Once your environmental allergies are specifically identified a completely customized, targeted treatment plan can be created individually for you.

The Importance of Treating (Even) Asymptomatic Ocular Allergies and Their Associated Inflammation

Symptoms are what a patient feels and experiences; this is the subjective aspect of the examination. Signs are what Dr. Muller can measure, observe, and quantify using medical technology, tests, and the microscopes in her office; this is the objective aspect of the examination.

Ocular allergies are one of the most common sources of irritation and inflammation of the eyes and eyelids. It is not uncommon for a person to have asymptomatic ocular allergies and not have traditional allergy symptoms such as sinus congestion, sneezing, runny nose, postnasal drip, scratchy throat, etc. Often because ocular allergies are asymptomatic and not causing discomfort, they go undiagnosed.

To achieve the goal of having the healthiest and most comfortable eyes and eyelids and the best vision it’s imperative that all sources of ocular irritation and inflammation are identified and properly treated.

Ocular allergy testing is typically a component of an initial evaluation in which Dr. Muller rules in or out the most common sources of ocular irritation and inflammation. With or without symptoms, a positive ocular allergy test shows the immune system is reacting to environmental allergens.

In some people the eyes and the eyelids are the primary, sometimes the only, part of the body affected by this allergic inflammation. This inflammation destabilizes the tear film adversely affecting and damaging the ocular surface, the eyelids, the lacrimal and the Meibomian glands.

Untreated ocular allergies will significantly limit the successful treatment of dry eye, Meibomian gland dysfunction, blepharitis, ocular rosacea, and all ocular surface conditions. This is due to the headwinds caused by the inflammation from untreated ocular allergies. The converse is also true; treating ocular allergies creates a healthier environment for the eyes and eyelids, allowing all other aspects of the treatment to work more effectively.

Again, you do not have to feel allergy symptoms for ocular allergies to adversely affect your eyes and eyelids. Absence of symptoms does not mean absence of inflammation.

If ocular allergies are present then treating them is an integral part of a comprehensive, holistic, effective, optimized treatment plan; not treating the associated inflammation will limit success.

Key Points from the Medical Literature:

Ocular allergies directly damage Meibomian glands. Research demonstrates that inflammatory disorders of the palpebral conjunctiva and lid margin, including allergic conjunctivitis, impair the structure and function of Meibomian glands. [2]

A translational study showed that neutrophils driven by allergic inflammation physically obstruct Meibomian glands, and that neutrophil numbers in tears correlate with clinical severity of MGD. [3]

Patients with seasonal allergic conjunctivitis show significantly worse Meibomian gland morphology, higher dropout rates, and reduced gland function compared to controls. [5-6]

Ocular allergy is a recognized risk factor for dry eye disease.
Ocular allergy feeds directly into the "vicious cycle" of dry eye by promoting tear film instability, ocular surface inflammation and damage, and neurosensory abnormalities. [1]

The prevalence of dry eye among allergic conjunctivitis patients ranges from 31–36%, with perennial allergic conjunctivitis carrying the highest risk. [7]

The shared inflammatory mediators, including TNF-α, MMP-9, and elevated IgE, are significantly upregulated in patients with coexisting allergies and dry eye compared to dry eye alone. [8]

The conjunctiva is uniquely vulnerable. The conjunctiva is constantly exposed to airborne allergens and contains its own conjunctiva-associated lymphoid tissue (CALT), making it a primary site for IgE-mediated mast cell activation regardless of what is happening in the nasal mucosa. [9] This means a patient can have clinically significant ocular surface inflammation from allergen exposure without any nasal or respiratory symptoms.

Treating allergies is integral to MGD management.
Expert reviews on MGD treatment explicitly state that "addressing and treating concurrent ocular allergy is integral to symptom management". [10]

The AAO Dry Eye Preferred Practice Pattern emphasizes eliminating exacerbating factors and treating contributing ocular conditions as foundational steps before escalating therapy. [11]

The TFOS DEWS III report similarly highlights that identifying and treating the etiological driver of dry eye, which may include allergies is central to the management algorithm. [12]

*Please see below for all medical literature citations.

The first line of therapy is education and avoidance of your allergens.

Education: Dr. Muller and her staff place a huge emphasis on education. They spend a lot of time explaining your diagnosis, treatment options, and what you can do to have the healthiest, most comfortable eyes and eyelids, and maintain your best vision, always.

Dr. Muller always recommends minimizing your exposure to the things you’re allergic to.

To reduce your exposure to dust mites, which are most frequently found in bedding, upholstered furniture, carpets, and curtains, Dr. Muller suggests:
• The use of dust-mite-proof encasings for mattresses, box springs, and pillows (e.g., zippered covers).
• Wash bedding often, and in hot water, and dry on high heat.
• Hard flooring is preferable to rugs and carpet. Blinds or shades are preferable to curtains.
• Vacuum frequently using a vacuum with a HEPA filter.
Regarding pollen:
• Keep windows closed when pollen counts are high.
• Use HEPA filters in HVAC systems and air purifiers.
• Disrobe and shower after being outside to reduce the amount of pollen on your body and in your hair, and to minimize the amount of pollen you carry into your home.
• Limit outdoor activities when pollen levels are high (especially early morning).
Additional suggestions:
• Use exhaust fans in bathrooms and kitchens to reduce the possibility of mold.
• Clean mold-prone areas and humidifiers with diluted bleach (1 cup bleach in 1 gallon of water) or white vinegar.
• Avoid indoor smoke as smoke can worsen allergy symptoms.
• If you're allergic to pet dander, keep pets out of the bedroom.

