This article is more than 5 years old. Information may no longer be current.
Anterior segment experts: You are red eye doctors
Embrace your day-to-day duties so that patients can be treated earlier and more effectively.
Click Here to Manage Email Alerts
It was a typical Wednesday afternoon in the clinic at SkyVision. We were filled to the gills; every chair in the lobby was occupied and every lane in use. Pretty much every patient was in the office for exactly the same thing. For 4 solid hours, all I saw was a steady stream of patients with some kind of red eye. I introduce myself as an eye surgeon, live for the time I spend in the OR, and continuously think of how best to discuss the latest developments in advanced IOL technology or LASIK with my patients. But like all who live and work in the anterior segment but a very few, preops, surgery and postops do not constitute the majority of what we do. The reality is that you and I are doctors of the red eye.
I know, I know — it is not very sexy to be a red eye doctor. You are out to dinner at a fancy restaurant meeting the parents of your son’s fiancée when they discover you are a doctor. Do you really want to tell them the truth, that what you do for most of your day is see folks who come in with red and sometimes goopy eyes? No way. You are going to tell them you are an eye surgeon, just like I would.
Whether you have accepted the reality that you are a red eye doc publicly or privately, acceptance leads one to the inevitable conclusion that as long as this is what you do, you should go ahead and do it as well as possible. Just like treating dry eye, taking care of people who have a red eye will generate loads of goodwill, among both your patients and their primary care doctors. Making an accurate diagnosis of the underlying cause of the redness and then targeting that diagnosis with appropriate, effective treatment saves your patients from extended misery from their red eye, as well as the time and money that is sometimes necessary if that diagnosis is inaccurate.
Darrell E. White
Common and complex causes
Red eye is incredibly common as a presenting complaint in the clinic, and thankfully there are some rather common and benign entities that allow it to be diagnosed and treated with little more than handholding and some reassurance. The best example of this, of course, is the benign subconjunctival hemorrhage. While this is effectively diagnosed by your receptionist as the patient walks through the front door, your patient is still likely to be quite concerned by her red eye. The few minutes you spend explaining that it probably is only due to the fact that she is straining in the loo and not some phantasmagorical and rare cancer might save her countless sleepless nights, even though you know she did not even need to be in the office that day. The red eye is always a big deal for the patient.
As easy as it is to diagnose and “treat” some of the common causes of the red eye, a substantial percentage of patients who present with complaints of redness actually represent some of the most complex diagnostic challenges we face. Pretty much all of our ocular surface disease armamentarium comes into play for these patients. Dry eye, meibomian gland disease, infectious conjunctivitis and allergy are all on the board with essentially every patient. Indeed, all of the cool new diagnostic tools we have come together to work with the most traditional aspects of care when it comes to making an accurate diagnosis or at least narrowing the possible diagnoses to the point at which treatment is more finely targeted.
Making the diagnosis
The magic in being a red eye doctor is, I think, in making the diagnosis. “If it’s X, then the treatment is Y” is fairly well established for us with most of the entities we might encounter. All good medical care starts with taking a careful history of the problem, whether this is done entirely by you or mostly by one of your technicians. Simple stuff such as “How long has this been going on?” and “Do you wear soft contact lenses?” can almost seal the deal before you even turn on the slit lamp. A contact lens patient who slept in his daily wear contacts for the entire week of spring break in Cabo makes you think corneal ulcer, for instance. The history, especially if taken by a technician, can also lead to the utilization of some of the wonderful point-of-service diagnostic tests I have written about — tests that will rule in or rule out some large diagnostic categories. For example, a patient with a red eye that is tearing and symptoms that came on approximately a week after the start of an upper respiratory infection would probably benefit from being tested with AdenoPlus (RPS); a positive result sets your course of action before you even enter the room.
AdenoPlus, TearLab tear osmolarity and InflammaDry (RPS) are available to help guide our diagnosis, and we can expect to have point-of-service tests that will soon allow us to detect levels of IgG and IgA in the tears (note to device companies: hurry up!). As an aside, determining a probable cause of allergic conjunctivitis is now possible in our offices with the new Doctor’s Allergy Formula testing program. In the end, though, the diagnostic rubber meets the road for us once we sit down at the slit lamp. Are there follicles or papillae? What is under that upper lid? Are those vessels causing the redness episcleral or scleral? Is the cornea clear and the anterior chamber deep and quiet? How about those meibomian glands — what happens when you push on the lids? The red eye doctor earns her keep when she settles into the oculars.
In these less-than-halcyon days of “health care reform,” it will become more important to justify your place in the care systems that will arise. One way to do that is to demonstrate that your ability to diagnose and treat common problems is superior to other options available to patients. Here your “competition” is not only a family practitioner or pediatrician but also the ER and a nurse at an urgent-care clinic. Making an accurate diagnosis of the underlying cause of the red eye is critical in choosing the most appropriate treatment, and making that effective therapeutic call earlier is not only better care but more cost-effective care. You are an anterior segment expert; this is right in your wheelhouse. Embrace your status as a red eye doctor and encourage these patients to come to your office first. Having an ophthalmologist treat the red eye is better for the patient and better for our health care system as well. Repeat after me: “I’m a red eye doctor, and I’m proud!”
There, doesn’t that feel better?