Clinical Pearls

Here are some random observations on a wide range of issues related to optometric practice and patient care.

As part of our lectures, we are privileged to answer many hundreds of questions and offer our perspectives on a wide range of issues germane to optometric practice. Here, we share a number of these pearls, pointers and philosophies. We hope you enjoy these random observations. Some are strictly informative. Others are meant to stimulate thought, but all are focused on helping you sharpen your patient care skills.

Viroptic (trifluridine), Vyzulta (latanoprostene bunod), Zioptan (tafluprost) and Xalatan (latanoprost) are kept under refrigeration at the pharmacy, but do not need to be kept refrigerated by the patient. However, if the patient has some Viroptic (or generic trifluridine) remaining following acute treatment, advise that the medicine be kept in the refrigerator to be used in the event of a recurrence. The patient can then restart therapy without delay until they can see you in your office in a day or two. Regarding latanoprost, if a patient acquires three bottles at one time, two of the bottles should be stored in the refrigerator. This is not absolutely necessary, but is probably a good idea, just the same. Also note that Zioptan is also stored under refrigeration, but the patient can keep these unit-dose dispensers at room temperature for a week at a time.

Many altruistic, apolitical (and perhaps uninformed) primary care physicians may purposefully steer your/their patients to eye surgeons for diabetic retinal examinations. You need to do two things to take charge of this. First, let all your patients know that you have a keen interest in diabetic eye disease, and that you are skilled in its care. Otherwise, you could well have an established patient develop diabetes and be directed elsewhere for continuing eye care. Second, become acquainted with the primary care physicians in your area and share with them your training and willingness to help them care for their diabetic patients. Many primary care physicians have no idea of the breadth and depth of optometric training and our expertise in diabetic eye disease.
Diabetic patients who develop diplopia resulting from 3rd or 6th nerve palsy usually regain normal visual function within three months. If you see no improvement in the diplopic posture within a month or two, or if there are other neurologic signs or symptoms, then a scan should be considered.
Use Paremyd (Akorn) to dilate most of your patients most of the time. Paremyd is quick, easy, effective, and it wears off relatively quickly. Reserve 1% tropicamide and 2.5% phenylephrine for those difficult-to-dilate patients and those who present with symptoms compatible with retinal detachments and other potentially serious disorders.
We always dilate young children and infants especially at their first visit. (Alcon) is a combination drug that has been around for many years which perfectly meets the challenge of pediatric dilation. It is a combination of 0.2% cyclopentolate and 0.1% phenylephrine HCl. We highly recommend Cyclomydril's use for pediatric dilation. It can be used in infants; be sure to read the precautions and contraindications.
It is imperative that we as a profession further enhance of communication with the medical community. Having access to a dictation system (on-site or off-site) is becoming increasingly crucial as optometry further integrates into the mainstream of health care delivery. If you stop and think about it, good interprofessional communication not only enhances patient care, but shows you to be an integral member of your patient's health care team. For patients with diabetes or those taking Plaquenil, we have preprinted forms we simply complete and fax to the primary care physician (and/or endocrinologist or rheumatologist). These forms are available on this website on the "Diabetes Update" and "Plaquenil Update" icons.
When conducting a monocular therapeutic trial with a drug that has a 24-hour cycle (like a non-selective beta-blocker or a prostaglandin), have the patient dose the drug every day of the trial, except on the day of the evaluation (or the night before, in the case of a prostaglandin). This is an excellent way to measure the drug's effectiveness over a full 24-hour cycle.

For acute angle closure events, be sure to keep acetazolamide tablets, brimonidine, and a beta-blocker readily available. The prostaglandins are relatively slow-onset drugs and have no role in acute angle closure or acute IOP elevation management.

A large percentage of patients who sustain a retinal tear, break or rhegmatogenous detachment will have a release of either RPE pigment granules, red blood cells, or both. These tend to migrate into the retrolental vitreous and can be readily visualized via standard slit lamp biomicroscopy. Known as "Shaffer's sign," these granules look like "paprika" or "tobacco dust," and are evidence of a break in the retinal tissues. Thorough binocular indirect ophthalmoscopy and/or a 3-mirror gonioscopy should be undertaken to search for such a tear or break.

