Week 3 Case Study Part 1
Patient is a 19 year old Male who presents today with a complaint of bilateral eye discomfort that began 2-3
days ago. The eye discomfort is reported as a 2/10 on the pain scale and is describe
...
Week 3 Case Study Part 1
Patient is a 19 year old Male who presents today with a complaint of bilateral eye discomfort that began 2-3
days ago. The eye discomfort is reported as a 2/10 on the pain scale and is described as a constant “gritty” or
sand like feeling. He further reports his eyes are itchy and have watery drainage or tearing. He reported having
redness that temporary relieved with OTC visine, but the eye irritation continued. The patient does not recall
any recent trauma or foreign object in his eyes. He denies any crusting or purulent drainage. He does note that
he has an occasional runny nose with intermittent congestion but no sneezing. His past medical history includes
seasonal nasal allergies which flares up only in spring and is controlled with Loratadine 10mg and Fluticasone
Nasal Spray in peak season. The patient further denies any ear pain, throat pain or redness, fever, chills, SOB or
wheezing.
Physical assessment essentially negative with the exception of noted pale and boggy nasal turbinate’s as well as
mild to moderate swelling and clear drainage. Bilateral eyes with noted photosensitivity and diffuse conjunctiva
redness and tearing. Visual acuity remains 20/20 bilaterally (uncorrected), no foreign object noted, no mass,
lesions or crusting on lids. Fundiscopic examination WNL.
Differential Diagnoses:
-Allergic conjunctivitis is caused by a type I immune response to an allergen. The allergen binds to a mast cell
and crosslinking to IgE occurs, leading to mast cell degranulation and initiation of an inflammatory cascade
(Leonardi, Castegnaro, Valerio &Lazzarini, 2015). This results in release of histamine from mast cells, as well
as other mediators, including tryptase, chymase, heparin, chondroitin sulfate, prostaglandins, thromboxane, and
leukotrienes. Histamine and bradykinin immediately stimulate nociceptors, resulting in itching, increased
vascular permeability, vasodilation, redness, and conjunctival injection (Leonardi, Castegnaro, Valerio &
Lazzarini, 2015).
-Viral/Infective conjunctivitis occurs as a result of reduced host defenses and external contamination. Infectious
pathogens can invade from adjacent sites or by a blood-borne pathway and replicate within the conjunctival
mucosal cells (Epocrates, 2018). Both bacterial and viral infections initiate a leukocyte or lymphocytic
inflammatory cascade leading to the attraction of red and white blood cells to the area. These white blood cells
reach the conjunctival surface and accumulate there by easily moving through the dilated and highly permeable
capillaries (Leonardi, Castegnaro, Valerio & Lazzarini, 2015).
-Dry eye disease (DED) is a multifactorial ocular surface disease characterized by a loss of homeostasis of the
tear film due to tear film hyperosmolarity and instability, ocular surface inflammation and damage, and
neurosensory abnormality. This results in ocular discomfort, dryness, and visual disturbance (Epocrates, 2018
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