Diagnosis: Dry eye syndrome
This patient has dry eye syndrome. Dry eye syndrome can have multiple etiologies including decreased tear production (typical of autoimmune conditions such as Sjogren’s) or may be exacerbated by environmental/occupational circumstances (increased screen time, decreased blink etc). It can also become worse following corneal procedures such as LASIK, as was the case for this patient.
Treatment
First line treatment for dry eyes is lubrication with frequent artificial tear drops. For patients with severe dry eyes, preservative free artificial tears can be used to avoid further irritation from the preservative in the drops. If patients also have blepharitis (see below), eyelid massages with warm compresses are also advised. For patients with severe dry eyes or an autoimmune component, anti-inflammatory drops such as Restasis (cyclosporine) or Xiidra (lifitegrast) may be prescribed in conjunction with lubricating drops.
Common causes of “Red eye”
Other etiologies on the differential for this case include other causes of “red eye” such as blepharitis, conjunctivitis, subconjunctival hemorrhage, pterygium, scleritis, episcleritis, corneal ulcer, corneal abrasion, uveitis, and pterygium.
Chronic dry eye syndrome and blepharitis can cause redness of the conjunctiva which is usually diffuse and bilateral. Blepharitis refers to inflammation of the eyelids and meibomian glands which produce an essential part of the tear film, and leads to dryness symptoms. It may be characterized by crusting around the lashes. When one particular meibomian gland becomes clogged, this leads to build of tear film in the duct which forms a bump on the eyelid which is referred to as chalazion. Preseptal cellulitis refers to infectious inflammation of the eyelid which can be caused by a chalazion, but is not the only cause.
Subconjunctival hemorrhages are collections of red blood cells within the conjunctival from a broken conjunctival blood vessel. They hemorrhages are usually sectoral and form a solid red appearance. These commonly occur after eye rubbing, valsalva maneuver, and less frequently with poorly controlled hypertension. (Side image credit, license: CC BY-SA 3.0)
A pterygium develop from UV exposure causing elastoid degeneration to the conjunctiva which then grows onto the cornea. These are benign growths but must be monitored for obstruction of the visual axis. If they are approaching the visual axis or frankly obstructing it, surgical excision is considered. However, they may recur. (Side image credit, license: CC BY-SA 3.0)
Uveitis may cause sectoral or diffuse conjunctival redness, but is typically characterized by significant photophobia.
Conjunctivitis refers to inflammation of the conjunctiva which has myriad etiologies including infectious, inflammatory, allergic, and toxic (commonly topical medication induced). It is characterized by redness and inflammation of the entire conjunctiva, including the portion which lines the inner aspects of the eyelids. Associated purulent discharge is suggestive of a bacterial etiology, whereas viral etiologies may be accompanied by tearing but not discharge.
Scleritis refers to inflammation of the sclera and surrounding vessels. While most commonly autoimmune in nature, it can also be infectious. In contrast to episcleritis, which is inflammation of the more superficial episclera, scleritis is associated with dull, boring, pain that is exacerbated by eye movements. It is most commonly associated with rheumatoid arthritis. (Side image credit license: CC BY-SA 3.0)
Hyphema refers to collection of red blood cells in the anterior chamber and is most commonly caused by trauma leading to iris vessel injury and bleeding into the anterior chamber. In this example image, there is a mild subconjunctival hemorrhage located inferiorly as well. (Side image credit, license: CC BY-NC-ND 3.0)
Corneal pathologies, such as abrasions and ulcers, may be cause conjunctival injection due to the eye’s inflammatory response to this insult. These are characterized by severe, sharp eye pain due to the significant innervation of the cornea. A corneal abrasion refers to de-epithelialization of the cornea, while a corneal ulcer refers to a break in the epithelial with associated infiltrate. In addition to redness of the conjunctiva, breaks in the corneal epithelial will be highlighted by fluorescein staining and presence of infiltrate may cause a hazy appearance to portions of the affected cornea.
Finally, it’s always important to consider vision-threatening causes of red eye, such as acute angle closure and secondary forms of angle closure glaucoma. These red eye etiologies are typically associated with sudden change in vision and severe pain (see cases 6, 8, and 9 for more information).
References and Additional Resources:
- Cronau H, Kankanala RR, Mauger T. Diagnosis and Management of Red Eye Primary Care. Am Fam Physician. 2010;81(21):137-144.
- “EyeWiki: Dry Eye Syndrome.” Available at: https://eyewiki.aao.org/Dry_Eye_Syndrome.
- “EyeWiki: Dry Eye in Sjogren’s Syndrome.” Available at: https://eyewiki.aao.org/Dry_Eye_in_Sjogren%27s_Syndrome.
Case 4 Index
Case 4 Introduction
Case 4 Additional History
Case 4 Physical Exam
Case 4 Additional History