Ophthalmology: Gritty, irritable eyes

In the fourth part of the series, Sophia Pathai, and Andrew McNaught explain possible causes of gritty, irritable eyes

Although it may seem a trivial problem, gritty irritable eyes cause discomfort for many patients. Patients on the ward will probably mention their symptoms to you and then expect you to help alleviate their problems. Irritable eyes also account for many consultations in primary care, because the symptoms can affect all age groups.

History

Find out if the problem is long standing or more acute. The patient will often volunteer that their eyes feel irritable. This tends to occur in both eyes at the same time. Ask if the eyes are sore rather than painful.¹ Does the patient feel there is a foreign body or burning sensation, or do the eyes feel gritty or itchy? Ask about watering of the eyes and the presence of any discharge. The patient may have noticed that their eyelids are crusted when they wake up in the morning.

As usual, it is wise to find out about any concurrent medical condition, particularly recent infections of the upper respiratory tract, as these can frequently precede
adenoviral conjunctivitis. Also take note of any systemic disease, particularly collagen vascular diseases including rheumatoid arthritis, as these conditions can be associated with gritty irritable eyes. Ask about any drugs the patient is taking because many, from the contraceptive pill to ß blockers, can cause ocular discomfort as a side effect.

Examination

Start by looking at the patient in general. Are there any telltale signs of systemic disease? (See next month's's studentBMJ for a more detailed discussion of ocular manifestations of systemic disease). Look at the facial skin, particularly around the eyes and the eyelids, for conditions such as seborrhoeic dermatitis or acne rosecea, as patients with these conditions can go on to develop problems associated with ocular discomfort.

Moving on to the ophthalmic examination, when examining the eyelids, look at the lash margins--do they seem crusted or reddened with prominent superficial vessels? Assess the state of the eyelashes; are they sparse, are they growing in the right direction, or are they not present at all? Look for any discharge that may have collected around the medial canthus (where the upper and lower lids meet nasally). Look at the conjunctiva and any pattern of redness--assess if any infection is diffuse or sectorial and whether it is bilateral or just affects one eye. Continue your examination by testing the visual acuity and then examining the cornea, pupils, and fundus in turn. Do not forget that although gritty irritable eyes suggest anterior segment disease, it is still important to carry out a full examination to ensure that you do not miss any important clinical signs and also so that you get the opportunity to continue to practise fundoscopy.

Conjunctivitis

Sore, red eyes are often thought to be attributable to conjunctivitis. Although this may be an important and common cause of these symptoms, it is still important to keep an open mind and to come up with a differential list. The conditions discussed here can also present with gritty irritable eyes, so it is worth considering if any features of the history or examination make one of these conditions more likely.

Purulent exudate in bacterial conjunctivitis

Viral conjunctivitis often causes itching, burning, and a foreign body sensation. A viral cause (usually adenoviral) is often suggested by a preceding cough or cold or contact with an infected person. It may start in one eye and then become bilateral. Examination shows a watery, mucous discharge and red swollen eyelids. A preauricular lymph node may be palpable. Artificial tears and cold compresses may help reduce discomfort, but a topical antibiotic is not necessary. The natural history of the condition is that it is self limiting and should resolve over one to two weeks. Occasionally, it can cause ocular complications such as the development of a pseudomembrane or decreased acuity (due to infiltrates within the surface of the cornea). If these complications occur then refer the patient to an ophthalmologist.

Rose bengal staining devitalised cells in dry eye syndrome

Bacterial conjunctivitis causes more redness and foreign body sensation than itching. A purulent discharge is also an important feature to note. Common organisms include Staphylococcus epidermidis and Staphylococcus aureus. Be aware that in sexually active patients, gonococcal conjunctivitis may cause a purulent discharge, chemosis, and eyelid swelling of acute onset. Chlamydial conjunctivitis may also be seen in young adults, although the discharge is often thin and stringy rather than purulent.

Herpes simplex virus can cause conjunctivitis. Herpetic vesicles may be seen along the lid margin or eyelids. There is often a foreign body sensation or burning but rarely itching. Cool compresses often help to alleviate the symptoms. Ophthalmic referral may be necessary to monitor for corneal involvement or anterior chamber inflammation.