When patients present with a symptomatic posterior vitreous detachment (PVD), they have about a 10% chance of a retinal tear or break. The most common age for these events is the early 60s. Although the probability of occurrence is small, always vigorously search for a retinal tear or break. Patients with acute PVD who have no retinal breaks on presentation have a very slight chance of developing one in the weeks afterward. If all looks well at the initial visit, still counsel your patients there is very small risk that a problem may still occur, and to contact you right away if there are any changes in vision. Many doctors re-dilate in six weeks as their standard protocol.

Be sure to check the blood pressure of all patients having any type of acute microvascular event. Uncontrolled systemic hypertension remains a major cause (or contributing factor) to a host of vascular and neurological eye problems. Additionally, we advise you to have your staff check the blood pressure on all of your patients over age 40; it's just good patient care.
Remember, anyone weighing less than 135lbs. is at increased risk for maculotoxicity if they are taking the standard 400mg/d dosage of Plaquenil. Below 135lbs., there is an inverse relationship between body weight and maculotoxic potential, i.e., the lower the body weight, the greater the potential for visual loss. Further, beyond five years of ongoing therapy, there is an increasing risk over time.
It has been demonstrated that losing 6% of body weight is usually curative for most cases of idiopathic intracranial hypertension (formerly known as pseudotumor cerebri). Therefore, it is incumbent upon us to encourage these patients in this regard during their follow-up visits.
Spontaneous venous pulsations are usually extinguished at about 20cm/H2O (the units of CSF pressure measurement). The opening pressure reading as measured by lumbar puncture (always following a head scan to rule out a true mass) in patients with idiopathic intracranial hypertension (ICP) is usually between 250 and 60cm/H2O.
It has traditionally been advised to use hypertonic (5%) ointment at bedtime in patients with recurrent corneal erosion (RCE). While there is nothing wrong with this, many patients do begin to experience irritation after a few days' use. We have found that preservative-free ophthalmic lubricating ointment or a gel-based product performs well in these situations, and are much less likely to become irritating. Bear in mind that a breach in the integrity of the basement membrane plays a key role in the RCE cycle. The basement membrane takes six to eight weeks to fully heal. What we are trying to achieve with lubrication at bedtime is the prevention of a re-break or re-tear, allowing time for these tissues to completely heal. While this conservative approach may well work, we tend to more aggressively address this painful condition. If legally allowed in your state, you might try one of two of these more clinically curative approaches to RCE in an effort to prevent any further erosive events.

Medical: Oral doxycycline 100mg q.d. x 1 week, followed by 50mg q.d. x 2 months, along with Lotemax q.i.d. x 1 month, then b.i.d. x 1 month. A concomitant lipid-based artificial tear and GenTeal Gel at bedtime are helpful, especially for the first two weeks.
Procedural: Perform "anterior stromal micropuncture" by making numerous micropunctures into and through the epithelial basement membrane/Bowman's layer complex. This profoundly simple procedure is done at the slit lamp with a bent stromal micropuncture needle (these stromal micropuncture needles are available through many ophthalmic supply houses).Treat the lesion and 1-2mm of the surrounding tissue. Then place a bandage soft lens on the eye and prophylax with generic Polytrim q.i.d. x 4 days and follow up in 24 to 48 hours. These iatrogenic micropunctate corneal abrasions heal in two to three days in most cases. Instilling a drop of a topical NSAID in the office, with or without short-acting cycloplegia, can make the procedure even more comfortable.

