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At Issue: Distinguishing ocular allergy from dry eye

At Issue posed the following question to a panel of experts:
“What signs and symptoms do you consider in distinguishing ocular allergy from dry eye?”

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Patient history
important

Ray Jui-Fang Tsai

Ray Jui-Fang Tsai, MD: Ocular allergy or allergic conjunctivitis is due to allergy to a particular substance that induces allergic reaction. The symptoms are itching, redness, tearing, burning, blurred vision, mucous production and dry sensation.

Dry eye syndrome is also a common disorder and is due to the abnormal tear film that results from one of the following etiologies: decreased tear production, excessive tear evaporation or an abnormality in the production of mucus or lipids in the tear layer. The symptoms for dry eye syndrome are dry eyes, sandy, gritty sensation, burning, itching, redness, blurred vision, mucous discharge, foreign body sensation and photophobia.

Symptoms seem to worsen in dry climates, in windy conditions or with prolonged use of the eyes (eg, reading, watching TV), and toward the end of the day.

When both allergic conjunctivitis and dry eye syndrome happen in mild or moderate conditions, except for inflammation, they share similar symptoms and signs. Even by using a Schirmer’s test, it is still hard to differentiate these two diseases clearly. Therefore, taking the patient’s history carefully is important.

Two methods of testing are crucial for making a differential diagnosis of the two diseases. One is fluorescent clearance test. Repeating the fluorescence-assisted Schirmer’s test (1 minute) at 5 minutes, 10 minutes, and 20 minutes intervals is a useful examination for tear production diagnosis. Rose bengal testing is another important test. However, to get the clear diagnosis, the first step is to reduce inflammation by using preservative-free steroid eye drops for 1 or 2 weeks, followed by the fluorescent clearance test or rose bengal test.

For Your Information:

• Ray Jui-Fang Tsai, MD, is Professor of the Graduate Institute of Medical Science and Wu-Fu Chen Chair in Preventing Blindness at Taipei Medical University. He can be reached at 1F, 117, Section 1, Hoping E. Road, Taipei 106, Taiwan; +886-2-3393-8088; fax: +886-2-3393-8698; e-mail: raytsai@ms4.hinet; Web site: www.tpei.com.tw.

Wide
overlap

Ehud I. Assia, MD: Allergy is a response reaction, therefore it has a different pattern than tear deficiency, which usually exhibits a more chronic behavior. Allergy occurs in response to allergens, usually airborne and typically seasonal. Changing environmental conditions may alleviate or eliminate allergic symptoms. Allergy is more common in children and young adults and often occurs in several members in the family. Association with other allergic or atopic manifestations, such as eczema or asthma, is highly suggestive of IgE mediated response. Hypertrophy of conjunctival papillae is the hallmark of allergic reaction and correlates with the severity of the disease. Allergic response is almost always bilateral, and itching and tearing are the most common complaints.

Dry eyes usually occur in elderly patients and are more common in women. Fluorescein, rose bengal or lisamine green staining demonstrates punctuate epithelial defects in the palpebral fissure. Fluorescein break-up time and Schirmer tests are indicative if positive, however they do not rule out dry eye if negative. Typically, patients with dry eyes suffer from burning sensations and fatigue while reading or watching TV or a computer screen, whereas allergic patients more commonly complain of increased lacrimation. Impression cytology to define cell density and expression of antigens is spared for advanced cases and not practiced routinely.

Response to therapy may also be used to differentiate the two diseases. Allergic conjunctivitis responds to anti-inflammatory (steroidal and nonsteroidal), anti-allergic and mast cell stabilizing medications, whereas dry eyes are relived by lubricants and, in advanced cases, by cyclosporine A. However, patients with allergic irritation are also relieved by lubricants, whereas anti- allergic drugs may act also as lubricating agents. There is a wide overlap between the two diseases. Dry eye may be part of the allergic response, and empiric therapy is sometimes given without precise diagnosis.

For Your Information:

• Ehud I. Assia, MD, can be reached at Meir Hospital, Sapri Medical Center, Tsharnihovski St. 44281, Kfar Saba, Israel; 972-9-7471527; fax: 972-9-7472427; e-mail: assia@netvision.net.il.

Signs, symptoms and tests Juan Murube, MD, PhD: My criteria for distinguishing these two conditions are outlined in the accompanying table.	Juan Murube
For Your Information: Juan Murube, MD, PhD, can be reached at Clinica Murube, San Modesto 44, E-28034 Madrid, Spain; 34-917-350-760; fax: 34-917-340-956; e-mail: murubejuan@terra.es.

Consider
demographics

Jose L. Güell, MD, PhD, and Javier A. Gaytán-Melicoff, MD: Although both pathologies are immunologically related, clear signs of tissue inflammation are seen in ocular allergy; on the other hand, dry eye syndrome is one of the most underdiagnosed ocular diseases, and it is directly related to a low quantity and quality of tear production by the lacrimal gland. Other ocular pathologies with dry eye symptoms, like blepharitis, should be differentiated.

One of the first things to consider is demographics. Allergic conjunctivitis is related to younger patients and acute presentation at regular intervals (seasonal), and is associated with external allergens, atopia or contact lens wear. Dry eye syndrome presents in a mild to moderate degree that progresses even with treatment, mostly in post-menopausal women, and is sometimes also related to chronic contact lens wear in younger people and to other immunologic diseases like Sjögren syndrome, rheumatoid arthritis or lupus.

Diagnosis of both pathologies can be made at a slit-lamp exam, even in cases where ocular allergy affects tear film distribution. Frequent signs and symptoms could be present in both pathologies: itching, burning, redness, tearing, pain or photophobia. Characteristic signs like bulbar or tarsal papillaes (Horner-Trantas dots or Maxwell-Lyon), scarring, shield-like ulcer, giant papillaes and pseudoptosis are seen in a severe expression of ocular allergy. Dry eye syndrome is almost always referred to as ocular sand sensation, sometimes associated with a decrease in visual quality or acuity; in these cases it is important to explore the ocular surface quality, including tear film. Fluorescein dye, rose bengal staining and the more useful breakup time (BUT) can give us information about mucus and lipidic layers. A Schirmer’s test with anesthesia will help to evaluate the aqueous layer but is less used. If the diagnosis is unclear, an impression cytology (Goblet cells, T cells and eosinophil concentration) is useful and easy to perform in the office.

With the more frequent incidence of dry eye after LASIK, we should be aware of this, even in young refractive patients.

For Your Information:

• Jose L. Güell, MD, PhD, department chief and associate professor at Universidad Autónoma Barcelona, and Javier A. Gaytán-Melicoff, MD, of the Cornea and Refractive Surgery Fellowship Program, can be reached at the Cornea and Refractive Surgery Department, Instituto de Microcirugía Ocular (IMO) de Barcelona, C/ Munner No. 10, 08022 Barcelona, Spain; +34-93-253-1500; fax: +34-93-417-1301.