Ophthalmology Survival Guide

Transcription

1 Ophthalmology Survival Guide

2 Introduction No doubt about it, starting a residency is very difficult. As a new first-year resident, the recurrent theme seems to be "I wish I had known this sooner" or "I wish someone had told me that." This guide is designed to do just that. It is to be a quick stop for information. We intend for it to be as concise and practical as possible. References are provided when appropriate. Obviously, it is not complete by any stretch of imagination, and you will definitely need to consult the abundant reference materials available in our great C.S. O'Brien Library. This is designed to be a foundation on which we hope you will build. We review the manual on a yearly basis in order to make it as up-to-date as possible. As you go through the year please, think about additions or deletions that may be appropriate and suggest these changes for future editions. Two key things to remember when you re starting call: 1) Don t blind anyone if you are ever unsure what to do ( Should I go in or not? ) err on the side caution. Just see the patient. 2) You re never alone there s always back-up available. Every senior resident has at one time been a first-year. Welcome to Iowa! As you will soon find out, this is a great department with a profound and far-reaching legacy of ground-breaking research and excellent patient care. You are now a part of that family and we re happy to have you! Iowa City, July 2014 Page 2

3 Table of Contents... 1 Introduction... 2 Table of Contents... 3 UIHC Layout... 6 Driving Directions to UIHC... 7 On-Call tips: When seeing a patient... 8 On-Call tips: Documentation and follow up On-Call tips: Odds and Ends Corneal Drawing Symptoms as a Clue To Cause of a Red Eye Superficial Keratitis - Differential Diagnosis Based on Distribution Corneal Abrasion/ Foreign Body Corneal Ulcer How to Culture a Corneal Ulcer Chemical Injury Trauma Hyphema Post-Op PKP Management Classification of the Anterior-Chamber Angle Laser Settings Guide to Fundus Drawing Retina Studies Bilateral Optic Disc Edema Anisocoria Dilating a Child Using the Retcam Page 3

4 Postoperative Troubleshooting Things To Remember From Internship Driving with a Visual Impairment (as of 6/22/13) Generic Names, Brand names & Cap Colors Abbreviations Phone Lists Basic Phrases In Spanish FAQ Notes Page 4

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6 UIHC Layout The Buildings of the Hospital are in alphabetical order (by last name) from North to South. Boyd Tower (BT) - aka General Hospital Roy Carver (RC) John Colloton (JC) John Pappajohn (JP) Pomerantz Family Pavilion (PFP) Elevators A, B, C Elevators D, E Elevators F, G, H Elevators I, J Elevators K, L, M The wards are named by floor number, then building, then often as West or East. When you get off the elevator and start walking down one of the wards, the first nurses' station you come to will be the "West" nurses' station, and if you keep going you will come to the "East" nurses' station The key to knowing where you are is the elevators. They are in alphabetical order, starting with Elevator A in Boyd Tower down to Elevator M in Pomerantz Family Pavilion. Floor Elevator: Burn Unit 8 JC G (H) Call Room Ophtho 7 JC H CT Scanner 3 JC H CVICU 4 JC G (H) East Room 8 JC D ER 1 RC D Main OR 5 JC/JP G (H) Med Psych 4 SE (Gen. Hospital) C Microbiology 6 BT A MICU 5 RC E Molecular Ophtho lab 4 Med Labs MRI/Reading Room Lower Level JC G or F Neuro/Neuro-surg 6JCW G (H) NICU 6 JP I Ocular Path 2 MRC BB Ophtho Inpatient 3 RC D (**There is a slit lamp on 3 RC, Room #2) Peds Eye Inpatient 2 or 3 JCW G (H) Pharmacy, Outpatient 2 PFP K Pharmacy, Main 1 Gen Hospital C PICU 7 JP I Radiology Reading Room 3 JC F SICU 5 JP I Specimen Control 6 RC E Main Cafeteria 1 Gen Hospital C On-call room: 7404 JCP Page 6

