my patients are relying on over the counter medications for short term relief of their symptoms.  If symptoms are mild, over the counter drops can offer complete relief without large copay costs.  Here is a breakdown of the best drops you can pick up without a prescription.

THE BEST: A straight anti-histamine will relieve itching, without any major side effects.  Both of these drops have BAK as the preservative, so if you are known to have major preservative sensitivity, these could cause some irritation.  If you are going to buy an allergy eye drop, I recommend purchasing one of these 2:

ALAWAY:  My most recommended OTC drop

It's finally spring!  I know this fact is a blessing to me since I hate being cold, but for many Americans the transition into spring means untold suffering.  In my area, allergies are a way of life.  By the second week in March my car was permanently covered in a disgusting yellow dusting and my chair was filled with patient after patient with the first flare up of their seasonal ocular allergies.  How do you know if your irritation and discomfort is an allergic reaction? Let's discuss--

Redness, watering, and swelling of the conjunctiva are classic

SYMPTOMS
Itching. Itching.  And itching.  Your eyes may look red, water or feel dry, or you may experience a foreign body sensation, but itching is universal with allergies.  Contact lenses will feel uncomfortable and my patients complain that their lenses feel "dirty."  Mucus debris will deposit on the lenses and you may get some mucus discharge as well. Children often have a hard time telling you what they are feeling, so watch out for eye rubbing.  

SIGNS
The most classic sign I look for are called papillae: red elevations that form from inflammation of the conjunctiva (the tissue that lines the inner eyelid).  Papillae can be different shape and sizes, but they always mean allergy.  Other major signs of allergy are redness (called hyperemia) and swelling (called chemosis).

Fine papillae have red vascular cores.  Even though they are small, the number of papillae in this photo indicates a severe allergic reaction.  Photo from andrewgasson.co.uk

Large cobblestone papillae are found more often in children who suffer from a severe type of allergy called "vernal conjunctivitis".  Frequent eye rubbing is the first tip off!

TREATMENTS

• For mild cases, artificial tears may be enough.  Best for temporary relief for mild itching.

• For moderate cases where papillae are are lot less severe than the two photos above, I like to use anti-histamine/mast cell stabilizer combinations.  There are numerous over the counter drops, but my favorites are Zaditor and Alaway.  Prescription drops are much more effective, with common once daily drops including Pataday and Lastacaft.  They provide relief from itching within 5 minutes of instilling the drop

• Severe cases where there is substantial swelling, large papillary reaction, and marked discomfort, I like to also use a low strength steroid.  My favorite is Alrex, which can be used safely without risk of an intraocular pressure spike.  On really resistant cases, I have used FML or Lotemax ointment (steroid ointments) that can be applied under the eyelid to reduce swelling.

HOW TO PREVENT YOUR ALLERGIC REACTION FROM GETTING SEVERE
If you have undergone allergy testing or know certain irritants that really set off your symptoms, you can track their arrival in your area at pollen.com .  Plan ahead and start using drops as soon as you know symptoms should be forthcoming.  The drops work best when they have a few days to get into your system.  Mast cells in your body release histamine, which is the culprit behind your allergy reaction.  Any drop with a mast cell stabilizer will prevent this release of histamine, but if you start taking the drop after the histamine is released, the mast cell stabilizer isn't effective!