What are the possible causes and treatments for tearing and itchiness in the right (R) eye associated with new onset facial asymmetry on the left?

Urgent Neurological Evaluation Required for Suspected Bell's Palsy with Concurrent Allergic Conjunctivitis

This patient requires immediate evaluation for acute facial nerve paralysis (Bell's palsy) affecting the left side, while the right eye symptoms represent a separate allergic conjunctivitis that needs concurrent treatment.

Critical Assessment of Facial Asymmetry

The new onset left-sided facial asymmetry is the most concerning finding and demands urgent neurological evaluation. This presentation suggests acute facial nerve paralysis rather than structural facial asymmetry 1.

Key Distinguishing Features to Assess Immediately:

• Complete vs. incomplete facial involvement: Bell's palsy typically affects the entire hemifacial musculature, including forehead weakness (inability to wrinkle forehead or close eye completely on affected side) 1
• Associated symptoms: Ask specifically about hyperacusis, decreased lacrimation, altered taste (dysgeusia), or reduced salivation on the left side 1
• Temporal progression: Idiopathic facial nerve paralysis presents acutely over hours to days 1
• Red flags requiring immediate imaging: Recurrent paralysis, additional neurologic deficits beyond CN VII, history of head/neck malignancy, or lack of recovery within 2-3 months 1

Differential Diagnosis Considerations:

While Bell's palsy is most common, the combination of ipsilateral eye symptoms (though on opposite side here) raises consideration for:

• Ramsay Hunt syndrome: Look for vesicular rash in ear canal or on face
• Lyme disease: Obtain travel/tick exposure history
• Stroke: Assess for central vs. peripheral pattern (forehead sparing suggests central lesion)
• Tumor compression: Especially with atypical features 1

Management of Right Eye Allergic Conjunctivitis

The 2-week history of tearing and itchiness in the right eye represents allergic conjunctivitis requiring separate treatment 2, 3.

First-Line Treatment Algorithm:

Step 1: Dual-Action Topical Agents

• Start olopatadine 0.1% or ketotifen twice daily to the right eye 3, 4, 5
• These provide rapid onset (within 30 minutes) with both antihistamine and mast cell stabilizer effects 3
• Store drops in refrigerator for additional cooling relief 3

Step 2: Adjunctive Measures

• Apply cold compresses to right eye for several minutes multiple times daily 6, 3
• Use refrigerated preservative-free artificial tears to dilute allergens 6, 3
• Instruct patient to avoid eye rubbing, which can worsen symptoms and potentially cause keratoconus 6, 3
• Implement allergen avoidance: wear sunglasses outdoors, use hypoallergenic bedding, shower before bed 6, 3

Step 3: If Inadequate Response After 48 Hours

• Add loteprednol etabonate for 1-2 weeks maximum 6, 3
• Measure baseline intraocular pressure before starting and monitor periodically 6, 3
• Perform pupillary dilation to evaluate for cataract formation 6, 3

Critical Pitfalls to Avoid:

• Never use punctal plugs in allergic conjunctivitis as they prevent flushing of allergens 3
• Avoid chronic vasoconstrictor use which causes rebound hyperemia (conjunctivitis medicamentosa) 3
• Limit oral antihistamines as they worsen dry eye and impair tear film 6, 3
• Do not use topical antibiotics which are not indicated and cause toxicity 3

Coordination of Care

The facial asymmetry and eye symptoms may be unrelated conditions requiring parallel management:

For the Facial Nerve Paralysis:

• Urgent referral to neurology or otolaryngology within 24-48 hours 1
• If Bell's palsy confirmed, typical treatment includes oral corticosteroids (prednisone 60-80mg daily for 7-10 days) initiated within 72 hours of onset
• Eye protection is critical: artificial tears during day, lubricating ointment at night, eye taping if incomplete closure 1
• Follow-up at 2-3 months to ensure facial function recovery; lack of improvement warrants imaging 1

For the Allergic Conjunctivitis:

• Follow-up in 1-2 weeks to assess response to dual-action drops 3
• If using corticosteroids, check intraocular pressure at each visit 6, 3
• Consider allergist referral if symptoms persist despite maximal topical therapy 3

Special Consideration: Bilateral Involvement

While the presentation describes left facial asymmetry and right eye symptoms, carefully examine both sides. Bilateral hemifacial spasm presents with asymmetric, asynchronous facial contractions typically starting unilaterally in the eyelid 7. However, the acute 2-week timeline and tearing/itching favor separate etiologies rather than a unified diagnosis.