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Discussion: Patient presents with complaint of ocular itching
A Panel of clinicians discusses possible causes and treatments for the skin and the eye.
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Eric D. DonnenfeldEric D. Donnenfeld, MD, FACS: This is a common problem that you might see in your office. A 43-year-old patient complains of itching. Burning in the morning is usually going to be blepharitis. How about itching? What does it tell you as a diagnostic aid?
Peter A. D’Arienzo, MD, FACS: Obviously, with itching you want to think of allergy. You almost cannot make a diagnosis of allergic conjunctivitis unless the patient reports some itching.
Dr. Donnenfeld: Itching is overwhelmingly associated with allergy, not always, but overwhelmingly. So that is a strong diagnostic aid. The patient had burning and irritation, and you look at his skin. He has dry, scaly lids with hyperpigmentation, fissuring and lichenification (Figure 1), and there are similar findings on the flexor surface of the body (Figure 2). Can you describe what you are seeing here when you look at this patient’s lids, and what does it tell you about the patient?
Michael B. Raizman, MD: The thickening of the lid skin, the fissuring, is characteristic of eczema or atopic dermatitis on the lids. Some patients will have this in association with generalized eczema and a tendency toward atopy. Some patients can get this appearance simply from wiping their eyelids with tissues a lot. So your patients with epiphora, for instance, they may not have true atopy or bad allergies, but they are always dabbing at their eyes with a tissue, and you can get a hypersensitivity reaction on the lids that looks just like this from the epiphora and wiping the eyes. This is generally a contact hypersensitivity or atopic appearance, and it will go away if patients stop touching and rubbing their lids. This only appears from the mechanical irritation that is self-induced.
Dr. Donnenfeld: When you hear the diagnosis of eczema, do you look at any other part of the skin to help you make your diagnosis?
Dr. Raizman: Patients will usually tell you that they have eczema. The flexor surfaces of the arms and the legs are the most commonly affected.
Dr. Donnenfeld: And this will be helpful in your diagnosis.
Dr. Raizman has it right. This is a diagnosis of eczema. Dr. Rapuano, when you see a patient like this come into the clinic at Wills Eye Institute, what is your management?
Christopher J. Rapuano, MD: Often they have a history of this, and they have seen a dermatologist.
Dr. Donnenfeld: Let’s stop right there. Most patients have not seen a dermatologist. They should see a dermatologist.
Dr. Rapuano: If they are bad enough like that, they may have seen a dermatologist.
Dr. Donnenfeld: I think that is an important point. This patient should get a dermatological consult, so that is a great pearl for everybody because there is a lot of systemic management of these patients.
 The patient has dry, scaly lids with hyperpigmentation, fissuring and lichenification. | ||
 Similar findings on the flexor surface of the body.Images: Ophthalmic Consultants of Long Island | ||
Dr. Rapuano: Right. It is not only their eyes that they are complaining of typically, it is a lot of other things going on in their bodies. So dermatology consult is certainly one thing to consider.
As far as the eyes go, you have to think about the allergic things going on, and it is often combined with dryness, and they may be on some anti-allergy medications, systemic antihistamines that are increasing their dryness, too. So when it is bad like this, I put them on a topical steroid to get them over the hump.
Dr. Donnenfeld: You put them on a topical steroid to their lids. Do you like an antibiotic steroid cream?
Dr. Rapuano: Antibiotic steroid cream is OK. I do not think they need an antibiotic with it at this point. They can get an FML ophthalmic cream.
Dr. Donnenfeld: Would anyone here use an antibiotic for a patient like this? A lot of us do use antibiotics.
Dr. Raizman: I think it is a mistake, actually. You do not need the antibiotic. The antibiotics can be sensitizing. These patients are already susceptible to contact hypersensitivity. Neomycin is absolutely the most potent sensitizing agent there is, so I definitely avoid that. I do not use neomycin at all in my practice, especially not in the form of topical. But even something like tobramycin can be sensitizing in lids, and you do not need the antibiotic.
