Clinical Pearls, Pointers & Philosophy
Here are some random observations on a wide range of issues
related to optometric practice and patient care.
As part of our lectures, we are privileged to answer many
hundreds of questions and offer our perspectives on a wide
range of issues germane to optometric practice. Here, we share
a number of these pearls, pointers and philosophies. We hope
you enjoy these random observations. Some are strictly informative.
Others are meant to stimulate thought. But all are focused
on helping you sharpen your skills.
• Viroptic (trifluridine) and Xalatan (latanoprost) are
kept under refrigeration at the pharmacy, but do not need to
be kept refrigerated by the patient. However, if the patient
has some Viroptic (or generic trifluridine) remaining following
acute treatment, advise that the medicine be kept in the refrigerator
to be used in the event of a recurrence. The patient can then
restart therapy without delay until they can see you in your
office in a day or two. Regarding Xalatan, if a patient acquires
three bottles at one time, two of the bottles should be stored
in the refrigerator. This is not absolutely necessary, but
is probably a good idea, just the same.
• Engage your patients with diabetes. Always inquire about
their hemoglobin A1C level. If they don’t know what you’re
talking about, take a moment to educate them. Metrika (www.A1CNOW.com)
has excellent brochures available for free that discuss this
crucial parameter of diabetic assessment and monitoring. You
can keep these brochures in your office for the benefit of
your patients, or you can direct your patients to Metrika’s
web site.
• Many altruistic, apolitical (and perhaps uninformed)
primary care physicians may purposefully steer your/their patients
to eye surgeons for diabetic retinal examinations. You need
to do two things to take charge of this. First, let all your
patients know that you have a keen interest in diabetic eye
disease, and that you are skilled in its care. Otherwise, you
could well have an established patient develop diabetes and
be directed elsewhere for continuing eye care. Second, become
acquainted with the primary care physicians in your area and
share with them your training and willingness to help them
care for their diabetic patients. Many primary care physicians
have no idea of the breadth and depth of optometric training
and our expertise in diabetic eye disease.
• Diabetic patients who develop diplopia resulting from
3rd or 6th nerve palsy usually regain normal visual function
within three months. If you see no improvement in the diplopic
posture within a month or two, or if there are other neurologic
signs or symptoms, then a scan should be considered.
• Use Paremyd (Akorn) to dilate most of your patients most
of the time. Paremyd is quick, easy, effective, and it wears
off relatively quickly. Rev-Eyes (Bausch & Lomb) can be
used in conjunction to accelerate visual recovery. Reserve
1% tropicamide and 2.5% phenylephrine for those difficult-to-dilate
patients who present with symptoms compatible with retinal
detachments and other potentially serious disorders.
• We always dilate young children and infants especially
at their first visit. Cyclomydril (Alcon) is a combination
drug that has been around for many years which perfectly meets
the challenge of pediatric dilation. It is a combination of
0.2% cyclopentolate and 0.1% phenylephrine HCl. We have used
Cyclomydril hundreds of times with excellent success, and highly
recommend its use for pediatric dilation. It can be used in
infants; be sure to read the precautions and contraindications.
• Former President Jimmy Carter and the Amercian Optometric
Association have urged the optometric community to make a renewed
effort to detect amblyogenic defects in children at an early
age, with the ultimate goal of preventing lifelong visual compromise.
At SECO, President Carter, the spokesperson for the AOA’s InfantSEE
program, advocated for free amblyopia screenings for very young
children. While providing professional services gratis sounds
like a non-revenue generating exercise, such humanitarian gestures
will win the hearts and loyalty of mothers and fathers. Performed
with a spirit of caring and concern, such services could become
another excellent source of new patients.
• It is imperative that we as a profession begin to open
the lines of communication with the medical community. Having
access to a dictation system (on-site or off-site) is becoming
increasingly crucial as optometry further integrates into the
mainstream of health care delivery. If you stop and think about
it, good interprofessional communication not only enhances
patient care, but shows you to be an integral member of your
patient’s health care team. For patients with diabetes or those
taking Plaquenil, we have preprinted forms we simply complete
and fax to the primary care physician (and/or endocrinologist
or rheumatologist). These same forms are available on this
website on the "Diabetes
Update" and "Plaquenil
Update" pages.