Both the medical and procedural approaches alter the biochemical environment of the basal layers of the epithelium/Bowman's membrane complex, resulting in a more firm adhesion of these structures, thus "defibrillating" recurrence.
Occasionally, and for a multiplicity of reasons, a patient's pupils may already be pharmacologically dilated when first seen in your office. A good surrogate for optic nerve function is the "red cap test." Simply ask the patient to observe the redness of the cap on one of your eyedrop bottles out of the good eye, and explain that this represents a dollar's worth of redness. Then have the patient observe the red cap out of the affected eye, and ask how much the red cap is now worth relative to the good eye. This test can be very helpful in quasi-quantifying any unilateral optic nerve dysfunction.
Here's a real helpful thought for those patients who present with an acute pupillary abnormality. Old photographs can usually confirm a history of congenital anisocoria. But for quantitatively significant, acute cases (commonly the larger of the two is the problem pupil), there are two consistent precipitating causes:
– OTC vasoconstrictors
– Scopolamine motion-sickness patches
Always question the patient about these two possibilities. Anticholinergic eyedrop exposure must be considered if the patient is in any way involved in health care, where inadvertent contact with such agents could occur. Of foremost concern is ruling out Horner's or Adie's pupil but, this being done, the above possibilities need to be considered.
When examining for pupillary abnormalities, a UV lamp (Woods or Burton) can facilitate evaluation in a dark room. Keep the light source below fixation and about two feet away from the patient's eyes to avoid any constriction due to the visible light coming from the lamp source. The low-grade fluorescence of the crystalline lens helps to outline the pupillary borders, thus enabling pupil size in dim illumination.
To summarize pupillary abnormalities, if there is no ptosis or EOM involvement, then the anisocoria is invariably benign.

Topical NSAIDs are excellent adjuncts for ocular surface pain, but topical NSAIDs are extremely poor substitutes for topical corticosteroids in suppressing tissue inflammation. There are numerous topical NSAIDs. Prolensa and Ilevro are the newest of these, and are used only once daily.

Since nonsteroidal anti-inflammatory drugs inhibit prostaglandin production, can they be used with a prostaglandin medicine? Absolutely! NSAIDs are also referred to as cyclooxygenase (prostaglandin synthetase) inhibitors. This class of drugs merely hinders the production of prostaglandins. NSAIDs have no effect on the prostaglandin receptors on cell membranes. The pressure-lowering prostaglandin drugs are prostaglandin receptor agonists and their action is in no way altered by drugs that inhibit the synthesis of endogenous prostaglandins.

Two ophthalmic medicines have a slight yellow color: Alocril (nedocromil, Allergan) and Vigamox (moxifloxacin, Alcon). Be sure to tell patients about this in advance so they don't think they have a defective product.

Baseline intraocular pressure assessment should be established as early in life as is practical, generally somewhere in the teen years. The use of the Icare rebound tonometer (www.Icaretonometer.com), or a Goldmann handheld applanation tonometer, or a tonopen could enable IOP measurement in even younger patients. Such measurement takes on greater relevance if there is a family history of glaucoma or if optic nerve cupping is suspicious. We commonly look at the optic nerve heads of attendant family members with any young person with large cup-to-disk ratios. It may be that larger C/D ratios are merely a family trait.

Regarding tonometry, there many reasons why slit lamp-mounted Goldmann applanation tonometry is difficult or even impossible to accomplish in many patients. For such patients, we recommend trying the Icare tonometer. It is handheld, atraumatic, and requires no topical anesthesia. Most patients hate or dread the airpuff tonometer! This antiquated technology should be replaced with the Icare tonometer.

Always palpate for preauricular lymphadenopathy in any red eye where adenoviral infection (EKC) is suspected. The presence of a palpable node in the presence of a watery eye is virtually always pathognomonic of EKC.

Because of the highly contagious nature of EKC, it is important to accurately diagnosis this condition. In most cases, the diagnosis is a clinical one, but there are many times when the differential diagnosis is challenging and uncertain. This is why all OD offices should keep on hand a few AdenoPlus kits. This device is quick and simple to use. You can have an answer in just 10 minutes, and this can often be an enormous help in the care of patients with an acute red eye.

Do ophthalmoscopy on all new patients, even if they are in for a problem-oriented visit such as a corneal foreign body, etc. It is our ethical and legal duty to screen for potentially blinding diseases such as glaucoma. A quick ophthalmoscopic assessment of the optic nerve head would catch any moderate to advanced glaucoma. As we are all aware, some people only come to an eye doctor if they have a problem, so don't miss these screening opportunities.

We are proud to be O.D.s. Our lab coats, shingles, stationery, etc., state: Ron Melton, O.D., and Randall Thomas, O.D. Occasionally, this gives us the opportunity to explain to inquiring patients what exactly "O.D.s" do. We are pleased to explain to any patient the very special and unique package of care an O.D. is able to provide. It's kind of like the old saying, "If you always do what you've always done, you'll always make what you've always made." Our profession is evolving beautifully, taking on more responsibilities and providing a broader scope of professional services. We need to do some serious introspection of our image, and present a "new and ever-improving" impression to the public.

