This week I’ve seen some interesting anterior eye cases.  

On Monday, my afternoon clinic was only half full so I took the opportunity to catch up on my CET (there’s an interesting article on digital eye strain in Optometry in Practice, the journal-like magazine that appears randomly from the College of Optometrists).  After a couple of hours and four non-interactive points, I was getting a little bored so it was a relief when an older gentleman walked in, handkerchief in hand, dabbing at his left eye.

Mr T was a bit fed up: he’d been to the pharmacist who told him to go to the GP who had, in turn, sent him to me.  He’d been round the houses, with a sore eye, and he was a little grumpy.  His GP had given him chloramphenicol ointment so that was a positive, at least.

Just from sitting across from him, it was pretty obvious what was wrong.  His eyelashes were turning in.  Mr T was due a full sight test so we decided to do a refraction as well as a health check as he felt his vision wasn’t affected by the trichiasis.

The eye test was pretty standard: a small change in his prescription and a touch of cataract in both eyes.  The right eye was perfect, the left sore, watery and red.  I had a good look, everting both lids.  I removed a length of white, stringy mucous from his inferior fornix and popped in some fluorescein.  Unsurprisingly, there was staining on the inferior cornea, some crisscrossing lines where the eyelashes were brushing against the epithelium, sloughing off enough cells to create little furrows like a freshly ploughed field.

I pulled his lower lid down a little and his lid margin sprang outwards, correcting the eyelash direction.  When he blinked, they went straight back into his eye.

I told him that I could remove the eyelashes that were misplaced but this wouldn’t be a permanent fix.  He would have to either come in regularly to have it done or I could refer him to have them permanently removed.

At this point it was difficult to say if the main issue was entropion or misdirected eyelashes.  Mr T’s lashes were long and catching in his eye with each blink.  Was the problem with the lashes turning the (loose) lower lid in or was it the lower lid misdirecting the lashes? Or both? There was only one way to really find out.

We decided to epilate the eyelashes.  I have a small set of very good tweezers that are meticulously cleaned with alcohol and stored in a pouch after each use (I got three lots of them from Superdrug for a total of 99p because of a pricing glitch).  I’m quite proud of my 33p tweezers:

Revlon-by-Marchesa-tweezer

Anyway, I popped in some OXB 0.4 and waited a few moments for it to kick in.

“That feels a lot better.”

“That’s the anaesthetic working, unfortunately it’ll only last half an hour so you might have some discomfort after it’s worn off…  I’m going to come very close to your eye with these tweezers so I want you to keep looking up. You might feel a pressure or pinching but try to keep looking up.”

I put the slit lamp on 10x magnification, adjusted the beam width and focus so I could see the middle portion of his lower eyelid.  I got the tweezers in position then went back to looking through the slit lamp.  I started removing the lashes, pulling from as close to the base of the lash as possible*.  It took a few minutes but finally, he could blink without an eyelash straying over his lid margin.  Looking at him, you couldn’t tell that he’d had most of the lashes from his lower left lid removed (his eyelashes were fine and blonde, which was ideal really).  Another bonus was that his lower lid was no longer turning in.

I told him to continue using the chloramphenicol ointment for the next few days, until the corneal abrasions from the lashes had healed completely.  I also reminded him not to rub his eyes for the next 30 minutes because of the anaesthetic.

The next morning, Mr T popped in to see me and his left eye was back to normal.  Again, you couldn’t tell he was missing any lashes unless you looked on the slit lamp.  He was in a great mood and thanked me for taking time to see him the day before.

On Thursday, I had a young man come in with a slightly red, watery left eye.  He was a construction worker and thought a small piece of wood from some scaffolding had gotten into his eye.

He wasn’t photophobic, he didn’t seem to be in much pain and his eye was, at most, a grade 1.5 on the Efron scale for conjunctival and limbal redness.  I thought, like many other patients before him, he had suffered a small corneal abrasion and had assumed that the wood was still in his eye when it had really been flushed out with tears.

Anyway, I did a quick history and symptoms, checked vision in both eyes (right eye was better than left but he said he had an Rx that wasn’t with him so I didn’t worry about it too much) and did pupil reactions.  So far so good.

I jumped on the slit lamp, quick look in the right eye then over to the left.  And oops, there was a 1 x 2mm wooden skelf embedded in the centre of his cornea.  I mean, right in the middle.  He should’ve been in a lot more pain, surely.

I everted his lids to check that there were no other bits of building site lurking out of sight.  Everything was fine.  Well, except for the bit of wood sticking out of his central cornea.

My thought process was quite simple: I’ll put in some anaesthetic, I’ll see how deep it is and if I’m unsure about anything, I’ll send him straight to the hospital.  So, I told him that he did indeed have some wood in his eye and it was in a difficult place so I would see what I could do but there was a chance I would have to refer him.  He seemed to be quite happy with that so in went the OXB 0.4 and out came one of my trusty sterile needles.

I asked him to look to his nose and then gently pressed the flat part of the needle’s tip into the cornea just at the edge of the skelf.  I got underneath the wood with minimal effort and it just fell off his epithelium.  It wasn’t embedded as I first thought: it was pretty much resting on the cornea, stuck in place by its rough surface.  I was pretty chuffed at the outcome and, when I checked the cornea for staining, there was only the shallowest outline.  Just in case, I recommended chloramphenicol ointment and gave him a minims of cyclopentolate to use in case of ciliary spasm.  I also advised systemic painkillers and sunglasses.

Job done.

 

* This is the best way to pull out any hair: if you pull from the middle or top, sometimes the hair will break.  It’s thickest at the bottom so you get a better grip too.  This information comes from years of experience as a slightly** hairy woman.

** Okay, very hairy.

Advertisements