Review of Cornea






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Clinical Pearls from Melton and Thomas

The annual Clinical Guide to Ophthalmic Drugs, which accompanies this issue, is so filled with information that we couldn’t fit it all into one package. So, here’s an extra excerpt of choice clinical pearls.
Ron Melton, O.D., and Randall Thomas, O.D., M.P.H.

6/16/2010

We’re privileged to answer many hundreds of questions and offer our perspective on a wide range of issues on optometric practice. Here are some of the pearls we’ve picked up along the way. (For more, see this year's Clinical Guide to Ophthalmic Drugs.)

• If you don’t rapidly cure patients of their eye complaints, or correct their vision to their level of satisfaction, they’ll seek care from another doctor. Such attrition can be curbed by an honest, open conversation with the patient about expectations and outcomes and the natural history of the condition.

• When treating red eyes, be sure to explain to the patient the nature of his/her condition—and, most critically, explain the anticipated time course to improvement and/or recovery.

• It’s critically important to tell the patient that your prescribed therapy should bring quick improvement—however, if there is no improvement in just a couple of days, or if the condition worsens, tell the patient to contact you immediately or return to your office. If you don’t have such a conversation and things do not go as anticipated, the patient may simply seek care elsewhere. Bottom line: Talk to your patients!

• When you encounter a red eye(s) and the diagnosis is not clear, consider a steroid (or at least a combination antibiotic-steroid) as initial therapy. Many optometrists’ typical default maneuver is to prescribe an antibiotic in these uncertain situations. However, most such red eyes are inflammatory in nature, particularly if there is no discharge.

• If the patient’s only symptom of allergic conjunctivitis is itching, then a topical antihistamine/mast cell stabilizing drug is all that’s needed. If, however, the patient has both symptomatic itching and signs, as exhibited by conjunctival injection (with or without chemosis) and eyelid edema, then unhesitatingly initiate therapy with an inflammation-reducing steroid, such as loteprednol (either 0.5% or 0.2%, depending on severity), every two hours for a couple of days, then q.i.d. for a week, and then perhaps b.i.d. for another two to four weeks. If indicated, long-term control can be obtained with a topical antihistamine/mast cell stabilizer, such as over-the-counter ketotifen.

• Any round or oval-shaped pathologic process at or near the limbus is almost always inflammatory and merits the use of a topical corticosteroid. The only exception to this rule that we can think of is a herpes simplex lesion—but an HSV lesion would be linear in its morphology, making it easily distinguishable.

• Herpes simplex keratitis can be effectively treated with topical trifluridine, topical ganciclovir or a systemic antiviral, such as 400mg generic acyclovir prescribed five times daily for one week. Interestingly, and somewhat counter-intuitively, the oral therapy is the least expensive of these three options, and has been shown to be equally as efficacious as topical therapy.

• Thygeson’s superficial punctate keratitis (SPK) is ideally treated with Alrex (loteprednol 0.2%, Bausch + Lomb). It can be dosed q.i.d. for one week, then perhaps b.i.d. for another week or two. We encourage our patients with Thygeson’s and those with chronic, recurrent uveitis to keep their steroid eyedrops readily available so they can initiate therapy as soon as the condition manifests. We advise our uveitis patients to see us within two or three days for a definitive evaluation if they need to start their drops while out of town or over a weekend.

• In the unlikely event that a patient’s IOP increases secondary to the use of corticosteroid eyedrops, it usually occurs within two or three weeks of onset of therapy. Acute therapy with any chemotherapeutic agent in eye care is unlikely to go beyond this timeframe. However, when therapy is prolonged (as in uveitis, stromal keratitis, post-corneal transplant, dry eye, etc.), be sure to measure the IOP around the two-week mark, and probably again in another two weeks. If there is no increase in IOP by two to four weeks of therapy, then one is unlikely to occur.

• Conventional teaching holds that adult-onset toxoplasmic retinochoroiditis is secondary to in utero exposure. It is now is well established that perhaps half of all adult-onset cases are acquired, and are not associated with any prior exposure.1 Uncooked or raw meat, and exposure to cat feces are the two most common sources of acquisition. ELISA (enzyme-linked immunosorbent assay) titers can help confirm a diagnosis, but ELISA data is not conclusive. The most common in utero infections can be remembered by the acronym TORCH: Toxoplasmosis, Rubella, Cytomegalovirus and Herpes virus.

• General observations regarding patients with low-tension glaucoma: they are usually middle-aged women who have, or have had, migraine headaches, take aspirin, and perhaps have a disc hemorrhage. Be sure to ask about cold hands, as Raynaud’s disease can be associated as well. Always rule out buried drusen as a cause for unexplained visual field defects. Finally, if these patients are taking blood pressure medicine (at night), their diastolic pressures could be dipping below 55mm Hg. Such sustained systemic nocturnal hypotension can set the stage for, or exacerbate, low-tension glaucoma, and is also a risk factor for ischemic events, such as stroke, anterior ischemic optic neuropathy and central retinal vein occlusion.

• Because patients with pseudoexfoliation can have considerable zonular weakness (with or without an increase in intraocular pressure), consider sending these patients for cataract surgery earlier than patients without pseudoexfoliation. This may achieve a more successful outcome, because zonular weakness progresses over time.

• We love extended-wear soft contact lenses—when worn on a daily-wear basis! We always strive to educate our patients about the 10- to 15-fold increased risk of serious keratitis when lenses are worn overnight, and we carefully document this discussion in our charts.

We also stress to our patients the critical need to have reasonably up-to-date eyeglasses. To stress the importance of this, we say something like, “I am not trying to sell you a pair of glasses; I will gladly write you out a prescription and you can get them wherever you like. But it is important to have a decent pair of glasses for backup.” What more can you do?

1. Gilbert RE, Stanford MR. Is ocular toxoplasmosis caused by prenatal or postnatal infection? Br J Ophthalmol. 2000 Feb;84(2):224-6.



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