What condition is suggested by several weeks of conjunctival injection followed by a month of painful dry eye?

Bloodshot Eyes Followed by Painful Dry Eyes: Differential Diagnosis

This clinical presentation of several weeks of conjunctival injection (bloodshot eyes) followed by a month of painful dry eye strongly suggests either post-viral dry eye syndrome (most commonly following adenoviral infection) or an evolving chronic inflammatory condition such as early ocular mucous membrane pemphigoid, graft-versus-host disease, or medication-induced keratoconjunctivitis.

Most Likely Diagnosis: Post-Viral Dry Eye Syndrome

The sequential pattern—initial conjunctival injection transitioning to painful dry eye—is most consistent with post-viral keratoconjunctivitis sicca, particularly following adenoviral infection. 1

Supporting Evidence:

• Epstein-Barr virus (EBV) conjunctivitis specifically lists dry eye syndrome as a potential sequela following the acute follicular conjunctivitis phase 1
• Adenoviral conjunctivitis can progress to chronic ocular surface inflammation with subsequent tear film instability 2
• The timeline matches: initial viral conjunctivitis (weeks of redness) followed by inflammatory dry eye (month of painful dryness) 1, 2

Key Clinical Features to Assess:

• Recent viral illness history: fever, upper respiratory symptoms, pharyngitis, or known exposure to viral conjunctivitis 3, 2
• Photophobia during initial phase: suggests corneal involvement typical of adenoviral keratoconjunctivitis 2
• Bilateral vs. unilateral presentation: most viral causes become bilateral, though HSV remains unilateral 3, 2
• Discharge character evolution: watery discharge initially, transitioning to minimal discharge with dryness 2, 4

Critical Alternative Diagnoses to Exclude

1. Ocular Mucous Membrane Pemphigoid (OMMP)

This is a vision-threatening condition that presents with chronic conjunctival injection followed by progressive dry eye due to goblet cell loss and mucin deficiency. 1

Red flags for OMMP:

• Age over 60 years, particularly women 1
• Progressive conjunctival scarring beginning in the fornices 1
• Symblepharon formation (adhesions between bulbar and palpebral conjunctiva) 1
• Punctal stenosis and keratinization 1
• Recent initiation of topical glaucoma medications (pilocarpine, timolol can induce OMMP-like disease) 1

2. Medication-Induced/Preservative-Induced Keratoconjunctivitis

Chronic use of topical medications, particularly glaucoma drops, can cause progressive conjunctival injection followed by severe dry eye. 1

Key features:

• Gradual worsening with continued medication use 1
• Inferior fornix and bulbar conjunctival follicles 1
• Contact dermatitis of eyelids with erythema and scaling 1
• Punctal edema 1

3. Graft-Versus-Host Disease (GVHD)

In patients with history of allogeneic stem cell transplantation, chronic GVHD commonly presents with conjunctival injection progressing to severe keratoconjunctivitis sicca. 1

Diagnostic criteria:

• History of hematopoietic stem cell transplantation 1
• Onset typically 3+ months post-transplant (chronic phase) 1
• Bilateral presentation with pseudomembranous conjunctivitis 1
• Systemic involvement: skin, liver, GI system, lungs 1

4. Stevens-Johnson Syndrome (SJS) or Toxic Epidermal Necrolysis (TEN)

Acute mucocutaneous reaction with severe ocular sequelae including chronic dry eye. 1

Critical features:

• Recent medication exposure: sulfonamides, barbiturates, phenytoin 1
• Acute episode with membrane formation on palpebral conjunctiva 1
• Systemic mucosal involvement 1
• Severe conjunctival scarring with goblet cell loss 1

Diagnostic Workup Algorithm

Immediate Assessment (All Patients):

1. Detailed medication history: topical eye drops (especially glaucoma medications), systemic medications (sulfonamides, NSAIDs, antivirals) 1
2. Slit-lamp examination with fluorescein staining: assess for corneal involvement, conjunctival scarring, symblepharon, punctal stenosis 1, 3
3. Eyelid eversion: examine superior tarsal conjunctiva for papillary reaction, scarring, or keratinization 1
4. Schirmer test: quantify tear production (≤5mm suggests severe aqueous deficiency) 5, 4
5. Tear break-up time: assess tear film stability (<10 seconds abnormal) 4, 6

History-Specific Investigations:

• If recent viral illness: supportive diagnosis of post-viral dry eye 1, 2
• If age >60 with progressive symptoms: conjunctival biopsy to rule out OMMP 1
• If stem cell transplant history: systemic GVHD evaluation 1
• If recent medication initiation: trial discontinuation if medically safe 1

Management Approach

For Post-Viral Dry Eye (Most Likely):

First-line therapy:

• Preservative-free artificial tears: 4-6 times daily, refrigerated for enhanced cooling effect 7, 4
• Warm compresses and lid hygiene: address secondary meibomian gland dysfunction 4, 6
• Omega-3 fatty acid supplementation: anti-inflammatory effect 4

Second-line therapy (if inadequate response after 4-6 weeks):

• Topical cyclosporine 0.05% (Restasis®): immunomodulator for inflammation-mediated tear suppression, BID dosing 5, 4
• Punctal plugs: for severe aqueous deficiency (Schirmer ≤5mm) 4, 6
• Short course topical corticosteroids: for acute exacerbations, with monitoring for IOP elevation 7, 4

Critical Pitfall to Avoid:

Do NOT use punctal plugs in active inflammatory conjunctivitis or if OMMP is suspected, as they prevent flushing of inflammatory mediators and can worsen disease. 7

When to Refer Urgently to Ophthalmology:

Immediate referral indicated for: 3, 2

• Decreased visual acuity
• Severe ocular pain (not just irritation)
• Corneal infiltrates or ulceration on fluorescein staining
• Progressive conjunctival scarring or symblepharon formation
• Suspected OMMP, GVHD, or SJS/TEN
• Failure to improve after 4-6 weeks of appropriate therapy

Prognosis

• Post-viral dry eye: typically improves over 2-6 months with appropriate management 1, 4
• OMMP: progressive disease requiring aggressive immunosuppression to prevent severe vision loss 1
• GVHD: chronic management required, often with systemic immunosuppression 1
• Medication-induced: usually improves with discontinuation of offending agent, though may take months 1