How one dresses and carries him- or herself is most certainly a personal choice. That said, we would like to offer our perspective as well as what an article in the optometric literature had to say concerning this issue. Optometrists need to look at least as good in the eyes of our patients as do the other doctors in our various communities. In our case, we practice in urban and suburban settings, so we generally wear dress shirts and a necktie, and always a full-length, white lab coat with our names embroidered neatly above the left breast pocket. As the saying goes "Dress for Success." Following is what a review study found on this subject: "So what do your patients prefer you to wear? One study, which reviewed 31 other articles on this question, found that patients do indeed want their doctors to dress professionally, preferably in a white coat with a nametag. Patients tend to favor more formal dress, and give high ratings to a shirt and tie, dress pants, skirts or dresses, and dress shoes."

If you are providing services beyond "Eyes Examined/Contact Lenses," please redesign your shingle/signage to portray to the public a truer reflection of what you do. Here are some suggestions:
- Adult and Pediatric Eye Care
- Family Eye Care
- Comprehensive Eye Care
- Routine and Medical Eye Care Services

We are in a new era now, and many times our signage woefully misrepresents the broad range of services we provide.
We truly need to begin to work more cooperatively as a unified profession. One way to do this is to rely on one another for patient consult visits. There are O.D.s who still commonly refer out otherwise simple eye problems to M.D.s. Please consider having these patients see an O.D. in the community who commonly handles medical eye problems. This helps build our profession and public confidence in the diversity of optometric specialty care.

We need to change our image from eye "exams" to eye "care". "Eye care" is more comprehensive in defining optometric practice.

Occasionally, you will encounter patients who present with a red eye that could be one of several disease processes. For example, the cause could be acute dry eye, a small abrasion, recurrent erosion, or herpetic keratitis, etc. From time to time, it can be impossible to differentiate the diagnosis at the patient's initial presentation. Rather than have the patient pay for an expensive topical antiviral when you are not sure it is truly needed, give them a sample of an artificial tear to use every one to two hours until you see them back the next day. Buy yourself some time for the condition to evolve to a diagnosable presentation, or improve. Tell your patient exactly what thoughts and approaches you are considering to relieve their condition, but explain that you feel it would not be in their best interest to pursue a definitive course of action until you are certain of the diagnosis.
Not all patients with bacterial conjunctivitis present with obvious mucopurulent discharge. Some even clean their eyes, lashes and face prior to presenting, unwittingly exacerbating the diagnostic challenge. In these less-than-obvious cases, carefully examine the lacrimal lake for mucopurulent debris. Darken the room lights, set your slit lamp on high magnification, narrow down the beam, and critically examine the lacrimal lake (as looking for cells in the anterior chamber). Like aqueous, the lacrimal lake should be optically empty. If there is significant microparticulant debris, and the history and other clinical findings are compatible with bacterial conjunctivitis, then this can seal the diagnosis.
About 20% of the time, Thygeson's superficial punctate keratitis is unilateral, which means it could be confused with herpes simplex disease. A real help in differentiating the two is the degree of conjunctival injection. Usually, a Thygeson's eye is white or minimally injected, whereas the HSV eye is usually grade II or more injected. Corneal sensitivity testing can be helpful as an adjunct. Further, Thygeson's is very rapid in onset, whereas HSK usually builds over a few days. These three clinical considerations can greatly facilitate the differential diagnosis.

Patients with adult inclusion conjunctivitis (chlamydial conjunctivitis) usually have had a red eye for a week or more before you see them. They have likely been to a doctor and may have been placed on a topical antibiotic (which is why they are seeking a second opinion). If you observe "giant follicles" within the inferior forniceal conjunctiva on the affected side, think about chlamydia. Proper treatment is oral azithromycin (two 500mg tablets) taken in a single dose. This 1,000mg one-time dose is chlamydiacidal in most all cases. Also available is a 1,000mg granular suspension in a single-dose foil packet. Just dissolve the granules in half a glass of water, and bottoms up! Both approaches are equally effective. Most patients are clinically improved in about three days. Also, in-office culture kits specific for chlamydia are readily available through numerous medical supply houses.