 • For acute angle closure events, be sure to keep acetalzolamide
tablets, brimonidine, and/or a beta-blocker readily available.
The prostaglandins are relatively slow-onset drugs and have
no role in acute angle closure or acute IOP elevation management.
• When conducting a monocular therapeutic trial with a
drug that has a 24-hour cycle (like a non-selective beta-blocker
or a prostaglandin), have the patient dose the drug every day
of the trial, except on the day of the evaluation (or the night
before, in the case of a prostaglandin). This is an excellent
way to measure the drug’s effectiveness over a full 24-hour
cycle.
• For goodness sake, if you are not an AOA member, we strongly
urge you to join! We’re all in this together, and hopefully,
we’re all striving for common goals. We promise you, a strong
AOA safeguards all of our practices. Call 1-800-365-2219
to inquire.
• A large percentage of patients who sustain a retinal
tear, break or rhegmatogenous detachment will have a release
of either RPE pigment granules, red blood cells, or both. These
tend to migrate into the retrolental vitreous and can be readily
visualized via standard slit lamp biomicroscopy. Known as “Shaffer’s
sign,” these granules look like “paprika” or “tobacco dust,”
and are evidence of a break in the retinal tissues, even before
ophthalmoscopic, or 3-mirror gonioscopic observation is attempted.
• When patients present with a symptomatic posterior vitreous
detachment (PVD), it’s our experience that they have about
a 10% chance of a retinal tear or break. The most common age
for these events is the early 60s. Although the probability
of occurrence is small, always vigorously search for a retinal
tear or break with binocular indirect ophthalmoscopy and scleral
depression. Patients with acute PVD who have no retinal breaks
on presentation have a 2-5% chance of developing them in the
weeks afterward. If all looks well at the initial visit, still
counsel your patients there is the small risk that a problem
may occur, and to contact you right away if it does.
• Be sure to check the blood pressure of all patients
having any type of acute microvascular event. Uncontrolled
systemic hypertension remains a major cause (or contributing
factor) to a host of vascular and neurological eye problems.
• Check with your state’s Social Security/Disability Assessment
Office to inquire about conducting visual disability examinations.
The AOA or your state association can help guide you to the
correct governmental office in your state. Disability examinations
can be yet another revenue stream for your practice, and a
good service for your community.
• If your patient reports an allergy to penicillin, it
is probably wise to also avoid using cephalosporins, such
as cephazolin (Keflex), since there is a 5 to 10% cross-allergenicity
with penicillin.
• Let’s take the word “recurrent” out of recurrent corneal
erosion by getting more aggressive in managing patients with
this painful, debilitating disorder. Rather than playing around
with the so-called traditional (or conservative) approaches,
begin to employ (if legally allowed in your state) one of two
more clinically curative approaches in an effort to prevent
any further erosive events.
Medical: Oral doxycycline 100mg q.d. x 1 week, followed by 50mg
q.d. x 2 months, along with Lotemax q.i.d. x 1 month, then b.i.d.
x 1 month. Concomitant artificial tears and GenTeal Gel at bedtime
are helpful, especially for the first week or two.
 Surgical: Perform “anterior stromal micropuncture” by making
numerous micropunctures into and through the epithelial basement
membrane/Bowman’s layer complex. This profoundly simple procedure
is done at the slit lamp with a stromal micropuncture needle.
Treat the lesion and 1-2mm of the surrounding tissue. Then
place a silicone hydrogel bandage soft lens on the eye and
treat with a fluoroquinolone q.i.d., and Voltaren or Acular
LS q.i.d., and follow up in 24 hours. These iatrogenic micropunctate
corneal abrasions heal in a day or two in most cases. For a
detailed description of this procedure, consult the excellent
textbook Atlas of Primary Eye Care Procedures, by Drs. Casser,
Fingeret and Woodcome. Any school or college of optometry bookstore
will have this Appleton & Lange publication.
