A 45-year-old black female presented for a second opinion about an intermittent "sticking" sensation in her right eye. She reported no history of trauma, and indicated that the issue began four days earlier. The patient explained that she had visited another eye care provider who diagnosed her with dry eye; however, the drops that were prescribed weren't working effectively.
Her systemic history was remarkable for hypertensive medications. She had no known previous ocular history (before the other practitioner made the dry eye diagnosis) and reported no allergies.
Her best-corrected visual acuity measured 20/20 O.D. and 20/20 O.S. at distance and near. External examination was normal, and there was no evidence of afferent pupilary defect.
Her intraocular pressure measured 19mm Hg O.U. The dilated fundus examination was normal. The pertinent anterior segment findings are illustrated in the photograph.
How would you approach this case? Does this patient require any additional tests? What is your diagnosis? How would you manage this patient? What’s the likely prognosis?
External view of our 45-year-old patient who complained of a "sticking" sensation in her right eye.
Additional testing might include sodium fluorescein or lissamine green staining to uncover any corneal compromise. You should also perform upper eyelid eversion. Furthermore, depending on the location and nature of the symptoms and signs, double eyelid eversion with a Desmarres Lid Retractor (Anthony Products, Inc.) may be required.
The diagnosis in this month’s issue is corneal irritation secondary to eyelash entrapment within the lower puncta.
Foreign bodies that enter the eye without becoming logged or entrapped in conjunctival or corneal tissues will produce variable and intermittent discomfort depending upon their size, location, physical composition and ability to impact sensitive tissues.
When foreign bodies, such as a speck of dirt or an eyelash, become logged underneath the superior eyelid, the pain response will be severe, because the eye lid exerts pressure on the foreign body, creating discomfort in both the lid and sensation on the cornea (from pressure or from disfigurement of the corneal epithelium causing exposed nerve endings). However, if the same debris becomes entangled or engulfed in loose conjunctiva, discomfort may only be intermittent secondary to the entity being moved by a mechanical rub, cushioned by lacrimation, or soothed by enshrouding tissues––all which may mask the foreign body’s mass effect.
In these instances, patients may complain of intermittent irritation caused by periodic exposure of the foreign matter secondary to eye movement and blinking. Such cases require careful biomicroscopic inspection of the precise location that the patient reported experiencing the sensation. If the object broke apart or disintegrated into something too small to visualize, the clinician may need to lavage the entire area or blind swab the tissues. Single- or double-lid eversion may be required. In our patient, we used forceps to lift the lash from the orifice.
Topical supportive treatment, such as artificial tears and cold compresses, can soothe minor tissue irritations, dilute concentrations of particles and mechanically wash way loose, residual debris. More significant injuries may require light cycloplegia, depending upon the local inflammatory response; topical and oral non-steroidal anti-inflammatory agents; and topical antibiotics, if significant injury to the cornea or conjunctiva has occurred. Topical steroids should be reserved only for cases that exhibit severe concomitant inflammation.
In our patient, there was no corneal damage. When we removed the lash, the sensation and threat was gone. We prescribed no additional treatment or follow-up.