What are the likely causes and recommended management for redness, dryness, and mild periorbital erythema in an elderly man residing in an assisted‑living facility?

Red, Dry Eyes with Periocular Erythema in an Elderly Assisted-Living Resident

This presentation is most consistent with dry eye syndrome (DES), which affects 19% of adults over 80 years and is exacerbated by multiple age-related risk factors common in assisted-living facilities, including polypharmacy, environmental conditions, and reduced blink rates. 1

Initial Assessment and Diagnosis

The combination of red, dry eyes with mild periocular erythema in an elderly male strongly suggests dry eye disease, potentially complicated by blepharitis or meibomian gland dysfunction. 1

Key diagnostic features to confirm:

• Symptoms of ocular irritation, burning, or foreign body sensation that worsen throughout the day 1
• Visible signs including decreased tear meniscus, conjunctival injection, and periocular skin changes 1
• Environmental exacerbating factors common in assisted-living facilities (low humidity, air conditioning drafts, increased screen time) 1

Critical red flags requiring urgent ophthalmology referral:

• Moderate-to-severe eye pain unrelieved by lubricants 2
• Vision loss or significant blurred vision 2
• Corneal involvement (infiltration, ulceration) 3
• Copious purulent discharge suggesting bacterial infection 3

Immediate Management Strategy

Step 1: Environmental and Medication Review

Identify and eliminate exacerbating factors: 1

• Review medications for anticholinergic agents, antihistamines, diuretics, antidepressants, and antianxiety medications—all associated with increased dry eye risk in elderly patients 1, 4
• Modify environmental conditions: humidify ambient air, redirect air conditioning vents away from face, use side shields on spectacles 1, 2
• Eliminate cigarette smoke exposure, which adversely affects the tear film lipid layer 2, 5

Step 2: Ocular Surface Lubrication

Initiate preservative-free artificial tears at least 4 times daily, increasing frequency based on symptom severity. 1, 2 Preserved tears should be avoided if using more than 4 times daily due to risk of preservative-induced toxicity. 2, 5

• Apply lubricating ointment at bedtime for overnight protection 2, 5
• Use lipid-containing tear supplements if meibomian gland dysfunction is suspected (most common presentation in elderly patients) 1

Step 3: Lid Hygiene Protocol

Implement twice-daily warm compresses and lid hygiene: 2, 5

• Apply warm compresses to closed eyelids for 5-10 minutes using battery-powered or microwaveable devices 2, 5
• Perform gentle eyelid massage after warm compresses to express thickened meibomian gland secretions 2, 5
• Cleanse eyelid margins with diluted baby shampoo or commercial eyelid cleaners to remove crusting 2, 5

Step 4: Periocular Skin Treatment

Apply hydrocortisone 1% cream to the affected periocular skin 3-4 times daily for maximum 2 weeks. 2, 5 This addresses the mild periocular erythema while avoiding prolonged corticosteroid exposure that can cause skin atrophy and telangiectasia. 2, 5

• Apply hypoallergenic, preservative-free moisturizing cream to periocular area at least once daily to restore skin barrier 2, 5

Escalation for Inadequate Response (2-4 Weeks)

If symptoms persist despite initial management:

Consider anti-inflammatory therapy: 1

• Topical cyclosporine 0.05% twice daily demonstrates success rates of 74% in mild, 72% in moderate, and 67% in severe dry eye by preventing T-cell activation 1, 2
• Short-term topical corticosteroid eye drops for 2-4 weeks maximum during acute exacerbations 1, 2
• Topical antibiotic ointment to lid margins once or twice daily for 2-4 weeks if blepharitis is present 1, 2

For refractory periocular dermatitis:

• Tacrolimus 0.1% ointment applied once daily to external eyelids demonstrates 89% response rates 2, 5

Arrange ophthalmology evaluation within 4 weeks if symptoms persist despite initial treatment. 2, 5

Special Considerations for Assisted-Living Residents

Elderly patients in assisted-living facilities face unique challenges: 6, 4

• Polypharmacy is nearly universal and contributes significantly to dry eye (up to 30% of persons over 65 affected by medication-induced sicca) 1, 7
• Reduced manual dexterity may limit ability to self-administer frequent eye drops 1
• Cognitive impairment may affect symptom reporting—staff should monitor for functional decline, increased confusion, or behavioral changes that may indicate worsening ocular discomfort 1

Important pitfall: In elderly assisted-living residents, infection may present atypically with minimal fever or classic signs. 1 While dry eye is most likely, bacterial conjunctivitis should be considered if purulent discharge develops, requiring topical broad-spectrum antibiotics. 3

Underlying Systemic Disease Screening

Approximately 10% of patients with clinically significant dry eye have underlying Sjögren syndrome. 1, 7 Consider rheumatology referral if:

• Severe xerostomia accompanies ocular symptoms 7
• Symptoms are refractory to standard therapy 7
• Patient has other autoimmune features (arthralgia, fatigue) 7

Long-Term Management Expectations

Counsel the patient and facility staff that dry eye syndrome is a chronic condition requiring long-term maintenance therapy, as symptoms often recur when treatment is discontinued. 1, 2, 5 The disease is usually not curable but can be effectively managed with appropriate ongoing treatment. 1