- Email: [email protected]
Thunderstorm-related asthma: Not only grass pollen and spores
CORRESPONDENCE 537
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limited from consuming the food products that declare the presence of food allergens. Now they also have to avoid food products labeled with allergy advisory statements. This severely limits their choices of food products and further adds to their parents’ frustration, especially knowing that possibly 90% or more of these food products with allergy advisory statements actually do not contain food allergens. Although further data are needed on the prevalence of milk, egg, soy, or wheat allergens in food products labeled with allergy advisory statements, it would seem reasonable to place more responsibility on the food companies to accurately measure the amount of food allergens in their products and to provide clearer information for parents or patients with food allergy. Peck Y. Ong, MD From the Division of Clinical Immunology/Allergy, Children’s Hospital Los Angeles, and the Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, Calif. E-mail: [email protected]. Disclosure of potential conflict of interest: The author has declared that he has no conflict of interest. REFERENCE 1. Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol 2007;120:171-6. Available online January 3, 2008. doi:10.1016/j.jaci.2007.11.006
Reply To the Editor: I am quite sure that many of the readers of our article1 share the perspective of Dr Ong.2 Certainly, patients with peanut allergy are frustrated by the proliferation of food products bearing advisory labels for peanuts. Our data showing that 90% of such products contain no detectable peanut protein surely adds to the frustration. No wonder that increasing numbers of patients with peanut allergy are ignoring advisory labels and consuming such products, as shown in Fig 1 of our article. Yet let me emphasize that these patients are taking a risk when they choose to ingest products bearing advisory labels. The potential risk of experiencing allergic reactions on 1 of every 10 or even every 100 occasions is unacceptable. Certainly, I would agree with Dr Ong that the food industry should analyze such products for residual peanut and only put advisory labels on products where such a quantitative risk assessment would indicate some level of risk. However, the US Food and Drug Administration has not established a safe threshold level for peanut residues in foods. Because there is no established guidance on safe levels, the food industry chooses to err on the side of consumer safety. It is important to emphasize that we only analyzed 2 samples of each product, and therefore we cannot categorically state that a particular product never contains detectable peanut residues. If particulate peanut contamination is possible because of use of shared processing equipment, then the occasional spike of peanut residue could occur, leading to some packages of potentially hazardous product that would justify the advisory label; we might just have missed selecting such samples. Finally, I would note that my laboratory intends to conduct a similar survey for detectable residues of peanut in packaged foods bearing advisory levels to ascertain whether trends are changing over time. Furthermore, my laboratory is currently conducting an analytic survey of products bearing advisory labels for milk. Steve L. Taylor, PhD From the Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, Neb. E-mail: [email protected].
Disclosure of potential conflict of interest: S. L. Taylor has received grant support from Advance Food Company; Agrana Fruit US, Inc; Ajinomoto Corporate Services, LLC; Amy’s Kitchen, Inc; Archer Daniels Midland Company; Barry Callebaut; Ben & Jerry’s Homemade, Inc; Blommer Chocolate Company, Inc; Blue Diamond Growers; Bodendorfer-Johnson, LLC; Bunge Milling, Inc; Cadbury; Campbell Soup Company; Cargill, Inc; Charm Sciences, Inc; Chr. Hansen, Inc; Coca-Cola Company; ConAgra Foods, Inc; Continental Mills, Inc; Danone Research; DSM Nutritional Products; Ecolab, Inc; General Mills, Inc; Gerber Products Company; Givaudan Flavors Corporation; H. C. Brill Company, Inc; Hershey Foods Corporation; H. J. Heinz Company; John B. Sanfilippo & Son, Inc; Kellogg Company; Kerry Ingredients; Keystone Foods, LLC; Kraft Foods Global, Inc; Lallemand, Inc; Malt-O-Meal Company; Manildra Group USA; MARS Snackfood US, LLC; McCormick & Co, Inc; Neogen Corporation; Nestec Ltd.–Nestle USA; Newly Weds Foods, Inc; Norland Products, Inc; Oscar Mayer; PepsiCo, Inc; Proctor and Gamble; Ralston Foods; R-Biopharm, Inc; Sara Lee Corporation; Schweppes Americas’ Beverages; Sensient Flavors, Inc; The Solae Company, LLC; Tate & Lyle Unilever; and Wm. Wrigley Jr. Company. REFERENCES 1. Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol 2007;120:171-6. 2. Ong PY. Are allergy advisory statements helpful to patients with food allergy? J Allergy Clin Immunol 2008;121:536-7. Available online January 21, 2008. doi:10.1016/j.jaci.2007.11.007
