A Patient with a Nuisance Problem
or Something More Serious?
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When I was a 3rd year optometry student at the New England College of Optometry, one of my clinical rotations allowed me to go to nursing homes and senior citizen communities throughout Boston to provide eye care to patients and residents. The “Mobile Eye Unit” required the students to carry heavy equipment in foot lockers.
Biomicroscopes, trial lenses, frames, sphygmomanometers for blood pressure measurements,
lensometers, and non-contact tonometers were brought to each site.
This experience and its resultant professional rewards is why I still offer these services today. I am the staff optometrist at many nursing homes and provide homebound eye care. Vision testing equipment has become more portable and computerized compared to 20 years ago. A small Pentax hand-held lensometer fits into a briefcase. A hand-held
Tono-Pen provides intraocular pressure measurements. Ophthalmoscopes and binocular indirect ophthalmoscopes with condensing lenses provide a medical evaluation of all structures of the eyes. Using trial lenses and a trial frame provides refraction information for a patient whether they are in their bed, sitting in a chair, or in a wheelchair.
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I recently received a phone call from a nurse who works at a nursing home. She stated that a 56-year-old female Caucasian resident had a picking sensation in her left eye that had started the night before. I asked the nurse to describe what she saw and she stated that, “it looked like a raised area on the temporal side of conjunctiva of the left eye.” I asked her if it looked red and bloodshot like conjunctivitis or did it look “bloody” like a
sub-conjunctival hemorrhage? She said that it was neither. I had a few thoughts as to what it could be and asked about the residents’ other medical conditions. I saw her later that day.
This relatively young woman had been a diabetic for 30 years. She already had both lower limbs amputated below the kneecap. She also suffered from high blood pressure. The patient had cataract surgery on the left eye 3 years ago and had a cataract developing in the right eye. When I asked about bifocal glasses after cataract surgery, she said, “they never worked and that there had been some problems after the cataract surgery.”
The intraocular lens in the left eye appeared to be “wrinkled” through a non-dilated pupil. She had multiple laser treatments on each retina. There was a pinguecula that was raised and vascularized on the left temporal conjunctiva. Her last dilated retinal examination was 3 years ago. There were retinal changes including micro-aneurysms and exudates consistent with her diabetes and hypertension. Her visual acuities with eccentric viewing and without correction were OD: Finger counting @ 5’ and OS: Light Perception.
A pinguecula is a common, non-cancerous growth of the clear conjunctiva that lays over the sclera of the eye. The appearance resembles a small, yellow nodule on the conjunctiva which can appear on the nasal or temporal side. Feeder blood vessels can create a vascularization of the pinguecula causing an inflammation which is referred to as pingueculitis. If a pinguecula grows onto the cornea, this is now called a pterygium and can affect one’s vision. Depending on the size and the location of a pterygium, a surgical removal or “peeling off” of the pterygium can restore normalcy. Pterygiums can create refractive changes especially astigmatic changes. The causes of pingueculas include long-term sunlight exposure, UV exposure, wind exposure, and consistent eye irritation.
People in the sun-belt states, people living in higher elevations, and those people who do not wear protective eyewear are at higher risk for developing this condition. UV protective sunglasses, polycarbonate lenses or UV treated CR-39 lenses should be used by those at higher risk. It is always a good idea to recommend these lenses to the general public as well. People who water-ski in the bright sunshine with reflections off of the water, snow skiers who ski at higher elevations and in the sunlight, and sun worshippers in general may benefit by wearing sunglasses or goggles with the highest UV protection available. UV radiation can also create other problems in the structures of the eye including photokeratitis, photoconjunctivitis, cataracts, and melanoma of the eyelids. This is a very dangerous location for this skin cancer. Since the skin is so thin on the eyelids the cancer can spread rather quickly.
A pinguecula may increase in size over many years. Usually no treatment is needed. Lubrication with artificial tears, liquigels, or ointments can be helpful to reduce irritation. Sometimes the temporary use of mild non-steroidal anti-inflammatory eye drops can be helpful. Rarely, the growth may need to be removed if there is discomfort or for cosmetic reasons.
My patient had a few more serious problems than her pinguecula. The pinguecula was a nuisance problem. I prescribed artificial tears to be used 3X per day and celluvisc at night. If this does not resolve her problem, a non-steroidal anti-inflammatory drop will be considered. I also scheduled an appointment for her to see an ophthalmologist that she had not seen in the past. Her significant decreased vision due to her diabetes and hypertension was a concern. She will need some laser treatments and her visual prognosis is probably “guarded” at best. The wrinkling of her intraocular lens implant was also a concern.
According to the website www.ophthalmologyweb.com/Tech-Spotlights/26429-Advances-in-Intraocular-Lens-Design-to-Further-
Reduce -Capsular-Opacification/, “in some patients undergoing cataract surgery, opacification results from proliferation of lens epithelial cells into the posterior capsule. This is likely due to the anterior or equatorial epithelial cells that remain following removal of the cataract, some of which may become activated. These lenticular epithelial cells proliferate posteriorly and form an opaque membrane of the posterior capsule over time. In the process, these cells acquire fibroblast-type properties with contractile capacity, thereby leading to contraction and wrinkling of the posterior capsule in some cases.”
I also have scheduled her to see a low vision specialist/optometrist who may help her with quality of life issues. Her diabetes is a life threatening illness. Her battle with this dreaded problem had already created a loss in her mobility due to her amputations. Some may consider the quality of both her life and her vision as limited with serious concerns for her health in the future. Sometimes diabetic patients forget that their eyes need to be checked and dilated every year. Treatment and management done earlier can prevent complications later. This patient was unhappy with not only her current circumstances but for her future outlook as well. Her visual problems after cataract surgery did not help her have an opinion that anything or anyone could help her. Sometimes a new approach and a new perspective medically can reassure the patient that everything that can be done will be done, even under such dire circumstances.
This case is important from a perspective that all aspects of the eye care profession will try to come together to help this patient. I was called to address the patients’ chief complaint. This primary care problem was treated but there were other problems that had to be managed on a secondary care level. The retinal specialist/ophthalmologist will address the more serious problems of her diabetes and hypertension with the hope of managing and saving her retina and her remaining vision. I advised the ophthalmologist about the “wrinkled” appearance of the IOL that I saw. He will also have her see another ophthalmologist who is a cataract surgeon when this problem needs to be addressed.
Once her medical-eye problems have been stabilized, another eye care professional/optometrist who specializes in low vision will try to improve her vision through optical aids and magnification devices. Yet another optical professional, an optician, will then take the optical results to design and create glasses, optical magnifiers, or low vision devices so that this patient can have some improved vision and perhaps regain some independence. This is a classic example of tri-ophthalmic care – the ophthalmologist, optometrist and optician working together to benefit the patient – a wonderful concept.
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