I am certain that you, as I do, quickly review a patient’s chief complaint and clinical history before you enter the exam room. The patient’s age, sex, race, medical history, and medications run through your mind as you plan the course of the patient interview and clinical exam.

As “blurry vision” is most likely near the top of the chief complaint list for many of our patients, a good refraction sets the base of information upon which we construct our patient profile. Etymologically, the word “presbyopia,” from the late 18th century, is derived from the Greek presbus or “old man” + ōps, ōp or “eye” (www.lexico.com ), which hints to us that age is at the core of the vision changes that beset presbyopes.

Of course, tear film dysfunction often contributes to or can be the primary cause of a patient’s visual complaints at distance and/or at near. In considering differential diagnoses for presbyopic patients, let us consider some pathologic changes of the ocular surface/adnexa that are more common in this age group.

Be on the Lookout

Vision and refraction established, remember to examine the full face of mask-clad patients at every visit. Brow position and eyelid evaluation are a critical starting point for a dry eye examination. Are the eyebrows and eyelids in a proper anatomical position? Has the patient had brow or eyelid cosmetic surgery or botulinum toxin injection (remember, we are talking about the presbyopic age group)? Is there a complete closure of the eyelids? What does the eyelid snap-back test reveal?

Lower eyelid laxity/ectropion denotes outward rotation of the eyelid margin. Facial nerve palsy often results in paralytic ectropion, particularly in the elderly (Weinberg, 2013). Some interesting current-events data: there have been several cases of peripheral facial nerve palsy following administration of the BNT162b2 SARS-CoV-2 vaccine in real-world data (Shemer et al, 2021). I, personally, have encountered three cases since March 2021. These results are preliminary and possibly are anecdotal incidents, and no cause and effect can be concluded at this time.

Is there eyelid retraction? There is a broad differential diagnosis for eyelid retraction, which has been well reviewed (Bartley, 1995).

Any condition that creates laxity or that limits motion of the lower eyelids can contribute to scleral show (Loeb, 1988). Scleral show occurs with aging as the lower lid loses its muscle tone and the skin becomes more elastic. It also can occur as a result of losing soft tissue volume in the cheeks. Scleral show, with increased exposure for the ocular surface, is a set-up for exposure-related dry eye.

Conjunctivochalasis (CCH) is a conjunctival condition characterized by loose, redundant conjunctival folds. CCH is a common cause of ocular irritation and discomfort, especially in the elderly, and it is often overlooked in clinical practice. Although often asymptomatic, CCH may cause symptoms related to tear film instability and/or to delayed tear clearance (Marmalidou, 2018).

When a Correction Is the Problem

Correction strategies for presbyopia and cataracts may directly or indirectly challenge the ocular surface. Contact lenses disturb the normal structure of the tear film and can interact negatively with the ocular surface, further deteriorating an already unbalanced tear film in presbyopes. Recall that cataract (think presbyopia-correcting intraocular lenses) and corneal refractive surgeries sever corneal nerves and disrupt the corneal epithelium and ocular surface, which can influence surgical outcomes and aggravate dryness symptoms in older age groups (Lafosse et al, 2020).

Conclusion

There is much to parse through in the global dry eye workup, especially for presbyopes. Remember this quick checklist of age-related challenges to the ocular surface in your ocular surface/dysfunctional tear syndrome exam. CLS

For references, please visit www.clspectrum.com/references and click on document #307.