A 27-year-old Caucasian female patient reported to the office with a chief complaint of dry, irritated eyes of two weeks’ duration. She explained that her eyes became red over the previous two weeks and that use of Visine made them less red but didn’t stop the discomfort. 

The patient’s systemic and ocular histories were unremarkable and she denied exposure to chemicals or allergies of any kind. However, she had recently started oral over-the-counter allergy medications for the symptoms of clogged ears.

Slit lamp exam of the patient revealed these findings. What might be the origin?

Slit lamp exam of the patient revealed these findings. What might be the origin? Click image to enlarge.

Her best-corrected entering visual acuities were 20/20 OU at distance and near. External examination was normal with no evidence of afferent pupillary defect. The biomicroscopic examination of the anterior segment is demonstrated in the photograph. Goldmann applanation tonometry measured 15mm Hg OU. The dilated fundus findings were normal peripherally and centrally, with normal nerves and maculae. 

Additional studies included examination of the eyelids for blepharitis, distichiasis or trichiasis. The phenylephrine blanch test could also be employed to assess the depth of the inflammation. Sodium fluorescein staining was completed to assess the status of the corneal epithelium. The lacrimal lake should be observed and Schirmer tear testing can be completed to quantify the volume of tear production.


The condition discussed in this issue is dry eye perpetuated by the initiation of oral antihistamines. Medical interventions necessitate management of the underlying cause. There are four principle etiologies that contribute to ocular surface disease: (1) mechanical issues, (2) lipid dysfunction, (3) aqueous deficiency and (4) mucus deficiency.1-7

Ocular surface anatomy includes tear production apparatus (lacrimal gland, glands of Wolfring and Krauss), the lipid glands preventing evaporation (meibomian, Zeiss and Moll) and adnexa contributing to lid-globe congruity and tear movement (conjunctivae, pars ciliaris, pars lacrimalis, and nasal lacrimal system).1-7 Interruption here creates surface dryness and accompanying symptoms.1-11

Mechanical issues can be divided into three subcategories:12-21

(1) medical/environmental contributors (medications, airflow, dust, debris, contact lenses or toxins)

(2) lid malposition inducing poor tear coverage (entropion, ectropion,, trichasis, symblepheron and lagophthalmos)

(3) globe-affecting pathologies moving the eye in the orbit, creating a coverage anomaly or volume shortage (tumor, thyroid dysophthalmopathy)

Dysfunction of the lipid-producing glands provokes evaporative dry eye. Blepharitis produces lipases which hydrolyze cholesterol esters creating fatty acids and increased tear evaporation. Free fatty acids are toxic to the corneal epithelium, resulting in epitheliopathy and inflammation (meibomian gland dysfunction or MGD).11

Aqueous deficiency—subnormal lacrimal gland production—is related to age (hormonal and homeostatic remodeling). Inflammatory processes from systemic disease (sarcoidic infiltration) or autoimmunity (Stevens-Johnson) can also slow tear secretion.22-24 Gender/hormonal fluctuations in estrogen and progesterone diminish lacrimal gland stimulation in women.22-24 Medications including antihistamines, beta blockers, antidepressants and diuretics also are implicated.25-27 Obstructed lacrimal ducts due to scarring (cicatricial pemphigoid, trachoma and chemical/radiation exposure) are also known offenders.11-20 Neurological gland block (tumors, trauma, vascular accidents or ischemic vascular disease) can also stop tear production.

Mucus deficiency arises secondary to all of the above-named etiologies. Mucus lowers the wetting coefficient, permitting tears to couple with the epithelium.28-30

Patient Evaluation & Treatment

Workup for dry eye includes a through history (environmental issues, contact lens history, medications, present illness, exacerbating factors, relieving factors and attempted treatments). Examination includes tear break-up time to assess lipids, lacrimal lake observation, tear volume testing (phenol red thread or Schirmer test strip) and sodium fluorescein evaluation of the cornea.31 In cases of suspected systemic disease, laboratory testing or imaging may be appropriate.

Treatment is aimed at resolving the root cause and symptomatology. The TFOS Dry Eye Workshop and Delphi Panel suggest a stepped approach in accordance with the underlying pathology.32-39 For aqueous deficient dry eyes, tear supplementation or salivatory stimulation can increase tear volume.31 Patients with exposure keratopathy require thicker emollients and ointment at bedtime. Stimulating the lacrimal gland with topical cyclosporine while reducing inflammation via topical steroidal therapy is effective.40-44 Patients with filamentary findings or morning syndrome (abrasion upon waking) may benefit from nocturnal soft lens bandaging.45 Patients with blepharitis or MGD can be treated with topical and oral antibiotics (tetracyclines), lid scrubs and warm compresses.11,46 Oral nutritional supplements (omega-3 fatty acids) can supply tear-building blocks and augment mucus-producing capability. Punctal plugs, cautery, gold weight installation and tarsorraphy are advanced considerations.47-54

Ocular surface disease is a complicated process requiring thoughtful investigation. Most cases require reevaluation and monitoring to prevent evolving surface disease. This patient was placed on topical tear supplementation therapy OU. Recognizing that the oral antihistamine was necessary to alleviate to ear issue, it is not be discontinued.

Dr. Gurwood thanks Dr. Balachandran for contributing this case.

Dr. Gurwood is a professor of clinical sciences at The Eye Institute of the Pennsylvania College of Optometry at Salus University. He is a co-chief of Primary Care Suite 3. He is attending medical staff in the department of ophthalmology at Albert Einstein Medical Center, Philadelphia. He has no financial interests to disclose.

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