When older patients complain of transient visual loss (most usually unilateral), two primary diagnostic possibilities should come to mind: giant cell arteritis (GCA) and carotid stenotic/ulcerative disease. To rule out GCA, pursue the history specific to new onset headache (the most common symptom), as well as scalp tenderness, jaw claudication (discomfort/pain with mastication), weight loss, and malaise. Always get an erythrocyte sedimentation rate (ESR/sed rate), as this is usually elevated in the setting of inflammatory arteritis. For men, the normative value is their age divided by 2. For women, this value is determined by taking their age plus 10 divided by 2. Beyond ordering the sed rate, consider getting a C-reactive protein (CRP). The cutoff is 2.45 in the setting of GCA. Further, since thrombocytosis commonly occurs in GCA, also order a CBC (complete blood count), which will quantify the platelet fraction. For suspected carotid artery disease, examine the retina for Hollenhorst plaques, and auscultate the carotid arteries. Don't forget to get out your stethoscope and listen for a bruit. Never hesitate to order carotid duplex (Doppler/ultrasound) studies if carotid artery disease is suspected. This cannot be overemphasized!
In our experience, patients in nursing homes and advanced care facilities are largely abandoned by their eye doctors. Many are on eye medications that are needless, or they are plagued with chronic blepharitis, trichiasis, dry eyes, and occasionally, very advanced cataracts. We urge you to consider spending at least a half a day a month in one or more of these settings. The rewards can be immense from both humanitarian and financial perspectives. The AOA has developed packets containing very helpful information regarding both hospital and nursing home services.
If at all practical, get on the hospital staff in your community, especially in rural areas. Your expertise in this setting would be enormously helpful. Not only will the patients and hospital benefit, so will your practice.
Your tax dollars are at work for you at the National Eye Institute. They have an abundance of excellent, politically-correct patient education brochures on a variety of topics germane to primary eye care. The institute will send you any of these at either no cost or a modest cost. Visit www.nei.gov.
While we like all the new retinal and optic nerve scanning devices, we are reminded of the attending physician discussing a specific patient during hospital grand rounds. As she and her residents looked over the lab results, she observed: "If these lab tests continue to be abnormal, we will need to examine the patient!" It is nice to have new technology, but we need to keep our clinical skills impeccable. Don't lose your diagnostic perspective amidst a flurry of digitized devices.
In patients with iritis or episcleritis who are resistant to the steroid taper and flare back up, have them start taking 400mg q.i.d. of ibuprofen for two to four weeks, then 400mg b.i.d. for two to four weeks. Many times, this can be helpful in enabling a successful steroid taper. Just a fine point for those unusual cases.
Don't hesitate to charge a fair fee for your professional services. The Medicare reimbursement schedule provides a good benchmark for the relative value of various procedures eye doctors provide.
The "ophthalmology" codes need to be renamed "eye care" codes, just like the PDR for Ophthalmology is now entitled, PDR for Ophthalmic Medicines. Also, it is preferable to generically address optometrists and ophthalmologists as "eye doctors," not as "eye care practitioners."
Take a good look at your "red eye" or problem-oriented patients before you zoom in on the slit lamp examination. Noticing subtle dermatologic clues (e.g., seborrheic dermatitis; hemifacial droop; lagophthalmos; ptosis; early zoster dermatitis, facial rosacea) can augment your examination, allowing for proper diagnosis and treatment.

For filamentary keratitis, following proparacaine anesthesia, use fine-tipped jewelers' forceps to snip the filaments from their attachments. Following filament "epilation," you can choose to either aggressively lubricate the eye with a lipid-based artificial tear, or place a silicone hydrogel bandage lens along with an antibiotic drop q.i.d. for 1-2 days until the micro-abrasions (where the filaments were removed) are healed. Once the acute filamentary crisis is past, pursue ongoing measures of your choice to maximize tear film function.

The most common cause of eye stickiness upon awakening is excess mucus resulting from dry eye syndrome. A good history and slit lamp exam will enable the differential diagnosis of dry eyes from an early, or low-grade, bacterial infection. Remember, dry eye disease is epidemic, while bacterial infection in adults is rare. Other clinical entities where excess mucus (not mucopurulence) is a common feature are allergic and chlamydial conjunctivitis.

