Case Study:

A 19-year-old male college student presents with a chief complaint of bilateral eye discomfort that began 2-3 days ago. The discomfort is described as a 2/10 in intensity and is constant in both eyes. The patient reports that the eyes feel “gritty, like sand caught in your eye,” with mild to moderate discomfort. He has tried over-the-counter Visine eye drops once, which temporarily improved the 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 any mucoid or purulent drainage.

The patient has a history of seasonal allergies that typically occur in the spring, for which he takes loratadine 10 mg daily and fluticasone nasal spray daily. He has not experienced these symptoms before and has not had an eye exam in several years. The patient denies any fever, chills, sore throat, cough, shortness of breath, chest pain, or wheezing. Additionally, he 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 with no signs of acute distress
• Eyes: Bilateral conjunctiva show diffuse redness, tearing, and light sensitivity. No foreign bodies, masses, or lesions noted. Visual acuity is intact with 20/20 vision 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, bilateral eye redness, itching, tearing, and a gritty sensation, along with the absence of purulent discharge or recent illness, strongly suggests allergic conjunctivitis.
2. Viral Conjunctivitis: This is less likely given the absence of symptoms such as mucous discharge, crusting of the eyelids, and a recent history of viral illness. However, it remains a consideration.
3. Bacterial Conjunctivitis: This is considered less likely due to the lack of purulent discharge, decreased vision, or significant irritation, which are more typical of bacterial infections.

Diagnosis:

• Allergic Conjunctivitis is the most likely diagnosis based on the patient’s symptoms, physical findings, and history of seasonal allergies.

Plan:

• Management: The patient should continue using antihistamine eye drops (e.g., ketotifen) to alleviate the itching and redness. Loratadine and fluticasone nasal spray should be continued during the allergy season.
• Education: The patient should avoid known allergens when possible and refrain from rubbing the eyes to prevent further irritation.
• Follow-Up: The patient should return for a follow-up if symptoms worsen or do not improve with treatment.