Reaffirming the Importance of Routine Eye Exams

By Joseph Hallak, Ph.D., O.D., Robert Wertheimer, M.D.,
Gwen R. Gnadt, O.D., M.P.H., James Maisel, M.D.,
Elsa K. Rahn, M.D., & Marcelle Morcos, M.D.

Many consumers believe they're saving money when they purchase their contact lenses from alternative sources, but they often don't consider the value of routine comprehensive eye care. Recently, we saw two patients who reaffirmed our office policy to check every patient when we dispense a contact lens.

CASE 1: NEUROSENSORY DETACHMENT

N.M., a 22-year-old woman, had a history of high myopia and an alternating esotropia. Her manifest refraction was -17.50D OD and -17.00D OS, for which she had been using daily wear soft contact lenses with 20/20 vision in each eye.

N.M. returned to our office three months later to pick up her new lenses. A quick check revealed best corrected visual acuity of 20/20 OD and 20/80 OS. Slit lamp exam was unremarkable. She had been unaware of any visual deficit, but dilated funduscopic examination of the left fundus revealed loss of the foveal reflex and a subtle area of hyperpigmentation of the fovea with small foci of retinal hemorrhage. Fluorescein angiogram revealed hyperfluorescence extending from the choroid into the foveal avascular zone with evidence of minimal leakage. A small area of blocked fluorescence was present which corresponded to the foci of retinal hemorrhage.

Fluorescein angiography confirmed a Fuch's spot with evidence of subretinal neovascularization in the center of the macula and neurosensory detachment. A Fuch's spot in a high myope may be a harbinger of subretinal neovasculariztion, neurosensory and pigment epithelial detachments, with significant and irreversible visual loss. A retina specialist recommended postponing laser treatment due to the central location of the lesion and the high risk of worsening the central vision. We told this patient to return every two months to ensure early detection of recurrence and early intervention.

CASE 2: IRIS CYST OR TUMOR

R.M., a 42-year-old woman, came to our office by way of a third party insurance plan to update her spectacle prescription. She had just removed her soft contact lenses, which she had renewed from her ophthalmologist six months earlier. Her last exam was two years prior.

R.M. is a myopic anisometrope with -4.00 -1.00 x 125 OD and -2.25 -0.50 x 065 OS. Her uncorrected vision was 20/400 OD and 20/200 OS. BCVA was 20/25 in each eye. Ophthalmoscopy was unremarkable. Conjunctiva, sclera and anterior chambers were normal, and we saw no pupillary defects. However, the right eye showed a localized 2.0mm elevation on the iris midway along the 8 o'clock line that appeared to be produced by a mass deep in the surface of the posterior iris.

R.M. returned to her ophthalmologist who confirmed the suspect iris mass and referred her for another opinion. Gonioscopy showed increased pigmentation in the angle but no evidence of a tumor extending from the ciliary body. Scleral depression showed no ectropion uvea or increased vascularity. A high frequency ultrasound revealed an ovoid cyst of 1.1mm x 0.89mm, causing a localized angle closure, as well as another smaller cyst posterior to the original lesion. Fortunately, the diagnosis was multiple iris cysts, a benign condition. We are following R.M. for changes.

It's important to differentiate an iris cyst from an intraocular tumor. Cysts will displace the iris stroma anteriorly with a normal or slightly thinned appearance, while tumors actually rise from the iris stroma, producing a distinct lesion with feeder vessels. A careful pre- and post-dilation evaluation of the iris using direct and retroillumination and gonioscopy are essential. Other tests such as B-scan and high frequency ultrasound are useful.

DON'T SKIP THE EXAM

Every time a contact lens is dispensed, visual acuity, slit lamp and sometimes cursory ophthalmoscopy are musts. If we hadn't examined these patients at the dispensing visit, we wouldn't have detected these conditions. To compete with mail-order, charge cost for the lenses and add a fee for dispensing and evaluation. Remind patients that there's no substitute for a whole office dedicated to keeping their eyes healthy. CLS

References are available from the editors. To receive them via fax, call (800) 239-4684 and request document #29.

Drs. Hallak, Maisel, Rahn and Morcos are staff and Dr. Wertheimer is a resident at the Nassau County Medical Center, Division of Ophthalmology, N.Y. Dr. Gnadt is an attending optometrist at the Northport Veterans Administration Medical Center.