CLINICAL CHALLENGES
Looking at the Big Picture
When searching for an explanation to a patient's condition, consider the less obvious.
By Eric Schmidt, O.D.

Throughout the course of our busy clinical days we encounter patients who present with seemingly routine findings that we may trivialize. Often these patients have clinical findings that add up, or so we think, to an easy diagnosis. But occasionally an underlying cause throws a monkey wrench into our diagnosis and treatment.

For these patients, especially those who have seen other doctors for the same condition, we need to take a step back and take a more global look at the whole presentation and not just at the slit lamp findings. The following case is a perfect example.

Meeting angry Alan

Alan, a 25 year old male, had had an "infection" for more than two months that no other doctor had been able to clear up. Needless to say, he wasn't thrilled to see yet another eye doctor and was quick to express his dismay with me and "those other ones" who couldn't rid him of his eye problem. Alan explained to me that his right eye had been irritated consistently for the past two months and that his right eye was producing a steady amount of mucous discharge throughout the day.

He insisted that the eye didn't hurt but repeated that it was irritated. He expressed that he was becoming frustrated with the condition and the fact that he has used three different drops prescribed by two different doctors and yet saw no improvement in his condition.

Listing recent treatment

According to Alan, the first doctor told him he had allergies and prescribed olopatadine HCl 0.1% (Patanol) OU b.i.d. After using the drop for about two weeks with no improvement he returned to the doctor, who then prescribed "a stronger drop," which turned out to be loteprednol etabonate 0.2% (Alrex).

After one week of instilling the loteprednol q.i.d. OD, Alan noted unremitting discharge and sought another doctor who allegedly told him that his lenses were causing the condition. The second O.D. instructed Alan to discontinue wearing his lenses and prescribed pemirolast potassium 0.1% (Alamast) OU b.i.d. He was supposed to return to that doctor in two weeks and was told that he may have to be fit with a different type of lens.

Alan told me that he stayed out of his contact lenses for two weeks and used his drops as prescribed but didn't notice any improvement in his condition. He told me that he started wearing his lenses again because he didn't see well with his glasses. He also stopped using the drops because nothing seemed to make a difference. He was clearly frustrated with this experience and was, "at the end of his rope." I also got the impression that he was in my office rather begrudgingly and not hopeful about a better outcome.

Learning of a past problem

Before his current problem, Alan had worn contact lenses without any problem for more than 11 years. The first symptom was a little irritation that he attributed to wearing an old contact lens. He noted a small amount of mucus at first, but the discharge became more prolific over the next week. He said that changing the lens didn't alleviate the situation and that the irritation remained constant for the two-month period and the discharge has become progressively worse. Alan said that now he's constantly rubbing at his eye to remove the mucus. Curiously his OS has remained unaffected throughout this time. The OS didn't feel uncomfortable and there's been no discharge or redness. I also asked Alan if his OD felt any better when he wasn't wearing his lens. He answered that it didn't but said that the lens felt more uncomfortable in the OD than OS.

Alan's sordid past

Alan had a rather rocky ocular history. He was nearsighted and had been wearing glasses since the age of four. When he was 13 years old he suffered a retinal detachment OD, (presumably from myopic stretching), which was repaired with surgery. It left him with impaired vision OD but with his contact lenses he said that he saw well with his OS. Since he was 14 years old he had worn various types of soft lenses without any difficulty. He had been wearing these disposable lenses on a two-week basis for the past six years. He'd been prescribed an extended wear regimen, in which he was to remove the lenses weekly and dispose of them every two weeks. He told me that he was "pretty good" about sticking to this regimen, but did allow that he would "go over" two weeks on occasion. Up until two months ago he had no further trouble with his eyes or his lenses.

Alan wasn't taking medications, other than the multitude of drops that had been prescribed. He was wearing CIBA Focus Weekly contact lenses, -10.00 OD and -9.50 OS. The base curves were 8.4 OU.

