What's Your Diagnosis
by John A. McGreal, Jr., OD
As seen in Primary Care Optometry News, May 2000

A 36-year old black man was seen in consultation on the request of his internist. While making hospital rounds, the internist noticed that the patient slept with his eyes open that his inferior corneas were unusual.

The patient's chief complaint was a foreign body sensation in each eye, which he had experienced for a year. The symptoms were chronic and progressive. History was remarkable for numerous hospital admissions for complications of diabetic mellitus. Family history was remarkable for hypertension. Social history was remarkable for previous illegal IV drug use.

The review of symptoms was remarkable as follows: neurological/spino-cerebellar degeneration, genitourinary/penile implant (ED), endocrine/diabetes mellitus, cardiovascular/hypertension and psychiatric/substance abuse.

Physical exam

The physical examination was performed in the office. The patient was oriented to time, place and person. Mood and affect were normal. Visual acuity was 20/20 OD/OS without correction. The confrontation visual fields were normal. The pupils were equal, round and normally reactive. There was no afferent pupillary defect.

The external exam revealed symmetric incomplete blink/closure. The biomicroscopic examination revealed severe inferior corneal thinning and scarring OU. The lens was clear, and the iris was normal. The conjunctiva was unremarkable. The applanation intraocular pressures were 18mm Hg OU.

The dilated fundus examination revealed a cup-to-disc ration of 0.5 with talc retinopathy OU. (Talc retinopathy is caused by talcum powder that does not dissolve in the blood stream and is found in the blood stream and is found in the retina. Drug dealers sometimes dilute illegal IV drugs with talcum.) The Shirmer's test was 5 mm in 5 minutes OU.

Corneal thinning, scarring

The differential diagnosis of this patient's anterior segment condition includes sicca syndrome, trichiasis, lid/globe incongruity, staphylococcal disease and exposure keratopathy. Exposure keratopathy can result from a history of Bell's palsy, cerebrovascular accident or neurotrophic keratitis. The physical examination leads one to conclude that exposure, related to poor blinking, nocturnal desiccation and incomplete closure is the appropriate diagnosis. The secondary diagnosis is talc retinopathy, which resulted from previous IV drug use. The patient has been evaluated and treated for this in the past.

Most patients with ocular surface disease benefit from tear supplements and punctal occlusion. Lid taping or ointments at bedtime also may be useful. In this case, using ointments that blur vision in a wheel-chair bound patient with severe hypertension and diabetes would be difficult. Lid taping would also not be practical.

Aggressive treatment The patient was aggressively treated with tear supplements and permanent silicone punctal occlusion. There was some improvement, but because of extreme thinning of the cornea and risk of perforation, the patient underwent unilateral medical tarsorrhaphy. (Note: This patient was treated several years ago, and newer therapies described below would be attempted prior to surgical intervention.) The goal was to protect and preserve the anterior segment of one eye in the event of increased scarring or perforation of the fellow eye. The patient remained on high viscosity artificial tears in both eyes and was followed closely. A more modern approach to managing this case today would include the use of artificial tears, punctal occlusion and clear tear gels. These products offer the benefits of ointment (hydration and prolonged contact time) and clarity of vision afforded by eye drops. Eyelid weights (MedDev Corp.) could also be affixed with double-sided tape to achieve better corneal coverage, especially at bedtime. These measures would preclude the use of surgical tarsorrhaphy and have quality-of-life advantages in patients with disabilities. Liposomal sprays helpful Evolving products and technologies that may be beneficial in cases such as this include the use of liposomal sprays and topical cyclosporine. Liposomal sprays are a novel delivery system that are applied to the eyelid skin in a fine mist. They rehydrate the skin while adding lipid to the precorneal tear film, which reduces the evaporative loss of tears. Cyclosporine is a T-cell lymphocyte suppressor that is widely used systemically in transplant recipients to modulate rejections. Topically, it reverses the inflammatory infiltrate in the lacrimal glands and stimulates the production of aqueous tears. Final Food and Drug Administration approval for this indication is pending.