Slit lamp shows contact lenses staved off symptoms

“Case Scenario,” illustrates how a specific device’s image aided in patient management.

PATIENT

A 37-year-old white female; chief complaint: foreign body sensation OU when not wearing contact lenses (CLs).

EXAM FINDINGS

Entering distance vision: OD 20/400: -3.00-0.50 x100, 20/20; OS 20/400: -2.50-0.25 x115; 20/20 with CLs: OD -3.25 and OS -2.50. No sleeping in CLs.

APPROACH

Marco Ultra M2 slit lamp with iPhone 6

DIAGNOSIS

Mucin balls on superior tarsal conjunctiva; clear spheres, each <0.50mm, about 10 scattered diffusely OD and OS; and mild superior corneal punctate keratitis. CLs were a barrier, preventing symptoms.

MANAGEMENT

Compounded 10% n-acetylcysteine (NAC) ophthalmic drops.

PATIENT CARE TIP

Face wash exfoliating beads and hormonal changes could be the culprit, but in this case, the cause is a mystery.

CODING

T15.11XA, T15.12XA, T15.11XD, T15.12XD OM

CASE STUDY

Note the only remaining mucin ball at a follow-up exam after starting treatment.

 

 

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DR. SPENCER practices at Ginter Eyecare Center, where he specializes in glaucoma, therapeutic optometry, specialty contact lenses, family vision and laser vision evaluations with the Laser Eye Center of Lubbock.