If a patient is sent to you to rule out Wilson's hepatolenticular degeneration, carefully examine the superior peripheral corneal endothelial tissues, both with and without gonioscopy, looking for evidence of copper deposition in the tissues. These tend to be younger patients (20s or 30s) with behavioral or GI disorders, and are commonly referred by gastroenterologists or psychiatrists/psychologists.

Some patients have such advanced dry eye disease that both the upper and lower puncta merit occlusion. There are times when the pendulum swings too far, and epiphora occurs. These situations are best remedied by using a flow controller-type plug. These plugs are not totally occlusive, but allow some lacrimal egress and thus promote good ocular surface lubrication without exceeding the point of diminishing return. Such intervention is not commonplace, but when fine-tuning is required, these flow controller-type plugs perform nicely.

The Glaucoma Progression Analysis software by Carl Zeiss is a major advance in detecting progression of visual field defects. Not only can it be helpful prospectively, it can retrospectively analyze the visual field data collected over the past several years. If you have SITA, you need to investigate adding this software.

It is not a sin to patch a corneal abrasion. Large abrasions are often best managed with a drop of proparacaine, a topical NSAID, and 1% cyclopentolate followed by Polysporin ophthalmic ointment under a well-fixed pressure patch. Alternatively, use a silicone hydrogel lens placed over the above eye drops, along with a preservative-free artificial tear q.i.d. and generic Polytrim q.i.d. Follow abrasions daily until re-epithelialization occurs. For children with smaller abrasions, cycloplege in the office, then use a generic topical NSAID and generic Polytrim q.i.d., and a high-viscosity artificial tear q.i.d.

We recommend a 30-2 visual field for any neurologic testing. We recommend a 10-2 visual field when performing Plaquenil assessments. It makes no difference whether the red target or white target is selected; just be consistent. We always use the white target; it's just simpler and more efficient for your staff.

When examining and characterizing the optic nerve, be sure to record whether the assessment was done with a two-dimensional view (i.e., direct ophthalmoscope) or a three-dimensional view (i.e., slit lamp-enabled 90D, or similar condensing lens). A 0.3-appearing cup with a direct can be a 0.5 or 0.6 cup with a stereoscopic view, which is why it is important to specify the type of instrument used. We highly recommend all optic nerve head cupping assessments be made with a stereoscopic view.

The breakdown products from fingernail polish are a common cause of contact blepharoconjunctivitis. We now routinely treat these patients with 0.1% triamcinolone cream. The frequency of application is proportional to the severity of the expression, but is usually t.i.d. for two to three days, then b.i.d. for two or three days, then q hs for two to three days. Triamcinolone comes in a large 15gm tube and is inexpensive. Be advised that it is not an ophthalmic preparation and states on the label, "Not for Ophthalmic Use." We have used triamcinolone to care for many hundreds of patients, and it is our non-ophthalmic steroid of choice. For those patients (or doctors) who prefer an ophthalmic preparation, prescribe FML or Lotemax ointment. These latter two medicines are much more expensive and all three perform equally as well.

Schirmer testing is the least useful diagnostic test for dry eye. The diagnosis can be made by a careful history, with clinical examination confirmation and quantification. We thoroughly examine the volume of the lacrimal lake, examine the cornea with fluorescein dye, and measure the tear film breakup time. This should allow near perfect diagnostic accuracy. If you feel compelled to go the extra (usually unnecessary) mile, use lissamine green dye. Avoid rose bengal because of its rather marked capacity for burning and stinging. Other so-called "high tech" diagnostic devices are rarely needed.
When performing a fluorescein-enabled tear film break-up time, try to use a sparse amount of fluorescein dye. If the fluorescein strip is too heavily wetted, or too much fluorescein is instilled, the results can be marred. Just enough dye to color the tear film is the ideal amount. Otherwise, it may be necessary to wait several minutes for the drainage of the excess dye to attain a reliable result.

If you truly believe you have a patient with fungal keratitis, culture it and initiate therapy with amphotericin B (which can be made into an ophthalmic eye drop by a hospital-grade, compounding pharmacy) and Natacin (natamycin), which can be shipped overnight from Alcon. We have our fugal keratitis patients use both medicines hourly (while awake) for a few days, then taper based upon clinical response. All this is best done in consult (telephone or office visit) with a corneal specialist.

