What is the initial workup for a patient presenting with a feeling of tired eyes?

Initial Workup for Tired Eyes

The initial workup for tired eyes should focus on identifying dry eye disease as the most common cause, requiring a comprehensive ocular history, external examination, and slit-lamp biomicroscopy to assess tear film quality and ocular surface integrity. 1

History Taking

The evaluation begins with a detailed symptom characterization and risk factor assessment:

Symptom Assessment

• Duration and pattern of symptoms (constant vs. intermittent, time of day when symptoms worsen, relationship to activities such as reading or computer use) 1
• Quality of symptoms beyond "tired eyes" (burning, grittiness, foreign body sensation, photophobia, blurred vision) 1
• Exacerbating factors (wind, air conditioning, heating, low humidity environments, prolonged visual tasks, digital screen use) 1

Critical Red Flags to Exclude

• Pain, photophobia, and blurred vision together require immediate ophthalmologic referral to rule out vision-threatening conditions including acute angle-closure glaucoma, severe uveitis, or infectious keratitis 2
• Variable symptoms with fatigue, variable ptosis, or diplopia suggest myasthenia gravis and require specific testing 1
• Symptoms in patients over 50 with headache, scalp tenderness, jaw claudication, or malaise warrant immediate ESR, CRP, and CBC to exclude giant cell arteritis 1

Medication and Medical History

• Topical medications (artificial tears, glaucoma medications, vasoconstrictors, preservative-containing drops) 1
• Systemic medications with anticholinergic effects (antihistamines, diuretics, antidepressants, beta-blockers, isotretinoin) 1
• Contact lens use (type, wearing schedule, hygiene practices) 1
• Ocular surgical history (LASIK, cataract surgery, eyelid surgery) 1
• Systemic inflammatory diseases (Sjögren syndrome, rheumatoid arthritis, lupus, sarcoidosis) 1
• Dermatological conditions (rosacea, psoriasis, seborrhea) 1

Physical Examination

External Examination Components

• Eyelid assessment: incomplete closure, infrequent blinking, eyelid lag or retraction, margin erythema, meibomian gland abnormalities 1
• Skin examination: facial changes consistent with rosacea, scleroderma, or seborrhea 1
• Lacrimal gland: enlargement suggesting systemic disease 1
• Cranial nerve function: particularly cranial nerves V (trigeminal) and VII (facial) 1

Slit-Lamp Biomicroscopy (Essential)

• Tear film evaluation: inferior meniscus height, debris, mucous strands, foam, tear break-up time and pattern 1
• Eyelid margins: meibomian gland orifice metaplasia, expressibility and character of secretions (turbid, thickened, foamy), vascularization, keratinization 1
• Eyelashes: trichiasis, distichiasis, madarosis, collarettes, deposits 1
• Conjunctiva: punctate staining with fluorescein or lissamine green, hyperemia, conjunctivochalasis, papillary reaction, follicles, scarring 1
• Cornea: epithelial defects, infiltrates, edema, neovascularization 1
• Puncta: patency, position, presence of plugs 1

Diagnostic Testing

First-Line Tests

• Visual acuity testing with appropriate correction is essential baseline documentation 2
• Tear break-up time: assess tear film stability 1
• Ocular surface staining: fluorescein for cornea, lissamine green for conjunctiva 1

Additional Testing When Indicated

• Ice pack test (2 minutes for ptosis, 5 minutes for strabismus) if variable symptoms or ptosis suggest myasthenia gravis 1
• Meibomian gland expression: assess quality and quantity of secretions 1
• Schirmer testing: may be considered but not routinely necessary for initial workup 1

Immediate Referral Criteria

Refer immediately to ophthalmology if:

• Moderate to severe pain unresponsive to initial management 1, 2
• Vision loss or significant visual complaints (blurred vision, floaters, flashing lights) 3, 2
• Corneal infiltration or ulceration 1, 3
• Suspected acute angle-closure (pain, photophobia, blurred vision, mid-dilated pupil) 2

Common Pitfalls

• Do not start corticosteroids before ophthalmologic examination, as they may worsen infectious conditions or mask accurate diagnosis 3
• Do not dismiss symptoms in patients over 50 without excluding giant cell arteritis, which can cause permanent vision loss 1
• Do not overlook systemic disease associations: tired eyes may be the presenting symptom of Sjögren syndrome, myasthenia gravis, or thyroid eye disease 1
• Preservative toxicity: patients using artificial tears four or more times daily should use preservative-free formulations 1