Red Eye Practice Station

Presenting complaint:

• Jessica is a 42 year old lady presenting with 4-6 week history of bilateral sore red eyes.
• People have commented her eyes look red.
• It occurs on most days but is usually better at the weekends.
• It is worst at the end of a long day.
• She experiences both eyes being sore and gritty with watery discharge.
• At times her vision feels a bit blurry but clears after she blinks.
• She hasn’t found anything that relieves it other than resting her eyes.
• No pain as such but often they feel like they are “burning”.
• No photophobia.
• No itching.
• Generally feels well in herself with no other visual symptoms.
• No trauma.

ICE:

• Her main issue is the soreness.
• She wants to know why her eyes feel like this and wants something to stop this happening.

Ocular History:

• No known ocular history.
• No previous ocular surgery.
• Wears glasses and contact lenses (daily disposables) for about 15 hours a day.
• No family ocular history she knows of.

Past Medical History, Drug History & Allergies:

• Well in herself.
• Has asthma and sometimes gets migraines.
• No regular medication, only uses blue inhalers if she needs it which is rare for her.
• No allergies.

Social History:

• Lives with her husband and two children. Is a busy mum.
• She works in a call centre and is on the computer in the office all day.
• No unwell contacts and no foreign travel in the last 3 months.

Observations:

• Respiratory rate = 18 breaths per minute.
• O2 sats 98% on air - no supplemental oxygen.
• Blood pressure 120/80.
• HR 72 beats per minutes, regular and strong pulse.
• Temperature 37.7ºC.

Eye Examination:

• Visual Acuity with glasses: Right eye 6/6, Left eye 6/6.
• Colour vision normal on Ishihara right and left eyes.
• Pupils show fast reflexes (direct and consensual) with no Relative Afferent Pupillary Defect (RAPD) right and left.
• Normal ocular motility - no pain, no diplopia.

Ophthalmoscopy/Fundoscopy:

• Lids & lashes normal - no erythema, crusting or lash debris.
• Both eyes show epiphora.
• Bilateral diffuse conjunctival injection.
• Cornea is clear, no opacities or scarring.
• Contact lenses not in situ.
• Anterior chambers are deep and quiet both eyes.
• Crystalline lenses is clear both eyes.
• Vitreous is clear in both eyes.
• Discs are healthy & pink with cup:disc ratio of 0.3.
• Maculae are both normal.
• Retina is flat with no breaks, tears or holes right and left.

State your top diagnosis.

• This is a case of dry eye.
• Acceptable differentials; allergic conjunctivitis, viral conjunctivitis & meibomian gland dysfunction (MGD).

State 3 Risk Factors for Dry Eye:

• Increasing age.
• Lid disease - blepharitis, MGD, ectropion.
• Contact lens wear.
• Diabetes
• Sjogren’s syndrome, Rheumatoid arthritis.
• Air-conditioned environment.
• Reduced blink rate - staring, computer work.
• Inadequate hydration.

What simple lifestyle changes could you recommend to Jessica to help with her symptoms?

• Good hydration & diet (omega fish oils).
• Reduce contact lens wear time.
• Take regular breaks from the computer/screens.
• Pay attention to her blinking - encourage blinking.

What medical management could you offer Jessica and how would you proceed if your first line choice was not working?

• Start with simple over the counter lubricant eye drops - hypromellose or carmellose drops.
• Can step up to dry eye drops containing sodium hyaluronate.
• Then step up to products containing Trehalose.
• Then add ointments/gels at night.
• Address any lid disease - regular lid hygiene, warm compresses and avoid make up.
• Consider referral for specialist review if all above steps are not helping.

Can Jessica use the eye drops you’ve chosen whilst wearing contact lenses?

• She can use dry eye drops that are preservative free with her contact lenses.
• She should check on the product box whether it says the drop is suitable for use with contact lenses.
• Ointments/gels are not suitable for use with contact lenses, particularly soft contact lenses.

How often can Jessica use the dry eye drops?

• Technically there is no limit. It can be as often as hourly.
• Typically we start at three times a day and build up as required to control symptoms.

Are they any side effects with common dry eye drops?

• Typically they are tolerated very well.
• Sometimes people can react to preservatives in the drops.
• Preservative free formulations should be sought preferably.