CLINICAL CHALLENGES
The Transplanted Gardener
Studying the facts and fine-tuning the treatment let this patient continue enjoying her hobby.
By Eric Schmidt, O.D.

People are relocating within the United States at a faster pace than ever before. In my area, for instance, we're the benefactors of many people moving in from colder climates. These "transplants" enjoy the warmer weather and the benefits that it provides.

Unfortunately for some, the change in environmental conditions can also spark a change in immunological status and some individuals may find themselves battling new systemic and ocular conditions that they didn't encounter in their "native" home. This article will introduce you to one such person and her case.

Meeting the new patient

M.P. was a delightful 68-year-old woman who came in to our office because her eyes were no longer as delightful as the rest of her. She and her husband had moved to North Carolina from Newfoundland one year earlier and for the past six months her eyes had been really irritating her. M.P. said that she had always had allergies but that they'd gotten much worse since her move to North Carolina. She also told me that she previously didn't have any eye problems other than needing glasses but now her eyes had become chronically uncomfortable.

M.P. explained that the irritation had gotten worse over the summer and was now accompanied by stringy discharge. Reading had become more difficult for her because of some blurring, but also because her eyes felt sore when she kept them open for periods of time. M.P. also said that her eyes get red and feel red. M.P. told to me that she's an avid gardener but now between her eyes and her allergies she can't be outside as much as she would like.

Gathering the facts

As I spoke with M.P. I noticed the following: She didn't blink much, her eyes weren't horribly injected but they did lack the "luster" seen in a healthier eye (see photo at left) and she had telangiectasis and a rather ruddy complexion to her face and nose. M.P. was taking loratadine 10 mg (Claritin) q.d. for seasonal allergies, levothyroxine sodium tablets (Synthroid) for hypothyroidism and one 81 mg aspirin daily.

M.P., who currently wasn't using any eye drops, told me that she had used different types of artificial tears in the past but that none of them really made her eyes feel any better and that because of that fact, she hadn't used any recently.

Proceeding clinically

I measured M.P.'s visual acuity (VA) at 20/30 in her right eye and 20/30-2 in her left eye. Her pupils were 5 mm round and reactive with no afferent pupil defect. Her extraocular muscles showed no restrictions but she did experience a bit of discomfort upon right gaze. A refraction gave her subjectively better 20/25 vision with +0.25 more power in each eye.

The slit lamp examination revealed 1+ meibomian gland inspissation but no lid debris. There were few papillae on the inferior and superior palpebral conjunctiva. I noted a mild amount of bulbar injection with a preponderance to the intrapalpebral conjunctiva and superior limbal area. The cornea had a faint haze to it.

After I instilled sodium fluorescein dye (NaFl) I saw 1+ superficial punctuate-type staining that coalesced OU (see photo at left). I also noticed that the tear film was mottled in both of the patient's eyes. The surface of M.P.'s eyes also stained with Rose Bengal dye.

M.P.'s IOPs were 17 mmHg in her right eye and 16 mmHg in her left eye. When I examined her fundus I saw central hard drusen in her right eye and and her left eye with a few soft drusen as well in the left macula.

A case of simple dry eye?

I had my technician perform a Schirmer's #2 test on M.P., the results of which were 0 mm of wetting in both eyes. I measured the tear break-up time as two seconds in her right eye and four seconds in her left eye. Based on her signs and symptoms, it made sense that M.P. suffered from chronic dry eye syndrome, but some evidence pointed to another either concurrent or causative condition such as ocular rosacea.

I faced the challenge of determining whether M.P.'s dry eye was a result of her lid disease or just exacerbated by it. Also because of the severity of the non-wetting and the chronicity of it, I felt that it may be more difficult than normal to get her to feel better.

For cases similar to this one I like to try to break it down into its simplest parts and work my way to a treatment plan from there. I also try to treat one problem at a time when I'm not sure how much each is contributing to the overall condition. So for M.P., I first implanted silicone punctal plugs and recommended she instill one drop each minute of a non-preserved artificial tear drop (TheraTears) for five minutes t.i.d. in both eyes.

I saw M.P. three weeks later, at which time her VA was unchanged but she said that her eyes felt somewhat better. When I specifically asked her for a percentage of improvement she told me they felt 30% better. Her ocular surface still showed mild Rose Bengal and NaFl staining, but less than before.

Her Schirmer's strips measured 6 mm in her right eye and 4 mm in her left eye. She had improved but she still wasn't "normal." She said that her eyes still really irritated her when she was reading at night and when she worked in her yard.

More work to do

In addition to the dry eye condition, M.P. also had surface inflammation caused by meibomitis. The punctal plugs and the artificial tears had improved the surface disease but the meibomitis was still persistent. So in addition to the artificial tears, I prescribed fluorometholone (eFlone, FML, etc.) for both eyes q.i.d. to quell the inflammation.

Checking on the treatment

I asked M.P. to return in two weeks for a reassessment and at that visit she noted that her eyes seemed "much better." Her VA was now 20/20 in both eyes and there was no longer any Rose Bengal staining on the ocular surface. A mild amount of NaFl stain persisted intrapalpebrally. Her Schirmer's test was now 6 mm in her right eye, 5 mm in her left eye -- essentially unchanged from before.

For the first time in many months M.P. wasn't in chronic eye discomfort. We had made a lot of progress, but now we had to attempt to eradicate the NaFl staining and keep her eyes comfortable for the long term.

Forging ahead

Because of the telangiectasis on her cheeks and nose and her dry eyes, I felt that M.P. had ocular rosacea contributing to her problems. The best way to combat this skin disorder is with doxycycline, so I prescribed 100 mg q.a.m. I had M.P. discontinue the steroid drops but continue using the artificial tear drops t.i.d.

After one month on this regimen she returned saying that her eyes were comfortable. Her VA remained at 20/20 in both eyes and the ocular surface was completely free of Rose Bengal and NaFl stain.

Over the next year, M.P.'s eyes remained comfortable for the most part, although she would have episodes where her eyes got worse and the NaFl stain reappeared. (She admitted that she wasn't using the artificial tears as I had prescribed.)

Putting on the final touches

During this past year the FDA approved cyclosporine ophthalmic emulsion 0.05% (Restasis). Because of the chronicity of M.P.'s condition and her inability to use the artificial tears regularly, I prescribed cyclosporine q.12.h. for both eyes. I also decreased the doxycycline to 50 mg q.a.m. and suggested to her allergist that she switch from an oral antihistamine to a nasal steroid for her allergies.

It has been 17 months since I first saw M.P. At her last visit she was happy about the course that her eyes are taking and they remain comfortable. She says that her crocus and iris garden is "breathtaking!"

Contributing Editor Eric Schmidt, O.D., is director of the Bladen Eye Center in Elizabethtown, N.C. E-mail him at kenziekate@aol.com.