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Ocular surface disease may be multifactorial, presenting a challenge to the physician in making a correct diagnosis and management plan.
Reviewed by Jonathan Solomon, MD
Bowie, MD-Even the most experienced ophthalmologists sometimes have to exert extra effort to ascertain if a patient’s complaints of ocular discomfort arise from dry eye, allergies, contact lens problems, or a combination of chronic and seasonal issues.
“It can be almost impossible to separate the myriad, multifaceted rationales for someone’s current ocular surface state,” said Jonathan Solomon, MD, who is in private practice in Bowie, MD. “There can be a little bit of allergy going on, a little bit of dry eye, some occupational component, and in addition maybe some aqueous deficiency due to an underlying autoimmune disorder.”
“It’s sometimes better to look at things globally with an understanding of the different causes but to treat systemically and with a willingness to dabble in it all,” he added.
Dr. Solomon prefers to start with simple homeopathic remedies and then move on, as needed, to medication.
When obtaining the history before the examination, the focus should be on the primary complaint or chief concern and getting detailed information, Dr. Solomon said.
Consider the time of year, the patient’s home and workplace environments, any recent travel, comorbidities, and other medications.
“This helps identify a number of features that may contribute to inflammation or irritation on the ocular surface,” Dr. Solomon said.
One diagnostic tool he recommends is a point-of-care test (Doctor’s Allergy Formula, recently acquired by Bausch + Lomb) that uses a panel of 60 regionally specific allergens. The test includes outdoor, indoor, and seasonal allergens and can be updated.
Looking for clues
Dr. Solomon also likes to be proactive, encouraging patients who are susceptible to allergies to come to the office just before the spring and fall allergy seasons to be screened for hypersensitivities that could exacerbate their condition.
He also recommends such screening for patients with aqueous dry eye who are being treated with cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) or who have meibomian gland dysfunction (MGD).
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“I believe that often these ocular surface diseases are prone to seasonal exacerbations,” Dr. Solomon said. “That gets back to this idea that it’s not safe to assume any longer that it’s one disease entity alone that causes problems. It tends to be these co-contributors that cause problems.”
Helpful clues from conversation with the patient and observation or examination include itchiness, head congestion, runny nose, headaches associated with eye itching or tearing, or puffiness to the lids. Other clues may appear in the form of conjunctival chemosis, hyperemia, and papillary response.
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“These are the things that are more consistent with allergic conjunctivitis from a symptomatic standpoint,” Dr. Solomon said.
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“But often it’s a mixed reaction because these patients tend to be hypersensitive to begin with,” he continued. “It’s not uncommon for these patients also to be in contact lenses, so there may be a component of hypoxia. The cornea can also have a measure of dryness related to contact lens overwear or abuse, so it’s rarely a straightforward presentation. You have to be flexible in your delivery and be willing to look outside the box when these patients come in. It requires a bit of interpretation.”
Factors to consider
Treatment has to take into consideration that while some of the allergens may be temporary, the underlying etiology may persist.
For example, an eye inflamed due to posterior blepharitis or MGD will not have a healthy lipid layer or be able to clear potential allergens.
Dr. Solomon recommends a hypochlorous acid-based lid and lash cleanser (Avenova, (NovaBay Pharmaceuticals).
“This will improve the tear quality by removing the debris that will build up and occlude the meibomian gland orbit and enable the oil glands that reside just behind the lash line to express the contents with a little less back pressure and then be incorporated with greater facility with the water component of the tears,” he said.
Artificial tears are recommended for many ocular surface disorders.
However, they may have a mainly dilutional effect, and a lubricant drop could be more effective, Dr. Solomon said, adding that he sends a sample bottle of these drops home with every patient, regardless of their diagnosis.
If a patient has to use the drops more than twice a day, it is time to consider underlying problems with the aqueous layer, a diagnosis of dry eye, and treatment with cyclosporine.
Combining products that treat the oil and water components of the tear film produces synergy that could create an ocular environment more resistant to allergens and insults that could trigger dry eye.
While medications are often needed to relieve the discomfort of ocular allergies or dry eye, patients can also benefit from such simple techniques as applying cold compresses at the end of the day to remove debris from lids and lashes and reduce swelling, Dr. Solomon said.
If any debris accumulates overnight, a lukewarm washcloth can be used in the morning.
But a physician’s recommendations for improving everyday eye health as well as addressing allergies or dry eye will be of little use unless patients act on them. Ophthalmologists should talk to patients about maintaining a healthy tear film throughout the year and, as allergy season approaches, emphasize ways to mitigate the inevitable onslaught of irritants.
Jonathan Solomon, MD
Dr. Solomon did not report any commercial relationships.