Red eye, foreign body sensation, epiphora, blurred vision must be suffering from dry eye?

Editor's Note Dry eye may be one of the biggest "scapegoats" ever made for an eye diagnosis. Dry eye is a unique, multifactorial disease that not only leads to overdiagnosis of patients, but also to underdiagnosis of patients. Red eye, foreign body sensation, epiphora, and blurred vision are all symptoms of dry eye, but they can also suggest other conditions, and it's important to distinguish between these conditions. Mistaking the symptoms of other conditions for dry eye can be frustrating for both patients and doctors, especially when treatment is maximized without improvement. Here are five reasons why dry eye is often misdiagnosed. Many symptoms of binocular vision problems overlap with symptoms of dry eye, including intermittent or persistent blurred vision, diplopia, visual fatigue, and discomfort. If the patient complains of these symptoms but has few or no ocular surface symptoms, a mask test and vergence assessment must be performed. This suggests an underlying binocular vision problem, such as decompensated phoria. In this case, it is imperative to add prisms to the patient's eyeglass prescription or to refer them for vision treatment. Second eyelid and eyelash abnormality The eyelid is the main defender of the ocular surface. Therefore, it is important to evaluate lid tightness, laxity, and position in dry eye patients. Various eyelid abnormalities such as nocturnal proptosis, facial paralysis, age-related eyelid laxity, thyroid eye disease, entropion, ectropion, and blepharoplasty syndrome can cause poor eyelid closure, which in turn leads to insufficient protection of the ocular surface. If the eyelid does not adequately protect the ocular surface from the external environment, dry eye symptoms can persist even with optimal dry eye treatment. In this case, surgical intervention by an ophthalmologist may be required to improve symptoms. Punctal stenosis is another common eyelid abnormality. Similar to patients with dry eye, patients with punctum stenosis may experience epiphora and eye discomfort. In all cases of epiphora, the punctal opening should be carefully assessed. Referral to an ophthalmologist for consideration of surgical intervention is important for these patients. Trichiasis can also be the culprit in irritating the ocular surface. Wrongly oriented eyelashes can scratch the cornea and conjunctival tissue when blinking. Trichiasis should be considered if the pain is not relieved with eye drops. Eyelid and eyelash health are key to assessing ocular discomfort and should not be ignored during slit lamp examinations. Be sure to fully evaluate all four eyelids to confirm that there are no anatomical or mechanical abnormalities causing discomfort. Three Abuse of Cosmetics or Grooming Operations The cosmetics industry is huge, with numerous grooming operations and products (such as false eyelashes, eyelash dyes, mascara, eyeliner, glitter eyeshadow, etc.) used for the eye area. It is important to ask patients about the different products they use and how they are used to help identify whether cosmetic products are the "originator" of dry eye symptoms. In some cases, cosmetics may be the sole cause of lipid layer disruption, and symptoms usually subside with discontinuation or changes in the product. Where to apply makeup is also an important factor to consider. A study conducted by the University of Waterloo examined, documented and quantified the migration of glitter from eyeliner to the tear film when eyeliner was applied at two different locations behind and in front of the lash line. The results of the study showed that eyeliner was the most likely to migrate and most stained the tear film when applied to the back of the lash line. Ideally, patients should avoid using eyeliner and other makeup behind the lash line. In addition, the type of cosmetic also has a great influence on the patient's symptoms. Cream-based or liquid-based cosmetic products have less chance of migrating to the ocular surface than powder-based or solid-based cosmetic products because they flake less. Remind makeup patients to remove all makeup, such as eyeliner, mascara, eye shadow, and foundation, completely before going to bed. Mechanical friction of the eyelid against the pillow can promote the migration of cosmetic particles to the ocular surface, continuing to cause irritation and possibly blockage of the meibomian glands. The best way to remove makeup is with baby shampoo or a specially formulated over-the-counter makeup remover. Tetraconjunctivitis Conjunctivitis is a common problem that manifests as loose, neoplastic tissue in the bulbar conjunctiva. The prevalence of conjunctivitis increases with age and is one of the most common comorbidities of dry eye. Mild cases may get better with eye drops, but if the conjunctivitis is severe, surgery to remove excess tissue is recommended. Five Thygeson superficial punctate keratopathy (TSPK) Although TSPK is uncommon, if the patient complains of photophobia and foreign body sensation, TSPK is an important differential diagnosis. At present, the etiology of TSPK is unknown, some reports suggest that it is related to the virus, and other reports suggest that it may be related to the gene HLA-DR3. Most cases of TSPK present between 5 and 30 bilateral (although possibly asymmetric) paracorneal punctate intraepithelial lesions that are whitish or gray, breadcrumb-like or granular in appearance, and stained with fluorescein . The treatment of choice for TSPK is topical corticosteroids, which have been shown to reduce signs and symptoms, whereas artificial tears and bandaged contact lenses provide only relief. Glucocorticoid doses are usually tapered over weeks to months. Topical cyclosporine has also been reported to be a successful treatment option. Summary Red eye, foreign body sensation, epiphora, and blurred vision are all symptoms of dry eye and may indicate other conditions as well. The prevalence of conjunctivitis increases with age and is one of the most common comorbidities of dry eye. If the patient complains of photophobia and foreign body sensation, TSPK is an important diagnosis of exclusion to keep in mind. Reference: https://modernod.com/articles/2022-july-aug/five-signs-its-not-just-dry-eye?c4src=article:infinite-scroll