The second line of therapy is aimed at decreasing your symptoms and the inflammation associated with your allergies.

NOTE: You can have environmental allergies and not have "traditional" allergy symptoms. Unfortunately, your allergies will still cause irritation of your eyes and eyelids exacerbating your ocular surface conditions (i.e. dry eye, Meibomian gland dysfunction, blepharitis, ocular rosacea, etc.).

For allergy symptoms that affect your eyes (i.e. red eyes, itchy eyes, tearing, puffy eyelids, dark circles under your eyes, etc.) you may be instructed to use artificial tears, prescription antihistamine eye drops, cold gel packs, etc. You should not take antihistamine tablets by mouth, especially if you have dry eye, as antihistamines by mouth exacerbate your dryness (from head to toe) as a side effect.

If you have symptoms involving your nose and throat (i.e. a runny nose, sneezing, scratchy throat, sore throat, cough, headaches, tiredness, lethargy, sinus congestion, sinusitis, post-nasal drip, etc.) you may be instructed to use various natural, over the counter products, such as Arm and Hammer Simply Saline Nasal Mist, and/or antihistamine nasal sprays. Decongestant nasal sprays such as Afrin and Sinex should not be used for more than 2 or 3 days to avoid a rebound effect. Again, it is recommended that you refrain from taking antihistamine tablets by mouth because of their drying effect.

The third line of therapy for allergies (and associated medical conditions such as asthma, eczema, postnasal drip and sinusitis) is immunotherapy.

Immunotherapy has been used for decades in the United States and extensively all over the world.  There are several ways to administer immunotherapy: subcutaneously as weekly allergy shots (SCIT), or by placing drops or tablets under your tongue, known as sublingual immunotherapy, or SLIT.

With allergy shots, the allergens to which you are allergic are mixed together, placed in a syringe and administered as an injection given once each week in a doctor’s office.

With custom sublingual immunotherapy (SLIT) drops the same group of allergens is mixed together, but instead of putting the mixture into a syringe, the solution is placed into a small bottle (very similar to a bottle of eye drops).  This bottle is given to you, along with clear instructions for placing a couple of drops under your tongue once a day in the convenience of your own home; no needles, no weekly doctor’s appointments.

Both sublingual immunotherapy (SLIT) and weekly subcutaneous allergy shots (SCIT) are customizable for multiple allergens.

These two forms of immunotherapy are equally effective as long as you're compliant with the one you choose.

While equally effective assuming compliance, sublingual immunotherapy (SLIT) drops offer the benefit of daily micro-dosing. This micro-dosing, as compared with one larger, more intense weekly dosage, allows for a gentler, more consistent immune modulation with a steadier, less aggressive, stimulation of the immune system and thus a better safety profile.

Immunotherapy consists of two phases: the escalation phase and the maintenance phase. The escalation phase typically takes ten to twelve months, and the maintenance phase typically takes about twenty four months.

Custom sublingual immunotherapy is safer, more convenient and more comfortable than weekly shots which has been shown to significantly enhance compliance.

Our patients are benefiting greatly from being successfully desensitized using custom sublingual immunotherapy (SLIT) drops.

Immunotherapy is intended to reduce or eliminate your allergy symptoms, associated medical conditions and their symptoms, and your need to take medication. Immunotherapy works by desensitizing you, or recalibrating your immune system by exposing your immune system, in a slow and controlled way, to increasing dosages of your allergens.  By doing this, your body learns tolerance and won’t have the same allergic inflammatory reaction upon future exposure to your allergens.

Custom sublingual immunotherapy in drop form has been used throughout Europe and Asia for decades and has been proven to be both safe and effective.

Sublingual immunotherapy drops are a natural, homeopathic way to treat your allergies and can be more cost effective than allergy shots or taking allergy medications. For allergy shots, the cost of the weekly doctor’s appointment typically involves a copay with or without coinsurance and a deductible, time away from work, transportation costs, etc. The cost associated with medication for symptomatic relief of your allergies can add up over the course of years and the ongoing use of these medications is simply not healthy.

The goal of sublingual immunotherapy drops is the long-term reduction or elimination of the inflammation caused by your allergies, the improvement in associated medical conditions, and the reduction of your need to take medications.

Much of the morbidity associated with untreated, or under-treated, environmental allergies can be prevented with proper diagnosis and treatment.

It is not uncommon for medical treatments to be used in an "off label" way. Sublingual Immunotherapy (SLIT) drops are an example of an FDA approved treatment being used “off label” *. Please read the explanation below.