Eye Drops, Tonometry, and various Reactions from Patients

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Eye Drops, Tonometry, and various Reactions from Patients

                                                                                        29 August 2017

Instilling Eye Drops in Kids

I have been an optometrist for 40 years.

One thing I had always dreaded was when I needed to “dilate” or cycloplege a young child.

Trying to get drops in, would often entail a lot of crying or screaming from the apprehensive child.

It has been only recently that I found I could get the drops to take effect, with essentially no protests or difficulty.

I tell the child, “You can close your eyes, and I’m just going to “wet your eyelashes” with these drops.”  

I typically recline the chair slightly, so the child’s face is upward slightly.  

Then I drip on a couple of the dilating drops on one eyelid, and gently wipe the drops around the eyelashes.  

Then I repeat that process for the other eye.  I blot the excess fluid, so it doesn’t run down the child’s face.

Then, for good measure, a couple minutes later I repeat the “wetting” process a second time.

I have already given the child a tissue.  I tell the child she can open her eyes, then I let the child sit with the parent, usually for about 1/2 hour.

And I am typically amazed what a great dilation I got -- even though the kids eyes were closed when applying the drops.

For Adults, it is usually helpful to instill an anesthetic drop prior to putting in dilating drops.  

For kids, putting the drops on closed lids, I don’t even use the anesthetic drops.

For so many decades, I had struggled to pry open the eyelids of kids -- and deal with all their emotional and physical outbursts -- but ultimately, I found it could work with their eyelids closed.

About 20 years earlier, at a CE class, an OD described a way to make “Pixie Dust”  -- a combination of various dilating agents -- that would be sprayed on the outside of kids (closed) eyelids, to achieve painless dilation.  One of my colleagues then asked our HMO pharmacists to mix up those drops.  The pharmacy department refused  -- and we never went the “Pixie Dust” route.  

It was many years later I found -- Just wet the eyelashes, and you can get good dilation with no emotional trauma.

+++++++

Applanation Tonometry

I have had some strange reactions to applanation tonometry.  

A few cases, where the patient passed out or fainted in the middle of the tonometry.  One time, the patient “threw up” after the applanation procedure.  

One time, I had an adult male who kept backing away from the slit lamp every time I got close with the probe.  He then covered his face with his hand, and start sobbing in the chair, “No, doctor, no.”

(This last case was a high enough myope that he could see the test probe coming, and was too apprehensive to submit to tonometry.  At the time (1979), I was in a solo clinic in Germany, and didn’t have an NCT (Non-Contact Tonometer).  When I attempted Schiotz, his apprehension was even worse.  Actually, that’s when he covered his face with his hand, and start sobbing in the chair, “No, doctor, no.”  

A year later, I had an NCT.  The same patient was back.  I did the NCT.  The patient was very calm through the procedure.  I then looked back at my notes, and saw this was the patient who was sobbing in my chair when I attempted Applanation and Schiotz.)

I was once discussing this “tonometry” problem with an OD.  She said, “This is strange, but it usually seems like it’s the big, tough-looking guys who more often pass out during tonometry.”

My comment was, “Right.  It’s sort of a “trapped rat syndrome.”  This big guy is always in control.  Always tough, and doing things his way.  Now he has to surrender, and let some small-sized woman do some scary looking procedure  -- on his eyes.  He’s trapped & can’t defend himself.  And passes out, instead.

Another one of my Optometrist co-workers a couple decades ago, was telling me that I should do Applanation, instead of NCT.  I told him of the problem patients I had in the past, and that I reserve Applanation for times when I can’t get suitable readings with the NCT.

This OD (Gene Grubbs), however, told me the most compelling story of a difficult situation with Applanation Tonometry.

Dr. Grubbs was in the Navy, assigned to the Philippines.  He was doing an eye exam on a US Navy person.  He was doing his usual routine for tonometry. 

 “I’m just going to look at your eyes with this blue light.  Just hold steady and look straight ahead.”

The patient then asked, “Doc.  Are you going to touch my eye?”

Gene repeats, “Just hold steady and look straight ahead.”

The patient is more agitated, then repeats louder, “DOC.  ARE YOU GOING TO TOUCH MY EYE?”

Gene repeats, “Just hold steady and look straight ahead.”

The patient gets even more agitated, and asks even louder, “DOC.  I NEED TO KNOW IF YOU ARE GOING TO TOUCH MY EYE?”

Gene then pauses, sort of sits back and says, “As a matter of fact, I was planning on touching your eye.”

The patient then states, “DOC.  IF YOU TOUCH MY EYE, I’LL KILL YOU.  I’ll regret it tomorrow.  BUT, I’LL KILL YOU.

Gene then moves the slit lamp away, and writes in the chart, “Patient refuses tonometry.”  At the time, Dr. Grubbs didn’t have an NCT in his clinic.  So, no tonometry.

Further discussion with the patient, revealed the sailor had been a prisoner of war, and he had been tortured, by having things put in his eyes.  Ever since then, he was so defensive, that --- “IF YOU TOUCH MY EYE, I’LL KILL YOU.”

So you never know what demons are in someone’s past that could suddenly erupt.

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Non-Contact Optometry

Related to these stories, I have also had some strange reactions to the NCT.

I figure it is so harmless, I have always tried to do the procedure, even on kids.  I can remember once an 11-year old boy who was so apprehensive, and sobbing, that he could not submit to the test.  Then I also remember an adventurous 4-year old girl who was eager and willing to have the test.

A stranger situation was a burley, bearded, trucker guy, in for his first eye exam.  The clinic I was covering (around 2005) had an old version of a Reichert NCT.  For patients who have never had the procedure, I start off on the “demonstrate” setting.  I have the patient get in place, and on the “demonstrate” setting, I have them feel the air puff on closed eyelids.  Then after they know what it feels like, and that it is harmless, they calmly take the NCT test, on open eyes.

Well, this truck driver reacted so intensely to the “demonstrate” setting that I had a hard time calming him down, so he could hold still for the actual test.

And then I got readings for both eyes in the high 20s.  I thought, “Great  -- now I’m going to have to try to get an applanation on this guy as well.”

I finished his eye exam, and then at the very end, I set him up for the applanation.  As he understood what was to go on next, he pushed away the slit lamp, and fairly quickly exited the exam room.  There was no way he was going to sit for that procedure.  The guy’s wife was there, and I explained what was going on.  And how I needed to recheck the reading.  She was familiar with the test, and had it before, and realized it was no big deal.  I suggested that since he would not submit to the test, done by me, then he should get it rechecked by another eye doctor.  The wife agreed to go forward with that.

As I started on the next patient, I realized I had left the NCT on “demonstrate” when I was trying to check NCT on the truck driver.  His extreme reaction to “demonstrate” had distracted me so much, that I lost track of my usual procedures.  I spent so much time and energy trying to calm the patient down, I didn’t switch the NCT back to the normal testing mode.  And since it didn’t come up with the usual “demonstrate” reading (typically “49” or “50”) -- I didn’t realize it was on demonstrate.  I guess when the NCT (on demonstrate) strikes a real cornea, it shuts down the force of the “puff” mid-way through the demonstrate cycle, and doesn’t reach a force of “49” or “50.”

The next day, I told the OD at that clinic what had happened, and that the patient should be called to come back in for a recheck.  The OD decided it wasn’t worth the effort, and to just leave that case alone.  He was just too intense of a patient.