Atopic or vernal conjunctivitis is suggested by itching and discharge. The patient may have a history of atopy and of a seasonal recurrence. Large conjunctival papillae may seen on everting the eyelid; this is done by pulling down at the lashes, while rolling the lid over a fulcrum such as a cotton wool bud positioned along the lid crease. Similar signs and symptoms may also be seen in an allergic conjunctivitis (hayfever), and there is often a history of an inciting agent. Both conditions should respond to topical vasoconstrictors and antihistamines. Severe cases may require topical steroid treatment under specialist supervision.

Chronic conjunctivitis lasts longer than four weeks, with similar symptoms as discussed above. This type of problem may be seen in patients who develop sensitivity to eye drops through long term use--for example, in patients with glaucoma. Discontinuing the medication often relieves the problem, but make sure that the patient has an follow up appointment with an ophthalmologist to consider alternative treatment. Another less well known cause of chronic conjunctivitis is Molluscum contagiosum. Look for dome shaped umbilicated shiny nodules which may be visible on the eyelid. Continual shedding of toxic viral products from these lesions into the conjunctiva is manifest as a chronic conjunctivitis. These patients often benefit from removal of the molluscum either by simple excision or cryosurgery.

Other causes of irritable eyes

Blepharitis is a condition rarely considered by the non-ophthalmologist. It is common, and, although not sight threatening, it can be a cause of considerable concern to a patient with chronic sore irritable eyes. The patient may have a variety of symptoms including itching, burning, foreign body sensation, tearing, and crusting around the eyes on waking. When examining the patient remember to look generally and at the face. For example, patients with acne rosacea may go on to develop ocular rosacea which is a form of chronic blepharitis. Examination of the eyes reveals crusty red thickened eyelid margins often with prominent superficial blood vessels. Conjunctival injection and a small amount of mucous discharge may be present. The treatment for blepharitis is long term "eyelid hygiene," which involves the use of warm compresses and eyelid scrubbing. Occasionally a short course of topical antibiotics is necessary. The important point to explain to the patient is that although it is a chronic problem it is not sight threatening; eye departments often have patient information leaflets about the condition which are useful in providing further guidance on management.

Eyelid crusting in blepharitis

Dry eye syndrome is another common problem. Patients have similar symptoms of burning and foreign body sensation. Paradoxically, they may also have excess tearing, worsened by smoke, heat, or air conditioning. Slit lamp examination is often helpful as a scanty tear film may be visible as well as superficial corneal defects in the interpalpebral region (the area where the eyelids meet). Dry eyes may be an idiopathic problem, but they can also be associated with a variety of systemic conditions, notably the collagen vascular diseases. In addition some drugs can cause dry eyes as side effect. These associations illustrate the value of a full history and general examination. Dry eye syndrome may produce symptoms similar to blepharitis, however, the eyelid crusting and thickening is not seen with dry eye syndrome. It's also wise to exclude any secondary cause for a dry eye, mainly eyelid abnormalities that lead to exposure of the cornea--for example, a seventh nerve palsy or senile ectropion may prevent full closure of the eyelid (see our article in March's studentBMJ on problems of the eyelid). If there is no secondary cause for the dry eyes then treatment is often symptomatic in the mild to moderate forms: artificial tears may be used regularly throughout the day, with an ocular lubricant at night. Severe dry eyes, particularly those caused by an underlying chronic systemic disease, may need specialist attention, and occasionally surgical intervention is required.

Molluscum contagiosum on the upper eyelid

Recurrent corneal erosion syndrome can cause much angst for the patient and the doctor. The patient usually complains of recurrent ocular pain and tearing, usually worst first thing in the morning on waking. The diagnosis is made from the history as the patient often recalls a history of corneal abrasion in the affected eye. A history of recent trauma, previous corneal abrasion, or ocular surgery should make you suspect this condition. Occasionally, a hereditary corneal dystrophy may be responsible, and there is often a family history. Mild roughening of the corneal epithelium or a full corneal abrasion may have occurred. Often the signs have resolved by the time the patient sees an ophthalmologist, but the history points to the diagnosis. Treatment is in the form of ocular lubricants and artificial tears, often for a long period. The patient should be made aware about the natural history of the condition, as they are often anxious about its recurrent nature.

Andrew McNaught, consultant ophthalmic surgeon, West London Ophthalmology Rotation

Sophia Pathai, senior house officer, West London Ophthalmology Rotation
Email: sophia.pathai@talk21.com


studentBMJ 2003;11:1-42 February ISSN 0966-6494

1. Pathai S, McNaught A. Ophthalmology: The painful red eye. studentBMJ 2002;10:452-3. (December.)