Examination «

Examination

The patient’s visual acuity was 20/20 in both eyes, but he had a variable refraction that changed by 0.5 to 0.75 D depending on the visit. Anterior segment evaluation was unremarkable. Fluorescein staining demonstrated inferior punctate epithelial keratopathy bilaterally. The tear film breakup time was less than 6 seconds, and lissamine green demonstrated minimal conjunctival staining.

It could be seen during the slit lamp evaluation with fluorescein that tear volume was reduced. The patient’s tear osmolarity was slightly elevated at 318 mOsm/L in one eye and 315 mOsm/L in the other. Corneal topography showed abnormalities consistent with moderate to severe dry eye. Interferometry demonstrated incomplete blink, and a light test with a transilluminator indicated presence of microlagophthalmos. Meibography and tear MMP levels were unremarkable.

Which of the following steps could I take to establish the patient’s diagnosis?

○	a. Continue with contact lens wear and lubricating eye drops No. The patient’s dry eye symptoms could have been induced by contact lens wear. Continuing lens wear and lubricating eye drops would not help determine the cause of this patient’s problem. Please select again.
○	b. Reduce lens wear time and use lubricating eye drops more often This would not help with diagnosis. Prior to proceeding with management, the cause of the patient’s dry eye should be determined. Please select again.
○	c. Discontinue contact lens wear but continue with lubricating eye drops This was not the step I took. Although both symptoms and clinical examination suggest the presence of moderate to severe dry eye in this patient, at this point its cause was not clear. Continuing dry eye treatment with lubricating eye drops may confound the diagnosis of this patient’s problem. Please select again.
○	d. Discontinue contact lens wear and all eye drops Yes. The patient’s symptoms and clinical examination strongly suggest that he has moderate to severe dry eye, which would explain why he was unable to wear his contact lenses for a full day. However, the question remains as to whether the primary driver of his condition was contact lens wear or his lid closure problems including incomplete blink and microlagophthalmos. Removal of all the confounding factors including the contact lenses and the lubricating drops can help determine the origin of the patient’s problem.

Jack L. Schaeffer, OD, FAAO, is president, CEO, and chief of optometry at Schaeffer Eye Center in Birmingham, AL. He is a consultant for Bausch + Lomb.

Shire Test Prep

Examination

Which of the following steps could I take to establish the patient’s diagnosis?

Eye Care Professionals Only