Article Date: 4/1/2004

the dry eye file
Does Dryness Mean Dry Eye?
The symptoms aren't always so straightforward.
Milton M. Hom, O.D., F.A.A.O.

Dry eye is a perplexing and confusing disease -- years spent studying dry eyes can result in more questions than answers. Efforts to simplify management into cookbook methods can worsen our understanding. Here are a few things that I've learned about dealing with the disorder.

It's not always what it seems

One notable area of confusion surrounds symptoms. Recently, I've been learning that a symptom of dryness doesn't necessarily mean that the patient has dry eye disease -- dryness could mean many things. For example, it can be a side effect of another process going on in the eye. Many patients who have external eye diseases (ocular allergies, bacterial disease and viral infections) will complain of dryness. Most of the time, the dryness manifests itself as a secondary complaint, but it can, however, be the patient's primary concern.

Figure 1: Stained nodule located in right eye under white light.

Case report

A 26-year-old female had moved from San Francisco to the Los Angeles area about seven months before her visit to my office. She was experiencing dryness and irritation since relocating and the hot weather exacerbated her symptoms. I ran an Ocular Surface Disease Index (OSDI) and found 15.9 at baseline. Tear break-up time (TBUT) was four seconds; viewing with a Tearscope revealed a slight deficiency in the lipid layer (Yokoi Grade 1).

Slit lamp evaluation showed a nodule located at seven o'clock on the limbal area of the right eye (see Figure 1). The nodule stained with fluorescein (see Figure 2).

Figure 2: Fluorescein staining of perilimbal nodule.

Zeroing in on a diagnosis

The nodular inflammation was a conjunctival phlyctenule, which usually occurs secondary to an allergic hypersensitivity response of the cornea. However, many times the pathophysiology is unclear. Traditionally, it's most common (60% of cases) in females during their first and second decades.

Symptoms usually include tearing, ocular irritation, mild to severe photophobia and a history of similar episodes. If any of these symptoms were associated with a Staphylococcal infection, then mucopurulent discharge will be present. In the past, it's been associated with tuberculosis.

What are your options?

Treatment options include eyelid hygiene for mild cases. Moderate- to-severe cases can require topical steroids such as prednisolone acetate (Pred Forte) or loteprednol (Alrex or Lotemax) or steroid-antibiotic combinations (Tobredex). If you suspect a Staph reaction or acne rosacea, prescribe doxycycline (generic) 100 mg t.i.d. or erythromycin (Erythromycin) 250 mg q.i.d. p.o.

For this particular woman's case, I prescribed cyclosporine (Restasis) b.i.d. for off-label use. My idea was to use the anti-inflammatory properties of cyclosporine with it's high safety margin. Cyclosporine would also address the significant dryness component of the eye.

Figure 3: At one week, the phlyctenule was gone.

Flash forward

At the one-week visit, the OSDI improved to 4.5, indicating a normal eye. TBUT still remained four seconds; tearscope showed improvement to a normal lipid layer (Yokoi Grade 0). The slit lamp revealed no phlyctenule present (see Figure 3). Staining was apparent in the same region, but I didn't see any elevation or nodule. The patient reported that her symptoms were relieved.

Many times, the symptoms don't always match the severity of the signs. The OSDI is helpful in monitoring subtle changes in symptoms. In this case, the patient's score improved from mild symptoms to completely normal. We routinely run the OSDI on all of our dry eye patients because it helps us measure results as well as shows patients whether their treatment is working or not.



Optometric Management, Issue: April 2004