Thunderstorm-related asthma: Not only grass pollen and spores To the Editor: In the September 2007 issue of the Journal, Pulimood et al1 suggest sensitization to Alternaria species to play a key role in thunderstorm-related asthma. In the editorial of the same issue, Marks and Bush2 provide a review of environmental factors involved in asthma epidemics, listing 4 necessary conditions to make them possible.2 In the list they cited fungal spores and grass pollen as the unique airborne allergens (points 1, 2, and 3) that are implicated in the pathogenesis of thunderstorm-related asthma. This is not completely true. During the episode registered in Naples on June 4, 2004 (between 1:30 and 2:00 AM), 6 adults (3 women and 3 men between 38 and 60 years old) and a girl of 11 years had attacks of severe bronchial asthma, and the attack was nearly fatal in one case.3,4 This is the first report of thunderstorm-related asthma in the Mediterranean area. All patients received treatment in emergency departments, and one was admitted to an intensive care unit for very severe bronchial obstruction and acute respiratory insufficiency. All subjects were outdoors when the thunderstorm struck. None of the 7 subjects regularly took antiallergy drugs, antiasthma drugs, or both, confirming the findings of Pulimood et al.1 Four had a history of asthma, whereas 2 had a history of only rhinitis. We found that all 7 patients were sensitized, with allergic respiratory symptoms on exposure, to Parietaria species pollen but were not sensitized to grasses or other aeroallergens, such as other pollen grains and molds.3,4 Parietaria species is an urticacea weed that is widespread in the Naples and Mediterranean area, with a spring and summer pollen season in part contemporaneous with that of grasses.5,6 During the thunderstorm, the concentration of airborne Parietaria species pollen grains was particularly high, with a peak of 144 grains/m3 being recorded on June 3, whereas airborne concentrations of grasses and Alternaria species were very low. Air pollution levels for both gaseous and particulate components based on the hourly concentrations of nitric dioxide, ozone, and respirable particulate matter were not particularly high in Naples on June 3 and 4. There is clear evidence that Parietaria species
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pollen was a risk factor for an asthma epidemic during the thunderstorm in Naples, with a close temporal association between the arrival of the thunderstorm, a major increase in the concentration of Parietaria species pollen grains, and the onset of the epidemic. We completely agree with Marks and Bush2 about the ‘‘4 necessary conditions’’ for asthma epidemics, but more than fungal spores and grass pollen have to be taken into consideration. The same mechanisms might involve other pollen grains in different geographic areas, depending on the seasonality of thunderstorms and allergenic pollen. Gennaro D’Amato, MDa Lorenzo Cecchi, MDb Gennaro Liccardi, MDa From athe Division of Respiratory and Allergic Diseases, Department of Respiratory Diseases, High Specialty Hospital A. Cardarelli, Naples, Italy, and bthe Interdepartmental Centre of Bioclimatology, University of Florence, Florence, Italy. Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest. REFERENCES 1. Pulimood TB, Corden JM, Bryden C, Sharples L, Nasser SM. Epidemic asthma and the role of the fungal mold Alternaria alternata. J Allergy Clin Immunol 2007;120: 610-7. 2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstormrelated asthma. J Allergy Clin Immunol 2007;120:530-2. 3. D’Amato G, Liccardi G, Viegi G, Baldacci S. Thunderstorm-associated asthma in pollinosis patients. Available at: http://bmj.bmjjournals.com/cgi/eletters/309/6947/131/c. Accessed December 7, 2007. 4. D’Amato G, Liccardi G, Frenguelli G. Thunderstorm-associated asthma in pollinosis patients. Allergy 2007;62:11-6. 5. D’Amato G, Ruffilli A, Ortolani C. Allergenic significance of Parietaria (pellitoryof-the-wall) pollen. In: D’Amato G, Spieksma F, Bonini S, editors. Allergenic pollen and pollinosis in Europe. Oxford: Blackwell Scientific Publications; 1991. p. 113-8. 6. D’Amato G, Cecchi L, Bonini S, Nunes C, Annesi-Maesano I, Behrendt H, et al. Allergenic pollen and pollen allergy in Europe. Allergy 2007;62:976-90. Available online January 3, 2008. doi:10.1016/j.jaci.2007.10.046
