Patient with Dry Eye Syndrome
Grace M. Wang, Shahzad I. Mian
Abstract
Dry eye syndrome is a common condition that can be challenging to manage. Here we present a
case of a young man with severe dry eye syndrome without any associated systemic etiology.
Management of his dry eye syndrome presented a significant challenge with use of a number of
pharmacologic as well as non-pharmacologic treatment modalities. A combination of these therapies
may benefit patients, either by treating the underlying condition or providing symptomatic relief.
History
A 27-year-old gentleman was referred to the University of Michigan Kellogg Eye Center for
evaluation of severe dry eyes. He had been experiencing dry eye symptoms including itching, burning,
and foreign body sensation for a few years, and had been managed with artificial tears as needed and
punctal plugs in all four puncta. He reported a history of recurrent corneal infections, including a
corneal ulcer in the right eye shortly prior to the time of presentation, which was successfully treated
with ofloxacin 0.3%.
His medical history was remarkable for seasonal allergies, Raynaud’s disease, and an episode of
nonspecific polyarthritis likely due to viral origin at age 20, with subsequent unremarkable
rheumatologic work up. His only other medication was cetirizine, which he was taking for seasonal
allergies.
Examination
Ocular examination showed visual acuity without correction of 20/15 in each eye. External
examination, pupils, extraocular motility, confrontation visual fields, and IOP were normal. Slit lamp
exam showed three punctal plugs in place, with the left upper punctum being open. On upgaze, his
inferior cul-de-sac in both eyes showed blunting with loss of normal folds, indicating conjunctival
scarring, likely from underlying atopy. His cornea exam was significant for severe diffuse punctate
epithelial erosions with positive Rose Bengal staining in both eyes, with the erosions forming linear
patterns in the left eye. There was a small stromal scar in the inferonasal quadrant of the right
peripheral cornea, consistent with a recently treated ulcer. The tear film break up time was shortened to
3 seconds in both eyes. Schirmer test with the use of topical anesthetic revealed 0mm of wetting in both
eyes after 5 minutes. The rest of his anterior segment exam as well as fundus exam were normal.
Discussion and diagnosis
Dry eye syndrome is a common problem with varying severities of clinical presentation. In
patients with more severe disease, it can be symptomatically debilitating and difficult to manage. Poor
protection of the ocular surface can affect visual acuity, or predispose patients to other disease
processes such as corneal ulcers, as evident in this patient.
Complete evaluation of dry eye syndrome includes a detailed review of systems in addition to a
thorough ophthalmic examination. A number of underlying ocular and systemic conditions can cause
dry eye disease. Common etiologies may include anatomic variation, poor tear production, and
inflammatory conditions. In this patient, history of atopy and the use of cetirizine were thought to
contribute to the reduction of his tear production. Subsequently, he underwent repeat rheumatologic
evaluation, which was negative for RF, HLA-B27, ESR, except a nonspecific finding of positive ANA.
Treatment of primary dry eye syndrome is focused on addressing aqueous tear deficiency and
increased tear evaporation. Lubricants including artificial tears, gels, and ointments are typically first
line. These agents provide symptomatic relief as well as ocular surface protection. For those with more
severe disease associated with conjunctival injury, topical cyclosporine A 0.05% has been shown to
effectively reduce symptoms as well as improve objective measurements of dry eye disease including
TBUT (tear break up time), Schirmer test, and OSDI (ocular surface disease index) in some patients [1-3].
Autologous serum (AS) tears have become an increasingly popular second line treatment for dry eye
syndrome. AS biochemical contents include immunoglobulins, vitamin A, fibronectin, and growth
factors that promote epithelial healthy by mimicking natural tears more closely than artificial tears.
Studies have illustrated better symptomatic relief with the use of AS tears, and some recent clinical trials
have shown greater objective improvement in TBUT and OSDI compared to artificial tears alone[4-6].
Other pharmacologic treatment in dry eye syndrome target underlying conditions that
contribute to dry eyes. Short courses of mild topical steroid can be helpful particularly in patients with
conjunctival inflammation, which can aggravate dry eye symptoms. In patients with comorbidities of
blepharitis or ocular rosacea, which lead to increased tear film evaporation and contribute to dry eye
symptoms, oral doxycycline or azithromycin can be used to treat the underlying cause and improve dry
eye symptoms. For blepharitis associated with ocular demodecosis, tea tree oil has been found to be
effective [7, 8].
For patients with dry eye symptoms associated with systemic inflammatory conditions, systemic
anti-inflammatory treatments such as oral steroids can be considered, especially during a flare episode
of the condition. In patients with Sjögren’s syndrome, oral pilocarpine has also been found to improve
symptoms [9-11].
Additional non-pharmacologic treatments are also available to aid the management of dry eye
syndrome. Punctal occlusion, which reduces the rate of tear drainage, can be achieved by plugs or
thermal cautery. Warm compresses, lid scrub, and LipiFlow thermal pulsation can provide relief for
patients whose dry eye symptoms are complicated by blepharitis and Meibomian gland dysfunction. For
patients who fail combinations of the above pharmacologic treatments, scleral lenses, such as PROSE, or
“prosthetic replacement of the ocular surface ecosystem”, can be used as well [8].
Our patient was initially managed with a short course of topical fluorometholone 0.1% to reduce
ocular inflammation. In addition, left upper punctal plug was replaced, and he was initiated on
cyclosporine 0.05% drops. He did well for several years with some improvement and was followed
locally. On a subsequent return visit, he continued to have dry eye symptoms though his corneal surface
on exam was much improved. He later underwent punctal cauterization after punctal plugs were
repeatedly lost. He also tried AS tears as well as LipiFlow thermal pulsation without much additional
relief of symptoms. The patient elected to be treated with PROSE, which he found helpful. At the most
recent visit, his corneal surface was excellent and his Schirmer test with the use of topical anesthetic
improved to 3mm and 4mm in the right and left eye. However, he continued to have lid irritation and
dry sensation. He was initiated on topical tea tree oil wipes.
Conclusion
This case illustrates the multi-faceted problem of dry eye syndrome and the plethora of
treatment options. In treating patients with this chronic condition, an ophthalmologist has many choices
in both pharmacologic and non-pharmacologic treatments to help the patient. Identification of
underlying causes of dry eye is important in selecting the appropriate treatments.
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