April 1, 2022
By Thomas Aller, OD, FBCLA, Collaborator, Brien Holden Vision Institute
If your daily disposable wearers are suffering from allergies and may start to reduce wearing time, you may only need to prescribe any of your favorite antihistamine or mast stabilizing eye drops.
Authoritative bodies such as the American Academy of Optometry, American Optometric Association, American Academy of Ophthalmology, and the World Council of Optometry have declared that identifying young patients at risk for myopia progression and treating those patients with the available medicines and optical interventions should now be considered the standard of care for myopia.1-3 As practitioners begin to adopt myopia management strategies into their practices, they may start to realize that there are numerous interactions between their myopia treatments and other conditions, and that to achieve optimum overall outcomes, myopia cannot be managed in isolation.
Over my 30 years of actively researching and managing myopia progression, I have been convinced in recent years that along with the epidemic of childhood myopia, there is an epidemic of dry eye disease developing. This finding led to my proposed Grand Unified Theory of Optometry. I argue that there are significant parallels between digital device usage and myopia progression, dry eyes with meibomian gland dysfunction, and macular degeneration.4 That last one is likely the interaction least supported by the data and most challenging to prove, so for this article, I’m going to substitute allergic conjunctivitis as the interaction of interest.
How Allergies Affect Myopia Treatment
At first glance, allergic conjunctivitis and myopia control may not seem to relate to one another. In fact, patients with seasonal or perennial allergies may need those conditions adequately controlled before initiating orthokeratology (OrthoK), for example. If a child is a vigorous eye rubber due to allergies, dry eyes, or just out of habit, the corneal surface may be somewhat compromised, and/or the topography may be distorted. This distortion may result in poor data capture on the initial topography, particularly for custom OrthoK designs, causing the initial lenses to underperform.
Allergic conjunctivitis has been reported to be associated with greater amounts of astigmatism. Indeed, if these increased levels of astigmatism are transitory in nature, it would be best to see if specific interventions might result in more normal topographies.5 There may be few experiences less satisfying or more annoying for the patient, parents, and the eye care practitioner than an OrthoK treatment that starts with poor vision, unreliable lens designs, or discomfort related to underlying allergies. Since the best solution for this type of failed OrthoK fitting is to discontinue the treatment and allow the eyes to go back to baseline, unaffected by interactions with allergies, it is best to be disciplined at the beginning of myopia treatment and stabilize the ocular surface. This discipline would, of course, be rewarded with better initial treatment outcomes in the case of dry eyes as well. Pre-existing allergies could also interfere with soft lens treatments for myopia progression. Still, there wouldn’t necessarily be quite the need to wait for normalization of topography and temporary astigmatism to initiate treatment.
The other way that interactions between allergies and myopia may arise is when the treatments trigger the allergies and then interfere with the treatment objectives. While there are several animal studies in which it has been shown that brief periods of myopia-suppressing stimuli can overcome more extended periods of myopia-stimulating conditions. This would suggest that myopia treatments in humans may only need to be part time. However, most human studies have shown better treatment outcomes with full-time wear.6,7 Given these findings, anything that might interfere with full-time wear, such as uncomfortable lenses, irritated eyes from dry eye or allergies, or suboptimal corneal reshaping due to mucous contamination of the back surface curves of OrthoK lenses, will likely reduce the myopia progression control being sought with these interventions.
Adjusting Treatments for Allergy Sufferers
One excellent approach to contact lens treatments for myopia is to choose daily disposables, long known to have less tendency to trigger allergies and giant papillary conjunctivitis, but which may provide additional ocular comfort for allergy sufferers, even as compared to non-lens wearers.8,9 So, if your daily disposable wearers are suffering from allergies and may start to reduce wearing time, you may only need to prescribe any of your favorite antihistamine or mast stabilizing eye drops. A drug-eluting daily disposable contact lens recently received FDA approval.10 Though it is a single vision lens, that category may grow to include myopia control lenses in the future.