Reply To the Editor: We thank D’Amato et al1 for drawing our attention to a thunderstorm-related asthma outbreak that was associated with another pollen, in this case the weed pollen Parietaria species. We agree that the 4 conditions we outlined in our editorial2 need not only apply to grass pollens, although most previous reports do appear to have been linked to this form of pollen. However, any pollen grains, grass, weed, or tree, that are abundant and can rupture and release respirable allergenic starch granules would be expected to behave in a similar way in the presence of a thunderstorm outflow. Guy B. Marks, MBBS, PhDa Robert K. Bush, MDb From athe Woolcock Institute of Medical Research, Sydney, New South Wales, Australia, and bthe William S. Middleton VA Hospital, Madison, Wis. E-mail: G.Marks@unsw. edu.au. Disclosure of potential conflict of interest: R. K. Bush has consulting arrangements with Greer Laboratories and has received grant support from the National Institutes of Health. G. B. Marks has declared that he has no conflict of interest. REFERENCES 1. D’Amato G, Cecchi L, Liccardi G. Thunderstorm-related asthma: not only grass pollen and spores. J Allergy Clin Immunol 2008;121:537-8. 2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstormrelated asthma. J Allergy Clin Immunol 2007;120:530-2. Available online January 21, 2008. doi:10.1016/j.jaci.2007.10.047
Intranasal corticosteroids reduce ocular symptoms of allergic rhinitis as a class effect To the Editor: In their study of fluticasone furoate nasal spray, Kaiser et al1 make an important but possibly underappreciated contribution to the growing amount of evidence demonstrating that intranasal corticosteroids (INSs), as a class, reduce the ocular symptoms associated with allergic rhinitis (AR). Unfortunately, the authors concluded that ‘‘older INSs failed to show consistent efficacy for ocular symptoms in adult subjects with SAR’’ (seasonal allergic rhinitis), and characterized fluticasone propionate (FP) and mometasone furoate (MF) nasal sprays as ‘‘older’’ INSs. However, the literature supports the positive effect on ocular allergy symptoms of older INS agents as a class effect. One possible reason that older studies may not have consistently shown a positive effect for ocular symptoms is that those studies did not focus on the ocular domain of allergy symptoms, but combined all symptoms into a single component of the total nonnasal symptom score. However, studies published over the past 5 years with FP, MF, budesonide, triamcinolone acetonide, and beclomethasone dipropionate have collected and reported ocular allergy signs and symptoms separately. In the article by Bernstein et al2 cited by Kaiser et al,1 a 28-day study comparing FP, oral loratadine, and placebo found that subjects treated with FP had statistically significant decreases compared with placebo in the total ocular symptom score, which was the sum of scores for the symptoms of itching (pruritus), tearing (epiphora), and redness (erythema). The data also suggested that FP had reduced ocular symptoms more than or comparable to oral loratadine. The positive effect of MF on ocular allergy symptoms was seen in an analysis of pooled data from 4 randomized blind studies. Subjects who received MF had significantly greater reductions in total ocular symptom score and the component symptoms of itching, tearing, and redness than those who received placebo over the entire 2-week course of the study, which was similar to the study by Kaiser et al.3,4 Mometasone furoate had an onset of effect starting at 24 hours of initiation of treatment.4 Ocular symptom scores also decreased significantly in pediatric patients with perennial AR after 1 year of treatment with budesonide,5 adolescents and adults with seasonal allergic rhinitis who received triamcinolone acetonide,6 and patients with chronic rhinosinusitis with and without allergy given beclomethasone dipropionate, which significantly improved ocular tearing, itching, and redness as well as blepharedema.7 In conclusion, these clinical studies have demonstrated that many of the INSs have a positive effect on the ocular symptoms of AR. The positive effect appears to be a class effect of INSs, and not, as Kaiser et al1 imply, solely an attribute of fluticasone furoate. The results of the studies conducted with the other older INSs and the results of the study by Kaiser et al1 indicate that all of these agents may have a similar positive effect on the ocular symptoms of AR. Leonard Bielory, MD From the Departments of Medicine, Pediatrics, Ophthalmology, and Visual Sciences, Division of Allergy, Immunology and Rheumatology, New Jersey Medical School, Newark, NJ. E-mail: [email protected]. Disclosure of potential conflict of interest: L. Bielory has consulting arrangements with Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis, Genentech, UCB Pharma, MedPointe, Inspire, and Vistakon and has received grant support from Pfizer, Forest, Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis,
J ALLERGY CLIN IMMUNOL VOLUME 121, NUMBER 2
