1 C Diagnosis and Management of Dry Eyes Part 1 Dr Colm McAlinden, BSc (Hons), MSc, PhD and Dr Eirini Skiadaresi, MD January Detailed Answers IMAGE A Image Courtesy of Professor Giuseppe Ravalico 1. What clinical sign is shown in Image A? a. Khodadoust line b. Symblepharon c. Lisch nodules d. Ankyloblepharon The clinical sign shown here is symblepharon, which represents a partial or complete adhesion of the palpebral conjunctiva (lower pink part of the umage) of the eyelid to the bulbar conjunctiva (covering the sclera) of the eyeball. Khodadoust line is a sign of rejection in corneal graft surgery and appears as a faint white line in the cornea. Lisch nodules are yellow-brown pigmented hamartomatous nodular aggregates of dendritic melanocytes affecting the iris, often seen in people aged over 6 years and commonly associated with neurofibromatosis type 1. Ankyloblepharon represents adhesion of the eyelids together at the margin such that the eye cannot be opened. 2. In a patient with the clinical sign shown in Image A who is currently self medicating with artificial tears, is referral to an ophthalmologist indicated? a. Referral is not indicated as this is typically a sign of dry eye and symptoms can continue to be managed with lubricants
2 b. Referral is indicated as this is a sign of a potential sight threatening auto-immune condition c. Referral is indicated only if the patient is over 65 years of age and symptoms persist d. Referral is indicated only if there is anterior chamber inflammation also present Symblepharon can be caused by conjunctival sequelae of trachoma or trauma, whilst there is also association with autoimmune disorders such as cicatricial pemphigoid and, in severe cases, rosacea. As such, patients should be referred to an ophthalmologist for further investigation. 3. If slit lamp examination reveals flattening of the plica and keratinization of the caruncle along with the sign shown in Image A, what is the MOST likely diagnosis? a. Ocular cicatricial pemphigoid b. Systemic lupus erythematosus c. Ocular lymphoma d. Epidermolysis bullosa Cicatricial pemphigoid is a rare chronic autoimmune subepithelial blistering disease characterized by erosive skin lesions of the mucous membranes and skin, including the conjunctiva, which results in scarring. The other conditions listed do not cause scarring although epidermolysis bullosa is associated with blistering of mucous membranes too. IMAGE B Image Courtesy of Dr Edward Boshnick 4. What is the MOST appropriate combination of tests to use in clinical practice to aid diagnosis and monitoring of the condition and procedure shown in Image B? a. Schirmer I and II tests and lactoferrin assay b. Rose bengal staining, Schirmer I test and impression cytology c. Lissamine green staining, Schirmer II test and lysozyme analysis
3 d. Tear break up time with fluorescein, Schirmer I test and tear film osmolarity Assessment of the tear film should always begin with the least invasive tests first. Furthermore, the most relevant clinical tests associated with evaluating dry eye after LASIK refractive surgery relate to assessing tear quality and quantity, which are diagnosed by measuring tear break up time with fluorescein (least invasive) and the Schirmer I test respectively. Tear osmolarity also gives an indication of tear quality but is more invasive than sodium fluorescein testing, as it requires a tear sample to be extracted from the eyes. 5. Which of the following systemic disorders is NOT typically considered a relative or absolute contraindication for the procedure shown in Image B? a. Sjögren syndrome b. Rheumatoid arthritis c. Amyloidosis d. Multiple sclerosis All of the conditions listed are associated with dry eyes except multiple sclerosis, which is a demyelination disorder. Amyloidosis rarely causes dry eyes and dry mouth through protein deposition in the lacrimal gland, affecting tear production, whilst Sjögren syndrome and rheumatoid arthritis cause infiltration and inflammation of the lacrimal gland, also affecting tear production. These conditions have consequences on post-operative risk of dry eye with LASIK, whilst there is also risk associated with healing of the corneal flap too. 6. By what mechanism does the procedure shown in Image B cause dry eyes? a. Intraoperative dilatation of the nasolacrimal duct b. Interference with the greater petrosal nerve c. Severing of corneal nerves during flap creation d. Changing the ph of the tears In certain cases, LASIK can cause dry eyes after penetrating the corneal surface and severing the nerves when creating the flap. This in turn reduces corneal nerve sensitivity, which reduces the eye s ability to detect a need for lubrication, hence resulting in inadequate tear production. IMAGE C Image Courtesy of Professor Giuseppe Ravalico
