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FURTHER COMMON PROBLEMS IN THE DIFFERENTIAL DIAGNOSIS OF INFLAMED RED EYES:

1. DRY EYE VERSUS CHRONIC INFECTIOUS CONJUNCTIVITIS There are forms of infectious conjunctivitis that, besides their chronic nature, are characteri- z e d b y m i l d a n d n o n - c h a r a c t e r i s t i c s y m p t o m s ( m i n i m a l o r n o h y p e r a e m i a , m i n i m a l o r n o

discharge). The subjective complaints in these cases can be similar to those in mild dry eyes. It is not correct to treat such cases with combined (antibiotic and corticosteroid) eye drops and ointments, which is a common practice in certain countries amongst some GPs. Chronic infec- tious cases should be treated by topical antibiotics, as they are caused by microorganisms (usu-

ally by diplococci or by chlamydia). Dry eye cases have to be treated with artificial tears. It is advisable to refer patients with chronic irritative eye disease to a specialist, to obtain proper diagnosis and further treat the patient according to the advice of the ophthalmologist. [5]

2. MARGINAL/BORDERLINE DRY EYE VERSUS TIRED/OVERUSED EYES There are patients whose tear secretion and the stability of their precorneal tear film is suffi- cient under normal conditions. Environmental changes (drought, hot air, smoke or dust in the air etc.), certain activities (reading, staring at a computer screen), however, lead to a decrea- sed blinking rate and the development of subjective complaints (discomfort, burning, foreign

body sensation, sensation of dryness etc.) and sometimes also to the appearance of mild objec- tive signs of dry eyes (decreased stability of the tear film and even punctate staining of the corneal epithelium). The problem is complicated by the fact that ophthalmologists in different countries and with different training use varying criteria (and different normal values) when classifying the diagnosis of dry eyes. Therefore, certain patients with mild dry eye symptoms are diagnosed as “dry eye” by one ophthalmologist and “not yet manifest dry eye” by another. The symptoms of marginal/borderline dry eyes resemble those of simple tired/overused eyes. It is bad practice to give either of these two groups of patients vasoconstrictor eye drops. Occasional (only when complaints are present) use of artificial tears helps in marginal/border- line dry eyes, while reducing and possibly eliminating the factors and circumstances that cause or aggravate the symptoms of tired/overused eyes is the best solution in the latter group of patients. [6]

3. OCULAR SURFACE DISEASE “Ocular surface disease” is the general name given to diseases that change the structural (macroscopic or microscopic), physical or chemical characteristics of the surface of the corneal and conjunctival epithelium, and by doing so interfere with the formation or maintenance of a sufficiently stable precorneal tear film. This is a large and diverse group of diseases of the anterior segment of the eye, ranging from degenerations and dystrophies, through scars, vesi- cules, bullae, chronic oedema to symblepharons and large irregularities of the corneal curva- ture. These different diseases may be the cause of, and appear in the form of chronic irritation of the eye. Their common characteristic is that the corneal surface (sometimes only a part of it) is drying out, in spite of the fact that the eye is full of tears or is even tearing. These patients usually benefit from the use of artificial tears (viscous solutions or gels), but may also need

specific treatment (therapeutic contact lenses, excimer laser or surgery). [7]

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THE DIFFERENTIAL DIAGNOSIS OF THE RED EYE

4. TOXIC CORNEAL EPITHELIOPATHY (KERATOCONJUNCTIVITIS MEDICAMENTOSA) Every dry eye specialist occasionally examines patients who have several weeks’ or even months’ long medical history of uni- or bilateral eye inflammation, and report that they have

been treated by several doctors with a number of eye drops and ointments and that their eye(s) did not heal; on the contrary with each new medication their condition became worse.

They may even produce the boxes of 10 –15 or more drugs, or a list containing the names of all the medications that they have previously used (various antibiotics, anti-inflammatories, sometimes even antivirals, artificial tears, and often combined drops and ointments). The eye(s) of these patients show conjunctival hyperaemia, large numbers of small epithelial lesions on the cornea, and sometimes oedema of the corneal epithelium. The slit lamp appe- arance of these corneas resembles that of dry eyes, but the eyes are full of tears, and the patients usually have epiphora (persisting, excessive tearing). The condition develops due to the constant and unnecessary use of eye drops and ointments, and is caused by the toxic effect of preservatives contained in most of these eye medications. If the patient stops the use of pre- servative containing topical drugs, improvement occurs in 1 – 2 days. The use of preservative free artificial tears may be considered, especially if the patient does not easily accept that “no treatment is the best treatment” for his/her long standing disease. [8]

5. EPISCLERITIS AND SCLERITIS Episcleritis and scleritis are less common causes of inflamed red eyes. The latter is usually asso- ciated with systemic autoimmune diseases (rheumatoid arthritis, Wegener granulomatosis,

polyarteritis nodosa, systemic lupus erythematosus), sometimes with other inflammations like polychondritis or herpes zoster infection. Episcleritis is superficial and appears as a circumscri- bed hyperaemic area on an otherwise white eyeball, while scleritis is deeper and usually cau- ses diffuse, sterile inflammation of the anterior or posterior sclera, and the overlying conjunc-

tiva. Scleritis may be recurrent and sometimes results in the appearance of circumscribed but multiplex necrotic areas of the sclera. The search for underlying systemic disease is essential. Treatment of episcleritis is with topical NSAID eye drops, but the disease is usually self limiting (heals without any treatment). Scleritis is treated with corticosteroids, or with a combination of NSAIDs and steroids. In most cases of scleritis, besides extensive local treatment, the syste- mic administration of anti-inflammatory drugs is also necessary. [9]

REFERENCES

  • 1.

    Petricˇek I., Prost M., Popova A.: The Differential Diagnosis of Red Eye: A Survey of Medical Practitioners of Eastern Europe and the Middle East. Ophthalmologica 220:229–237 (2006)

  • 2.

    Ebhert R.H.: The experimental approach to inflammation. Chapter 1. in: Zweifach B.W., Grant L., McClusky R.T. [Eds.]: The Inflammatory Process. Academic Press, New York – London (1965). page: 5.

  • 3.

    Vaughan D., Asbury T., Tabbara K.F.: General Ophthalmology. A Lange medical book. 12th ed. (1989)

  • 4.

    Hollwich F.: Ophthalmlogy. A short textbook. 2nd ed., Thieme, Stuttgart (1985)

  • 5.

    Thygeson P., Kimura S.J.: Chronic conjunctivitis. Trans. Am. Acad. Ophthalmol. Otolarygol. 67:494

(1963) 6. Mackie I.A., Seal D.V.: The questionable dry eye. Br. J. Ophthalmol. 65:2 (1981)

THE DIFFERENTIAL DIAGNOSIS OF THE RED EYE

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