Both the medical and surgical procedures alter the biochemical
environment of the basal layers of the epithelium/Bowman’s
membrane complex, resulting in a more firm adhesion of these
structures, thus “defibrillating” recurrence.
• Remember, anyone weighing less than 135lbs. is at increased
risk for maculotoxicity if they are taking the standard 400mg/d
dosage of Plaquenil. Below 135lbs., there is an inverse relationship
between body weight and maculotoxic potential, i.e., the lower
the body weight, the greater the potential for visual loss.
• It has been demonstrated that losing 6% of body weight
is usually curative for most cases of pseudotumor cerebri.
Therefore, it is incumbent upon us to encourage these patients
in this regard during their follow-up visits.
• Spontaneous venous pulsations are usually extinguished
at about 200mmH2O (the units of CSF pressure measurement).
The opening pressure reading as measured by lumbar puncture
(always following a head scan to rule out a true mass) in patients
with benign intracranial hypertension (a.k.a. pseudotumor cerebri)
is usually between 250 and 600mmH2O.
• Occasionally, and for a multiplicity of reasons, a patient’s
pupils may already be pharmacologically dilated when first
seen in your office. A good surrogate for optic nerve function
is the “red cap test.” Simply ask the patient to observe the
redness of the cap on one of your eyedrop bottles out of the
good eye, and explain that this represents a dollar’s worth
of redness. Then have the patient observe the red cap out of
the affected eye, and ask how much the red cap is now worth
relative to the good eye. This test can be very helpful in
quasi-quantifying any unilateral optic nerve dysfunction.
• Voltaren and Acular LS are excellent adjuncts for ocular
surface pain, but topical NSAIDs are extremely poor substitutes
for topical corticosteroids in suppressing tissue inflammation.
• Since nonsteroidal anti-inflammatory drugs affect prostaglandin
production, can they be used with a prostaglandin medicine?
Absolutely! NSAIDs are also referred to as cyclo-oxygenase
(prostaglandin synthetase) inhibitors. This class of drugs
merely hinders the production of prostaglandins. NSAIDs have
no effect on the prostaglandin receptors on cell membranes.
The pressure-lowering prostaglandin drugs are prostaglandin
receptor agonists and their action is in no way altered by
drugs that inhibit the synthesis of endogenous prostaglandins.
 • Two commonly-used ophthalmic medicines have a slight
yellow color: Alocril (nedocromil, Allergan) and Vigamox (moxifloxacin,
Alcon). Be sure to tell patients about this in advance so they
don’t think they have a defective product.
• Baseline intraocular pressure assessment should be established
as early as is practically possible, generally somewhere around
ages8 to 10. The use of a Goldmann handheld applanation tonometer
or a Tono-Pen could enable IOP measurement in even younger
patients. Such measurement takes on greater relevance if there
is a family history of glaucoma or if optic nerve cupping is
suspicious. We commonly look at the optic nerve heads of attendant
family members with any young person with large cup-to-disk
ratios. It may be that larger C/D ratios are merely a family
trait.
 • Always palpate for preauricular lymphadenopathy in any
red eye where adenoviral infection (EKC) is a possibility. The
presence of a palpable node in the presence of a watery eye is
virtually always pathognomonic of EKC.
• Do ophthalmoscopy on all new patients, even if they
are in for a problem-oriented visit such as a corneal foreign
body, etc. It is our ethical and legal duty to screen for potentially
blinding diseases such as glaucoma. A quick ophthalmoscopic
assessment of the optic nerve head would catch any moderate
to advanced glaucoma. As we are all aware, some people only
come to an eye doctor if they have a problem, so don’t miss
these screening opportunities.
