Case Study:

A 19-year-old male college freshman presents with bilateral eye discomfort that began 2-3 days ago. He describes the discomfort as a 2/10 in severity, with a “gritty, like sand caught in your eye” sensation. The discomfort is constant and affects both eyes. The patient reports mild to moderate discomfort along with redness, tearing, and itching. He attempted to use over-the-counter Visine eye drops, which provided temporary relief of redness, but the gritty sensation, tearing, and itching persisted. The patient denies any eye injury, trauma, visual changes, or dryness. He also denies crusting of the eyelids or mucoid or purulent drainage.

The patient has a history of seasonal allergies that typically flare up during the spring, for which he takes loratadine 10 mg daily and fluticasone nasal spray. He has not experienced these eye symptoms before and has not had an eye exam in several years. He denies any systemic symptoms such as fever, chills, sore throat, cough, shortness of breath, chest pain, or wheezing. The patient does not smoke cigarettes but does report recreational marijuana use and drinking 3-6 beers per weekend.

Physical Examination:

• Vital Signs: Temp: 97.9°F, Pulse: 68, Respiratory Rate: 16, Blood Pressure: 120/75
• General Appearance: Well-appearing male, no signs of acute distress.
• Eyes: Bilateral conjunctiva shows diffuse redness, tearing, and light sensitivity. No foreign bodies, masses, or lesions noted. Visual acuity is 20/20 in both eyes.
• Nasal Examination: Pale, boggy nasal turbinates with moderate swelling and clear drainage.
• Ears: External auditory meatus examination is within normal limits.
• Fundoscopic Exam: Within normal limits.

Differential Diagnosis:

1. Allergic Conjunctivitis: The patient’s history of seasonal allergies, coupled with symptoms of bilateral eye redness, itching, tearing, and a gritty sensation, suggests allergic conjunctivitis. The absence of purulent discharge and the history of allergy exacerbation during springtime further support this diagnosis.
2. Viral Conjunctivitis: Although viral conjunctivitis is possible, the lack of recent illness, absence of mucous discharge, and the presence of itching make this diagnosis less likely.
3. Bacterial Conjunctivitis: This diagnosis is less likely due to the absence of purulent discharge, decreased vision, or significant eye irritation, which are typical of bacterial infections.

Diagnosis:

• Allergic Conjunctivitis (ICD-10 code H10.45): This diagnosis is supported by the patient’s bilateral eye redness, itching, tearing, history of seasonal allergies, and absence of purulent discharge or systemic illness.

Management Plan:

• Medications:
  • Loratadine (Claritin) 10 mg, Disp# 30, Sig: 1 tablet by mouth daily, RF: PRN.
  • Fluticasone Nasal Spray (Flonase) 50 mcg per actuation, Disp# 1 unit, Sig: 1 puff in each nostril BID (max of 2 puffs/actuations in each nostril/day), RF: PRN.
  • Visine-A (pheniramine/naphazoline) Ophthalmic Solution OTC, Disp# 0.5 oz, Sig: 1-2 drops in each eye every 6 hours as needed. Do not use for more than 2 weeks, RF: PRN.
• Patient Education:
  • The patient should avoid known allergens and refrain from rubbing the eyes to prevent further irritation.
  • The patient should practice strict hand hygiene and avoid sharing towels or bedding to minimize the risk of spreading any potential infection.
  • Recommend the patient take breaks when using electronic devices to prevent eye strain.
• Follow-Up:
  • The patient should return for a follow-up if symptoms do not improve within 7 to 10 days or if there is a significant change in vision or increased light sensitivity. If symptoms worsen or persist, referral to an eye specialist may be necessary.

Active Problem List:

1. Allergic Conjunctivitis: Likely triggered by seasonal allergens, currently managed with antihistamines and nasal spray.
2. Seasonal Allergic Rhinitis: History of springtime triggers, managed with loratadine and fluticasone nasal spray.
3. Recreational Marijuana Use: Potential exacerbation of eye irritation and allergies, patient advised on the risks.
4. Alcohol Consumption: Drinking 3-6 beers per weekend, potential interactions with antihistamine medication, patient advised on moderation.