he latest in our interactive dry eye exercises focused on a patient with a long history of ocular redness and discomfort. Over several decades, there had been many different management approaches tried. Some of these had been very varied, but common to all was a lack of any programmed approach, nor any regular follow-up allowing for modification of the initial intervention. Before summarising some of your views, it is worth repeating the details of the case and adding a few salient comments along the way.
Case
Patient CS3
- Female
- DOB 30/3/1959
- Caucasian ethnicity
Notes
- Female physiology makes dry eye disease more likely in women.1,2
- The patients age makes ocular surface and tear anomalies more likely even without previous predisposing factors and disease.
- Though many papers have cited Asian ethnicity as a risk factor for dry eye disease, this is now somewhat disputed.2
Presentation/background
- Patient booked in for full tear and lid assessment
- Chronic and variable symptoms suggestive of low grade, chronic ocular surface disorder have been a problem since she was in her twenties.
- Redness and/or discomfort has been variously diagnosed and treated as conjunctivitis or as ‘dry eye’.
- Occasional lid swelling, has been interpreted as allergic response.
- Previous management approaches have been haphazard and implemented sporadically. Patient is fed up and is keen to address the problem ‘once and for all’.
Notes
- A scattergun approach to management by different people over the years has left this patient despondent and having little confidence in clinical management.
- Management of the condition as conjunctivitis was primarily by general practitioners and I am sure this will not come as a surprise to readers.
History
- Strabismus surgery aged seven years – successful (now orthophoric) and minimal surface irregularity post-op, no significant scarring.
- Reports history of transient redness/discomfort/eye rubbing ‘for decades’ from her twenties.
- Use of vasoconstrictor topical agents (‘red eye drops’) ‘for many years’.
- Previous referral for persistent chalazion (10 years ago) – resolved without excision while waiting for appointment.
Notes
- Previous surgery can cause irregularity of the ocular surface through scarring and is always worth recording as a possible contributor to discomfort. In this case, no such significant irregularity was identified.
- Transient presentations are always worth investigating to ascertain any specific triggers of symptoms, such as associating with periods of sleeplessness, identifying seasonal patterns, looking for task-related associations such as working patterns and roles.
- The use of vasoconstrictors is not uncommon in patients who are attempting to self-treat. Their effectiveness with repeat treatments appears to reduce.3 Rebound hyperaemia is assumed to occur with ocular vasoconstrictor use. That said, some studies fail to demonstrate rebound with ocular vasoconstrictors,3 but other reports of it can be found in the literature.4
- Most chalazia are manageable in community practice with advice about firm application of sterile warm compresses. In a very few cases, excision may be required and in yet fewer cases, the persistent lesion turns out to be the highly malignant meibomian gland carcinoma. This rare lesion, with a high associated mortality rate, is thankfully extremely rare.
- Persistent or recurrent chalazia may indicate previous meibomian gland dysfunction or perhaps systemic association such as acne rosacea.
General health
- Good, no prescribed meds
- Diet ‘good’
- Non-smoker
Notes
- The impact of systemic drugs and of lifestyle factors such as smoking and air quality are always important to ascertain. Advice regarding these may be the crux of any management plan, and are all too often ignored in the rush to dispense drops.
Previous management
- No programmed approach.
- Recent use of 0.2% sodium hyaluronate drops have helped, but effect was short-lived .
- Various previous interventions have included:
- Golden Eye ointment (propamidine antibiotic) – bad reaction to this (‘eye swelled up’).
- Chloramphenicol antibiotic (both drops and ointment have been used on various occasions).
- Anti-allergic drops (type not known) have not helped.
- Has used ‘warm flannels’ in the past, but not convinced they helped.
- No nutritional supplements used.
- Cotton wool buds (soaked in warmed water) have been used on the lid margins on previous advice – likely poor compliance as ‘hated doing this’.
Notes
- As we all know, hyaluronic acid is a very effective way of alleviating dry eye symptoms. The extent of its activity may be modified in some drop preparations by other components designed to maximise the duration of the impact. Such additions include trehalose and guar.
- Golden Eye produce a range of ointments and drops aimed at over-the-counter management of acute bacterial conjunctivitis (some preparations include chloramphenicol) and blepharitis/dry eye. It was believed that this patient had used Golden Eye Ointment which contains dibrompropamidine isetionate (0.15% w/w) as the active ingredient along with liquid paraffin and dispersed polyethylene in mineral oil. The drops or ointment should not be used if the patient has a known allergy to the active ingredient (in this case likely to have been propamidine isetionate), or to any of the other ingredients included in the preparation. Similarly, if the patient is pregnant, trying to become pregnant or breast-feeding or wears contact lenses.
