reflections

A Real Eye Opener

The answer to a burning question is revealed.

TODD P. HAMILTON, O.D., ST. CHARLES, MO.

The most memorable lessons don't always come with Council on Optometric Practitioner Education (COPE) approval. Sometimes, they come from our patients. Here's my story …

Dilated and infuriated

A 36-year-old white woman, who was in for her annual exam the previous week was back in my chair and glowering at me. "My eyes are still dilated from that stuff you put in them," she reported, setting her chin and crossing her arms.

I was a little skeptical of her diagnosis because a tropicamide/phenylephrine cocktail would have long since worn off, and at the moment her pupils looked about 5mm around. I pointed this out, but she only threw-up her hands in aggravation.

"Well of course they look fine now! They're usually back to normal by nine o'clock." She pursed her lips, "I'm just lucky I don't have to be at work sooner."

Using history to solve mystery

"Let's take a look," I said, my face exuding that confident expression of a doctor who has the situation well at hand.

Hoping she was buying my sanguine demeanor and needing some time to wrap my brain around her last bit of information, I distracted her with some questions and testing:

• "Have you started any new medications since your last visit?"

"No," she replied.

• "Do you have any other symptoms?"

"No," she replied.

Testing revealed her vision was 20/20 O.U. Also, her pupils were normal, her ocular health was unremarkable, and she passed every other test I could think of with flying colors.

Hamilton syndrome?

Had I just stumbled upon an undiscovered condition? My hands were shaking with excitement as I finished leafing through my dog-eared copy of The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, never once finding a single reference for "pupils dilated until 9:00a.m."

I began imagining power-point presentations and journal articles, government grants and public-service announcements. I saw optometry students hunched over books, drumming the signs and symptoms of Hamilton Syndrome into their already frazzled brains. Jealous that we were there first, ophthalmology would offer up its own moniker, setting off a confrontation between the forces of plus and minus cylinder that would make the Cuban Missile Crisis look like an episode of Deal Or No Deal.

"Could my hemorrhoid cream be causing it?" the patient asked, snapping me out of my delusions of grandeur.

She explained she had just started using the cream on her lids at night to keep from getting bags under her eyes — talk about off-label.

I learned a lot in optometry school, but I don't recall the pharmacology of hemorrhoid cream making the list. Figuring it was worth a shot, we took a trip to the pharmacy next door. While we were there, I got some free continuing education after discovering the active ingredient in Preparation H is none other than phenylephrine 2.5%.

The patient picked up some new night cream. OM

DO YOU HAVE A MEMORABLE EXPERIENCE YOU'D LIKE TO SHARE? DISCUSS YOUR STORY WITH JENNIFER KIRBY, SENIOR ASSOCIATE EDITOR OF OPTOMETRIC MANAGEMENT, AT (215) 643-8139, OR -E-MAIL KIRBYJ@LWWVISIONCARE.COM. OM OFFERS AN HONORARIUM FOR PUBLISHED SUBMISSIONS.