EAACI 2024: Non-Allergic Red Eyes
Speaker- Serger Doan
Acute painful eyes can be caused by various factors, including allergic conditions leading to keratoconjunctivitis, particularly in atopic or vernal keratoconjunctivitis cases. Differential diagnoses for acute red eyes encompass conjunctivitis and keratitis, among others, with the initial assessment focusing on ruling out keratitis, scleritis, episcleritis, and uveitis. Acute infectious conjunctivitis, often viral, may stem from ENT infections, epidemics, or adenopathy, with adenovirus posing a significant concern due to its highly contagious nature and potential to induce immune keratitis. Post-resolution of conjunctivitis, corneal immune reactions can occur, affecting vision for weeks to months. Chronic conjunctivitis presents a clinical differential diagnosis, including allergy, dry eye, rosacea, fibrosis, infection, and hyperreactivity, while chronic keratitis may involve chronic epitheliopathy, infectious etiologies, or immune-mediated processes.
In the medical history of a dry eye patient, factors such as menopause, hormonal imbalances, and medication use (including anticholinergic and retinoid drugs) are notable, alongside symptoms like xerostomia, mucocutaneous dryness, and autoimmune diseases such as arthritis, thyroid disorders, and skin conditions. Common dry eye symptoms include dryness, stinging, burning, itching, red eyes, sensitivity to environmental factors like air conditioning and wind, and difficulty reading or using a computer for prolonged periods, often accompanied by tearing in windy conditions.
A dry eye can manifest as either aqueous deficient (quantitative dry eye) or evaporative. Quantitative dry eye may be associated with Sjogren syndrome or non-Sjogren dry eye, lacrimal deficiency, or systemic medication use. In contrast, evaporative dry eye can be intrinsic (e.g., meibomian oil deficiency, drug effects such as isotretinoin) or extrinsic (e.g., preservatives in topical drugs, contact lens wear, ocular surface diseases).
Dry eye investigation involves assessing tear film stability with tear breakup time (BUT), where <10 seconds indicates tear instability, typically associated with high sensitivity. Tear production can be evaluated through Schirmer testing (Schirmer I), with <5 mm in 5 minutes considered abnormal and >20 mm normal. However, the Jones test offers high specificity yet low sensitivity and reproducibility. Keratoconjunctivitis sicca suggests aqueous deficient dry eye, particularly in young women where Sjogren’s syndrome should be considered, with a risk of lymphoma over 40 if primary and ocular rosacea are also observed.
Sjogren’s syndrome presents with dry eyes, dry mouth, and dental caries. It can be primary or secondary to conditions like rheumatoid arthritis, lupus, and Hashimoto thyroiditis, diagnosed via ANA testing and accessory salivary gland biopsy. Meibomian gland dysfunction, primarily caused by perennial allergic conjunctivitis, menopause, isotretinoin use, and chemotherapy, is the leading cause of dry eye.
Rosacea is a significant differential diagnosis for allergic conjunctivitis, with chalazia indicating meibomian gland dysfunction. Nonspecific conjunctival hyperactivity is common in allergic and non-allergic dry eye patients, often manifesting as sensitivity to environmental factors.
In the first case, a 50-year-old man presented with severe itching of the eyelid margins for three years, partially responsive to topical steroids, without allergy or eczema. Examination revealed demodex infection, prompting lid hygiene with emollient and tea tree oil wipes, alongside ivermectin treatment. The second case involved Juliette, a 4-year-old with vernal keratoconjunctivitis and steroid dependence, presenting with unilateral red eye, photophobia, and tearing, along with chalazion suggestive of meibomian gland dysfunction and childhood rosacea, potentially sight-threatening. Treatment included addressing meibomian gland dysfunction and managing phlyctenular keratoconjunctivitis.
Likewise, the third case involves a 55-year-old, exhibited unilateral itchy eyes with mucous discharge and was diagnosed with floppy eyelid syndrome related to obesity and sleep apnea, necessitating surgical intervention. The fourth case involved a 9-year-old boy with unilateral blepharitis and eczema, unresponsive to steroids, presenting nodules indicative of molluscum contagiosum, highlighting the association with atopic conditions and immunodepression, requiring laser destruction.
Lastly, a 24-year-old with chronic conjunctivitis and bilateral red eyes, mucous discharge, and ventricular follicles, alongside genital infection, was diagnosed with Chlamydia trachomatis conjunctivitis via PCR, distinct from trachoma and treated with oral azithromycin.
European Academy of Allergy and Clinical Immunology (EAACI), 2024 31st May-3rd June, Valencia.