7 Driving Directions to UIHC Driving distances, in miles, from regional cities include: Des Moines: 110 Chicago: 220 Omaha: 245 Milwaukee: 260 St. Louis: 260 Kansas City: 290 Minneapolis: 300 Driving from the North (Eastern Iowa Airport): Take Interstate 380 South At mile marker 0, Interstate 380 South becomes Highway 218 South Take Highway 218 South for 3 miles to exit 93 (Melrose Avenue) Turn left onto Melrose Avenue Take Melrose Avenue for 2.4 miles to 5th stoplight at Hawkins Drive Turn left onto Hawkins Drive, and the Hospital is immediately on the right Follow signs to valet parking or appropriate parking ramp Driving from the East (Quad Cities Airport): Take Interstate 80 West to exit 242 (1st Avenue Coralville) At stoplight, turn left onto 1st Avenue Take 1st Avenue for 1.3 miles to 4th stoplight at 2nd Street (Coralville Strip) Turn left onto 2nd Street Take 2nd Street for 0.4 miles to 1st stoplight at Hawkins Drive Turn right onto Hawkins Drive Take Hawkins Drive for 0.6 miles, and the Hospital will be on the left Follow signs to valet parking or appropriate parking ramp Driving from the South: Take Highway 218 North to exit 93 (Melrose Avenue) Turn right onto Melrose Avenue Take Melrose Avenue for 2.4 miles to 5th stoplight at Hawkins Drive Turn left onto Hawkins Drive, and the Hospital is immediately on the right Follow signs to valet parking or appropriate parking ramp Driving from the West: Take Interstate 80 East to exit 239A (Highway 218) Take Highway 218 South for 3 miles to exit 93 (Melrose Avenue) Turn left onto Melrose Avenue Take Melrose Avenue for 2.4 miles to 5th stoplight at Hawkins Drive Turn left onto Hawkins Drive, and the Hospital is immediately on the right Follow signs to valet parking or appropriate parking ramp Page 7

8 On-Call tips: When seeing a patient Patients call us because they are worried and in need of help. Listen to them carefully. 1. Offer to see every patient who calls. Even if you don't think the situation is emergent, it's still wise to let patient decide not to come in right away. 2. Never hesitate to call for help. 3. Document, Document, Document. Take photos whenever possible. 4. Although there are many things we d rather do than be stuck on-call, it an amazing opportunity to learn. 5. Above all, help your fellow residents out whenever you can. Remember, we are in this together. I. Telephone calls from patients A. Identify 1. Chief complaint 2. Pertinent ocular symptoms a. Visual change b. Pain c. Redness d. Onset and duration e. Discharge B. General Rule: If in doubt, bring the patient in. 1. Good idea to offer to see all patients 2. "It is difficult to assess your problem without examining you. I would be happy to see you as soon as you can get here." 3. Obtain patient information (KEY!!) a. Name (full name, proper spelling) b. Individual identifiers (D.O.B., Hometown, Hospital # if known) c. Telephone number ask for cell phone if possible d. Seen previously at this clinic? Attending? 4. Set a time for arrival/appointment. If urgent tell them to come immediately and not to eat or drink if symptoms suggest a possible retinal detachment/globe injury/need for emergent surgery. 5. Established patients may come directly to the eye clinic; patients new to UIHC must go to the ED first. Tell the patient that the eye clinic will be locked. They will need to use the phone at the door to call the operator and ask for the eye doctor on call. 6. Request medical records if last seen in pre-epic era. a. Page and ask them to STAT charts to the eye clinic. 7. Document calls and follow-up plans for patients who cannot/will not come in that you feel need to be seen. II. Telephone calls from outside physicians and ERs A. Additional injuries? Is the patient stable? 1. Isolated globe trauma or eye problems decide if they can been managed in eye clinic or should be managed in ER. 2. Possibly unstable or other injuries transfer patient to UIHC through the ER. Facilitate communication between the referring physician/er and UIHC ER (6-2233) so transfer can be arranged and the patient accepted. Ask the ER to page you once the patient has arrived. B. Obtain referral information 1. Physician name and phone number 2. Referring physician should be kept informed (dictated letter +/- phone call) C. Request medical records (from transferring physician and old UIHC records as above) D. Special instructions Isolated open globe see Trauma section, open globe Page 8

