Surprises at the Slit Lamp

Female aged 42, complaining of mild FBS. Non-contact lens wearer.

SLK (superior limbic keratoconjunctivits) Other signs: tarsal papillary reaction. Usually bilateral, may be asymmetrical. Seen in soft CL wearers in conjunction with thiomersal preserved solutions. Seen in patients with thyroid problems. Can be associated with rheumatoid arthritis and Sjogrens. Other signs: filaments

Optometrist’s Management Unpreserved artificial tears Bandage CL Plug the upper puncta All of the above Refer

Bilateral Appearance Male aged 36. Asymptomatic. Routine eye exam.

Refer or not? Refer Don’t refer

Ectropion Uveae It is posterior pigmented iris epithelium on the anterior surface of the iris. Rare, congenital, non-progressive.

7 year old male c/o bilateral itchy eyes. No tarsal involvement.

Phlyctens Normally asymptomatic. Can be single or multiple. They are prone to recur, are thought to be due to a type of allergy to certain bacteria. Associated with TB, intestinal parasites, tonsilitis, ulcerative blepharitis.

Optometrist’s Management Lid hygiene (LH) and refer for steroids LH alone LH and OTC anti-allergy drops.

45 year old man had bilateral LASIK to correct hyperopia. 6 mths post-operatively (3mths after being discharged) he came in c/o intermittent blur around lights coming from his RE only. He had no symptoms at the time of presentation. bilateral LASIK to correct hyperopia IOPs were R:23 L:18 mm Hg

Optometrist’s Management Same day referral to ophthalmologist Refer to ophthalmologist within a week Refer to ophthalmologist via the GP Instil pilocarpine and refer immediately

Blue-eyed 28 year old female. R:-1.00/-0.75x180 VA 6/5 L:-1.00/-0.75x175 VA 6/5 6/5 6/5 Px reports disabling glare from headlights at night. Px also reports that she does not tan easily. Image from http://www.sarawakeyecare.com/Atlasofophthalmology/anteriorsegment/Anteriorsegment28albinoiris.htm Atlas of ophthalmology, ophthalmology unit, University of Malaysia and ophthalmology Department, Sarawak general hospital

Albinoidism Albinoidism is diagnosed when the patient has iris transillumination defects but normal VA, no nystagmus and no foveal hypoplasia. This is what differentiates it from albinism.

Optometrist’s Management Amber tinted glasses for night driving MAR coated glasses for night driving Grey tinted glasses for night driving Opaque tinted contact lenses Polarised glasses

Tints for Night Driving Yellow or amber tinted lenses have been shown to be dangerous for night driving. According to European standards lenses with less than 75% transmission (or greater than 25% absorption) should not be used for night driving. Ultravision make a hydrogel custom-made opaque tinted lens to any Rx and base curve.

Female aged 35. Routine eye exam. Non-contact lens wearer.

EyeRounds.org, the University of Iowa Image retrieved from: http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/pigment-dispersion-syndrome-glaucoma.html EyeRounds.org, the University of Iowa

Pigment Dispersion Syndrome IOP spikes sometimes during or after exercise. Associations: males, age 20 – 40, myopia. It is estimated that approx 30% of patients with PDS will develop pigmentary glaucoma with men three times more likely to develop glaucoma than women. Pigment stops dispersing at around age 40.

Optometrist’s Management Refer to ophthalmologist Monitor fields and IOPs every 3 mths and refer if they change Monitor fields and IOPs every 6 mths and refer if they change Monitor fields and IOPs annually and refer if they change

35 yr old female, full time soft CL wearer 35 yr old female, full time soft CL wearer. Asymptomatic but bothered by cosmetic appearance of red eye. Unilateral. Hyperaemia confined to temporal bulbar conjunctiva. No other findings or relevant history.

Episcleritis Inflammation of the episclera. Cause unknown. May be associated with rheumatoid arthritis, lupus, IBS, herpes, stress, hormonal changes. Most cases will resolve spontaneously within 2 – 3 weeks. Px can be referred for steroid drops to speed resolution.

A full time CL wearer comes in to you with unilateral episcleritis A full time CL wearer comes in to you with unilateral episcleritis. Does the patient have to cease lens wear until the condition has resolved? Yes No

Elderly, asymptomatic patient.

Crocodile Shagreen This is the result of an irregularity of the stromal collagen lamellae which occurs with age. Associated with older patients. Asymptomatic. No effect on vision.

Female. Age 45 Difficulty with night driving. R:-2.50/-0.25x35 VA 6/9.5 L:-2.25/-0.75x165 VA 6/9.5+2

Corneal Farinata Ageing change of the cornea Bilateral deep stromal opacities. Best seen on retro illumination They have no effect on vision and therefore require no treatment