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All they know is how they feel and how well they see.” • “Symptoms direct treatment. Ultimately, symptoms determine the success of our interventions.” • Our take: Doing a bunch of testing may generate revenue, but does it truly enhance patient care? Our care is symptom-driven. Let’s keep simple what is simple. White DE. It is still the symptoms: patients care about how they see and feel. Ocular Surgery News, April 25, 2020. REVIEW OF OPTOMETRY JUNE 15, 2020 25 ANTERIOR SEGMENT CARE S everal years ago in our state’s largest newspaper, there was an article describing a distraught lady who had been to 11 different eye doctors of all stripes over a two-year period for a chronic, low-grade foreign body sensation with occasional secondary tearing. Some poor soul even performed a dacryocystorhinostomy on this patient. As it turns out, “Dr. Eleven” was an optometrist who swept the recesses of the patient’s superior culde-sac, and out came a folded-over soft contact lens! Here’s the lesson—if you do not see a foreign body or other cause for the patient’s complaint, consider performing this maneuver: (1) Use a couple of drops of proparacaine. (2) Moisten the tip of the cotton swab with any eye ointment (for lubrication). (3) Have the patient look down and insert the cotton swab (as seen in Figure 1). (4) Gently sweep the entire culde-sac back and forth two to three times. If there is something hidden up there, it will generally come out with the swab. In our experience, pieces of (and sometimes even a whole) soft contact lens can be found beneath the upper lid. Except in severe dry eye, there is almost always a detectable reason for foreign body sensation; our job is to find it. There is yet another occasion to sweep the cul-de-sac: in the setting of giant fornix syndrome. This is a condition seen almost exclusively in older people with deep-set eyes that result in a pronounced and deepened superior fornix. This anatomic configuration allows for an inoculum of Staph. aureus to gather in the recesses of the cul-de-sac, thus resulting in a subacute to chronic conjunctivitis. Treating without removing this goop of inoculum will result in therapeutic failure. Once the sweep of the cul-de-sac is done, prescribing an oral antibiotic such as cephalexin 500mg BID for one week along with Besivance ophthalmic suspension (Bausch + Lomb) QID for 10 days, and a steroid eyedrop QID for one week can effect a cure. Figure 2 shows a case we nearly failed to properly treat because we failed to appreciate the presence of giant fornix syndrome.
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