American Academy of Ophthalmology Web Site: www.aao.org
Ophthalmic Pearls: External Disease
The Itchy Eye: Diagnosis and Management of Ocular Pruritus
Ocular pruritus is a common symptom that brings patients to the ophthalmologist’s office. It may be tempting to overlook this seemingly minor problem while assessing patients for potentially vision-threatening diseases. However, itchy eyes can be a major problem and source of anxiety for patients, often affecting their day-to- day quality of life.
Although a physician’s inclination may be simply to treat the symptom with topical mast-cell stabilizers or antihistamines, it is important to identify the underlying cause. By carefully and methodically determining the etiology of ocular pruritus, the clinician can select an appropriate treatment regimen and provide patients with the relief they seek.
What Causes Itchy Eyes?
Pruritus can be the chief complaint for a number of ocular surface diseases. Atopic keratoconjunctivitis, vernal keratoconjunctivitis, allergic conjunctivitis and atopic dermatitis are part of the spectrum of ocular allergies. Other causes of pruritus include dry eye syndrome, meibomian gland dysfunction, blepharitis, contact lens–induced conjunctivitis, giant papillary conjunctivitis and contact dermatoblepharitis. A complete history, review of systems and examination can help differentiate among these etiologies.
Many of the causes of ocular pruritus are immunologically mediated.
A thorough history and review of systems should include special attention to onset, duration and frequency of symptoms, as well as exacerbating factors and associated systemic complaints. The following questions may help narrow the differential:
A thorough examination will help reveal the underlying pathology.
Eyelids. Pay particular attention to the eyelids for:
Conjunctiva. Conjunctival signs include:
Cornea. Check the cornea for:
Management and Treatment
Once the diagnosis has been made, an appropriate treatment course can be selected (“Common Causes and Treatments for Ocular Pruritis,” next page).
Contact dermatoblepharitis/blepharoconjunctivitis. First, it is imperative to identify and discontinue use of the offending agent. Contact reactions to topical carbonic anhydrase inhibitors and brimonidine are commonly delayed several weeks or months. Once the irritant is eliminated, supportive treatment, including the use of cool compresses, is usually sufficient. Ocular lubrication with artificial tears or ointment is also helpful. Additional therapies include the use of mast-cell stabilizers, topical antihistamines and topical nonsteroidal anti-inflammatory drugs (e.g., ketorolac). Topical corticosteroids applied to the eyelid can hasten recovery in more severe cases.
Atopic dermatitis. Eliminate environmental and food allergens. Exacerbations on the skin can be treated with corticosteroid cream or immunomodulators (e.g., tacrolimus) in severe cases. Moisturizing the facial skin (specifically the eyelid) is important for long-term treatment. Systemic antihistamines and mast-cell stabilizers may also provide relief.
Dry eye syndrome. Lubrication of the ocular surface is the ultimate goal. Initial treatment with artificial tears (if the tears are used more often than four times daily, then a preservative-free formulation is necessary) and with lubricant at bedtime, is acceptable. Some patients may also require punctal plugs. Those who remain symptomatic may need topical cyclosporine A to increase tear production.
Allergic conjunctivitis. Once again, it is important to avoid or eliminate allergic triggers whenever possible. Supportive care with cool compresses can be helpful for some patients. The use of physical barriers (such as glasses) is also useful in limiting allergen contact. Artificial tears will help dilute any allergen remaining on the ocular surface. Topical vasoconstrictors (e.g., pheniramine, naphazoline, oxymetazoline) can be used on a short-term basis for symptomatic relief. For patients with more severe symptoms, topical (e.g., olopatadine, ketotifen), oral and intranasal antihistamines and mast-cell stabilizers (e.g., cromolyn sodium, lodoxamide) are often beneficial. Topical NSAIDs and corticosteroids should be used with caution and require frequent follow-up. Consultation with an allergist for desensitization therapy may be necessary for those patients who remain symptomatic despite these measures.
Vernal keratoconjunctivitis/atopic keratoconjunctivitis. Symptoms may be alleviated with topical antihistamines and mast-cell stabilizers. However, these patients tend to require more aggressive measures compared with those suffering from allergic conjunctivitis. Topical corticosteroids and even immunomodulators (such as cyclosporine A) may be necessary. Supratarsal corticosteroid injections have also been used to control symptoms. Patients with AKC are more prone to infectious complications (especially herpes simplex keratitis) and should, therefore, be monitored closely. Vernal keratoconjunctivitis classically affects young men in warm climates; these patients may find relief in cooler climates or air-conditioned environments. Shield ulcers may require plaque debridement and scraping at the ulcer base followed by aggressive treatment with topical corticosteroids and antibiotics.
Contact lens– induced conjunctivitis/ giant papillary conjunctivitis. Patients should first be advised to discontinue contact lens wear until the exacerbation has resolved. It is also appropriate to refit the lenses or to try different lenses and to advise patients about proper hygiene. It may be helpful to change to daily-wear contact lenses. Once the exacerbation hasresolved, mast-cell stabilizers are sometimes used as maintenance therapy. For those who remain intolerant, refractive surgery is an alternative.
Meibomian gland dysfunction/blepharitis. Education regarding proper eyelid hygiene is imperative. Warm compresses and twice-daily eyelid scrubs can help open inspissated meibomian glands. A clean washcloth dipped into baby shampoo diluted with water is commonly used for eyelid massage and scrubbing. Ocular surface lubrication with artificial tears can provide additional relief. Short-term use of a topical antibiotic (macrolides are often used) may be beneficial, while some patients will require a course of oral tetracyclines that are then tapered off. Staphylococcal marginal keratitis will often require the use of topical corticosteroids to quell the inflammatory response.
Frequent follow-up is often necessary for patients with ocular pruritus. Patients on topical NSAIDs need close monitoring (to date, only ketorolac is FDA-approved for this condition), and NSAIDs should only be prescribed on a short-term basis due to the risk of corneal melts and perforation. Patients taking topical corticosteroids also require close monitoring for superinfection and for the development of corticosteroid-induced ocular hypertension. For those patients who require an extended course of topical corticosteroids, combination therapy with a topical antibiotic may be indicated. Management of patients with systemic complaints is often facilitated by consultation with an allergist.