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Ask the Expert - Treating Dry Eye in Allergic Patients

Q. Many of my older female patients with allergic rhinoconjunctivitis complain of gritty and irritated eyes despite aggressive treatment of their allergic conjunctivitis. When should I suspect dry eye instead of or in addition to allergic conjunctivitis?

A. When the patient with allergic conjunctivitis is not responding to the usual treatment and continues to have ocular symptoms, consider the co-existence of dry eye syndrome. I believe that allergists often assume the primary care physician or ocular eye specialists have already addressed this issue, when many times both the patient and the clinician have stopped with the single diagnosis of “allergy”.

Dry eye syndrome, also known as dysfunctional tear syndrome, is a very common multifactorial disease estimated to be present in up to 30 percent of the population over the age of 50, but can involve all ages, including children. In contrast to allergic conjunctivitis, the dry eye syndrome is predominantly a disease involving the cornea. Dysfunction of any part of the lacrimal functional unit, which consists of the lacrimal glands, eyelids, and the ocular surface, can lead to the dry eye syndrome. Many systemic diseases, e.g. diabetes mellitus, Parkinson Disease and systemic medications, e.g., estrogens, SSRIs, anticholinergics, and even the second-generation non-sedating antihistamines are risk factors for the development of dry eye syndrome. Contact lens wearers are also at elevated risk of developing dry eye syndrome.

Common signs and symptoms include dryness, redness, irritation, gritty or foreign body sensation, burning, excessive tearing, photophobia, and blurred vision. As you will note many of these overlap with the symptoms of allergic conjunctivitis.

On clinical exam, you may note red eyes, blepharitis, and a reduced blink rate (normal is 17 to 26/minute), and improvement in visual acuity after repetitive blinking.

There is no “gold standard” for diagnosing the dry eye but many clinical allergists are starting to use the Schirmer tear test to measure the amount of tears being produced (using a filter paper or string embedded with a coloring agent) to assist in making the diagnosis. A validated questionnaire for dry eye has been shown to have excellent sensitivity and specificity, e.g. Dry Eye Questionnaire- 5 (DEQ-5) and should be considered for use by the allergist.

Treatment includes the following: 1) frequent use of artificial tears (preservative free are preferred), 2) requesting the patient to blink frequently when reading or doing computer work, 3) humidifiers in dry climates and dry heat, and 4) topical Cyclosporine A for more severe patients.

 
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