the contact lens exam
Examining Red Eyes
BY JEFF SCHAFER, OD, MS, FAAO
In contact lens practice, red eye visits are quite common. In fact, patients often present for their scheduled comprehensive exam with a red eye, forcing practitioners to change gears during the exam. Patients may think that one visit can solve both their red eye complaints and their vision complaints — and that they can walk away with a new spectacle and contact lens prescription. This isn't always possible depending on the condition, which isn't always obvious to the patient.
When patients present with a red eye, I start differentiating their signs and symptoms immediately. Although most patients believe they have "pink eye," red eyes can result from a variety of conditions that may include conjunctivitis, corneal injury, uveitis, acute angle closure glaucoma, episcleritis and scleritis.
Take a Detailed Case History
A thorough case history is probably the most important part of a red eye exam and can essentially make the diagnosis. Initially, I ask how long their eye or eyes have been red, and if one eye started before the other. Then I dig deeper into their reported symptoms and ask about any other symptoms they may be leaving out. In particular, I like to know if they've noticed any blurred vision or discharge and whether they've experienced any photophobia.
If I don't already know a patient's background, I ask if he's a contact lens wearer to determine whether the redness may be related to contact lens wear. If he is a lens wearer, I ask about the type of lenses he wears, wearing time including any overnight wear and how often he replaces his lenses.
Establishing the disinfection system a patient uses is a key feature of a red eye history. In fact, I often ask patients to describe in detail how they care for their lenses. In addition, I like to know whether they've experienced a similar incident in the past, and I ask about any history of trauma to the eye or recent illness. I always review patients' systemic medical history and inquire about environmental or drug allergies.
Performing the Exam
After gaining an understanding of a patient's complaints with my case history, I generally have a fairly good idea of the nature of the problem and at least a short list of differential diagnoses. At this point I've usually decided how I'm going to proceed with the exam. If the patient had been scheduled for his comprehensive exam, I may need to explain that the current visit will be more problem focused in nature and that resolving the red eye needs to happen before prescribing more lenses. I also educate the patient that medical insurance will cover the red eye office visit, which may be confusing to some.
I usually begin my examination with a gross look at the eyes outside of the slit lamp, noting the pattern of redness. I always check entrance visual acuities as well as pupil function and ocular motility. Of course, a careful slit lamp exam with fluorescein is mandatory, examining all ocular structures and documenting all findings.
Following the exam, I take the time to educate patients on my findings and to carefully explain their treatment plan, including any follow-up visits that may be necessary. I've found that red eye patients are very receptive to recommendations because they want us to fix what's wrong with them. This is an ideal time to also reinforce proper lens care, to encourage compliance and to educate patients about serious consequences of poor lens habits. CLS
Dr. Schafer is a clinical assistant professor and chief of the contact lens service at The Ohio State University College of Optometry.