9 III. Seeing patients on call in the clinic A. Make sure patient is stable take immediately to ER if unstable B. Screen and take history C. If situation is urgent and you need to dilate - check Va, Ta, pupils for RAPD, SLE for iris neovascularization, narrow angles first and then dilate before completing the history. D. See the patient and form an assessment and plan before calling the senior resident 1. Do your best tough at first!! 2. Don't be afraid to call. If any questions, check with your back-up. 3. Early in the year, always run patients by the senior resident later you will be able to manage more on your own. All patients going to the OR must being admitted and need to be seen by the senior resident. E. If things seem emergent or there has been a dramatic change in visual acuity call the senior resident right away before dilation. They may want to come in to verify an RAPD early in the year. F. If a patient appears surgical (i.e. open globe, canalicular laceration, lid margin laceration ) 1. Call back-up early 2. Last meal?? - keep NPO 3. Tetanus 4. History and physical 5. Consent form 6. Call anesthesia for pre-op evaluation ( ) 7. Call OR for available time (3-6400) 8. Call bed placement (4-5000) G. Admissions (corneal ulcer, endophthalmitis) 1. Call back-up early 2. History and physical; Consent 3. If the patient needs to be admitted post-op, get the admission orders ready 4. Call nurse supervisor (Adult: ; Pediatric: ) to arrange admission H. CT/MRI/X-ray: For patients being seen in clinic 1. Page the radiology resident on-call to ensure the proper protocol is being ordered 2. Put the orders in EPIC. 3. If giving contrast check BUN/Creatinine 4. Transport the patient to radiology * If you know a patient may need imaging, it is sometimes helpful to have the patients come through the ER rather than clinic. IV. Seeing patients on the floor or in the ER A. Think about what you may need for your exam B. Stock the call bag for your journey You should re-stock the call bag after each call and recharge instruments that need it. Place used instruments in the appropriate area in the nurses station. A comprehensive list of supplies should be located in the call bag to instruct you on what should be refilled / replaced. Remember to help each other out and to respect the call bag!!! Its home is in the room across from the nurses station. 1. acuity card 2. indirect ophthalmoscope 3. Finhoff with neutral density filters 4. tonopen and covers 5. drops fluorescein, proparacaine, tropicamide, phenylephrine (different if a child please refer to page 48) 6. near card with and spherical lenses 7. 90/20 D lens 8. portable slit lamp 9. other supplies as indicated by consult Page 9

10 C. Essential parts of your exam: 1. Check for RAPD 2. Visual acuity in each eye eye chart or near with appropriate add (loose lenses in call bag) 3. Motility 4. View of optic nerve and posterior pole 5. Ocular exam specific to trauma a. sub-conj heme!360 SCH and you cannot see sclera be cautious of occult open globe b. hyphema/hypopyon c. iridodialysis, traumatic mydriasis d. pigmented tissue visible anywhere e. periorbital ecchymosis/edema (need for canthotomy/cantholysis!) f. infraorbital paresthesia g. orbital rim step-offs h. lacerations i. subcutaneous emphysema j. telecanthus or rounding of medial canthus (medial wall fracture) k. facial asymmetry l. forced ductions if limited motility m. if suspicious of an open globe do not check IOP 6. Find out what ENT, G-Surg, Neuro Surg, Ortho, etc. plan to do with a multiple trauma patient to coordinate services and plan OR time if necessary. 7. Review CT scans 8. If the patient looks surgical and other services are moving fast, let the senior know right away. Otherwise, do the above prior to calling the back-up. V. Miscellaneous A. Diurnal pressure checks 1. Glaucoma tech will notify you of diurnal curve patients 2. You are responsible for 7PM, 10PM, and 7AM IOP checks 3. Communicate with your patient at the 7 PM check B. S/P vitrectomy patients a. Where to meet usually call from front door b. "I'm on call and may be tied up, but will try to be as punctual as possible" c. if you anticipate an excessive wait, call your back up 1. Retina fellow may call for IOP check 2. Communicate directly with the retina fellow on post-op patients 3. Never take lightly a retina patient complaining of head or eye pain! (May indicate endophthalmitis) C. Retinal detachments, retinal holes, etc. 1. Call retina fellow pager directly for evaluation of definite RD referrals after working it up. If unclear of what you re seeing, call your senior first prior to fellow. Remember: the B-scan is your friend! Page 10