4 7. A patient who is using N-acetylcysteine 5% eye drops presents with the clinical picture shown in Image C. What is this condition MOST likely to be? a. Corneal ulcer b. Acute anterior uveitis c. Vernal keratoconjunctivitis d. Filamentary keratopathy N-acetylcysteine is an anti-mucolytic medication. The image depicts filaments of mucous on the surface of the cornea, indicating the condition to be filamentary keratopathy. 8. What clinical feature is associated with the condition shown in Image C? a. Foreign body sensation and photophobia b. Ocular hyperaemia and occasional pseudoptosis c. Connective tissue disorders d. All of the above Patients presenting with filamentary keratopathy generally report ocular discomfort ranging from mild foreign-body sensation to severe pain due to dry eyes, variable tearing and photophobia, which in turn can lead to increased redness and drooping lids. Mucous filaments form when the normally soluble mucin component of the tear film becomes corrupted, causing it to precipitate out as particles or strands. Loose, compromised epithelial cells bind with these mucin strands, forming long filaments that adhere to damaged sites on the corneal surface. As the lids open and close with each blink, they tug at the loose end of the filaments, stimulating the painsensitive corneal nerves. Many patients with filamentary keratitis have underlying systemic conditions, particularly connective tissue disorders. Patients with immune deficiencies also are at greater risk. 9. Which one of the following is NOT associated with the condition shown in Image C? a. Keratoconjunctivitis sicca b. High intraocular pressure c. Recent cataract surgery with prolonged patching d. Bullous keratopathy Keratoconjunctivitis sicca can cause filamentary keratopathy as the normally soluble mucin component of the tear film becomes corrupted, causing it to precipitate from the reduced tear film. There is also an association with prolonged patching following cataract surgery, which can exacerbate dry eye, and bullous keratopathy whereby the cornea becomes permanently swollen due to endothelial dysfunction, eventually leading to blistering of the epithelium and disruption of the tear film.
5 IMAGE D 10. A patient presents complaining of a gritty eye and epiphora. What clinical sign is shown in Image D? a. Entropion b. Ectropion c. Distichiasis d. Madarosis The image depicts the lower lid of the eye to be folded outwards, which is known as ectropion. Entropion represents the lids folding in towards the eye whilst distichiasis represents abnormal eyelash growth from the meibomian gland orifices. Madarosis represents loss of the eyelashes. 11. Which of the following is NOT associated with the clinical sign shown in Image D? a. Facial nerve (cranial nerve VII) paralysis b. Ichthyosis c. Fuchs endothelial dystrophy d. Facial burn Ectropion can be caused by facial nerve (Bell s) palsy, which controls the orbicularis oculi muscle around the eye when it is palsied the muscle becomes weak and can no longer close the eye. Ichthyosis is a genetic skin disorder characterised by dry, thickened, scaly or flaky skin. Lamellar Ichthyosis can cause ectropion through fibrosis and shrinkage of the skin covering the eye lids. Facial burn of the skin around the eye can lead to scarring, fibrosis and shrinking of the lower lid, leading to ectropion.
6 12. If the clinical sign shown in Image D is associated with mild fluorescein staining on the inferior cornea and foreign body sensation but no infiltrates, which of the following is the MOST appropriate to recommend for the patient? a. Artificial tears as and when needed and avoid pulling the skin when wiping his tears. Review symptoms until surgery can be performed b. Iopidine eye drops and lid hygiene until surgery can be performed c. Prednisolone eye drops and warm compresses until surgery can be performed d. Chloramphenicol eye drops and weekly review until surgery can be performed Ectropion will most likely require surgical treatment to correct. Until this can be done, artificial tears will be required to manage the patient s symptoms of foreign body sensation and although there is mild fluorescein staining, which should reduce with the use of artificial tears, there are no infiltrates indicating that an infective or inflammatory process is not occurring. As such, chloramphenicol and prednisolone are not indicated. Furthermore, iopidine is a sympathomimetic which will only reduce ocular redness, not the presenting symptoms. References to aid completion of the exam Q1, Q2, & Q3: Hingorani M (1999) The Compromised Eye: Tear Film Abnormalities and Atopic Disease: Module 1 Part 10. Optometry Today. 39(October 8th): Q4, Q5, & Q6: Q7, Q8, & Q9: Q10, Q11, &Q12: Skorin Jr L (2001) Ectropian and its management. Optometry Today. 41(May 18th):