Progress Is Progress

A new patient presented to me with redness of the right eye that had been affecting her for several months. She had sought the help of many doctors, with no relief, until finally finding her way to me. On her first visit, as I was finishing up her anterior segment evaluation, I rolled away in my chair and wondered how I could help.

THE CASE

The patient, a 31-year-old female, had been experiencing recurrent redness in her right eye for about 3 months (Figure 1). She was previously told she had dry eye and was prescribed prednisolone acetate 1% drops on a taper schedule with no improvement. She reported no ocular pain, but noted that the redness worsened toward the end of the day and that she had never experienced anything like it before. She had no discharge, no recent upper respiratory tract infection, no fever, no recent COVID-19 infection, and no close contact with others experiencing similar ocular signs. Additionally, there was no history of ocular injury, current medications, or known allergies, and her review of systems was normal.

Preliminary Examination Findings

The patient’s preliminary exam findings were all within normal limits, and her VA was 20/20 OU. There was no preauricular lymphadenopathy, and the conjunctiva showed a diffuse grade 2+ injection OD. Adjacent to the inferonasal limbus on her right conjunctiva, I observed three gelatinous 1mm-stained phlyctenules with trailing vessels and one isolated phlyctenule adjacent to the superonasal limbus on the conjunctiva at the 2:00 clock position with trailing vessels, all within the interpalpebral region (Figure 2). Her right cornea showed diffuse trace superficial punctate keratopathy. The anterior chamber was deep and quiet. Lid eversion and examination of the papillary conjunctiva were within normal limits. The left eye and the remainder of the examination were unremarkable.

Because this was a classic phlyctenule, and a recurrence at that, I started the patient on ciprofloxacin every 3 hours OD, ketotifen fumarate drops every night at bedtime OD, and erythromycin ointment every night at bedtime OD. I excluded pred acetate for the time being, as it was not medically necessary, nor had it been effective for her in the past. I took note of the fact that what bothered the patient the most was the red appearance of her right eye, which was the rationale behind starting her on all the treatments for phlyctenules reported in the literature.¹ I sent a report to her primary care provider to rule out tuberculosis (TB) and sexually transmitted infections (STIs), which are common causes of phlyctenules, and scheduled a follow-up visit.²

First Follow-Up Findings

After 1 week, a mild improvement in symptoms was noted (Figure 3). The patient once again endorsed no pain. Her primary care provider ruled out the possibility of latent TB or an STI. On examination, there was grade 1+ injection in her right conjunctiva, and the phlyctenules were still present. Because of the improvement, I decided to restart her on pred acetate drops every night at bedtime OD for 1 week. I instructed her to continue with ciprofloxacin OD every 3 hours, ketotifen fumarate drops every night at bedtime OD, and erythromycin ointment every night at bedtime OD with another 1-week follow-up on the books.

2-Week Check-In

At the patient’s next visit, I was disappointed to see that her right eye had still not improved to my satisfaction (Figure 4). The trailing vessels had resolved, but she still had one phlyctenule. I vocalized my dissatisfaction, to which she expressed her relief at any improvement after dealing with the redness for so long, no matter how slow the progress.

Hoping for continued improvement, I had the patient continue on ciprofloxacin three times daily OD, ketotifen fumarate drops every night at bedtime OD, erythromycin ointment every night at bedtime OD, and pred acetate drops every night at bedtime OD, with a follow-up scheduled for another week out.³

3-Week Follow-Up

At the patient’s next follow-up visit, I was pleased with the appearance of her eyes and there was no visible phlyctenule (Figure 5). She was still using all her drops as indicated and reported significant relief. I had her discontinue the ciprofloxacin and ketotifen and continue with the erythromycin ointment every night at bedtime OD until the tube ran out. I gave her taper instructions for pred acetate drops every other night at bedtime OD for the coming Monday, Wednesday, and Friday, after which she would start artificial tears three times daily OU. We asked her to return in 1 month to monitor her progress.

Latest Update

At the patient’s 1-month follow-up visit, I observed healthy eyes (Figure 6). She had no recurrences, so I discontinued her artificial tears and had her begin taking high-quality omega-3 liquid supplements to maintain the improvement to her ocular surface.

She is currently due for her annual follow-up visit and has not experienced any recurrence of the ocular redness that initially brought her to my office.

TAKEAWAYS

This patient encounter serves as a reminder that any progress is still progress. Just as with this case, I have had many other patients come into the office with ocular surface issues that have been present for months, if not years. Symptom resolution may take just as long as clinical presentation. We are experts, and we must trust in our process. By taking our time and being determined in our treatment, we can positively affect a patient’s life in more ways than one.