I do not like to use fluorinated steroids on the lid skin because it is prone to cause atrophy of the skin, so I actually prefer hydrocortisone 1% or 0.5% cream, which the patients can buy over the counter. There are a lot of popular formulations, Cortaid (Johnson & Johnson) and the like. All of those will have a package insert that says, “Do not use around the eyes,” but you can reassure the patients it is safe to do that. If it gets in the eyes it causes a little bit of burning, but it is not dangerous. So I would much rather go with a weak hydrocortisone than a fluorinated product such as FML. Tell the patients not to use it for more than a couple of weeks and explain the potential dangers of steroids. That is my preferred therapy.
Dr. Donnenfeld: I think that is a pearl as well. I think there is no reason for antibiotics in this patient. That is the most common mistake I see in managing these patients — they are put on an antibiotic steroid combination. The antibiotic plays no role, and this is allergy. The antibiotic is sensitizing. It is toxic and sensitizing, which are two different issues, and sometimes just taking patients off of the antibiotic can be effective.
I think FML ointment is a good option for short-term use. And for long-term use, a hydrocortisone ointment that is available over the counter is sometimes effective.
Dr. Raizman: The dermatologist often prescribes desonide. That is one of their favorite products for facial use. It can also be used around the lid skin for long-term use.
But the bottom line is you want to treat the underlying disease and educate the patients so they do not need to use steroids chronically. This is a disease that will go away if you remove the offending agent and get the patients to stop touching and rubbing their eyes. The eczema will go away, and they will not need the steroids long term. So you need to give them a little bit of education along with prescribing the treatment.
Dr. Rapuano: And do you also use something like Protopic (tacrolimus topical, Fujisawa)?
Dr. Raizman: Protopic is an excellent option for long-term use.
Dr. Donnenfeld: What is Protopic?
Dr. Rapuano: These are topical cyclosporine derivatives. Elidel (pimecrolimus topical, Novartis) and Protopic are used for eczema on the body. There is a little bit of concern about induction of secondary tumors with high doses of these agents, but the amounts that we use on the eyelid skin are trivial and should not be a concern for our patients. And it is safe to use Protopic and Elidel long term around the eyes if necessary.
We use Protopic a good amount in patients, and it can be a miracle cure. Several months later, they can come back looking totally normal. It is very expensive.
Dr. Donnenfeld: What about steroid side effects?
Dr. Rapuano: No steroid side effects.
Dr. D’Arienzo: I wanted to mention the immunomodulators. I have done some work with allergists. Protopic is tacrolimus, and Elidel is pimecrolimus. These drugs are being developed as eye drops as well for dry eye. I think one good pearl is Elidel is a cream so the patients feel it is more comfortable. Protopic is an ointment. You may get a call from your pharmacy about it because it is an off-label use.
But the other pearl about atopic dermatitis that I see most commonly in clinical practice concerns nail polish. Whenever you see a woman come in with a thickened, scaly lower eyelid, look at the nails. Sometimes it is the nail polish because of the formaldehyde in the polish, or some women have the nails glued and may be allergic to the cyanoacrylate resin that is used to glue on the nails. So always look at the hands. Sometimes you will make that great diagnosis.
Dr. Donnenfeld: That is true. And you can usually find something environmental that has changed when this comes on acutely.
There are a lot of corneal complications that are associated with this. Patients can get neovascularization, irritation, foreign body sensation. We have talked about the skin manifestations, but how do you manage the eye itself?
Marguerite B. McDonald, MD, FACS: I find often in these patients their lids are so swollen that they get exposure keratitis, so you have to be careful of that. That is an indirect effect, but the lichenification causes the lids to not close properly, so I like a lot of unpreserved artificial tears, something like Celluvisc (carboxymethylcellulose sodium 1%, Allergan), and a lot of bland ointment at night.
Dr. D’Arienzo: In this case I think you are discussing atopic keratoconjunctivitis. Terry O’Brien published some data looking at Restasis (cyclosporine ophthalmic emulsion, Allergan) as a four-times-a-day drug for patients who were refractory with topical steroids. I think, however, maybe the full-strength cyclosporine from a compounding pharmacy might help the patient more when they have such significant corneal neovascularization.
Dr. Donnenfeld: I would stay away from the full strength. We have had a lot of experience. That is very sensitizing. This is an external disease case. We find the low doses helpful, and there are a dozen articles now on topical cyclosporine for eczema and atopic disease, and I think it is for long-term management.
