Dry Eye Dx and Tx
When Dry Eye Isn’t Dry Eye (Revisited)
BY AMBER GAUME GIANNONI, OD, FAAO
A 40-year-old female was experiencing dry eye symptoms in both eyes for several months. She reported generalized discomfort, mild redness, and occasional tearing. She had already seen an optometrist and an ophthalmologist and had been diagnosed with dry eye. However, treatment with artificial tears, warm compresses, and lid scrubs had not provided much relief. She reported that “soft” topical steroid use improved symptoms marginally, but her progress deteriorated once it was discontinued.
At her first visit with us, we quickly realized that she was actually suffering from a bilateral, chronic, low-grade, non-granulomatous anterior uveitis in addition to dry eye.
Within 48 hours of prescribing a robust topical corticosteroid, the discomfort and tearing were completely eliminated. She was tapered off slowly and, four months later, she continues to be free of uveitis and of dry eye symptoms. For this patient, no systemic cause could be determined (a blood panel was negative); we are monitoring her every three to four months.
Unfortunately, this case scenario is not an isolated one. We often joke that our “dry eye center” is actually a “uveitis center” in disguise. Frequently, patients are referred by exasperated practitioners who cannot seem to improve their patients’ dry eye symptoms.
We recently had a male patient who had been treated by two ophthalmologists and an optometrist for dry eye symptoms occurring over a three-year period, to no avail. He had a similar presentation to the patient above. We diagnosed a low-grade, chronic, bilateral uveitis. His symptoms were eliminated by the one-week follow-up visit.
Another male patient had been seen multiple times in a contact lens practice to refit and polish his left GP contact lens because of “generalized discomfort” complaints. He had an extremely subtle anterior chamber cell reaction in that eye, and his symptoms disappeared once we initiated a topical steroid. We ordered bloodwork, which came back positive for the HLA-B27 antigen. He was subsequently diagnosed with ankylosing spondylitis and is under the care of a rheumatologist.
Look Beyond the Expected
Acute uveitis presents as a sudden, painful event with light-sensitivity and the “classic” ciliary injection pattern around the iris. However, chronic, “smoldering,” low-grade uveitis can also mimic the complaints voiced by many dry eye sufferers—mild redness, tearing, and slight discomfort. It’s easy to assume that dry eye is the culprit because it’s common, and many patients display some signs. If you aren’t able to thoroughly evaluate the anterior chamber space (Table 1), it’s easy to overlook a few microscopic white blood cells floating around; the true origin of patients’ chronic symptoms can be missed and incorrectly chalked up to dry eye. CLS
1. Highest slit lamp illumination and magnification; short/narrow beam at an angle.
2. Eliminate all ambient room lighting (i.e., turn off the overhead lamp/projector, shut down the EMR screen, and close the exam room door).
3. Focus properly in the anterior chamber space for at least 30 seconds and evaluate for floating cells.
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.