Subscribe to RSS
Sub clinical or Sub Standard?
Maybe I just attract problems into my clinics. Maybe there is a sign on my door saying..
âproblemsâ¦then step this wayâ?
In the last 2 weeks, I have seen 5 patients who suffer with Myasthenia Gravis. One patient looked at me shocked when I said I knew what it was as his neurologist had only seen 1 case in 25 years!
However it is not these problems that cause me to write today, although the rarer cases like Myasthenia interest me greatly. Today my gripe is with a much more innocuous condition, SPE staining.
Maybe it is just my contact lens clinics, but it seems that the number of patients with diffuse SPE staining is increasing. The patients all generally wear fortnightly or monthly lenses, and generally all use a multipurpose solution. Many of these patients are asymptomatic and are completely unaware of my fascination with the fluorescein pattern I see.
Is SPE staining something to worry about?
With many optometric conditions the consensus is that if the patient is asymptomatic then no treatment is necessary. Much of the literature regarding SPE staining follows this methodology, saying that it is a sub clinical condition, so noting the presence and monitoring the condition is sufficient.
Surely if fluorescein is showing a diffuse pattern, the corneal integrity is compromised, even if only to a superficial epithelial level. Does this not raise the risk, even if only slightly, of further eye problems or infections? Is it better management to find a solution that does not cause this reaction, be it a different active ingredient, or a preservative free solution and have a stain free cornea? Â
If the incidence of diffuse staining is on the increase, should we not look at the cause? Are patients sensitive to the active ingredients in solutions, or is this another indication we are becoming more atopic as a nation and are âallergicâ? to the preservatives, for the incidence of allergies in patients in general is on the increase, with more nut allergies and asthmatic patients diagnosed every year?
So should we note it as sub clinical, or should we swap solutions? Please all vote now!
Find out more about the Andrasko Corneal Staining Grid: ‘The Staining Grid is an easy-to-use reference tool informing the eye care practitioner as to the level of biocompatibility of various contact lens/multipurpose solutions.’
Â
Facebook
Twitter
StumbleUpon
MySpace
Powered by FireStats
Sub clinical or Sub Standard? at Eye Care // Oct 5, 2007 at 2:59 am
[...] You’ll find more information about this here [...]
david cummins // Oct 5, 2007 at 9:02 am
Very interesting.
I also see SPE on a daily basis and am puzzled by how poorly these signs correlate with symptoms. SPE does however correlate more closely with diffuse bulbar conjunctival hyperaemia.
Question: Why do we bother with even instilling flouroscein in those patients with 90 – 100% lens comfort and a white (grade 0) bulb. conj.?
The ‘Andrasko Corneal Staining Grid’ is very useful, but does seem a bit damning for the biguanides. I wonder how Sauflon AIOL would reckon on this grid?
The new Optifree Replenish is causing a few problems over here in Barbados. Local optoms and ophthals have seen half a dozen cases of what looks like a viral keratoconjunctivitis (though no definitive pathology has been established) with use of this solution. All cases were treated with ocular anti-inflammatories and anti-bs and resolved fuly. All had previously used Optifree Express without problems.
*Watch out for this if you are swapping people to this new solution with enhanced moisture retention (supposedly!). Maybe Optifree Replenish will be the next solution to be withdrawn????*
I’ll keep the blog posted of there are any more cases.
DC
Peter Chapman // Oct 5, 2007 at 9:33 am
Hi David,
I agree totally regarding the solutions. Following the recall of Renu Moistureloc and Complete Moisture plus, i am approching with caution new solutions “with added comfort”.
I am not a solution manufacturer or an expert in this area, but at present there seems to be some correlation between the new generation of solutions and their ability to work effectively in certain environments. Luckily in the UK there seems to have been no definate cases linked to the solutions with problems, maybe indicating an environmental issue eg. humidity, when combined with certain care regimes, possibly not air drying cases?
I still recommend to all my patients to rub and rinse the lenses. Better to be safe than sorry.
I hope for the solution industry that Optifee Replenish is not the next solution to be hit with problems.
Regarding the instillation of fluorescein, we do this is ensure corneal integrity. Patients may not identify a symptom as a problem until further questioning. Also patient’s have variable pain and discomfort thresholds. What one person finds uncomfortable/painful another may not. There are also conditions where corneal sensitivity are increased and decreased so staining may be present but no symptoms to decreased sensitivity.
I look forward to hearing your experiences with the solutions in Barbados
Peter
david cummins // Oct 5, 2007 at 11:43 am
Hi Peter
Don’t get me wrong when it comes to fluorescein. I was not advocating throwing all my strips in the bin!
I am simply playing the devil’s advocate.
It is important, for all the tests that we carry out that there is a strong evidence-based reason for doing so. I am suspecting that in some cases, a symptom-led approach to the instillation of fluoroscein may be appropriate. After all, if the worst that we are going to find is inconsequential (not affecting our final decision or advice) superficial staining, what is the point? And if there is superficial staining then simply noting it down, without any attempt to qualify or quantify it, would not affect future decision making either, thus rendering the entire episode pointless.
I am firmly of the opinion that we MUST be able to use our time in the most productive ways possible. Simply doing a test parrot-fashion on every patient ‘because we think we should’ does not distinguish optometrists as highly-skilled clinicians.
This argument could be used about visual fields too. A lot of practices do fields on everyone! To me this is a vast waste of resources. It also means that some individuals who are at risk of pathology are having a screening test done when a more specific test could have been requested! This drives me nuts!
We are in danger of finding so many artefacts that we can no longer see what is real or significant any more.
Donald Cameron was recently urging practitioners to avoid defensive practise and I agree, we must ‘keep it real’ (to quote the famous medical ethics expert – Ali G!).
DC
Leave a Comment