limited from consuming the food products that declare the presence of food allergens. Now they also have to avoid food products labeled with allergy advisory statements. This severely limits their choices of food products and further adds to their parents’ frustration, especially knowing that possibly 90% or more of these food products with allergy advisory statements actually do not contain food allergens. Although further data are needed on the prevalence of milk, egg, soy, or wheat allergens in food products labeled with allergy advisory statements, it would seem reasonable to place more responsibility on the food companies to accurately measure the amount of food allergens in their products and to provide clearer information for parents or patients with food allergy. Peck Y. Ong, MD From the Division of Clinical Immunology/Allergy, Children’s Hospital Los Angeles, and the Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, Calif. E-mail: [email protected]. Disclosure of potential conflict of interest: The author has declared that he has no conflict of interest. REFERENCE 1. Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol 2007;120:171-6. Available online January 3, 2008. doi:10.1016/j.jaci.2007.11.006
Reply To the Editor: I am quite sure that many of the readers of our article1 share the perspective of Dr Ong.2 Certainly, patients with peanut allergy are frustrated by the proliferation of food products bearing advisory labels for peanuts. Our data showing that 90% of such products contain no detectable peanut protein surely adds to the frustration. No wonder that increasing numbers of patients with peanut allergy are ignoring advisory labels and consuming such products, as shown in Fig 1 of our article. Yet let me emphasize that these patients are taking a risk when they choose to ingest products bearing advisory labels. The potential risk of experiencing allergic reactions on 1 of every 10 or even every 100 occasions is unacceptable. Certainly, I would agree with Dr Ong that the food industry should analyze such products for residual peanut and only put advisory labels on products where such a quantitative risk assessment would indicate some level of risk. However, the US Food and Drug Administration has not established a safe threshold level for peanut residues in foods. Because there is no established guidance on safe levels, the food industry chooses to err on the side of consumer safety. It is important to emphasize that we only analyzed 2 samples of each product, and therefore we cannot categorically state that a particular product never contains detectable peanut residues. If particulate peanut contamination is possible because of use of shared processing equipment, then the occasional spike of peanut residue could occur, leading to some packages of potentially hazardous product that would justify the advisory label; we might just have missed selecting such samples. Finally, I would note that my laboratory intends to conduct a similar survey for detectable residues of peanut in packaged foods bearing advisory levels to ascertain whether trends are changing over time. Furthermore, my laboratory is currently conducting an analytic survey of products bearing advisory labels for milk. Steve L. Taylor, PhD From the Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, Neb. E-mail: [email protected].
Disclosure of potential conflict of interest: S. L. Taylor has received grant support from Advance Food Company; Agrana Fruit US, Inc; Ajinomoto Corporate Services, LLC; Amy’s Kitchen, Inc; Archer Daniels Midland Company; Barry Callebaut; Ben & Jerry’s Homemade, Inc; Blommer Chocolate Company, Inc; Blue Diamond Growers; Bodendorfer-Johnson, LLC; Bunge Milling, Inc; Cadbury; Campbell Soup Company; Cargill, Inc; Charm Sciences, Inc; Chr. Hansen, Inc; Coca-Cola Company; ConAgra Foods, Inc; Continental Mills, Inc; Danone Research; DSM Nutritional Products; Ecolab, Inc; General Mills, Inc; Gerber Products Company; Givaudan Flavors Corporation; H. C. Brill Company, Inc; Hershey Foods Corporation; H. J. Heinz Company; John B. Sanfilippo & Son, Inc; Kellogg Company; Kerry Ingredients; Keystone Foods, LLC; Kraft Foods Global, Inc; Lallemand, Inc; Malt-O-Meal Company; Manildra Group USA; MARS Snackfood US, LLC; McCormick & Co, Inc; Neogen Corporation; Nestec Ltd.–Nestle USA; Newly Weds Foods, Inc; Norland Products, Inc; Oscar Mayer; PepsiCo, Inc; Proctor and Gamble; Ralston Foods; R-Biopharm, Inc; Sara Lee Corporation; Schweppes Americas’ Beverages; Sensient Flavors, Inc; The Solae Company, LLC; Tate & Lyle Unilever; and Wm. Wrigley Jr. Company. REFERENCES 1. Hefle SL, Furlong TJ, Niemann L, Lemon-Mule H, Sicherer S, Taylor SL. Consumer attitudes and risks associated with packaged foods having advisory labeling regarding the presence of peanuts. J Allergy Clin Immunol 2007;120:171-6. 2. Ong PY. Are allergy advisory statements helpful to patients with food allergy? J Allergy Clin Immunol 2008;121:536-7. Available online January 21, 2008. doi:10.1016/j.jaci.2007.11.007