When removing a corneal foreign body with a basement of dense rust, first remove the bulk of the metal. Then use any sharp-tipped instrument of your choice to lift the rust plaque as a unit, or to fragment the residual rust. The Alger brush will only polish, not remove, densely compacted rust. So first break up the deposited rust, which then enables the Alger brush to completely (or nearly completely) remove all the foreign material. There is little or no wisdom in removing the foreign body and then waiting a day or two before removing the rust. Do the total job on the initial visit.

When a patient presents with a history of probable conjunctival foreign body, rather than use Fluress (or any other fluorescein/topical anesthetic agent), just use plain fluorescein dye. It may be a bit more uncomfortable for the patient, but this way the patient can immediately report to you whether or not the foreign body sensation remains. Otherwise, the patient may have to wait in your office 20 to 30 minutes for the anesthesia to wear off to be sure your treatment has resolved their symptoms.
Ocular pain control is generally accomplished with cycloplegia, a topical NSAID, and an oral analgesic. We generally recommend that a topical NSAID be used. For oral analgesia, we typically use ibuprofen 1600mg daily (i.e., two 200mg tablets q.i.d.). This dosage is highly effective and roughly equivalent to that of commonly used prescription analgesics and opioid analgesics. Our preferred prescription medicine is Schedule II Lortab 5 or Lortab 7.5 (these numbers refer to the mg strength of the hydrocodone). Lortab is a combination of hydrocodone and acetaminophen.

Punctal plug loss can be minimized by using calibrated "sizing devices" to accurately measure punctal diameter. We try to insert as large a diameter plug as is practical. These devices enable us to more precisely select a plug size that is less likely to extrude. Such devices are available from most companies who manufacture punctal plugs.

Remember that two tablets per day of the AREDS2 vitamin/mineral supplement can reduce the rate of progression of moderate to moderately-advanced atrophic macular degeneration by 25%. Always encourage your tobacco-addicted patients to stop smoking, as this is a significant risk factor for AMD.

Herpes zoster ophthalmicus is one of the diseases we most enjoy managing. Acyclovir 800mg 5 x day, or Valtrex 1,000mg t.i.d. p.o. nicely arrests the viral replication, and a potent steroid q 1-2h nicely controls any inflammatory keratitis and/or uveitis, and/or inflammatory trabeculitis (causing high IOP if these tissues are involved). Topical antivirals are not needed. Use cycloplegia p.r.n. An episode of varicella infection bolsters the immune system, which explains the exceedingly rare recurrence of adult zoster disease. Herpes simplex disease is prone to recurrence and behaves distinctly different from herpes zoster disease.

For patients plagued with chronic, recurrent HSK disease, it is well-established and safe to prescribe 400mg of acyclovir b.i.d. or 500mg of valacyclovir once daily for up to five disease-free years. This reduces the risk of recurrence by about 50%. Acyclovir and valacyclovir are available generically.

In patients with chronic diseases like glaucoma, dry eyes, keratoconus, recurrent herpes keratitis, recurrent uveitis, etc., don't educate them exhaustively at the initial visit. Rather, give them the basics, a good brochure, and answer all of their questions, but don't overload them. We generally give our patients a "Ph.D." in their condition over several visits, and always remind them to write down any questions they think of for us to go over at their next visit.

For patients with chronic staphylococcal blepharitis, a one or two-week course of Zylet ophthalmic suspension (q.i.d. for 1 week, then b.i.d. for an additional week) is helpful in three ways:

diminishes staph populations;
quiets the associated tissue inflammation;
physically softens and loosens scruff and collarette debris.

Zylet can be immensely helpful to patients. The only problem is that it works so well patients often ask for refills. Steroids are wonderful short-term, but long-term use is unwise. We always explain to our anterior blepharitis patients that it is persistent and meticulous eyelid hygiene that controls this condition, not any medicine. We long ago abandoned recommending baby shampoo for this purpose and now advise use of pre-moistened eyelid scrubs. Since patients can be notoriously non-compliant, this entire cycle of treatment and education may need to be repeated periodically.