Sinus congestion can lead to vision changes, dry eye syndrome

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Your first patient of the day’s chief complaint is “I have pain behind my eye,” “I have a headache over my eye,” “My vision is fluctuating,” “My eyes are itchy and red,” or all of the above. Where do you start?

The first 2 complaints always take the most time to figure out exactly what is happening and why there is pain because symptoms can range from mildly bothersome to very severe very quickly. Is it an acute or chronic issue? Constant or intermittent?

Let’s dive into allergy’s role here. Environmental allergens like pollen, dust, and dander can cause IgE-mediated inflammation.

The conjunctiva and the nasal and sinus mucosa have the same type of epithelium. Therefore, when an allergen is inhaled into the nose, the allergic reaction will also be present in the ocular conjunctiva and the mucosa of the sinuses. The anatomical connection between the eyes, nose, sinuses, and airway perpetuates the reaction. This can lead to rhinoconjunctivitis—as allergic conjunctivitis and allergic rhinitis often overlap—or rhinosinusitis, which is essentially a “head cold.”

The early-phase type I hypersensitivity reaction involves the release of histamine, which causes the initial sneezing, itching, and runny nose (rhinorrhea) but exacerbates vasodilation. More inflammatory mediators, such as prostaglandins and leukotrienes, will cause soft tissue swelling, decreasing the nasal diameter and increasing resistance to nasal airflow.¹ This means that the irritation of the tissues lining the nasal passages or sinuses sets off this chain reaction of inflammation, swelling, and mucous secretion, making it difficult to bring air in through the nose (inhaling/exhaling). The sinuses, normally filled with air, are now blocked with fluid and/or mucus. This extra fluid promotes germ growth and the potential development of sinusitis and ear or eye infections. Again, sinusitis is the inflammation of the epithelial lining of the sinuses from viral, bacterial, or allergic causes.

Anatomy of the allergy

Figure 1.The location of maxillary, frontal, sphenoid, and ethmoid paranasal sinuses. (Image courtesy of health.harvard.edu)

Reviewing the anatomical relationships of the sinuses to the eye is necessary to understand this further. The paranasal sinuses are air-filled extensions of the nasal cavity. All the sinuses drain back into the nasal cavity. The
4 paranasal sinuses are named after the bones they inhabit: maxillary, frontal, sphenoid, and ethmoid (Figure 1).

Figure 2.The branches of the trigeminal nerve, responsible for the sensation in the face, can be impacted by allergies. (Image courtesy of Richard J. Warren/plasticsurgerykey.com)

The first 2 branches of the trigeminal nerve are the ophthalmic and maxillary nerves. The sensation is supplied to the skin, mucous membranes of the sinuses and the eye (conjunctiva), and the teeth. The supraorbital nerve, a branch of the trigeminal nerve (via the frontal nerve), courses from behind the orbit outside of the muscle cone to exit through the supraorbital notch (Figure 2).

Now that we have reminded ourselves of the anatomy, we can say that sinus congestion can play a significant role in vision changes and dry eye syndrome. When sinuses become congested, it can lead to increased pressure and inflammation in the surrounding areas, including the eyes and nasolacrimal ducts. This can result in several effects on vision and eye health, such as the following:

Dry eye syndrome

Figure 3. The compounding effects of blocked tear ducts. (Image courtesy of alila07/dreamstime.com)

Multifactorial causes of dry eyes due to sinus congestion include the inflammatory, hypersensitivity response and the possible disruption of the normal flow of tears due to a partial or full obstruction of the nasolacrimal duct. This leads to poor tear quality, epiphora, itching, and redness (Figure 3).

Monocular diplopia

Monocular diplopia can be a possible visual complaint due to ocular surface disease stemming from dry eye syndrome.

Eyestrain and fatigue

Sinus congestion can contribute to eye fatigue, especially when the eyes are constantly strained due to vision changes or dryness. Another symptom of sinus congestion contributing to eyestrain and fatigue includes a feeling of heaviness in the eyes. This is exacerbated by other environmental factors such as prolonged reading or computer use.

Eye infection and/or inflammation

Sinus congestion can create a favorable environment for the growth of bacteria, leading to an increased risk of eye infections. These infections can exacerbate dry eye symptoms and cause additional vision problems.

Eye pain and pressure or facial pain

Inflammation of the sinus mucosa leads to swelling and subsequent blockage of the sinus openings (ostia). This prevents proper mucus drainage, resulting in increased pressure from the stretching of the sinus walls. This can be particularly noticeable when bending over or lying down. Patients usually describe this as a dull ache. Sinus congestion also narrows the nasal passages, and with the inflammatory cascade that produces mucus and tissue swelling, the pain/pressure sensation is triggered in the nasal cavity.

So that pain behind the eye or the headache above the eye stems from the supraorbital nerve, which is compressed from the sinus wall expansion, into the extraconal space (outside of the extraocular muscle cone). This pressure can also lead to blurred vision and difficulty focusing.

Photophobia

Photophobia can accompany sinus pain/pressure. It is also a common feature of dry eye syndrome.

Headache

A sinus headache is characterized by deep, dull pain in the forehead, cheeks, or around the eyes. Chronic inflammation may lead to neuropathic pain (abnormal nerve signals) such as trigeminal neuralgia, described as persistent pain, burning, or sharp pains in the face, scalp, or neck.

It is vital to mention that in severe cases of sinusitis, including cavernous sinus thrombosis or orbital cellulitis, the nerves can be compressed, causing radiating facial pain, numbness, or tingling. The optic nerve can also be under pressure; these vision changes are beyond what you would see with dryness. These qualify as an emergency and need stat imaging and emergent referral.

These effects of sinus congestion on vision and eye health can vary in severity and duration. It is important to promptly address sinus congestion to alleviate these symptoms and prevent further complications. Medical treatment, such as antihistamines (nasal and oral), decongestants, and nasal irrigation, can help relieve sinus congestion, with additional ophthalmic treatment also improving dry eye and allergy symptoms.

Reference:

1. Naclerio R. Clinical manifestations of the release of histamine and other inflammatory mediators. J Allergy Clin Immunol. 1999;103(3 pt 2):S382-385. doi:10.1016/s0091-6749(99)70216-2