Treatment Plan

Come On, Doctor...Be More Precise

treatment plan

Come On, Doctor... Be More Precise

December 2000

Grace, an 83-year-old female, presented with complaints of ocular irritation and blurred vision after reading. She took an oral beta blocker for hypertension and Coumadin. Visual acuities with correction were 20/30 OU. Neurologic findings were unremarkable. Slit lamp showed normal lids with reduced tear volume and focal conjunctival staining with rose bengal. She also had mild nuclear cataracts. We gave her a sample of GenTeal drops, which are hypotonic and have a "disappearing preservative." We recommended using the drops at least four times a day, more while reading.

The patient returned two months later, complaining of very irritated eyes, itchy eyelids and very reduced vision. Presenting acuities were OD 20/60, OS 20/200. General inspection revealed large areas of erythema around and below the eyes. Slit lamp exam showed tight, dry, scaly eyelids with inflamed margins. Most impressive was that the foreshortened skin had drawn the lid margins away from the eye, causing dramatic cicatricial ectropion, especially in the left eye. Both corneas stained markedly with fluorescein, but the left eye was by far the worst.

Problem Preservative

The patient's son said that since we did not prescribe a particular drop, they "grabbed something at the pharmacy" when the GenTeal was gone. He produced artificial tears preserved with benzalkonium chloride. The more Grace's eyes bothered her, the more she used the drops.

We diagnosed chronic contact dermatitis leading to cicatricial ectropion with accompanying exposure keratitis. We immediately discontinued the preserved drops and instructed her son to begin treating the dermatitis with 1% hydrocortisone cream b.i.d. We told the patient to use only GenTeal drops, and we specified the dosage. The patient's PCP gave her a short-acting steroid injection to work in conjunction with the topical treatment regimen.

When Grace returned two weeks later, her vision had improved, the skin around her eyes was no longer erythematous and dry and she had no ectropion in the right eye. We reduced the steroid cream to once daily, had the patient continue with the drops and added GenTeal gel at bedtime to the left eye.

Lesson Learned

The most important lesson is to be specific in instructing patients on how and when to use medications. Any time we prescribe a treatment regimen, legend or OTC, we must make sure the patient knows how and when to use it. The best method is to provide written instructions. In discussing treatment, make sure the patient knows the name of the product, the frequency of dosing and expected results or side effects. As Grace's case demonstrates, we need to instruct patients to use only the product recommended, not "something off the shelf."

Another good way to relay this information to patients is to write a prescription for all products (including OTC) that you recommend. We have found that most pharmacies are more than willing to label OTC products for patients. This has a two-fold effect: the label on the product tells the patient that it was prescribed for him, and the label reminds the patient of the proper method of instillation and frequency of dosing. This has helped us with compliance issues and avoids confusion for the patient. 

Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center. E-mail him at