Dry Eye Dx and Tx

When Dry Eye Isn't Just Dry Eye, Part 1

Dry Eye Dx and Tx

When Dry Eye Isn’t Just Dry Eye, Part 1



A 40-year-old Caucasian female was referred to my dry eye practice after several failed attempts by another practitioner in treating her chronically inflamed, dry eyes. This patient had initially presented to that practitioner with complaints of irritated, red eyes for several months. She reported having no itching, pain, or discharge. Over the course of several months, the practitioner had first prescribed a specific over-the-counter tear regimen, then topical corticosteroid therapy, then Restasis (Allergan).

Clues in the Initial Exam

At our first encounter, the patient reported medication-controlled hypothyroidism and systemic hypertension. Her slit lamp exam showed that the superficial and deep vessels of both eyes exhibited a marked corkscrew-like configuration (Figure 1). A dry eye workup was positive for moderate meibomian gland dysfunction. Expression revealed thickened, turbid secretions. Her tear lake and tear production were normal, as was her corneal health.

The extensive, bilateral corkscrew vessels led me to ask further questions related to thyroid eye disease and low-flow cavernous sinus fistula (LFCSF). She had been experiencing increased frequency of mild-to-moderate headaches, and she reported “pressure” in her head and eyes immediately upon waking in the morning. Additionally, she complained of intermittent diplopia and ocular discomfort of the right eye in superior-temporal gaze, also first thing in the morning. She noted that she often heard her own heartbeat pulsing in her ears. Hertel exophthalmometry revealed possible bilateral proptosis, with measures of 21mm in each eye (for this patient’s demographic, the upper limit for normal Hertel values is 20.1mm [Migliori, 1984]). Except for tortuosity of fine retinal arterioles, all other elements of the eye exam were normal.

Initiating Therapy

I prescribed daily warm compresses for five to 10 minutes, followed by manual gland expression and lid hygiene. I also prescribed a lipid-based artificial tear q.i.d. and an oral omega-3 supplement. On follow up, she reported a substantial improvement in her dry eye symptoms.

Regarding the other positive findings from her initial exam, we referred her to her primary care physician for imaging to rule out thyroid-associated orbitopathy, tumor, and LFCSF. As we await a diagnosis, she is being monitored closely for change as well as for the development of glaucoma, which is frequently associated with LFCSF.


Figure 1. Significant corkscrew-shaped vessels in the conjunctiva.

Consider the Whole Picture

We must care for our patients as whole beings, and take the time to ask appropriate follow-up questions. In this case, persistent injection despite several weeks of topical corticosteroid use should have alerted the practitioner that inflammation was not the root cause of the patient’s symptoms.

Finally, this patient’s dry eye symptoms were greatly improved after their specific cause was discovered and addressed. CLS

For references, please visit and click on document #213.

Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and is the Director of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.