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http://www.revoptom.com/content/c/20600/
VOLUME 5, NUMBER 2
June 19, 2015

WHAT DO YOU DO WHEN A PATIENT COMPLAINS OF CLASSIC DRY EYE SYMPTOMS, SUCH AS OCULAR DRYNESS AND BURNING, COMPUTER VISION SYNDROME OR END-OF-DAY CONTACT LENS INTOLERANCE, BUT YOU CAN'T DETECT ANY CLINICAL SIGNS?

True dry eye disease with significant corneal staining, and a tear film osmolarity score greater than 300mOsmol/L in both eyes. Click here to view larger image.
We've all seen such patients in day-to-day practice. These individuals often present with little to no corneal staining, mild meibomian gland dysfunction (MGD) and a tear film osmolarity measurement of less than 300mOsmol/L in both eyes. Keep in mind that such findings likely are indicative of disease processes other than dry eye, including:
  • Mild allergic conjunctivitis.
  • Epithelial basement membrane dystrophy or map-dot-fingerprint dystrophy.
  • Pinguecula and early pterygium.
  • Infection (e.g., conjunctivitis).
  • Anterior blepharitis (e.g., secondary to Demodex infestation).
  • Giant papillary conjunctivitis.
  • Salzmann's nodular degeneration.
  • Mild to moderate conjunctivochalasis.
However, one of the most common—and potentially overlooked—differentials is asthenopia secondary to eye alignment issues. Patients with vertical imbalance, convergence insufficiency, fixation disparity and proprioceptive disparity often will exhibit symptoms that mimic dry eye disease. They may complain of dryness, burning and irritation—particularly late in the day, while using a computer or tablet, or when reading a book. They also may report a history of frequent headaches.

Patients with asthenopia almost always have normal osmolarity readings and, with the exception of mild MGD or inferior corneal staining, usually do not exhibit any other signs of dry eye disease. For these individuals, appropriate treatment typically consists of prism use or vision therapy. Following intervention, the aforementioned symptoms frequently will improve or cease entirely.
http://www.revoptom.com/content/c/20600/

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