It’s been yet another interesting week.  I finally got my username and password for the on-line referral system and after a few phone calls (to two very lovely, very patient ladies at the NHS), I am now able to send referral letters straight to the hospital from the computer in my room.  I can even attach field plots and fundus photos.  Sadly enough, this has made me really happy and I’m hoping that, when I get my slit lamp camera working, I’ll be able to send anterior eye photos too!

In our practice, this week, we’ve been focusing on triage.  We have a triage sheet and it’s being used to make decisions on when a patient should be seen.  This is a great system – in my previous practice, we would have a constant stream of non-emergency eye complaints “squeezed in” because they were sent over by pharmacy or someone was bored while shopping and decided that their eye looked a little pink compared to yesterday.  It’s a bit of a nuisance when you have a full clinic to have to accommodate someone with vague symptoms or, worse, someone with hayfever who has always bought sodium cromoglycate for their itchy eyes but the pharmacist on that day sends them over “for a quick look”.

Having a triage sheet, with all the pertinent questions about flashing lights, floaters, pain, loss of vision, etc means that there’s less pressure on the optoms.

I had a couple of triage patients in a row on Saturday and I’ll list their history and symptoms.  See if you can guess what the diagnosis:

1) Young woman, contact lens wearer. For the last 3 weeks, her right eye has been watering constantly. It’s not sore but it is annoying.  She’s unable to wear her lenses for any length of time.  She reports discharge and, on questioning, she says it’s white and stringy.

I asked her about her daily routine.  She gets up, puts her lenses in (at this point, her eyes are fine) and then has a shower (she is very myopic so she wears her lenses to see the shampoo, etc).  After her shower, her lenses are still comfortable.

Then she puts her make-up on.  After this, her eye starts watering.

I asked if she has recently changed the type of make-up she wears. No, it’s the same foundation and mascara as always.  Did she open a new batch of mascara or foundation 3 weeks ago? Yes.

I did a full slit lamp check and her left eye was perfect but her right eye tear prism was double what it should be (it was around 0.6mm), FTBUT was fine.  No corneal staining.  Nothing under the lids (except some papillae on the upper eyelid) but there was a lovely line of white mucus along the lower lid.  In her tear film in the right eye, there were lots of powdery specks (missing in the left eye) so I wonder if she’s exacerbating the problem by rubbing/wiping her eye, therefore getting more make-up in the eye.

I told her that her that I suspected an allergy to her make-up and could she not wear any around her eyes for the next couple of days? She wasn’t particularly happy about this but agreed.  I also told her to leave her lenses out for a day or two until the papillae resolved.

The make-up she was wearing was pretty high-end so I told her to reintroduce the mascara and see if her symptoms returned – if not, the mascara was fine.  Then try the foundation.  I suspect it was the foundation causing the problems but I didn’t want her to throw out £60 of make-up for no reason.

Of course, I ended with the optom fail safe phrase: if it doesn’t get any better after discontinuing the make-up, come back and see me.  If it becomes painful or your vision is affected, return to us straight away.  If we aren’t open and you are worried, you can go to A&E.

2) Young man, welder.  He thinks he has some metal in his eye.  It’s been a little sore since yesterday.  He has had a lot of stuff in his eyes in the past and knows the feeling.  He used an eye bath last night but it still feels like there’s something there.

This one is very straightforward.  There’s no pain (it’s uncomfortable rather than sore, he admits), no photophobia.

I see nothing using white light so I pop some NaFl in the affected eye (again, the right eye) and have a good look at the epithelium.  Still nothing.  I evert the upper eyelid, no sign of any foreign bodies, just some mild papillae.

The only thing amiss is the FTBUT -it’s very short (2 seconds) and the tear film is breaking up in the same spot over and over again.  There’s nothing in that area that I can see (again, I switch back and forward from white light to Cobalt blue).  I assume that this part of the cornea was scratched and is now healed.  As it’s newly healed, it’s not wetting very well.

As he was a welder, I asked if he’d ever had a “flash” (photokeratitis) and, although he hadn’t, he knew people that did. I used this as a basis to explain how fast the cornea heals itself. I said that he probably did have a piece of something in his eye yesterday but he’d managed to get it out. It may have left a shallow scratch which has now healed.

I recommended comfort drops and safety specs* and then sent him on his way with the fail safe phrase.

*they all insist that they wear their safety specs at the start but, by the end of the 15 mins, most will admit that they don’t like them because they steam up/they don’t fit very well so they took them off just before the accident happened.

Before the triage, I had a gent come in for his first eye test in 5 years.  His VA was good, no problems.  On slit lamp, he had this growth coming from the inferior iris.  It looked like a little finger and crossed from the iris to the inferior corneal endothelium.  It was pigmented (same colour as his iris, a medium brown) and there was pigment on the endothelium in a little circle, just in front of this projection.

It hadn’t been mentioned before by an optom and the patient hadn’t noticed it himself (it was actually quite noticeable but, then again, I’m an optom – I tend to look a bit more carefully at my eyes than most people).  I used my super duper on-line referral system to ask for an ophthalmologist to take a look.

It didn’t look nefarious, it was evenly pigmented, well defined and wasn’t interfering with vision.  Has anyone else come across something similar? Although I referred it, I did explain to the patient that I was only referring because it was unusual and I wanted a second opinion but I wasn’t too worried about it.

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