• We are proud to be O.D.s. Our lab coats, shingles, stationery,
etc., state: Ron Melton, O.D., and Randall Thomas, O.D. Occasionally,
it gives us the opportunity to explain to inquiring patients
what exactly “O.D.s” do. We are pleased to explain to any patient
the very special and unique package of care an O.D. is able
to provide. It’s kind of like the old saying, “If you always
do what you’ve always done, you’ll always make what you’ve
always made.” Our profession is evolving beautifully, taking
on more responsibilities and providing a broader scope of professional
services. We need to do some serious introspection on our image,
and present a “new and ever-improving” impression to the public.
• Occasionally, you will encounter patients who present
with a red eye that could be one of several disease processes.
For example, the cause could be acute dry eye, a small abrasion,
recurrent erosion, or herpetic keratitis, etc. From time to
time, it can be impossible to differentiate the diagnosis at
the patient’s initial presentation. Rather than have the patient
pay more than $100 for trifluridine when you are not sure it
is truly needed, give them a sample of an artificial tear to
use every one to two hours until you see them back the next
day. Buy yourself some time for the condition to evolve to
a diagnosable presentation, or improve. Tell your patient exactly
what thoughts and approaches you are considering to relieve
their condition, but explain that you feel it would not be
in their best interest to pursue a definitive course of action
until you are certain of the diagnosis.
• We truly need to begin to work more cooperatively as a
unified profession. One way to do this is to rely on one another
for patient consult visits. There are O.D.s who still commonly
refer out otherwise simple eye problems to M.D.s. Please consider
having these patients see an O.D. in the community who commonly
handles medical eye problems. This helps build our profession
and public confidence in optometric care.
• Here’s a real helpful thought for those patients who
present with an acute pupillary abnormality. Old photographs
can usually confirm a history of congenital anisocoria. But
for quantitatively significant, acute cases (it is almost always
the larger of the two that is the problem pupil), there are
two consistent precipitating causes:
– OTC vasoconstrictors
– Scopolamine motion-sickness patches
Always question the patient about these two possibilities.
Anticholinergic eyedrop exposure must be considered if the
patient is in any way involved in health care, where inadvertent
contact with such agents could occur. Of foremost concern is
ruling out Horner’s or Adie’s pupil but, this being done, the
above possibilities need to be considered.
• If you are providing services beyond “Eyes Examined/Contact
Lenses,” please redesign your shingle/signage to portray to
the public a truer reflection of what you do. Here are some
suggestions:
- Adult and Pediatric Eye Care
- Family Eye Care
- Comprehensive Eye Care
- Routine and Medical Eye Care Services
We are in a new era now, and many times our signage woefully
misrepresents the broad range of services we provide.
• Not all patients with bacterial conjunctivitis present
with obvious mucopurulent discharge. Some even clean their
eyes, lashes and face prior to presenting, unwittingly exacerbating
the diagnostic challenge. In these less-than-obvious cases,
carefully examine the lacrimal lake for mucopurulent debris.
Darken the room lights, set your slit lamp on high magnification,
narrow down the beam, and critically examine the lacrimal lake
(as looking for cells in the anterior chamber). Like aqueous,
the lacrimal lake should be optically empty. If there is significant
microparticulant debris, and the history and other clinical
findings are compatible with bacterial conjunctivitis, then
this can seal the diagnosis.
• When examining for pupillary abnormalities, a UV lamp
(Woods or Burton) can facilitate evaluation in a dark room.
Keep the light source below fixation and about two feet away
from the patient’s eyes to avoid any constriction due to the
visible light coming from the lamp source. The low-grade fluorescence
of the crystalline lens helps to outline the pupillary borders.
 • How one dresses and carries him- or herself is most certainly
a personal choice. That said, we would like to offer our perspective
as well as what a recent article in the optometric literature
had to say concerning this issue. Optometrists need to look
at least as good in the eyes of our patients as do the other
doctors in our various communities. In our case, we practice
in urban and suburban settings, so we generally wear dress
shirts and a necktie, and always a full-length, white lab coat
with our names embroidered neatly above the left breast pocket.
