FDA approves new OTC allergy eye drops

Allergy season is coming. Millions of Americans will suffer from itchy and watery eyes shortly. The current treatment of itchy eyes can be done by only two types of OTC products, one is ketotifen- based, such as zaditor or allaway. Ketotifen has anti-histamine as well as mast cell stabilizer activity, and works generally well for itchy eyes. The other type is pheniramine- based, such as Visine-A and Opcon-A. This one only has anti-histamine activity. In addition, Visine-A contains a vasoconstrictor, which may temporarily relieves redness but over long-term may cause worsening red eyes.

For many patients, ketotifen may not be enough to relieve their itchiness. In such cases I often prescribe patanol or pataday (olopatadine 0.1% and 0.2% respectively). These usually work very well, and quite safe and well- tolerated, though patients have to come to see a doctor to get prescription.

Now FDA just approved patanol and pataday as OTC, and may be available as early as March 2, 2020. (news link https://www.mdmag.com/medical-news/pataday-fda-approves-prescription-allergy-eye-drops-over-the-counter-alcon)

This is great news. As patients no longer have to wait for weeks before getting an appointment from an eye doctor’s office. If your eyes are itchy, just go to the pharmacy to pick up some ketotifen or patanol if the former does not work for you. This will also reduce cost from health care system and reduce work productivity lost due to going to doctors’ offices. Of course I bet it will be expensive, but having easy access is the key point here. And hopefully generics become available in future to make it more affordable for consumers.

I see fluid coming up in my eye

Another case by Juan Ding, OD PhD

A young gentleman in his 20s came in complaining of poor vision in his left eye which worsened for the past 2 weeks, particularly that it bothered him to see ‘fluid seeping up’ in his left eye vision happening a few times in the past two weeks. No it is not seeing fluid in his left eye in a mirror, it is seeing that with his left eye.

He grew up in a middle east country, had congenital cataract and cataract surgery both eyes. When he was a young kid, he unfortunately had an injury to his left eye that made him completely blind in that eye. He wears a prosthetic shell in the right eye. After removing the shell, it is obvious that this eye has gone – it is withered (phthisis bulbi), with a white membrane (pannus) over the entire cornea. Importantly, there is no sign of infection in this eye, and it does not hurt.

The left eye had only hand motion vision, meaning he can see hand moving in front of his eye but no details. This eye also shows back and forth shaking (nystagmus), which sometimes happens with poor vision from a very early age. Eye pressure is 10, which is normal. There are a lot of cells (4+) in the anterior chamber, which means very severe inflammation. The pupil is irregular and completely stuck to the artificial lens behind (posterior synechiae). The dilation drops could not dilate the pupil at all, so I was not able to see anything behind. Additionally, there appears to be a white membrane on the artificial lens, further blocking any view to the back. Unfortunately in my small eye clinic we do not have B scan to check if there is any retinal detachment.

Further questioning did not yield much more useful information. The patient was aware that he did not see well out of the left eye, but he did not know why, and could not produce any previous medical record.

Given the finding, I prescribed steroid drops for inflammation, and atropine, a strong dilating drop to break the sticky pupil. I made an appointment for him to see our uveitis specialist in 2 weeks, hopefully the pupil will be dilated then for her to see.

The patient walked in to see another eye doctor of our department 6 days later, complaining that his sx did not improve with the drops. In this visit, his eye pressure went up to 29, which was attributed to steroid response. He was given timolol to lower eye pressure

One day later he walked in again, complaining seeing everything white with the dilating drops. His eye pressure in the left eye now became 5. This time the access doctor happened to be the uveitis specialist. She found still the same amount of inflammation that I saw, and found funnel retinal detachment (this is retina detached almost entirely except for the optic nerve head position, causing a funnel shape on ultrasound, as shown below) on B scan. She increased steroid dosage and referred him to our retinal surgeon.

funnel RD from web

image: Ultrasound scan showing a funnel retinal detachment (source: https://imagebank.asrs.org/file/1431/open-funnel-retinal-detachment). This is not my patient.


Weeks later, as I checked back the medical record to see how he’s doing. I found out that he went to Mass Eye and Ear (MEEI) in Boston. From their notes, it appears that he used to see eye doctors there, diagnosed with chronic funnel retinal detachment in 2015, but lost to follow up subsequently.

So the mystery is solved. His chronic retinal detachment is most likely the cause of his uveitis (eye inflammation), and bleeding in the vitreous (found on B scan at MEEI) would be the cause of worsening vision recently, and seeing ‘fluid going up’ in his vision.

Retinal surgeons at MEEI plan to do surgery for him, though the prognosis for vision is poor due to chronic macula off retinal detachment.

It is sad to see a young person who already is blind in one eye to lose vision in the other eye. Infants need to be screened for conditions such as congenital cataract. It is already late if you notice nystagmus. Fortunately this is done routinely in newborns and well visits by pediatricians. Eye injuries should be prevented, especially for boys. And if you already have a serious eye condition, like retinal detachment, please follow up with your eye doctor.