For short-term management, sometimes people come in with a lot of burning and irritation in their eyes, and the Restasis takes a long time to really kick in. Any little pearls so you can get the patients feeling better faster?
Charles B. Slonim, MD, FACS: I would consider a topical steroid for short-term use to treat the ocular surface as well — Alrex (loteprednol etabonate ophthalmic suspension 0.2%, Bausch & Lomb), Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch & Lomb), something that I have a lot of faith in without the side effect profiles just because of the molecule itself. But as Dr. McDonald mentioned, it is important to look at their lids. Frequently in these patients, the distance between the lid crease and the lid margin starts to shrink, and then the distance between the lid crease and the brow starts to shrink, and patients cannot get their eyes closed. The preseptal and pretarsal skin really becomes foreshortened in these patients as a result of the chronic nature of this condition.
From a topical ophthalmic ointment standpoint, I am an FML ointment guy. I think FML as an ointment and Lotemax or Alrex as a drop would be a perfect combination for these patients. I think once patients use the FML ointment on the skin two to three times a day for maybe 2 or 3 days, it is gone. It is gone that fast, and you do not have to worry about the long-term fluorinated steroids. On the surface of the eye, I have studied Alrex, and I have data on patients on Alrex for allergic conjunctivitis for 2, 3, 4 years in the study. I find Alrex a very safe product. For that reason, if this is what is bothering them, you certainly do not want to use a combination product. No antibiotics, but a topical steroid for short-term use, or even long-term use, if that is what gets them through their symptomatic time periods. I think an ester-steroid is a perfect steroid for the ocular surface.
Dr. Rapuano: There are published studies on vernal keratoconjunctivitis using Restasis twice a day with good results, and vernal and atopic are similar. So I use Restasis twice a day, and maybe four times a day would work better in some patients, but in anybody, all my atopic patients with any eye problems at all, because they are all going to be dry. They are all going to be on antihistamines, and anything that we can do to help their ocular surface is going to be beneficial.
Dr. Donnenfeld: Great. A lot of these patients are on oral antihistamines, and first-generation antihistamines are terribly drying to the ocular surface. Getting them on to the second and third generations, which Dr. Raizman has taught me in addition to using lubrication, is helpful.
For more information:
- Peter A. D’Arienzo, MD, FACS, can be reached at Manhasset Eye Physicians, PC, 1615 Northern Blvd., Manhasset, NY 11030; 516-627-0146; fax: 516-365-4750; e-mail: eyedoc63@aol.com. Dr. D’Arienzo has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Eric D. Donnenfeld, MD, FACS, can be reached at OCLI, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com. Dr. Donnenfeld is a consultant for Alcon, Allergan, Bausch & Lomb, InSite and Inspire.
- Marguerite B. McDonald, MD, FACS, can be reached at OCLI, 266 Merrick Road, Lynbrook, NY 11563; 516-593-7709; fax: 504-232-3641; e-mail: margueritemcdmd@aol.com. Ocular Surgery News could not confirm whether Dr. McDonald has a direct financial interest in the products mentioned in this article or if she is a paid consultant for any companies mentioned.
- Michael B. Raizman, MD, can be reached at New England Eye Center, Tufts University School of Medicine, 750 Washington St., Box 450, Boston, MA 02111; 617-636-4219; fax: 617-636-4866; e-mail: mraizman@tufts-nemc.org. Dr. Raizman has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Christopher J. Rapuano, MD, can be reached at Wills Eye Institute, 840 Walnut St., Suite 920, Philadelphia, PA 19107; 215-928-3180; fax: 215-928-3854; e-mail: cjrapuano@willseye.org. Dr. Rapuano is a consultant and lecturer for Allergan and a lecturer for Alcon and Inspire.
- Charles B. Slonim, MD, FACS, can be reached at Older and Slonim Eyelid Institute, 4444 East Fletcher, Suite D, Tampa, FL 33613; 813-971-3846; fax: 813-977-2611; e-mail: slonim@eyelids.net. Dr. Slonim is a consultant for Bausch & Lomb.