Patient with red eye reports no pain, discomfort
A 47-year-old male presented to the clinic with a complaint of ocular redness in the left eye for the past 2 weeks. He stated that he is often questioned by friends and co-workers about the redness. He denied any ocular pain, decreased vision or discomfort.
The patient suffers from type 2 diabetes mellitus, hypertension and hyperlipidemia for 5 years and adjustment disorder with depressed mood. He is medicated with: low-dose aspirin, chlortalidone, losartan, metformin, methocarbamol, risperidone, simvastatin and trazodone. He reported no allergies.
Preliminary findings yielded best corrected visual acuity of 20/20 OD, OS; normal extraocular eye movements and pupillary reactions; and appropriate ocular tension at 10 mm Hg OD and 11 mm Hg OS.
The anterior segment examination found that the lids were clean and clear, without lesions. The irises were flat and intact, without neovascularization. The anterior chambers were deep, with no cell or flare. The crystalline lens was clear, without opacities. The patient’s right conjunctiva showed mild diffuse hyperemia with clear, early fibrovascular tissue formation temporal. The left temporal conjunctiva showed a grade two focal hyperemia, which was worse around a 2 x 2 mm nodule in the left eye. The right cornea was clear without opacities, and the left showed fibrovascular tissue at the nasal limbus extending 2 mm toward the visual axis. Phenylephrine was instilled in the left eye, yielding a favorable blanching of the superficial vessels.
A dilated posterior segment examination was unremarkable, with no inflammation.
The patient was prescribed 1% prednisolone acetate, in the left eye only, four times daily for 7 days, three times daily for 7 days, twice daily for 7 days, then once daily for 7 days, then stop. Once the steroid was finished, the patient was directed to start ketotifen 0.025% twice daily in the left eye to help prevent inflammation. Follow-up was scheduled for 3 weeks.
Upon follow-up, the patient reported that his eye was still red and he noticed little improvement. He still reported no ocular pain or discomfort, just a cosmetic irritation.
Examination of the left eye showed grade one temporal conjunctival hyperemia, again greater around the 2 x 2 mm nodule.
What’s Your Diagnosis?
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After further consideration of ocular signs, symptoms and course of treatment, it was concluded that this was a simple pingueculitis. I explained to the patient that his ocular redness was due to a prominent vascular plexus that is related to fibrovascular tissue called a pinguecula. Pinguecula are very common, innocuous and usually bilateral and asymptomatic.
Differential diagnoses for this case may include an inflammatory insult, episcleritis or neoplasms, such as ocular surface squamous neoplasia (OSSN) or ocular adnexal lymphoma (OAL).
Episcleritis occurs when Tenon’s capsule and the episclera are infiltrated with inflammatory cells, but the sclera itself is not swollen. Thus, the superficial episcleral plexus becomes maximally congested within this corresponding area of inflammation. This inflammation may cause mild to moderate irritation or discomfort, but nothing severe. Generally, episcleritis is idiopathic; however, in recurrent cases a detailed blood work-up is warranted.
Diagnosis can be aided with instillation of topical phenylephrine, which causes blanching of the conjunctiva and, to a certain extent, the superficial episcleral vessels, allowing visualization of the underlying sclera. SD-OCT may be helpful in differentiation between scleritis and episcleritis.
Shoughy and colleagues discovered that patients with active anterior scleritis showed increased thickness of the sclera and presence of intrascleral hyporeflective areas of edema by OCT compared to patients with episcleritis and normal eyes.
OSSNs may appear similar to pinguecula or pterygium. Unlike the aforementioned, OSSNs generally are progressive and can have some white keratin deposits on the surface. These are generally only diagnosed after biopsy; however, recent imaging techniques provide much more specific detail for diagnosis. When these lesions were imaged with anterior segment SD-OCT, epithelial thickening of about 390 microns was observed, along with abrupt transition between normal and abnormal epithelium, defined as a rapid increase in both brightness and thickness of the epithelium (Nani, et al.).
OAL is a malignant neoplasm that is derived from a monoclonal proliferation of T- or B-lymphocytes. OALs are rare but are the most common primary orbital malignancy in adults. Ocular lymphoma occurs most frequently in the orbit, followed by the conjunctiva. These conjunctival lesions are easier to rule out, given their typical presentation is salmon-pink in color.
Ultrasonography has proven to be somewhat useful in detection of these lesions; however, computed tomography or magnetic resonance imaging with enhancement are usually the primary diagnostic imaging. However, similar to OSSN, histopathological examinations are ultimately used for diagnosis.
Treatment options that were discussed for the patient included: occasional ocular vasoconstrictors, pulses with mild steroid, artificial tears, intralesional injection of steroid and surgical procedures. Many patients complain about the appearance of superficial ocular features and often inquire what can be done to remove them.
While practicing in Beverly Hills, Calif., it was routine for a professional entertainer to come in trying to resolve unwanted ocular features. One patient always complained about a prominent vessel that lost her job opportunities, or so she claimed. She was managed with Alrex (loteprednol etabonate ophthalmic suspension, Bausch + Lomb) once daily and pulse at show time. This worked for her; however, some patients always feel there is a surgical option.
One colleague performs an “eye whitening” procedure and beautifully advertises it as a non-stitch, non-graft procedure that only takes an hour to perform. It is actually a procedure that involves extensive conjunctival resection and sometimes tenonectomy, much like the dissection performed for excision of pterygia but with no conjunctival or amnion grafting to cover the bare sclera, with the help of mitomycin C 0.02%.
Interestingly enough, the Institutional Review Board at the University of California, Los Angeles, published a statement on postoperative complications following cosmetic eye whitening after receiving numerous referrals of patients experiencing them. Reported complications include persistent conjunctival epithelial defects secondary to limbal stem cell deficiency, diplopia secondary to Tenon’s capsule scarring, scleral thinning with and without calcific plaque formation, scleral necrosis and infectious endophthalmitis.
After all of these risks, are favorable results achieved? There seems to be a varied mix in this answer. I like to compare this surgery to modern pterygium surgery. Surgeries to remove this stubborn tissue often seem to leave an undesirable appearance, even with the use of adjuvants.
- Auw-Haedrich C, et al. Br J Ophthalmol. 2001;doi:10.1136/bjo.85.1.63.
- Coupland SE, et al. Surv Ophthalmol. 2002;doi:10.1016/S0039-6257(02)00337-5.
- Lee S, et al. Am J Ophthalmol. 2013;doi:10.1016/j.ajo.2013.01.035.
- Nani AA, et al. Ocul Surf. 2015;doi:10.1016/j.jtos.2015.02.001.
- Shields J, et al. Ophthalmology. 2004;doi:10.1016/j.ophtha.2003.01.002.
- Shoughy S, et al. Am J Ophthalmol. 2015;doi:10.1016/j.ajo.2015.03.004.
- Vo RC, et al. Am J Ophthalmol. 2014;doi:10.1016/j.ajo.2014.07.032.
- For more information:
- William Smith, OD, practices at the Veterans Affairs Clinic in Jacksonville, Fla., and is an associate professor of optometry at the University of Incarnate Word. He can be reached at William.Smith30@va.gov.
- Edited by Leo P. Semes, OD, FAAO, a professor of optometry, University of Alabama at Birmingham and a member of the Primary Care Optometry News Editorial Board. He may be reached at email@example.com.
Disclosure: Smith has no relevant financial disclosures.