As the saying goes “Dress for Success.” Following is what a
review study found on this subject:
“So what do your patients prefer you to wear? One study, which
reviewed 31 other articles on this question, found that patients
do indeed want their doctors to dress professionally, preferably
in a white coat with a nametag. Patients tend to favor more
formal dress, and give high ratings to a shirt and tie, dress
pants, skirts or dresses, and dress shoes.”
—Is it Time to Hang Up the White Coat? Rev Optom 2004 Mar;
141(3): 35-37.
• The handheld Goldmann applanation tonometer is one of
our most cherished instruments. It is “gold standard,” is less
than half the cost of a Tono-Pen, and is clinically equivalent
to a slit lamp-mounted Goldmann tonometer. Two AA batteries
provide the power source. The handheld Goldmann applanation
tonometer is especially useful for patients who have difficulty
getting comfortable at the slit lamp, high anxiety blepharospastic
patients, children, and patients in wheelchairs. It is also
great for use at nursing homes, hospitals, and on mission trips.
We use ours several times a day and love it. Kowa and Perkins
manufacture clinically equivalent instruments, in our opinion.
• About 20% of the time, Thygeson’s superficial punctate
keratitis is unilateral, which means it could easily be confused
with herpes simplex disease. A real help in differentiating
the two is the degree of conjunctival injection. Usually, a
Thygeson eye is white or minimally injected, whereas the HSV
eye is usually grade II or more injected. Corneal sensitivity
testing can be helpful as an adjunct.
 • Patients with adult inclusion conjunctivitis (chlamydial
conjunctivitis) usually have had a red eye for a week or more
before you see them. They have likely been to a doctor less astute
than you and may have been placed on a topical antibiotic (which
is why they are seeking a second opinion). If you observe “giant
follicles” within the inferior forniceal conjunctiva on the affected
side, think about chlamydia. Proper treatment includes artificial
tears every two to four hours for several days and oral azithromycin
(two 500mg tablets) taken in a single dose. This 1,000mg one-time
dose is chlamydiacidal in most all cases. Also available is a
1,000mg granular suspension in a single-dose foil packet. Just
dissolve the granules in half a glass of water, and bottoms up!
Both approaches are equally effective.
• For patients plagued with chronic, recurrent HSK disease,
it is well-established and safe to offer them a one or two-year-long
course of 400mg of acyclovir twice daily. This prophylactic
approach reduces the risk of recurrence by about 50%. Acyclovir
is available generically and under the brand name Zovirax.
•
Speaking of risk reduction, remember that four tablets per
day of Ocuvite PreserVision has been shown in the AREDS study
to reduce the rate of progression of moderate to moderately-advanced
atrophic macular degeneration by 25%. Always encourage your
tobacco-addicted patients to stop smoking, as this is also
a significant risk factor for AMD.
• When older patients complain of transient visual loss
(most usually unilateral), two primary concerns should come
to mind: giant cell arteritis (GCA) and carotid stenotic/ulcerative
disease. To rule out GCA, pursue the history specific to new
onset headache (the most common symptom), aswell as scalp tenderness,
jaw claudication (discomfort/pain with mastication), weight
loss, and malaise. Always get an erythrocyte sedimentation
rate (ESR/sed rate), as this is usually elevated in the setting
of inflammatory arteritis. For men, the normative value is
their age divided by 2. For women, this value is determined
by taking their age plus 10 divided by 2. For suspected carotid
artery disease, examine the retina for Hollenhorst plaques,
and auscultate and palpate the carotid arteries. Don’t forget
to get out your stethoscope and listen for a bruit. Never hesitate
to order carotid duplex (Doppler/ultrasound) studies if carotid
artery disease is suspected.
• If at all practical, get on the hospital staff in your
community, especially in rural areas. Your expertise in this
setting would be enormously helpful. Not only will the patients
and hospital benefit, so will your practice.
• In our experience, patients in nursing homes and advanced
care facilities are largely abandoned by their eye doctors.