Thunderstorm-related asthma: Not only grass pollen and spores To the Editor: In the September 2007 issue of the Journal, Pulimood et al1 suggest sensitization to Alternaria species to play a key role in thunderstorm-related asthma. In the editorial of the same issue, Marks and Bush2 provide a review of environmental factors involved in asthma epidemics, listing 4 necessary conditions to make them possible.2 In the list they cited fungal spores and grass pollen as the unique airborne allergens (points 1, 2, and 3) that are implicated in the pathogenesis of thunderstorm-related asthma. This is not completely true. During the episode registered in Naples on June 4, 2004 (between 1:30 and 2:00 AM), 6 adults (3 women and 3 men between 38 and 60 years old) and a girl of 11 years had attacks of severe bronchial asthma, and the attack was nearly fatal in one case.3,4 This is the first report of thunderstorm-related asthma in the Mediterranean area. All patients received treatment in emergency departments, and one was admitted to an intensive care unit for very severe bronchial obstruction and acute respiratory insufficiency. All subjects were outdoors when the thunderstorm struck. None of the 7 subjects regularly took antiallergy drugs, antiasthma drugs, or both, confirming the findings of Pulimood et al.1 Four had a history of asthma, whereas 2 had a history of only rhinitis. We found that all 7 patients were sensitized, with allergic respiratory symptoms on exposure, to Parietaria species pollen but were not sensitized to grasses or other aeroallergens, such as other pollen grains and molds.3,4 Parietaria species is an urticacea weed that is widespread in the Naples and Mediterranean area, with a spring and summer pollen season in part contemporaneous with that of grasses.5,6 During the thunderstorm, the concentration of airborne Parietaria species pollen grains was particularly high, with a peak of 144 grains/m3 being recorded on June 3, whereas airborne concentrations of grasses and Alternaria species were very low. Air pollution levels for both gaseous and particulate components based on the hourly concentrations of nitric dioxide, ozone, and respirable particulate matter were not particularly high in Naples on June 3 and 4. There is clear evidence that Parietaria species
538 CORRESPONDENCE
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pollen was a risk factor for an asthma epidemic during the thunderstorm in Naples, with a close temporal association between the arrival of the thunderstorm, a major increase in the concentration of Parietaria species pollen grains, and the onset of the epidemic. We completely agree with Marks and Bush2 about the ‘‘4 necessary conditions’’ for asthma epidemics, but more than fungal spores and grass pollen have to be taken into consideration. The same mechanisms might involve other pollen grains in different geographic areas, depending on the seasonality of thunderstorms and allergenic pollen. Gennaro D’Amato, MDa Lorenzo Cecchi, MDb Gennaro Liccardi, MDa From athe Division of Respiratory and Allergic Diseases, Department of Respiratory Diseases, High Specialty Hospital A. Cardarelli, Naples, Italy, and bthe Interdepartmental Centre of Bioclimatology, University of Florence, Florence, Italy. Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest. REFERENCES 1. Pulimood TB, Corden JM, Bryden C, Sharples L, Nasser SM. Epidemic asthma and the role of the fungal mold Alternaria alternata. J Allergy Clin Immunol 2007;120: 610-7. 2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstormrelated asthma. J Allergy Clin Immunol 2007;120:530-2. 3. D’Amato G, Liccardi G, Viegi G, Baldacci S. Thunderstorm-associated asthma in pollinosis patients. Available at: http://bmj.bmjjournals.com/cgi/eletters/309/6947/131/c. Accessed December 7, 2007. 4. D’Amato G, Liccardi G, Frenguelli G. Thunderstorm-associated asthma in pollinosis patients. Allergy 2007;62:11-6. 5. D’Amato G, Ruffilli A, Ortolani C. Allergenic significance of Parietaria (pellitoryof-the-wall) pollen. In: D’Amato G, Spieksma F, Bonini S, editors. Allergenic pollen and pollinosis in Europe. Oxford: Blackwell Scientific Publications; 1991. p. 113-8. 6. D’Amato G, Cecchi L, Bonini S, Nunes C, Annesi-Maesano I, Behrendt H, et al. Allergenic pollen and pollen allergy in Europe. Allergy 2007;62:976-90. Available online January 3, 2008. doi:10.1016/j.jaci.2007.10.046
