This article is more than 5 years old. Information may no longer be current.
Managing chronic keratoconjunctivitis depends on accurate identification
Prescribing artificial tears and fresh air might sound simple, but it’s the answer to an ocular epidemic.
Click Here to Manage Email Alerts
CHESAPEAKE, Va. — Approximately 70% of patients with keratoconjunctivitis sicca have some amount of meibomian gland dysfunction. This may be one reason for today’s “epidemic” of dry eye patients. Virginia cornea specialist, Stephanie Marioneaux, MD, has a simpler explanation. “We live in such a dry world. With this whole advent of energy efficiency, every last bit of moisture is taken out of the air that we are in all day long. With all of the vents, the fans and the filtering systems, our patients are being bombarded by dry air all day long. It’s in their energy-efficient homes, energy-efficient buildings where they work, the malls, the schools and their climate-controlled cars,” Dr. Marioneaux said.
“The bottom line is that dry eye is an epidemic,” said Dr. Marioneaux, who is assistant professor of Ophthalmology at Eastern Virginia Medical School. “It used to primarily affect post-menopausal women, but now, with so many contributing environmental factors, it is widespread.”
Ever-growing computer use — especially among the pediatric set — is yet another reason for escalating dry eye. Dr. Marioneaux recommends frequent use of artificial tears to computer users, but acknowledges that children are notoriously recalcitrant when it comes to willingly accepting an application of eye drops. “Sometimes, I tell the parents to just put a note on the computer that says, ‘blink,’ to help their children remember to do just that,” she said. The normal voluntary blinking response rate of 12 times per minute is suppressed so drastically by computer use that a person perched in front of a computer screen might only blink once or twice per minute, she explained.
“With the environment being so dry, the tear film is already somewhat diminished, but with this added insult of not blinking, the eye dries out, and instead of seeing crisp, clear and sharp, there’s a smear over the vision,” Dr. Marioneaux said.
Constellation of symptoms
Managing this type of chronic keratoconjunctivitis is dependent on recognizing it, she said. “There’s a whole constellation of things that your patients will feel that they’ll never associate with dryness. They will have a smear on their vision — which improves with blinking — as long as the eyes aren’t too dry. The eyes will feel sandy and gritty, and they will even water, but these are emergency tears because the eye is so dry. Sometimes, they’ll get a stabbing pain that forces them to blink. Patients will come in, say their eyes are tired or strained and suggest that they need their eyeglass prescription changed. But eyes don’t get tired. They feel tired and strained when they’re dry,” she said.
Small children who are experiencing these symptoms will get closer and closer to the computer screen thinking this will help them see better and relieve the strained feeling, but just the opposite is true, Dr. Marioneaux said.
“Treatment never seems very serious. When you tell patients to apply artificial tears throughout the day, they think, ‘oh, that’s nothing,’ but you have to replenish the tears. Unfortunately, we don’t have a lot of good products that last long, because the products that last long smear the vision. So they have to put these artificial tears in all day long, sometimes up to 10 times a day,” said Dr. Marioneaux. “We recommend that, if patients know they are going to be doing activities where they will be concentrating, such as reading or looking at a computer screen, to go ahead and just start out by putting the artificial tears in at the start of the day or the activity. It’s important not to wait until the eyes are burning and aching, because by then it’s too late. The drops don’t last very long,” she stressed.
Some recommend increased water consumption to combat the loss of moisture in the air. Dr. Marioneaux said telling patients to remember to stay hydrated can help, “but you can still drink your recommended eight to 10 glasses a day and still have dry eye,” she said.
The ideal artificial tear would mimic the normal human tear and be released continuously over time. The newest generation of artificial tears mimics the electrolyte and bicarbonate balances that are present in normal tears.
A great masquerader
A type of chronic keratoconjunctivitis that is often confused with viral conjunctivitis is conjunctivitis c. or chlamydia. “With chlamydia, the patient gets a stringy, mucopurulent discharge, and the eye is red and irritated. Often, people won’t come in until they’ve had chlamydia for 2 to 3 weeks because, when they get it, they think it’s just an irritation that will go away on its own,” Dr. Marioneaux said.
The confusion occurs when patients do come in quickly after contracting conjunctivitis chlamydia. “If the patient does come in right away, it can be confused with the epidemic keratoconjunctivitis (EKC), which is a viral conjunctivitis. Chlamydia is sometimes confused with EKC because patients have follicles just like they do in EKC,” she said.
Toxic reactions and allergic reactions also get confused with chlamydia, Dr. Marioneaux pointed out. “Sometimes, people will have had it for 6 months and not have it diagnosed because they thought it was because of make-up that they were using. It’s fairly insidious. The patients can see, they can function and they try a bunch of over-the-counter topicals before finally coming in. Then, we have to culture to get a proper diagnosis,” she said.
Chlamydia is often misdiagnosed because the line of questioning regarding a patient’s sexual history is often overlooked or forgotten, Dr. Marioneaux said. There are some clues to identifying conjunctivitis chlamydia. “You not only find follicles on the conjunctiva but you also have them on the limbus, which doesn’t often happen in viral conjunctivitis,” Dr. Marioneaux said, “and you’ll also see sub-epithelial infiltrates on the cornea but you won’t see them until after the infection is several weeks old. They can even persist after the infection has resolved,” she said.
For Your Information:
- Stephanie J. Marioneaux, MD, can be reached at 300 Medical Park, Ste. 108, Chesapeake, VA 23320; (757) 547-5805; fax: (757) 547-1903.