- The use of chloramphenicol preparations might have been appropriate if dispensed at times when the patient had acute bacterial conjunctivitis, but questioning failed to establish any previous event where this had seemed likely due to the nature of any reported discharge.
- The possible allergic response to the anti-bacterial preparation suggests atopy may be possible, but the lack of information about previous allergic treatment or symptoms suggestive of allergy make further deduction difficult (she mentioned ‘rubbing’ but not ‘itching’ for example, but has suffered ‘lid swelling’ on occasions.
- The use of ‘warm flannels’ should make our hearts sink. Without a planned approach to the application of a clean compress of known temperature that persists long enough to liquify meibum, such compress treatments usually fail and also make patients less likely to comply with future, more systematic, approaches. Also, warm, wet flannels residing in bathroom environments are, in this authors view, not far from flexible Petri dishes of various cultures.
- The evidence base for nutritional adaptation/supplementation and improved ocular surface integrity is growing.5,6 That said, the widely publicised DREAM study7 suggested that ‘dietary supplementation with oral omega-3 fatty acids is no better than placebo in relieving signs and symptoms of dry eye disease.’ Considerable debate continues, however, both about the design of this study and its conclusions.8
Points of interest
- Previous prescription of tetracyclines 10 years ago – little benefit reported.
- Family history – four siblings with a variety of predisposing conditions (psoriasis, rosacea, eczema, iritis); has ‘lost track of who has what’.
Notes
- Tetracyclines taken orally are a commonly used and effective treatment for acne rosacea, a skin condition with a strong association with persistent anterior blepharitis and chalazia. This information suggests that, historically, a clinician may have thought there was some systemic influence on the patient’s condition. According to the Moorfields Eye Hospital website,9 blepharitis ‘is more common in skin conditions such as: seborrhoeic dermatitis, which causes an itchy rash on the skin and scalp (seborrhoeic dermatitis of the scalp is called dandruff); rosacea which causes the face to appear red and blotchy; acne in teenagers and young adults, which cases irritation and blockage of the glands in the centre of the face.’ Some have suggested that blepharitis is the commonest ocular manifestation of psoriasis.10 A wide range of autoimmune diseases exist with sometimes strong associations with ocular diseases such as iritis. Ocular symptoms may include dry or red eyes, foreign-body sensation, pruritus, photophobia, pain, visual changes, and even complete loss of vision.11 Obviously, each case needs to be reviewed in turn and ocular surface management only undertaken with full understanding or co-management of underlying disorders. Familial expression of these conditions is not uncommon so it was important to record what this patient knew of her family and their various complaints.
Lifestyle
- Variable indoor/outdoor activities (reading, gardening, singing).
- Drives.
- No excessive sun/UV exposure reported, always needs high factor sunscreen.
- No prolonged computer/screen use (maximum one hour).
- No excessive air-conditioned environment exposure.
- Wears eyeliner/make up.
Notes
- Along with what has been mentioned before, some information about eye lid make-up is often very useful. This patient thought she used ‘hypoallergenic’ cosmetics, but this was never completely established with confidence. The NHS website recommends ‘do not use eye makeup, especially eyeliner, while you have symptoms’ for those with blepharitis.12 Despite claims about hypoallergenic properties, good advice seems to be that people with eyelid inflammation should avoid using cosmetics such as eyeliner, mascara, and other makeup around the eyes.
Initial symptomatology/observation
- No indication of allergic response.
- No indication of infective conjunctivitis (viral or bacterial).
Notes
- Remember the importance of lid eversion before ruling out papillae or follicles that may point to infection or allergy
Clinical Findings (13/8/19)
General clinical
- Corrected acuity:
- R; 6/5 L; 6/5 (N5/N5 with +2.25DS add)
- All non-surface optometry findings unremarkable (and on file).
- General observation:
- Low grade telangiectasia on nose.
Tears (figure 1)
- Tear meniscus height reduced
- R; 0.1mm L; 0.1mm
- OSDI symptom score
- 31
- Osmolarity
- R 310 L; 315 mOsmL-1 (iPen)
- Schirmer within normal limits
- Non-invasive break up time or NIBUT moderate reduction (8.1/6.9 seconds)
- Interferometry pattern
- Poor lipid layer patency
- Break-up time
- R; three seconds L; four seconds
Figure 1: Summary of clinical findings
Lids
• Meibomian gland dropout (figure 2)
• Low grade, lower lids only assessed (on patient wishes)
• Blepharitis
• No obvious lash scaling/crusting
• Some madarosis (lash loss) R and L
• Significant lid margin telangiectasis (figure 3)
• Blink pattern
• Good blink rate
• Blink completion good
Figure 2: Meibography of the lower lids
Ocular surface
• No significant staining today
Your Discussion Points
The patient is asking for a systematic approach to alleviate a longstanding problem that she feels has never previously been properly addressed and all too often has been dismissed as ‘just a bit dry eye.’