Many are on eye medications that are needless, or are plagued
with chronic blepharitis, trichiasis, dry eyes, and occasionally,
total cataracts. We urge you to consider spending at least
a half a day a month in one or more of these settings. The
rewards can be immense from both humanitarian and financial
perspectives. The AOA has developed packets containing very
helpful information regarding both hospital and nursing home
services.
• Your tax dollars are at work for you at the National
Eye Institute. They have an abundance of excellent, politically-correct
patient education brochures on a variety of topics germane
to primary eye care. The institute will send you any of these
at no cost. Visit www.nei.gov, or call them at 301-496-5248.
• While we like all the new retinal and optic nerve scanning
devices, we are reminded of the attending physician discussing
a specific patient during hospital grand rounds. As she and
her residents looked over the lab results, she observed: “If
these lab tests continue to be abnormal, we will need to examine
the patient!” It is nice to have new technology, but we need
to keep our clinical skills impeccable. Don’t lose your perspective
amidst a flurry of digitized images.
• In patients with iritis or episcleritis who are resistant
to the steroid taper and flare back up, have them start taking
400mg q.i.d. of ibuprofen for two to four weeks, then 400mg
b.i.d. for two to four weeks. Many times, this can be helpful
in enabling a successful steroid taper. Just a fine point for
those unusual cases.
• Don’t hesitate to charge a fair fee for your professional
services. The Medicare reimbursement schedule provides a good
benchmark for the relative value of various procedures eye
doctors provide.
• The “ophthalmology” codes need to be renamed “eye care”
codes, just like the PDR for Ophthalmology is now entitled,
PDR for Ophthalmic Medicines. Also, it is preferable to generically
address optometrists and ophthalmologists as “eye doctors,”
not as “eye care practitioners.”
• Take a good look at your “red eye” or problem-oriented
patients before you zoom in on the slit lamp examination. Noticing
subtle dermatologic clues (e.g., seborrheic dermatitis, early
zoster dermatitis, facial rosacea) can augment your examination,
allowing for proper diagnosis and treatment.
 • For filamentary keratitis, following proparacaine anesthesia,
use fine-tipped jewelers’ forceps to snip the filaments from
their attachments. You can choose to either aggressively lubricate
the eye, or place a silicone hydrogel bandage lens along with
an antibiotic drop q.i.d. for 1-2 days until the micro-abrasions
(where the filaments were removed) are healed. Once the acute
filamentary crisis is past, pursue ongoing measures of your
choice to maximize tear film function.
• The most common cause of eye stickiness upon awakening
is excess mucus resulting from dry eye syndrome. A good history
and slit lamp exam will enable the differential diagnosis of
dry eyes from an early, or low-grade, bacterial infection.
Remember, dry eye disease is rampant, while bacterial infection
in adults is rare. Other clinical entities where excess mucus
(not mucopurulence) is a common feature are allergic and chlamydial
conjunctivitis.
• If a patient is sent to you to rule out Wilson’s hepatolenticular
degeneration, carefully examine the superior peripheral corneal
endothelial tissues, both with and without gonioscopy, looking
for evidence of copper deposition in the tissues. These tend
to be younger patients (20s or 30s) with behavioral or GI disorders,
and are commonly referred by gastroenterologists or psychiatrists/psychologists.
• Punctal plug loss can be minimized by using calibrated
“sizing devices” to accurately measure punctal diameter. We
try to insert as large a diameter plug as is practical. These
devices enable us to more precisely select a plug size that
is less likely to extrude. Such devices are available from
most companies who manufacture punctal plugs.
• Some patients have such advanced dry eye disease that
both the upper and lower puncta merit occlusion. There are
times when the pendulum swings too far, and epiphora occurs.
These situations are best remedied by using a Flow Controller
plug made by Eagle Vision. It is not totally occlusive, but
allows some lacrimal egress, thus promoting good ocular surface
lubrication without exceeding the point of diminishing return.
Such intervention is not commonplace, but when fine-tuning
is required, these Flow Controller plugs perform nicely.