Reply To the Editor: We thank D’Amato et al1 for drawing our attention to a thunderstorm-related asthma outbreak that was associated with another pollen, in this case the weed pollen Parietaria species. We agree that the 4 conditions we outlined in our editorial2 need not only apply to grass pollens, although most previous reports do appear to have been linked to this form of pollen. However, any pollen grains, grass, weed, or tree, that are abundant and can rupture and release respirable allergenic starch granules would be expected to behave in a similar way in the presence of a thunderstorm outflow. Guy B. Marks, MBBS, PhDa Robert K. Bush, MDb From athe Woolcock Institute of Medical Research, Sydney, New South Wales, Australia, and bthe William S. Middleton VA Hospital, Madison, Wis. E-mail: G.Marks@unsw. edu.au. Disclosure of potential conflict of interest: R. K. Bush has consulting arrangements with Greer Laboratories and has received grant support from the National Institutes of Health. G. B. Marks has declared that he has no conflict of interest. REFERENCES 1. D’Amato G, Cecchi L, Liccardi G. Thunderstorm-related asthma: not only grass pollen and spores. J Allergy Clin Immunol 2008;121:537-8. 2. Marks GB, Bush RK. It’s blowing in the wind: new insights into thunderstormrelated asthma. J Allergy Clin Immunol 2007;120:530-2. Available online January 21, 2008. doi:10.1016/j.jaci.2007.10.047
Intranasal corticosteroids reduce ocular symptoms of allergic rhinitis as a class effect To the Editor: In their study of fluticasone furoate nasal spray, Kaiser et al1 make an important but possibly underappreciated contribution to the growing amount of evidence demonstrating that intranasal corticosteroids (INSs), as a class, reduce the ocular symptoms associated with allergic rhinitis (AR). Unfortunately, the authors concluded that ‘‘older INSs failed to show consistent efficacy for ocular symptoms in adult subjects with SAR’’ (seasonal allergic rhinitis), and characterized fluticasone propionate (FP) and mometasone furoate (MF) nasal sprays as ‘‘older’’ INSs. However, the literature supports the positive effect on ocular allergy symptoms of older INS agents as a class effect. One possible reason that older studies may not have consistently shown a positive effect for ocular symptoms is that those studies did not focus on the ocular domain of allergy symptoms, but combined all symptoms into a single component of the total nonnasal symptom score. However, studies published over the past 5 years with FP, MF, budesonide, triamcinolone acetonide, and beclomethasone dipropionate have collected and reported ocular allergy signs and symptoms separately. In the article by Bernstein et al2 cited by Kaiser et al,1 a 28-day study comparing FP, oral loratadine, and placebo found that subjects treated with FP had statistically significant decreases compared with placebo in the total ocular symptom score, which was the sum of scores for the symptoms of itching (pruritus), tearing (epiphora), and redness (erythema). The data also suggested that FP had reduced ocular symptoms more than or comparable to oral loratadine. The positive effect of MF on ocular allergy symptoms was seen in an analysis of pooled data from 4 randomized blind studies. Subjects who received MF had significantly greater reductions in total ocular symptom score and the component symptoms of itching, tearing, and redness than those who received placebo over the entire 2-week course of the study, which was similar to the study by Kaiser et al.3,4 Mometasone furoate had an onset of effect starting at 24 hours of initiation of treatment.4 Ocular symptom scores also decreased significantly in pediatric patients with perennial AR after 1 year of treatment with budesonide,5 adolescents and adults with seasonal allergic rhinitis who received triamcinolone acetonide,6 and patients with chronic rhinosinusitis with and without allergy given beclomethasone dipropionate, which significantly improved ocular tearing, itching, and redness as well as blepharedema.7 In conclusion, these clinical studies have demonstrated that many of the INSs have a positive effect on the ocular symptoms of AR. The positive effect appears to be a class effect of INSs, and not, as Kaiser et al1 imply, solely an attribute of fluticasone furoate. The results of the studies conducted with the other older INSs and the results of the study by Kaiser et al1 indicate that all of these agents may have a similar positive effect on the ocular symptoms of AR. Leonard Bielory, MD From the Departments of Medicine, Pediatrics, Ophthalmology, and Visual Sciences, Division of Allergy, Immunology and Rheumatology, New Jersey Medical School, Newark, NJ. E-mail: [email protected]. Disclosure of potential conflict of interest: L. Bielory has consulting arrangements with Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis, Genentech, UCB Pharma, MedPointe, Inspire, and Vistakon and has received grant support from Pfizer, Forest, Schering-Plough, GlaxoSmithKline, Merck, Novartis, Sanofi-Aventis,