Remember to Evert
BY WILLIAM TOWNSEND, O.D.
Beverly, a 37-year-old spectacle-wearer occasionally wore disposable contact lenses. When we saw her for an eye health check, she had not worn her lenses for several months.
Recently, we had treated Beverly's mother and two of her daughters for adenoviral infection, so we were not surprised when she exhibited bilateral conjunctival injection, irritation and blurred vision. We were surprised that she also complained of itching, a symptom not usually associated with adenoviral infection. The itching was bilateral, but worse in the left eye.
Best corrected acuities were 20/20 for both eyes. Our examination revealed the typical clinical
picture of adenoviral keratoconjunctivitis -- mild corneal stippling bilaterally, grade II+ injection, follicles visible on the inferior tarsus of both eyes, and tender, easily palpable preauricular nodes.
I routinely evert the upper lids of my contact lens patients and patients with any ocular pathology. It's a habit that's paid off, especially in perplexing cases. When we everted Beverly's eyelids, we found grade I+ large papillae, almost identical to those found in early GPC, and more prominent in her left eye.
FIG. 1: BEVERLY'S LEFT INFERIOR TARSAL CONJUNCTIVA SHOW INJECTION AND FOLLICLES TYPICAL OF ADENOVIRAL KERATOCONJUNCTIVITIS.
FIG. 2: SLIT LAMP EXAMINATION SHOWED MODERATELY LARGE PAPILLAE TYPICAL OF THOSE FOUND IN GPC AND VERNAL CONJUNCTIVITIS.
We ruled out GPC because Beverly had not worn contact lenses recently, and we found no other irritant. We ruled out floppy eyelid syndrome because her lids were not loose and did not evert easily.
Because of the clinical presentation and strong history of atopy, we felt the patient had both vernal conjunctivitis and adenoviral keratoconjunctivitis. We prescribed Livostin, Voltaren and Alomide in both eyes, four times a day. Within a few days, Beverly reported significant relief from her symptoms; we instructed her to taper the medications. Two weeks later, all signs of viral disease were gone, and the papillae were smaller. Six weeks later, only one or two papillae remained; we prescribed a maintenance dose of Alomide in both eyes, twice a day, and Livostin as needed.
EVERSION TURNS UP TIMBER
Dewey, a 47-year-old male, went to the emergency room after a foreign body blew into his eye. The physician examined the eye and noted that the cornea stained with sodium fluorescein. He instilled an antibiotic drop, patched the eye and sent the patient home. As the evening progressed, Dewey's discomfort increased.
Two days later, when we saw Dewey, his visual acuity was OD 20/20, OS 20/30. Slit lamp examination revealed numerous abrasions in the upper aspect of the left cornea. We also noted mild anterior uveitis. We everted his eyelid and found a wooden chip, about 1.5mm by 0.5mm, deeply imbedded in the upper tarsus. We removed the chip, applied tropicamide 1% and gentamicin ointment, and pressure patched the eye. The next day, Dewey's acuities were equal, his anterior chambers clear and his cornea showed minimal staining We prescribed a regimen of topical antibiotic drops for five days.
We have seen patients who were treated for two years by their primary physicians for infection, allergy and other suspected conditions. Simply everting the lids provided us with the correct diagnosis, GPC. Another individual was subjected to CT scans and an extensive neurological workup to detect the cause of unilateral ptosis. Lid eversion provided us with the diagnosis, floppy eyelid syndrome.
With the availability of new tests and advanced technology, we may be tempted to overlook simple, diagnostic tests. We can often obtain the best clinical information by 'lowly' procedures such as lid eversion. CLS
Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center.