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Keratoconjunctivitis sicca

The patient will present as → a 56-year-old female complaining of persistent eye dryness, irritation, and a gritty sensation in both eyes for the past three months. She also reports occasional blurry vision that improves with blinking. Her symptoms worsen in air-conditioned environments and after prolonged screen time. She denies any history of recent eye infections or allergies. On examination, her visual acuity is within normal limits. A Schirmer's test reveals tear production of less than 5 mm in 5 minutes. Her tear film breakup time is reduced, and fluorescein staining reveals punctate epithelial erosions. Based on her symptoms and examination findings, she is diagnosed with keratoconjunctivitis sicca, also known as dry eye syndrome. The patient is advised to use artificial tears frequently throughout the day and is prescribed an ophthalmic lubricating ointment for nighttime use. She is counseled on lifestyle modifications, including taking frequent breaks from screen time, using a humidifier at home, and wearing sunglasses or wraparound glasses to reduce wind exposure outdoors. A follow-up visit is scheduled to monitor her response to therapy. If symptoms persist or worsen, further evaluation for underlying conditions such as Sjögren's syndrome or meibomian gland dysfunction will be considered. The importance of adhering to her eye care regimen is emphasized to prevent complications like corneal ulceration or vision impairment.

Keratoconjunctivitis sicca, also known as dry eye disease (DED), is a chronic dryness of the cornea and conjunctiva that results from insufficient tear production or increased tear evaporation

  • Common Causes include autoimmune diseases (e.g., Sjögren's syndrome, rheumatoid arthritis), aging, medications (e.g., antihistamines, beta-blockers), and environmental factors (e.g., screen time, air conditioning)
  • Symptoms often include dryness, burning, foreign body sensation, and sometimes blurred vision
  • Risk Groups include women over 40, individuals with autoimmune conditions, and those with prolonged screen exposure
  • Complications include corneal ulcers, infection, and impaired vision

Diagnosis of keratoconjunctivitis sicca is based on clinical symptoms and tear function tests

  • Schirmer's Test is used to measure tear production, with a reduced result indicating dry eye
  • Tear breakup test (TBUT) measures tear film stability, with a shorter time indicating increased tear evaporation
  • Slit-Lamp Examination can identify corneal and conjunctival changes associated with dry eye
  • Fluorescein Staining helps detect corneal surface damage due to inadequate tear coverage
Schirmer's test

Schirmer's test, placing the strip in the lower eyelid pouch

Treatment strategies for keratoconjunctivitis sicca aim to relieve symptoms and prevent complications

  • Artificial Tears are the mainstay of treatment, providing lubrication and relieving dryness
  • Topical Anti-Inflammatory Drops (e.g., cyclosporine or corticosteroids) can be prescribed to reduce inflammation
  • Environmental Modifications such as humidifiers and limiting screen time help reduce dry eye triggers
  • Punctal Plugs can be used in severe cases to reduce tear drainage and maintain tear film stability
  • Omega-3 Fatty Acid Supplements may also help reduce dry eye symptoms by improving tear film composition

Question 1
Which of the following is a common etiological factor for developing keratoconjunctivitis sicca?
A
Hypertension
Hint:
While hypertension is a common systemic condition, it is not directly linked to the development of keratoconjunctivitis sicca.
B
Diabetes
Hint:
Although diabetes is a risk factor for keratoconjunctivitis sicca and can affect various ocular components, it is more commonly associated with conditions like diabetic retinopathy rather than dry eye syndrome.
C
Use of antihistamines
D
Hyperthyroidism
Hint:
Typically affects the eyes by causing conditions such as Graves' ophthalmopathy, not keratoconjunctivitis sicca.
E
Vitamin A deficiency
Hint:
While severe Vitamin A deficiency can lead to xerophthalmia and dryness of the conjunctiva, it is less common in developed countries and not a typical cause of keratoconjunctivitis sicca.
Question 1 Explanation: 
Use of antihistamines is known to contribute to keratoconjunctivitis sicca by reducing tear secretion, which can lead to dry eyes. Antihistamines, especially first-generation ones, have anticholinergic effects that can inhibit lacrimal gland secretion, thus decreasing the aqueous layer of the tear film and exacerbating symptoms of dry eyes.
Question 2
What is the best initial test for diagnosing keratoconjunctivitis sicca in a patient complaining of chronic eye dryness and irritation?
A
Schirmer's test
B
Visual acuity test
Hint:
While important for general eye examinations, it does not specifically assess tear production or diagnose dry eye syndrome.
C
Corneal topography
Hint:
Used to map the curvature of the cornea for diagnosing corneal diseases and for planning surgeries, not directly for diagnosing dry eyes.
D
Intraocular pressure measurement
Hint:
Primarily used to screen for and monitor glaucoma, not for assessing dry eye syndrome.
E
Fundoscopic examination
Hint:
Used to view the internal structures of the eye, such as the retina, and is not useful for assessing dry eye conditions.
Question 2 Explanation: 
Schirmer's test is a diagnostic tool specifically used to evaluate tear production and is the best initial test for diagnosing keratoconjunctivitis sicca. It measures the volume of tear production by placing a filter paper at the edge of the eyelid and assessing the amount of moisture absorbed over a set time, typically five minutes. Reduced tear production indicated by this test is a hallmark of dry eye syndrome.
Question 3
Which of the following treatments is considered most appropriate for managing mild to moderate keratoconjunctivitis sicca?
A
Systemic corticosteroids
Hint:
These are generally reserved for severe inflammatory eye diseases and carry a higher risk of systemic side effects, making them less suitable for mild to moderate cases.
B
Topical cyclosporine
C
Oral antibiotics
Hint:
Not indicated for treating dry eye syndrome as it is not typically caused by a bacterial infection.
D
Punctal occlusion
Hint:
More appropriate for severe cases where maximal retention of existing tears is necessary.
E
Surgical intervention
Hint:
Typically considered only in severe or refractory cases where other treatments have failed, not for initial management of mild to moderate cases.
Question 3 Explanation: 
Topical cyclosporine is an immunosuppressive agent that increases tear production and improves tear film stability by reducing ocular surface inflammation. It is effective for long-term management of mild to moderate keratoconjunctivitis sicca and helps prevent further damage to the lacrimal glands.
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References: Merck Manual · UpToDate

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