Examining Alan

With his CL Alan's visual acuity (VA) was 20/200 OD, 20/20 OS. The VA did not improve OD with a pinhole occluder. Likewise his VA remained at 20/200 OD through a refraction of -12.25 - 2.75 x 65. His refraction OS was -11.75 - 0.50 x 010 for a VA of 20/25. His pupils were 6 mm equal, round and briskly reactive OU. There was no afferent pupil defect (APD). Extraocular muscles showed no restrictions OU. On confrontation field testing Alan exhibited an inferior constriction OD. The OS was full to confrontation fields. Alan wasn't exaggerating when talking about his mucus. Even without a slit lamp there was an apparent accumulation of mucus from his OD only. As Alan wiped the mucus away, more appeared five minutes later in enough volume to warrant another sweep with his tissue.

I examined Alan's anterior segments closely with the slit lamp. The OD revealed copious Grade 4 mucoid discharge that had built up on the lids and ocular surface. There was no meibomian gland inspissation and no lid debris other than the mucus. The bulbar conjunctiva showed Grade 1+ injection and the cornea exhibited trace superior punctuate keratitis when stained with sodium fluorescein dye. The anterior chamber was deep and quiet.

I everted the eyelid and was amazed to see huge papillae (see figure above), which were conspicuous not only because of their size and sheer numbers but also by the fact that they didn't appear inflamed. In fact, they almost seemed pale and had no follicles associated with them. I only saw a few small papillae on the inferior palpebral conjunctiva.

The OS showed trace papillae on the superior palpebral conjunctiva but was otherwise normal. The disposable lenses that Alan was wearing appeared in good shape. They were well positioned and free of deposits although the contact lens OD moved a bit more than the OS, especially on upper gaze. IOP was 13mm Hg OD, 15mm Hg OS.

Questioning the suspects

The first thing that came to my mind in this case is Chlamydia. Cases of Chlamydia often present similarly to this with the patient being treated with many different drops from multiple doctors for a red eye with no resolution. However, Chlamydia is marked by follicles and none were apparent in Alan's eyes. Also follicles are almost always seen in the lower fornix. This case involved the superior lid exclusively, so Chlamydia was unlikely.

Another likely etiology is giant papillary conjunctivitis (GPC), commonly seen in patients who have worn soft lenses for a long period of time. GPC is marked by mucous discharge and large papillae. Alan's lens didn't show excessive movement. GPC is generally bilateral but can be asymmetric. The papillae seen in GPC are typically inflamed looking -- a bit more red than those in this case. But this still remained a likely diagnosis.

Gonococcal conjunctivitis (GC) is marked by copious discharge as well. But unlike this case, GC eyes are usually injected and the discharge is purulent rather than mucoid in nature. Vernal catarrh was also a possibility, only this usually shows more corneal involvement and the patient with vernal catarrh is in great discomfort.

Finding the offender

The key to making this diagnosis was the papillae. Papillae of this magnitude are most likely incited by a foreign body. Alan's lenses were in good shape and his eye didn't appear to have a conjunctivitis as is seen in classic GPC. Also as I said, the papillae were so asymmetric that GPC seemed increasingly unlikely. I looked under the OD lid again and noted only large papillae.

I then double everted the lid and saw the culprit. I could visualize the silicone scleral buckle that had been used to repair the retinal detachment 12 years earlier. The scleral buckle had slipped forward over those years and was now extruding anteriorly enough to induce this papillary conjunctivitis!

I related my finding to Alan and explained the rarity of his situation. I arranged for a retinal consult the next week, during which the retinal specialist indicated that Alan would have to have the scleral buckle removed and replaced with another one.

Ending on a good note

Three months later, the majority of Alan's papillae had disappeared and the mucus was gone. Almost as importantly, a smile has returned to his face.

Contributing Editor Eric Schmidt, O.D., is director of the Bladen Eye Center in Elizabethtown, N.C. E-mail him at kenziekate@aol.