Leonardi A, Fauquert JL, Doan S, Delgado L, Andant N, Klimek L, Bozkurt B

Allergy, First published: 13 May 2020 https://doi.org/10.1111/all.14361

How should ocular allergies be treated in the time of COVID-19? How should topical steroids be used in patients with seasonal allergic conjunctivitis and the more severe and sight-threatening vernal and atopic keratoconjunctivitis? Should we continue using topical calcineurin inhibitors? Can systemic immunosuppressive/immunomodulatory therapies be used in severe cases where topical treatments are insufficient? What should our approach be to not-at-risk patients, at-risk patients, COVID-19-positive, and recovered COVID-19 patients? Thirty ocular allergy specialists from different countries responded.

For some time, people have been staying at home as much as possible due to COVID-19, but with the arrival of spring and the easing of restrictions, more people are starting to go out, leading to more exposure to pollen and an increase in allergic complaints. Especially in severe and sight-threatening allergic diseases such as vernal keratoconjunctivitis (VKC) and atopic keratoconjunctivitis (AKC), the long-term use of topical steroids and immunosuppressants may promote viral persistence and activation on the ocular surface. Although the virus that causes COVID-19 is rarely detected in the tears of infected individuals, conjunctivitis may emerge as a finding before or after respiratory symptoms.

In this study, questions were sent via REDCap to 20 ocular allergy working group members and 24 ocular surface disease specialists from Europe and other continents. The questionnaire asked for the respondents’ views on the treatment of seasonal allergic conjunctivitis (SAC), VKC, and AKC in the time of COVID-19. Treatment options were questioned for 4 categories: not-at-risk, at-risk, COVID-19-positive, and recovered COVID-19 patients. Respondents were asked to indicate their opinion on a 5-point Likert scale (strongly agree, agree, no opinion, disagree, strongly disagree).

Eighteen ophthalmologists and 12 allergists responded to the survey. For MAC, topical allergy drops (mast cell stabilizer, antihistamines, and dual-action drugs) were recommended for all patient categories. In case of nonresponse, topical steroids were recommended for not-at-risk and recovered COVID-19 patients. For patients with VKC and AKC, topical allergy drops were the first choice and topical steroids were the second choice. The consensus was to use short-term pulse steroid therapy when needed in all categories except patients with active COVID-19 infection, but there was no consensus on its use in individuals with active infection. Long-term low-dose steroid use was not recommended. There was also consensus about the use of topical immunomodulators in VKC/AKC patients. This was recommended by 90% of the respondents for not-at-risk patients, 66% for at-risk patients, and 50% for patients with active COVID-19 infection.

The use of systemic immunosuppressive therapy in patients with AKC refractory to topical therapy was a controversial issue even before COVID-19, and the experts did not consider it appropriate to initiate this treatment in patients with active COVID-19 infection. Most recommended local treatment for at-risk or recovered patients. Initiation of systemic treatment in at-risk patients was not considered an appropriate treatment option, while approximately half of the experts considered systemic steroid, cyclosporine, azathioprine, and dupilumab therapy appropriate for recovered patients with severe AKC.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/all.14361

Prepared by Banu Bozkurt MD.