Case Study # 1 An 86-year-old widowed female is brought to the office by her daughter-in-law. The patient complains of constant tearing and an itchy, burning sensation in both eyes. The patient states this is not a new problem, but it has worsened in the past week and is affecting her vision. The patient complains that her eyes are dry. She thinks the problem must be caused by one of her medications. Her patient medical history is positive for hypertension, atrial fibrillation, and heart failure. She has an allergy to erythromycin that causes rash and elevated liver enzymes. Medications currently prescribed include Furosemide 40 milligrams po twice a day, diltiazem 240 milligrams po daily, lisinopril 20 milligrams po daily, and warfarin 3 milligrams po daily. The physical examination reveals a frail older female with some facial dryness and slight scaling. Her visual acuity is 20/60 OU, 20/40 OD, 20/60 OS. The eyelids are erythematous and edematous with yellow crusting around the lashes. Sclera are injected, conjunctiva are pale, and pupils are equal and reactive to light and accommodation. The patient stating that her eyes have been progressively worsening over the last couple weeks, and that she believes it could be related to her medications, assists the health care provider in coming to a diagnosis. Diuretics and anti-hypertensives can contribute to dehydration. The patient states that it is affecting her vision, but a follow up question I would have is if she has more blurriness related to the tearing, if her visual field is narrowing or she has blind spots, or if she is having any floaters in her vision. The physical examination for eyes should include visual acuity, pupil responses, intraocular pressure, visual fields, and extraocular movements (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). This would allow the provider to assess if there are any disease processes occurring with the nerves or muscles, or if the disease process is only occurring with mucous membranes. A fluorescein exam with a slit lamp would show any scratches or ulcerations on the cornea that could potentially allow bacteria through the damaged membrane and infecting the eye further. Primary Dx: Blepharitis is a common eye condition that presents in one or both eyes with red and swollen eyelids, itching, burning, crusting of the eyelashes, excessive tearing, and redness eyes (EBSCO CAM Review Board, 2019). This occurs due to the oil glands being blocked causing the inability to lubricate the eye or can be caused by bacteria infesting the upper eye lash line (American Optometric Association, 2020). Because the patient is taking diuretics, it does put her at a higher risk of being dehydrated, especially if she is not sufficiently rehydrated to maintain homeostasis. The differential diagnose I have chosen for this patient is dry eye because of the medical history and medications she takes, however, the yellow crusting around the lashes in a primary sign of blepharitis. Differential Dx: Dry eye can occur in many situations, some involving the environment related to climate control, allergies, medications, dehydration, or systemic diseases. The lack of the ocular surface providing moisture and lubrication leads to a gritty sensation, pain, redness, ocular discomfort, fatigue, string mucous, tearing, visual disturbance, and photophobia (Azam, Hussain, Hussain, & Murad, 2016). Individuals at higher risk of dry eye are people are of older age, smokers, individuals with arthritis, hypertension, fibromyalgia, systemic lupus erythematosus, and diabetes (Azam, Hussain, Hussain, & Murad, 2016). It’s possible this patient may have first experienced dry eye, but her symptoms progressed to blepharitis due to the bacteria from her eyelid infecting her dry and possibly damaged cornea. The facial dryness and scaling on the patient’s face may also suggest dehydration or an underlying dermatologic disorder. Seborrheic dermatitis and Ocular Herpes are two other diagnoses I chose for this patient. Seborrheic dermatitis involves the shedding of skin cells from the scalp, which may or may not have affected the eyelids. Ocular Herpes is a herpes virus that infects the cranial dermatomes and presents as vesicular lesions on the face and around the eye, which can lead to infections of the eye, ulcers of the cornea, and potential blindness. Some treatment options for this patient would involve lubricating the eye, and due to the bacterial infection of the eyelids, using an eye antibiotic such as ciprofloxacin or gentamicin eye drops. Some patient education that may be needed is appropriate rehydration with the use of anti-hypertensives and diuretics to maintain homeostasis and a status of hydration for the skin and mucous membranes. Warm moist compresses can help in the morning with removing crustiness of the eyes, some other treatments are N-acetylcysteine, barberry, bayberry, omega fish oils, lutein, selenium, and vitamins A, B, C, E, and zinc (EBSCO CAM Review Board, 2019). If left untreated, blepharitis and dry eye can lead to blindness due to the damage of the cornea. References American Optometric Association. (2020). Blepharitis. https://www.aoa.org/patients-and- public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/blepharitis Azam, S., Hussain, M., Hussain, S., & Murad, N. (2016). Risk factors in dry eye. Opthalmology Update, 14(4), 140-144. Buttaro, T., Trybulski, J., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). Elsevier. EBSCO CAM Review Board. (2019). Alternative treatments to blepharitis. Salem Press Encyclopedia of Health. please response “Is this question part of your assignment? We Can Help!”
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