OCULAR SURFACE DISEASE SERIES: CASE STUDY # 4

Taking a Red-eye Flight

Exotic remedies and makeup trigger nonspecific conjunctivitis in a globe-trotting patient.

By John D. Sheppard, M.D., M.M.Sc.

When a patient presents with signs and symptoms of conjunctivitis, the cause often is easy to identify. Patients may say they have a history of allergies, or they have significant discharge and crusting that started in one eye and now affects both, or maybe they developed the problem after someone else at work or school had it. Some patients have clear signs of lid disease, or they're struggling with contact lens problems.

In other patients, the disease is harder to diagnose, so we look for lifestyle clues like exposure to dust and pollutants, computer use, unprotected sun exposure and hygiene habits.

When a world traveler came into my office with red, irritated eyes, my search for the cause started with her shocking array of over-the-counter treatments, and from that point, the journey only became more interesting.

Redness may be apparent, but if a patient's history doesn't indicate the cause, careful questioning may be necessary to make a diagnosis.

Weary Traveler

A 42-year-old woman was referred to my office by her primary care physician. Her bilaterally injected bulbar conjunctiva was obvious, and she told me her eyes were especially red, dry, irritated and "a little goopy" in the morning.

"I've tried everything, but nothing works," she said, so of course I asked her what she meant by "everything." She wasn't exaggerating. As her doctor suggested, she had brought her medications — a bag of 15 over-the-counter remedies labeled in five different languages, only one of which I could read.

The patient explained that she frequently travels to other countries for business. Between the long international flights, the climate-controlled hotels and offices, and the variety of environments at her global destinations, her eyes were constantly dry, red and irritated, and she'd bought many different remedies during her travels.

A Schirmer's test showed good tear production. She had some mild photophobia. Her visual acuity wasn't significantly affected, and she showed no infiltrates or staining. Therefore, this likely was a case of nonspecific conjunctivitis caused by exposure to toxic agents.

Given the grab bag of drops she had been using, my first step was to have her trash them all. The morning dryness suggested a topical antihistamine, while the chronic irritation, in particular, pointed to a strong possibility that there were preserved tears in the mix. As a first step, I ordered nonpreserved tears in the morning and as needed, with a more viscous preparation at bedtime. I asked her to return in 1 week, but when she came back, her condition hadn't changed.

More Surprises

Patients don't always give us all of the pertinent information up front. Sometimes it takes some digging. So I asked new questions.

1. How's your sleep? The patient's husband had informed her that she snores, and she has a little sleep apnea. But she didn't think the problem required a doctor, so she wasn't using continuous positive airway pressure (CPAP).

2. Do you sleep on your face? She sleeps on the right side of her face, and she noted that her right eye is always worse than the left in the morning. The patient was somewhat overweight, as well. When I everted the lid, I found the right side was loose and redundant and everted readily. The superior tarsus was inflamed.

3. What makeup and moisturizers do you use? From her rather large purse, another assortment of products emerged. This patient loves to shop abroad, and she had collected makeup and beauty treatments from every destination. She wasn't wearing eye makeup during her first visit, because she'd thought it best to remove it before visiting an ophthalmologist.

This time, her treatment plan was much more involved.We discussed surgery for the floppy eyelid, and she agreed to the procedure. Since it's impossible to change a person's sleeping style, I had her use a shield as a mechanical barrier to prevent recurrence of the floppy eyelid. I recommended CPAP, which the patient pursued through her primary care physician.

As much as it saddened my patient, her handbag of goodies had to follow the first one into the trash. I recommended that she switch to a brand of hypoallergenic makeup, such as Clinique or Jane Iredale, and encouraged her to shop more carefully in the future.

Finally, the ocular surface irritation had caused inflammation and left the surface unprotected against the environment. So I needed to reduce the inflammation and guard against any possible secondary infection by Staph or other bacteria. I prescribed loteprednol etabonate 0.5% and tobramycin 0.3% (Zylet) four times a day for 10 days. Tobramycin is a well-established broad-spectrum antibiotic that works against gram-negative and gram-positive bacteria. Loteprednol is an ester steroid with excellent anti-inflammatory activity and a favorable safety profile, so it's a good choice for treating ocular surface disease.

Cleared for Takeoff

When the patient returned a week after starting the combination treatment, her eyes were clear. She said she felt remarkably better — more comfortable than she'd felt in years. The combination of mechanical changes and medication brought the inflammation and its symptoms under control, and the patient finally ended her battle with nonspecific conjunctivitis. Today, she's looking at her travel destinations through fresh eyes with preservative-free tears, a blepharoplasty, tarsal shortening and safer makeup. She's also choosing better souvenirs.

Dr. Sheppard is professor of ophthalmology, microbiology, immunology and geriatrics, director of residency training, and clinical director of the Thomas R. Lee Center for Ocular Pharmacology at Eastern Virginia Medical School in Norfolk, and president of ProVision Network and Virginia Eye Consultants.

Indication

Zylet is indicated for steroid-responsive inflammatory ocular conditions for which a corticosteroid is indicated and where superficial bacterial ocular infection or a risk of bacterial ocular infection exists and where the inherent risk of steroid use in certain infective conjunctivitides is accepted to obtain a diminution in edema and inflammation.

Important Safety Information

As with other steroid anti-infective ophthalmic combination drugs, Zylet is contraindicated in most viral diseases of the cornea and conjunctiva and also in mycobacterial infection of the eye and fungal diseases of ocular structures. Prolonged use of corticosteroids may result in glaucoma, as well as increase the hazard of secondary ocular infections. The incidence of adverse events reported by subjects treated with Zylet included injection (approximately 20%) and superficial punctate keratitis (approximately 15%). The development of secondary infection has occurred after use of combinations containing steroids and antimicrobials. NOT FOR INJECTION INTO THE EYE. Steroids should be used with caution in the presence of glaucoma. The use of steroids after cataract surgery may delay healing and increase the incidence of bleb formation. If this product is used for 10 days or longer, intraocular pressure should be monitored even though it may be difficult in children and uncooperative patients.