As optometrists, we routinely treat patients who have rhinoconjunctivitis. But, while we have been trained to examine and treat the eye, we must not overlook the debilitating nasal symptoms of this allergic reaction. Here, well review treatment options to manage both the ocular and nasal symptoms of rhinoconjunctivitis.
 
Combination Disorder
Rhinoconjunctivitis is a combination of allergic conjunctivitis and rhinitis. A combination of topical eye drops, intranasal sprays and oral medications may be required to control rhinoconjunctivitis. Since multiple studies have shown that direct treatment to the affected site(s) has had the most successful outcomes, the simultaneous use of eye drops and nasal sprays would likely be the most effective in reducing both symptoms.^1-3

Ophthalmic Drops
If the patient is not very symptomatic, artificial tears alone may be effective in reducing the symptoms of allergic conjunctivitis because the artificial tear washes the offending allergen out of the eye. If the artificial tears do not resolve patient symptoms, however, consider a topical allergy medication. Ophthalmic drops with antihistamine properties have been proven effective in treating ocular itching and hyperemia, plus the nasal symptoms of rhinorrhea, sneezing and nasal itching.⁴ For example, olo-patadine 0.1% ophthalmic solution relieves nasal symptoms because it passes from the eye through the nasolacrimal duct and into the nasal cavity, where it acts directly on the nasal tissues.

If ophthalmic drops alone do not provide sufficient relief, consider adding either an intranasal spray or a systemic allergy medication, as one study found that combined treatment with olopatadine and fluticasone nasal spray was the most effective for complete relief of rhinoconjunctivitis.³ If this combination treatment is not suitable for your patient, there are many other treatment options.

Intranasal Sprays
While some researchers say that nasal treatments reduce nasal congestion and thus improve tear flow, others say there is no link between the nasal cavity and the ocular surface.⁵ Still, intranasal sprays can effectively manage the rhinitis symptoms that stem from rhinoconjunctivitis, because application allows for a higher drug concentration at the site of action in the nasal mucosa. There are five different types of intranasal sprays on the market:

Saline nasal irrigation, which effectively relieves symptoms in up to 50% of patients who have allergic rhinitis, as it effectively irrigates the nasal mucosa and washes the allergens away.⁶

Corticosteroids, which are particularly useful for reducing the quantity and activity of inflammatory mediators that stem from the rhinorrhea, sneezing, congestion and pruritis of rhinoconjunctivitis. In fact, a review of 11 randomized, controlled trials found that nasal corticosteroid sprays were more effective than oral allergy medications at reducing nasal symptoms.⁵ However, because of the local activity of these drugs, adverse reactions have included nasal irritation and nosebleeds (epistaxis).

Decongestant nasal sprays, which cause vasoconstriction and immediate reduction of nasal congestion, itching and rhinorrhea. Still, patients should not use these agents for more than five to seven days, as over-use may result in rebound vasodilation and increased nasal symptoms.

Mast cell stabilizers and antihistamine nasal sprays, which both help block the histamine-mediated allergic cascade. Cromolyn sodium is the only mast cell stabilizer available in nasal spray form. It has an excellent safety profile with reported adverse effects similar to pla- cebo. The Allergy and Asthma Medical Group and Research Center in San Diego reported that more than 92% of patients rated cromolyn sodium nasal spray as extremely helpful in relieving symptoms.⁷ However, patients may not experience the full effects for two to four weeks. The recommended dosing is every four to six hours.

Antihistamines may be less effective in treating nasal itching and rhinorrhea than corticosteroids. Still, MedPointe Pharmaceuticals had 3,608 patients try azelastin for two weeks and then complete a patient survey. Data for 1,402 of these patients, in whom oral antihistamines were unsuccessful, showed that 89% of patients reported relief of symptoms within one hour.⁸ Azelastin is the only available nasal antihistamine and is prescribed twice a day.

Oral Allergy Medications
 Oral allergy medications such as antihistamines and decongestants can also be effective in treating both rhinoconjunctivitis symptoms. But, they do not reach the same concentration at the sites of inflammation (eye and nose) as do topically administered medications. In addition, there are more side effects with these medications than with topical ones. These include drowsiness (sleepiness), impairment (decreased ability to drive) and sedation (sleepiness and impairment).⁹ In addition, oral antihistamines have been reported to cause dry eye, with a 50% decrease in tear flow and volume.¹⁰

Although, we routinely prescribe topical drops and oral medications (according to individual state laws), we need to remember the OTC and prescription nasal sprays to ensure the greatest patient satisfaction and compliance. Refer the patient to a general practitioner or allergist, if your states scope-of-practice laws do not allow you to prescribe these medications. 

1. Spangler DL, Abelson MB, Ober A, Gotnes PJ. Randomized, double-masked comparison of olopatadine ophthalmic solution, mometasone furoate monohydrate nasal spray, and fexofenadine hydrochloride tablets using the conjunctival and nasal allergen challenge models. Clin Ther 2003 Aug;25(8):2245-67.
2. Abelson MB, Welch DL. An evaluation of onset and duration of action of Patanol (olopatadine hydrochloride ophthalmic solution 0.1%) compared to Claritin (loratadine 10mg) tablets in acute allergic conjunctivitis in the conjunctival allergen challenge model. Acta Ophthalmol Scand Suppl 2000;(230):60-3.
3. Lanier BQ, Abelson MB, Berger WE, et al. Comparison of the efficacy of combined fluticasone propionate and olopatadine versus combined fluticasone propionate and fexofenadine for the treatment of allergic rhinoconjunctivits induced by conjunctival allergen challenge. Clin Ther 2002 Jul;24(7):1161-74.
4. Abelson MB, Turner D. A randomized, double-blind, parallel-group comparison of olopatadine 0.1% ophthalmic solution versus placebo for controlling the signs and symptoms of seasonal allergic conjunctivitis and rhinoconjunctivitis. Clin Ther 2003 Mar;25(3):931-47.
5. Weiner JM, Abramson MJ, Puy RM. Intranasal corticosteroids versus oral H1 receptor antagonists in allergic rhinitis: systematic review of randomised controlled trials. BMJ 1998 Dec 12;317(7173):1624-9.
6. Becker JM. Allergic Rhinitis. (from emedicine.com 2004)
7. Meltzer EO; NasalCrom Study Group. Efficacy and patient satisfaction with cromolyn sodium nasal solution in the treatment of seasonal allergic rhinitis: a placebo-controlled study. Clin Ther 2002 Jun;24(6):942-52.
8. Lerrick AJ. A prospective, open-label evaluation of azelastine (Astelin) nasal spray for the treatment of seasonal allergic rhinitis and perennial nonallergic (vasomotor) rhinitis. Todays Therapeutic Trends 2003:21(2);215-26.
9. Casale TB, Blaiss MS, Gelfand E, et al. First do no harm: managing antihistamine impairment in patients with allergic rhinitis. J Allergy Clin Immunol 2003 May;111(5):S835-42.
10. Nally L, Emory TB, Welch DL. Ocular drying associated with oral antihistamines (loratadine) in the normal population effect on tear flow and tear volume as measured by fluorophotometry. ARVO Abstract #92, 2002.