After discussion with a colleague (optometrist or therapeutic optometrist), please answer the following three points:
- How would you summarise the most likely cause of the patients concerns (in your answer, please refer to specific clinical results)?
- What would be your initial management plan regarding any apparent anomaly of both the tears and the lids?
- In case of persistence, is there anything in this presentation that might indicate a possible systemic influence?
Initial Comments
This patient shows some signs of historic, chronic, disease (madarosis, lid margin irregularity and telangiectasis). There is evidence of reduced tear volume and lipid layer patency, the latter likely to be linked with under-functioning of the meibomian glands. A phased approach might seem appropriate to first address (or try to) the lid gland concern, the tear stability and the discomfort. Preservatives might best be avoided. A follow-up is essential to see what impact such an approach makes and to review the state of the lids and tears. If resolution is not possible, the lid margins may need further attention, such as by use of IPL therapy.
Your Discussions
There were fewer responses than usual to this interactive exercise, possibly because of its more complex presentation. An example of a sensible response follows.
‘Most likely concern – symptoms associated with a mixed dry eye. Low tear prism height, higher osmolarity, poor lipid, meibomian gland drop out, history of chalazion, mild lash loss and lid telangiectasia all indicate poor tear function and poor lid health. They would be more likely, then, to experience infections like conjunctivitis. There is a general sensitivity (needing sun cream and having a reaction to Golden Eye ointment), although no allergy markers seen.
Initial management:
- MGD treatments heat masks like Eyebag or Blephasteam googles to get oils flowing better, with eye massage too to further assist gland clearance.
- Systane Complete eyedrops (however, these contain preservatives) or a bioprotective drop like Thea Thealoz Duo drops which are preservative free. As the patient is sensitive, we need to be cautious with any drop containing preservatives, particularly if long term use.
- Patient says they have a good diet. However, most people’s diets are not necessarily what a nutritionist would agree is a good diet. Refined sugars, processed meats and trans-fats are known to increase inflammation in the body. Sadly, Western diets may contain too much of these. Omega-3 is known to benefit eye health and has anti-inflammatory properties.
- Patient has a history of psoriasis in family which is an autoimmune condition and associated with inflammation, so management should also consider such possible influences.
If persistent – from the history it would suggest that it is already persistent and the patient has had history of issues for 40 years (sensitivity, eye rubbing, swollen lids); all variable but, most importantly, recurrent. I would suggest, along with the above treatments, a discussion about the possibility of an underlining inflammatory condition, possible influences of diet, and the influence of autoimmune conditions running in the family. Possibly seeing her GP to discuss further and have blood tests to see if any auto immune markers is appropriate.’
Author’s note – the initial management and that at a three-month follow-up appointment will be published in a future issue of Optician.
References
- Matossian C et al. Dry Eye Disease: Consideration for Women’s Health. Journal of Women’s Health, Volume 28, Number 4, 2019, pp502-514.
- Farrand KF et al. Prevalence of Diagnosed Dry Eye Disease in the United States Among Adults Aged 18 Years and Older. American Journal of Ophthalmology, 2017 Volume 182, Pages 90 to 98
- Abelson MB et al. Tolerance and absence of rebound vasodilation following topical ocular decongestant usage. Ophthalmology. 1984, 91(11), pp 1364 to 1367
- Soparkar CNS et al. Acute and Chronic Conjunctivitis Due to Over-the-counter Ophthalmic Decongestants. Archives of Ophthalmology, 1997, 115(1), pp 34 to 38
- Signes-Soler I et al. Nutrition and dry eye: a systematic review. Expert Review of Ophthalmology, 2019, 14:3, pp 133 to 150
- Larmo PS et al. Oral Sea Buckthorn Oil Attenuates Tear Film Osmolarity and Symptoms in Individuals with Dry Eye. Journal of Nutrition, 2010, 140, pp 1462 to 1468
- The Dry Eye Assessment and Management Study Research Group. Omega-3 fatty acid supplementation for treatment of dry eye disease. New England Journal of Medicine, April 13, 2018
- Moore J, Pazo E. Fatty Acid Nutrition and Dry Eye Disease. Optician, 18.05.2018, pp 33 to 36
- www.moorfields.nhs.uk/condition/blepharitis-0 Accessed 06.03.2020.
- Cram DL. Corneal melting in psoriasis. Journal of the American Academy of Dermatology, 1981, 5(5), p 617
- Patel SJ et al. Ocular Manifestations of Autoimmune Disease. American Family Physician, 2002, 66(6), pp 991 to 998
- www.nhs.uk/conditions/blepharitis Accessed on 06/03/2020