Vol. 2, #19   •   Friday, August 20, 2021


Review's Chief Clinical Editor
Paul M. Karpecki, OD, FAAO

Provides you with cutting-edge clinical strategies for optimal management of ocular surface disease and beyond.


Considering Complaints of Foreign Body Sensation


Many conditions mimic DED symptoms, although test findings point away from DED. Find out how vital dye staining can help.

The ultimate achievement of a doctor who focuses on dry eye disease (DED) is the ability to differentiate non-DED conditions early. According to research studies, if a clinician went solely off of patient symptoms, they would misdiagnose about 40% of the cases.1 Imagine having to remake 40% of your glasses prescriptions or a 40% failure rate of new contact lens wearers? That would not be an enjoyable way to practice.

Every day in clinic I’m presented with cases of patients who have dryness, burning, or a foreign body sensation as a chief complaint but do not have dry eye. In these cases, osmolarity typically measures between 280 and 295 and within 5 mOsmol/L between the two eyes. MG expression reveals normal to mildly turbid meibum, and there are only subtle signs like inferior staining or minimal atrophy on meibography.

So which conditions have complaints such as those listed above but test findings point away from DED? A partial list includes: trigeminal dysphoria including exophoria, convergence insufficiency, giant papillary conjunctivitis (GPC), conjunctival concretions, allergic conjunctivitis, epithelial basement membrane dystrophies (EBMD) such as map dot fingerprint dystrophy, trichiasis, recurrent corneal erosion, mucin-fishing syndrome, conjunctivochalasis (CCH); blepharitis including staphylococcal or Demodex before it starts to affect the meibomian and lacrimal glands; contact lens solution reactions; allergies to topical medication such a brimonidine for glaucoma or medicamentosa; pingeuculitis, exposure keratopathy, limbal stem cell deficiency (LCSD), Salzmann’s Nodular Degeneration (SND), floppy eyelid syndrome (FES), episcleritis, superior limbic keratoconjunctivis (SLK), and especially non-tight lid seal.

Staining of the concretion

Differentiating DED in Patients with Foreign Body (FB) Sensation
When DED testing appears normal, consider everting the eyelids to look for concretions or FES. NaFl dye will help identify concretions that are exposed and likely causing symptoms. Conjunctivochalasis is more evident with vital dye staining. Digitally moving the conjunctiva through the lower eyelid will provoke the FB sensation in patients with CCH. SND will appear as grayish/blue nodules or white hazy areas in the periphery. Triachiasis will be evident during the slit lamp examination, and areas where the lash has irritated the cornea or conjunctiva will be apparent with NaFL dye. SLK will be evident with superior corneal and conjunctival staining, and LSCD will only show corneal and limbal staining.

That withstanding, it’s possible to have any of these conditions as comorbidities with DED. In such circumstances they will often initiate a dry eye flare. Consider EYSUVIS to treat the short-term flare at a dosing of QID for up to 2 weeks, while also addressing the underlying causes.

KEY TAKEAWAY: DED exhibits many symptoms, including FB sensation. When routine dry eye tests are normal, consider adding others to help identify various conditions that can cause similar symptoms. In cases with DED comorbidities, be sure to treat the DED flareup and also the underlying causes.


1. Bron AJ, Tomlinson A, Foulks GN et al. Rethinking dry eye disease: a perspective on clinical implications. Ocul Surf. 2014 Apr;12(2 Suppl):S1-31.

Supported by an independent medical grant from Kala Pharmaceuticals

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