Blepharitis and Dry Eyes Treated with Multiple Drops

A 62-year-old Caucasian woman presented on referral from a glaucoma specialist for evaluation and management of her blepharitis and dry eyes. The patient reported symptoms of burning and irritation that had become worse over the prior 6 months. She described the symptoms as constant and debilitating to the point where she took a leave of absence from her job as an administrative assistant at an elementary school. She was even considering taking early retirement.

Therapy for her symptoms at that time included artificial tears (with preservatives) 4 times a day and eyelid hygiene with warm compresses. She was also using timolol maleate/dorzolamide twice daily and latanoprost at bedtime in both eyes.

External examination revealed no lagophthalmos. Slit lamp examination demonstrated 1-2+ meibomian gland inspissation of both sets of eyelid margins, but without an ability to express any viscous oils from the glands. The cornea demonstrated diffuse, fine punctate epithelial erosions throughout, with more concentrated staining in the inferior one-quarter of the cornea. Lissamine green staining revealed staining of the bulbar conjunctiva in the inferior one-quarter of the bulbar conjunctiva both nasally and temporally.

Schirmer I testing (without anesthesia) revealed 3 mm of wetting in both eyes after 5 minutes. Tear break-up time measured at 10 seconds in each eye. Best corrected visual acuity with her spectacles was 20/50 in the right eye and 20/70 in the left. Intraocular pressures measured at 14 mm Hg in both eyes.

Diagnosis

Multiple factors contributed to this patient’s ocular problems. Based on the low Shirmer I testing and inferior ocular surface staining, it would follow that she has aqueous tear deficiency as a component of her dry eyes. Just as important, she has diffuse corneal staining, which is characteristic of ocular surface toxicity. In this case, she was not only using 2 glaucoma eye drops that contained preservative and were likely causing significant ocular surface toxicity, but she was also using preserved artificial tears. Surprisingly, the blepharitis contributed little to her symptoms. In addition, exposure keratopathy, a common finding in some individuals, was not seen in this patient.

Treatment

For the patient’s ocular surface toxicity, we consulted with her glaucoma specialist for permission to change her medications to preservative-free timolol 0.5% twice daily, bromonidine tartarate 0.1% (preserved with Purite) and travoprost (preserved with Sofzia). Unlike older preservatives such as benzakonium chloride, both Purite and Sofzia break down on contact with the ocular surface. In addition, we changed her artificial tears to preservative-free artificial tears every 2 hours.

Six weeks after initiation of this new therapeutic regimen, the patient reported marked improvement of her symptoms and subjective improvement in her vision. The diffuse corneal staining had receded to only mild staining of the lower quarter of the ocular surface. Indeed, her vision had improved to 20/25 in both eyes, and her intraocular pressures remained stable. Punctal plugging was performed in the lower eyelids of each eye, and 3 months afterwards, with continued use of preservative-free artificial tears and her new glaucoma-drop regimen, the patient’s vision is now nearly 20/20 in both eyes, with minimal staining of the ocular surface.

Affect on Daily Living

With improved vision and symptoms, the patient was able to return to work. Ocular surface toxicity from preserved eye drops can compound already debilitating symptoms of dry eyes, and the toxicity can worsen visual acuity. Opthalmologists must recognize the different causes of ocular surface staining and to realize the profound impact on the patient’s life that these can conditions can have.