• The new Glaucoma Progression Analysis software by Zeiss-Humphrey
is a major advance in detecting progression of visual field
defects. Not only can it be helpful prospectively, it can retrospectively
analyze the visual field data collected over the past several
years. If you have SITA, you need to investigate adding this
new upgrade.
• It is not a sin to patch a corneal abrasion. Large abrasions
are often best managed with a drop of proparacaine, diclofenac
(Voltaren, Novartis), and 1% cyclopentolate followed by Polysporin
ophthalmic ointment under a well-fixed pressure patch. Alternatively,
use a silicone hydrogel lens placed over the above eye drops,
along with a preservative-free artificial tear q.i.d. and a
fluoroquinolone q.i.d. Follow abrasions daily until re-epitheliazation
occurs. For children with smaller abrasions, cycloplege in
the office, then use Voltaren q.i.d., a fluoroquinolone q.i.d.,
and a high-viscosity artificial tear q.i.d.
• We recommend a 30-2 visual field for any neurologic
testing. We recommend a 10-2 visual field when performing Plaquenil
assessments. It makes no difference whether the red target
or white target is selected; just be consistent. We always
use the white target; it’s just simpler and more efficient
for our technicians.
• When examining and characterizing the optic nerve, be
sure to record whether the assessment was done with a two-dimensional
view (i.e., direct ophthalmoscope) or a three-dimensional view
(i.e., slit lamp-enabled 90D, or similar condensing lens).
A 0.3-appearing cup with a direct can be a 0.5 or 0.6 cup with
a stereoscopic view, which is why it is important to specify
the type of instrument used. We highly recommend all optic
nerve head cupping assessments be made with a stereoscopic
view, if possible.
 • Most all of us have patients with problematic ocular
prostheses. Alcon makes an OTC eye drop under the name Enuclene.
It is a combination of tyloxapol (a detergent) and benzalkonium
chloride. Used q.i.d., it has been shown to enhance and maintain
comfort for many patients with prosthetic eyes.
• The breakdown products from fingernail polish are a
common cause of contact blepharoconjunctivitis. We now routinely
treat these patients with 0.1% triamcinolone cream. The frequency
of application is proportional to the severity of the expression,
but is usually t.i.d. for two to three days, then b.i.d. for
two or three days, then qhs for two to three days. Triamcinolone
comes in a large 4oz. tube and is inexpensive. Be advised that
it is not an ophthalmic preparation and states on the label,
“Not for ophthalmic use.” For those patients (or doctors) who
prefer an ophthalmic preparation, prescribe FML ointment.
 • If you truly believe you have a patient with fungal keratitis,
culture it and initiate therapy with amphotericin B (which
can be made into an ophthalmic eye drop by a hospital-grade,
compounding pharmacy) and Natacin (natamycin), which can be
shipped overnight from Alcon. We have our fugal keratitis patients
use both medicines hourly (while awake) for a few days, then
taper based upon clinical response. All this is best done in
consult (telephone or office visit) with a corneal specialist.
Like corneal ulcers, we have seen less than a handful of these.
 •
When removing a corneal foreign body with a basement of dense
rust, first remove the bulk of the metal. Then use any sharp-tipped
instrument of your choice to lift the rust plaque as a unit,
or to fragment the residual rust. The Alger brush will only
polish, not remove, densely compacted rust. So first break
up the deposited rust, which then enables the Alger brush to
completely (or nearly completely) remove all the foreign material.
There is little or no wisdom in removing the foreign body and
then waiting a day or two before removing the rust.
• Schirmer testing is the least useful diagnostic test
for dry eye. The diagnosis can be made by a careful history,
with clinical examination confirmation and quantification.
We thoroughly examine the volume of the lacrimal lake, examine
the cornea with fluorescein dye, and measure the tear film
breakup time. This should allow near perfect diagnostic accuracy.
If you feel compelled to go the extra (usually unnecessary)
mile, use lissamine green dye. Avoid rose bengal because of
its rather marked capacity for burning and stinging.
