Case Study:

A 19-year-old college freshman presents with complaints of bilateral eye discomfort rated as 2/10 in severity, along with tearing and itching that began 2-3 days ago. The patient describes the eye discomfort as constant and having a “gritty, like sand caught in your eyes” sensation. The patient tried over-the-counter Visine eye drops yesterday, which provided some relief. There is no history of fever, chills, or recent illness. The patient denies using contact lenses or glasses and reports never having experienced these symptoms before. The last eye exam was several years ago. The patient denies any eye injury, trauma, visual changes, or dryness. Additionally, there are no reports of crusting of the eyelids, or mucoid or purulent drainage.

The patient reports bilateral symptoms including redness, itching, tearing, and a foreign body sensation in the eyes. There is no ear pain or discharge, but the patient occasionally experiences a runny nose with intermittent nasal congestion and denies sneezing. The patient has a history of seasonal allergies, which are well-controlled with loratadine and fluticasone nasal spray during the spring months. The patient denies sore throat, cough, shortness of breath, chest pain, and wheezing. The patient does not smoke cigarettes but admits to recreational marijuana use and drinks 3-6 beers per weekend.

Explanation and Answer:

The symptoms presented by this 19-year-old patient—bilateral eye discomfort, redness, itching, tearing, and a gritty sensation—are highly suggestive of allergic conjunctivitis. This condition is common in individuals with a history of seasonal allergies, like this patient, who controls their allergy symptoms with loratadine and fluticasone nasal spray.

Allergic conjunctivitis occurs when allergens such as pollen, dust, or pet dander come into contact with the conjunctiva, leading to an allergic reaction. The gritty sensation described by the patient, along with the absence of purulent discharge and the presence of nasal symptoms (occasional runny nose and nasal congestion), further supports this diagnosis.

Recommended Management:

1. Antihistamine Eye Drops: The patient should be advised to use antihistamine eye drops, such as ketotifen, to reduce the itching and redness associated with allergic conjunctivitis.
2. Continuation of Allergy Medications: The patient should continue using loratadine and fluticasone nasal spray during allergy seasons to manage their overall allergy symptoms effectively.
3. Avoidance of Triggers: The patient should be encouraged to avoid known allergens and to minimize exposure to potential triggers, such as pollen or dust.
4. Eye Care: Advising the patient to avoid rubbing their eyes will help prevent further irritation and exacerbation of symptoms.

If symptoms persist or worsen, a follow-up appointment should be scheduled to reassess the condition and adjust treatment if necessary.