Suppose your myopic patients wear monthly replacement soft multifocals, three-month replacement custom bifocals, multifocals, or hybrid multifocals. In that case, your strategies could include increasing the replacement frequency, improving the efficacy of the cleaning procedures, prescribing the necessary medications, or switching to a daily disposable myopia management lens during allergy season.
If you treat myopic children with topical low-dose atropine either alone or in combination, you may encounter some patients who exhibit allergic reactions to the eye drop.11 These reactions seem more common in the higher dosages. Still, they could also be caused by various preservatives that the compounding pharmacy might use. It may be worth having a conversation with the pharmacist to see if an alternate preservative might be tried to help your patient tolerate the drug.
In conclusion, myopia management entails a broad range of optical, behavioral, and pharmaceutical strategies. Many interactions with the ocular tissue must be managed to have optimal outcomes. Untreated or poorly treated allergies, either at the beginning of myopia management or in the middle, unrelated to your treatment choices or triggered by those choices, are nothing to sneeze at. They can and should be managed to ensure optimal myopia control.
Thomas Aller, OD, FBCLA, is a collaborating scientist with BHVI.
- Modjtahedi BS, Abbott RL, Fong DS, Lum F, Tan D, Myopia TFo. Reducing the Global Burden of Myopia by Delaying the Onset of Myopia and Reducing Myopic Progression in Children: The Academy’s Task Force on Myopia. Ophthalmology. Jun 2021;128(6):816-826. doi:10.1016/j.ophtha.2020.10.040
- Brennan N, Nixon A. Managing Myopia – A Clinical Response to the Growing Epidemic. https://s3-us-west-2.amazonaws.com/covalentcreative/jjv/media/documents/Managing_Myopia_Clinical_Guide_Dec_2020.pdf
- WCO. Resolution: The Standard of Care for Myopia Management by Optometrists. https://worldcouncilofoptometry.info/resolution-the-standard-of-care-for-myopia-management-by-optometrists/
- Aller T. Myopia, dry eye, macular degeneration are linked to digital device use. Primary Care Optometry News: Healio 2017
- Kim Y, Oh I, Lee J, Sim CS, Oh YS, Lee J-H. Astigmatism Associated with Allergic Conjunctivitis in Urban School Children. Journal of Ophthalmology. 2019/11/11 2019;2019:9453872. doi:10.1155/2019/9453872
- Lam CS, Tang WC, Tse DY, Tang YY, To CH. Defocus Incorporated Soft Contact (DISC) lens slows myopia progression in Hong Kong Chinese schoolchildren: a 2-year randomised clinical trial. Br J Ophthalmol. Jan 2014;98(1):40-5. doi:10.1136/bjophthalmol-2013-303914
- Sankaridurg P, Bakaraju RC, Naduvilath T, et al. Myopia control with novel central and peripheral plus contact lenses and extended depth of focus contact lenses: 2 year results from a randomised clinical trial. Ophthalmic Physiol Opt. 07 2019;39(4):294-307. doi:10.1111/opo.12621
- Hayes VY, Schnider CM, Veys J. An evaluation of 1-day disposable contact lens wear in a population of allergy sufferers. Cont Lens Anterior Eye. Jun 2003;26(2):85-93. doi:10.1016/S1367-0484(03)00019-5
- Wolffsohn JS, Emberlin JC. Role of contact lenses in relieving ocular allergy. Cont Lens Anterior Eye. Aug 2011;34(4):169-72. doi:10.1016/j.clae.2011.03.004
- Wu L. First Drug-Eluting Contact Lens Wins FDA Nod – Contact lens releases antihistamine to treat itchy eyes. Accessed 03/02/2022, https://www.medpagetoday.com/allergyimmunology/allergy/97480
- Kothari M, Jain R, Khadse N, Rathod V, Mutha S. Allergic reactions to atropine eye drops for retardation of progressive myopia in children. Indian J Ophthalmol. Oct 2018;66(10):1446-1450. doi:10.4103/ijo.IJO_165_18