 • Herpes zoster ophthalmicus is one of the diseases we most
enjoy managing. Acyclovir 800mg 5 x day, or Valtrex 1,000mg
t.i.d. p.o. nicely arrests the viral replication, and Pred
Forte q1-2h nicely controls the inflammatory keratitis and/or
uveitis, and/or inflammatory trabeculitis (causing high IOP
if these tissues are involved). Topical antivirals are not
needed. Use cycloplegia p.r.n. This second episode of varicella
infection bolsters the immune system, which explains the exceedingly
rare. recurrence of adult zoster disease. Herpes simplex disease
is prone to recurrence and behaves distinctly different from
herpes zoster disease.
• It has traditionally been advised to use hypertonic (5%)
ointment at bedtime in patients with recurrent corneal erosion
(RCE). While there is nothing wrong with this, many patients
do begin to experience irritation after several instillations.
We have found that preservative-free opthalmic lubricating
ointment or a gel-based product performs well in these situations,
and are much less likely to become irritating. Bear in mind
that a breach in the integrity of the basement membrane plays
a key role in the RCE cycle. The basement membrane takes siz
to eight weeks to fully heal. What we are trying to achieve
with lubrication at bedtime is the prevention of a re-break
or re-tear, allowing time for these tissues to completely heal.
Ocular pain control is generally accomplished with cycloplegia,
a topical NSAID, and an oral analgesic. We generally recommend
that topical NSAIDs to be used q.i.d. While the risk is remote,
more frequent instillations could result in corneal integrity
compromise. For oral analgesia, we typically use ibuprofen
1,600mg daily (i.e., two 200mg tablets q.i.d.). This dosage
is highly effective and roughly equivalent to that of commonly
used prescription analgesics and narcotics. Our perferred prescription
medicine is Vioxx, two 25mg tabs (50mg_ qd, and our narcotic
choice is Schedule III Lortab 5 or Lortab 7.5 (these numbers
refer to the mg strength of the hydrocodone). Lortab is a combination
of hydrocodone and 500mg acetaminophen.
• For patients with chronic staphylococcal blepharitis, a
one or two-week course of TobraDex ointment (b.i.d. x 1 week,
then qhs x 1 week) is helpful in three ways:
1. diminishes staph populations;
2. quiets the associated tissue inflammation;
3. physically softens and loosens scruff and collarette debris.
This has been immensely helpful to our patients over the years.
The only problem is, it works so well that patients often ask
for refills. Steroids are wonderful, but long-term use is unwise.
We always explain to our anterior blepharitis patients that
it is persistent and meticulous eyelid hygiene that controls
this condition, not any medicine. Since patients can be notoriously
non-compliant, this entire cycle of treatment and education
may need to be repeated every six to 12 months.
• When a patient presents with a history of probable conjunctival
foreign body, rather than use Fluress (or any other fluorescein/topical
anesthetic agent), just use plain fluorescein dye. It may
be a bit more uncomfortable for the patient, but this way the
patient can immediately report to you whether or not the foreign
body sensation remains. Otherwise, the patient may have to
wait in your office 20 to 30 minutes for the anesthesia to
wear off to be sure you treatment has resolved their symptoms.
• When performing a fluorescein-enabled tear film break-up
time, try to use a sparse amount of fluorescein dye. If the
fluorescein strip is too heavily wetted, or too much fluroescein
is instilled, the results can be marred. Just enough dye to
color the tear film is the ideal amount. It may be necessary
to wait several minutes for the drainage of the excess dye
to attain a reliable result.
• In patients with chronic diseases like glaucoma, dry eyes,
keratoconus, recurrent herpes keratitis, recurrent uveitis,
etc., don't educate them exhaustively at the initial visit.
Rather, give them the basics, a good brochure, and answer all
of their questions, but don't overload them. We generally give
our patients a "Ph.D." in their condition over several
visits, and always remind them to write down any questions
they think of for us to go over at their next visit.
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