Therapeutic
ForumDry Corneas? Consider the Lid
Surgery corrects lid laxity, but treats the keratitis in the meantime.
by CHRISTOPHER
J. QUINN, O.D. A 57-year-old white female presents in your office complaining
of a 3-month history of a dry, gritty sensation in both eyes. She reports that
her symptoms increased in intensity over the past few weeks, and she complains
that her eyes seem “red” most of the time. The symptoms may be worse
in the morning but last the entire day. She has used over-the-counter vasoconstictors
without much relief.
Your examination reveals good visual acuity, a normal
neuro-ocular exam and normal intraocular pressure. Slit lamp evaluation demonstrates
mild diffuse bulbar conjunctival injection without follicular or papillary response.
Corneal examination reveals a dense band of inferior punctate keratitis in both
eyes. There is no infiltrate or ulceration present. Check Lid and Globe
Doctors overlook the importance of an external examination when evaluating
patients with chronic red eyes. You must carefully evaluate the globe and eyelids
for abnormalities before “turning up the magnification” behind the slit
lamp. A careful external examination should include checking the lids for proper
position, lid globe apposition, proptosis, and appropriate lid closure and blink.
Although patients with Bell’s palsy develop obvious cases of lagophthalmos,
patients may also develop lagophthalmos from increased lid laxity. This may result
in an incomplete blink that leaves an area of excessive drying, usually on the
inferior cornea and bulbar conjunctiva. The resulting irregular epithelial surface
often exhibits staining, as well as a rapid tear break-up time. These patients
often also have frank nocturnal lagophthalmos that increases the inferior corneal
drying, making symptoms worse in the morning. In these cases, your external examination
should also rule out whether incomplete lid closure is the result of proptosis,
not poor lid function.
The keratitis associated with lagophthalmos may
be severe, and dense punctate keratitis can be difficult to treat. You must address
the underlying cause of incomplete lid closure while attempting to heal the epithelial
surface.
In the case of Bell’s palsy, you must initiate frequent
lubrication with viscous lubricants and bland ointments to maintain the corneal
surface and prevent further epithelial breakdown. These patients are at risk for
developing secondary bacterial infections when the epithelium is compromised.
Consider early on whether surgical intervention with tarsorrhaphy (stitching the
eyelids together for temporary protection) or gold eyelid implants is indicated.
Most
cases require surgical correction of lid laxity as the definitive treatment. Management
First
start the patient on frequent lubrication with instillation of unpreserved artificial
tears as often as every 30 minutes. In cases that don’t respond well or when
the patient doesn’t comply, use more viscous agents and ointments. (Although
the more viscous the lubricant, the more likely it is to interfere with the patient’s
acuity and the less likely the patient is to maintain compliance.) In addition,
when significant epithelial breakdown exists, consider a non-toxic antibiotic
ointment to reduce the risk of secondary infection. Erythromycin ointment bid
is an excellent choice in this situation.
Taping the lid closed for sleep
at night can result in mixed success. Patients are often unable to achieve adequate
lid closure with taping, and problems with the tape are common. An alternative
treatment is to have the patient apply external eyelid weights. The weights attach
to the upper lid with a tissue adhesive and offer an excellent alternative to
lid taping while the patient awaits surgery. |