Over-the-counter drops for the treatment of Ocular Allergy

David A. Goldman, M.D.

About Author

As unemployment rates stay high and more people lose insurance coverage, increasing numbers of patients are asking their physicians for cheaper alternative medications. Ocular allergy is very common, with a prevalence at least four times that of nasal allergy symptoms¹. Symptoms can include itching, tearing, conjunctival edema, hyperemia, burning, and discharge. While there are many different causes of bilateral conjuncitivits such as atopic and vernal, allergic is the most common type encompassing 80-90% of all types. Many prescription strength anti-allergy ophthalmic drops are available and include Bepreve (ISTA), Lastacaft (Allergan), and Patanol/Pataday (Alcon). While effective, some patients are without insurance and simply cannot afford them. That said, some of the least expensive anti-allergy drops are available over the counter. In the majority of cases, these cost less than generic prescription medications. The question is: Do they work?

In short, the answer is 'yes'. That said, not all over the counter drops are created equal and it is our duty as ophthalmologists to steer our patients in the right direction. There are well over a dozen over the counter anti-allergy drops, but they are mainly composed of one or two similar active ingredients. These will be discussed below:

Pheniramine maleate/Naphazoline
This is the common ingredient in products such as Naphcon-A and Opcon-A. By combining an antihistamine and a vasoconstrictor, patients can experience both increased ocular comfort as well as decreased redness. Its current labeling is to use one to two drops up to four times a day as needed. Multiple clinical studies have proved efficacy of this combination^2,3. Unfortunately, rebound hyperemia and chemosis are frequent. Furthermore, a reactive conjunctivitis can occur which may take months to resolve⁴. A typical bottle may cost anywhere between $6 and $17.

Ketotifen fumarate
This is the common ingredient in the majority of OTC anti allergy drops including Zaditor (Novartis), Alaway (Bausch & Lomb), Zyrtec Itchy Eye and Claritin Eye. A second-generation H1-antihistamine/mast cell stabilizer, ketotifen is very effective in treating the signs and symptoms of ocular allergy. Their safety profile is excellent and Alaway can be used in children as young as three years old. It has been found to be more effective in reducing itching and redness when compared to fluorometholone acetate in the treatment of seasonal allergic conjunctivitis⁵. In a comparative study, 0.025% ketotifen fumarate was superior 0.1% olopatadine hydrochloride in relieving signs and symptoms of vernal conjunctivitis⁶. However, in a patient preference study on allergic conjunctivitis, patients preferred olopatadine drops to ketotifen drops, finding them more efficacious and comfortable⁷. Since this study, Alcon has released olopatadine hydrochloride ophthalmic solution 0.2% as a once-daily dosed anti-allergy drop Pataday. While the qd dosing certainly lends itself to better compliance, it can come at a significant financial cost to patients. These drops can cost between $9 and $28/bottle.

Alternative remedies
Similasan Allergy Eye Relief is a homeopathic eye drop with active ingredients listed as apis, euphrasia, and sabadilla. While there are some patient-reported anecdotes of clinical success, there are no clinical studies proving any benefit of this product. Though touted by the company as “eye doctor recommended”, I was unable to find one testimonial anywhere online, in their literature, or in their print advertisements. These drops cost between $7 and $15 a bottle.

Summary
Ultimately, over the counter drops can be very effective in treating the signs and symptoms of ocular allergy and can be especially helpful for those patients who have been hit hard by the financial crisis. While naphazoline/pheniramine maleate combination drops have been beneficial in clinical trials, there is more evidence supporting ketotifen fumarate drops which do not share the rebound hyperemia and chemosis. Unfortunately, not all patients with allergic conjunctivitis will respond to these drops. In the very least, however, they provide an inexpensive and readily available starting point for our patients with allergic conjunctivitis.

REFERENCES

1. K. Singh, L. Bielory. Ocular Allergy: A National Epidemiologic Study. Journal of Allergy and Clinical Immunology, Volume 119, Issue 1, Pages S154-S154
2. Dockhorn RJ, Duckett TG. Comparison of Naphcon-A and its components (naphazoline and pheniramine) in a provocative model of allergic conjunctivitis. Curr Eye Res. 1994 May;13(5):319-24.
3. Greiner JV, Udell IJ. A comparison of the clinical efficacy of pheniramine maleate/naphazoline hydrochloride ophthalmic solution and olopatadine hydrochloride ophthalmic solution in the conjunctival allergen challenge model.Clin Ther. 2005 May;27(5):568-77.
4. Soparkar CN, Wilhelmus KR, Koch DD, Wallace GW, Jones DB. Acute and chronic conjunctivitis due to over-the-counter ophthalmic decongestants. Arch Ophthalmol. 1997 Jan;115(1):34-8.
5. Borazan M, Karalezli A, Akova YA, Akman A, Kiyici H, Erbek SS. Efficacy of olopatadine HCI 0.1%, ketotifen fumarate 0.025%, epinastine HCI 0.05%, emedastine 0.05% and fluorometholone acetate 0.1% ophthalmic solutions for seasonal allergic conjunctivitis: a placebo-controlled environmental trial. Acta Ophthalmol. 2009 Aug;87(5):549-54. Epub 2008 Jul 9.
6. Hida WT, Nogueira DC, Schaefer A, Dantas PE, Dantas MC. Comparative study between 0.025% ketotifen fumarate and 0.1% olopatadine hydrochloride in the treatment of vernal keratoconjunctivitis. Arq Bras Oftalmol. 2006 Nov-Dec;69(6):851-6.
7. Leonardi A, Zafirakis P. Efficacy and comfort of olopatadine versus ketotifen ophthalmic solutions: a double-masked, environmental study of patient preference.Curr Med Res Opin. 2004 Aug;20(8):1167-73.