11 On-Call tips: Documentation and follow up A. Visit Types and Documentation There are three types of patients seen on call with subtle differences in the way documentation is initiated and co-signed. 1. Clinic patients These are patients who have previously been seen in our department such as post-op patients who need to be seen after hours. In order to document on these patients in EPIC, an encounter must be created by calling the ER at You will need to tell the ER the patient s name, MRN, faculty on call, and type of encounter comprehensive clinic. If the faculty on-call is not a comprehensive ophthalmologist, the encounter may display the exam type of a sub-specialty such as neuro-op or peds. Sometimes, Kaleidoscope doesn t get initiated at all in this situation. Although the ER should be able to enter this correctly, I have found that if you substitute a comprehensive faculty name when asked for the on-call doctor, the encounter almost always loads correctly. The appropriate on-call faculty will still need to sign the note so it shouldn t cause unnecessary liability. To view the patient s encounter after the ER has created it, open Patient Station in EPIC and then type in the patient s MRN. Then, while in Pt Station, click on the newly created encounter. You will now be able to enter a clinic note just as you would in general clinic using the ophthalmology exam and the comprehensive clinic note template. There is an ophthalmology exam activity on the navigator bar on the left once you are in the patient s encounter. You can use this (just as you would in clinic), to enter your exam. Just be sure that when you select your consult note template, that you select the eye Kaleidoscope consult note template to pull your in your Kaleidoscope exam information. This should be used for consult notes as well. Clinic notes will need to be co-signed. This will generally be directed to the faculty on-call unless you have spoken to a fellow or faculty about the patient or the patient was seen or will be seen by a fellow or faculty within 24 hours. 2. Inpatient consults These are patients on the floor who have an official consult entered into EPIC. When you are paged about these patients, you should remind the consulting team to enter an official consult order into EPIC. You will also want to ask if these patients can be dilated if needed. These patients may be found by using either Patient Station or the Pt Lists tab. Under the Pt Lists tab, patients can be found by floor under System Lists -> Consults -> Ophthalmology When the correct encounter is opened, click on the consult tab. Click Consult Note to open the clinic note text box. This prompts you to link it to the ophthalmology consult order if it has been placed. The Consults SmartText should appear in the consult note. Choose Eye Consult Note from the list. Under Objective, select whether the exam was performed in the clinic or at the bedside. You can either free text an exam or type.eyeconsultinpatient for an exam template SmartPhrase. You can type F2 to quickly navigate through the blanks in the exam template. Inpatient consults will also need to be co-signed using the same guidelines as for clinic patients. See the staffing section below for more information. It is a rule of thumb to discuss or the senior resident about all inpatient consults since faculty will need to be made aware of the consult. (Anytime you need to talk to faculty, the senior should be aware of the patient first.) 3. ER patients These are patients the ER is consulting you on OR patients our department have never seen before OR patients who you feel you may need ER assistance for things such as imaging, medication, sedation, or for security reasons. *Hint Patients with Medicaid who are not from Iowa will not be covered and should be directed to an appropriate facility in their own state. It is not your job to ask about insurance, rather make sure the call center transferring service looks into these details. The ER will create encounters for these patients. If you are sending the patient to the ER, you should let them know by calling These patients can be found by using Pt Station or Pt Lists under ETC. *Hint To view the ER grease board, log in as ETC instead of Ophthalmology LIP, but always document as an Ophthalmology LIP. An ER consult can be documented just like an inpatient consult. These notes must be cosigned as well. Many patients can be cosigned by the ER attending unless the patient is to be seen by a fellow or faculty soon. Page 11

12 *Hint - To administer medications in the ER, enter these into current visit orders. To print a prescription in the ER, enter this into the discharge orders similar to what you would in clinic. Generally the ER attending or resident will do all of the during visit and after visit orders you just need to let them know your recommendations at the end of the visit. B. Staffing Staffing can be a difficult and frustrating part of call. You will find some faculty prefers to staff most inpatient consults and others prefer to simply sign off on your notes. In general our more junior faculty want to be more hands-on with on call issues and our more senior faculty prefer, well, to not. If there are any questions about an individual faculty preference, ask your senior. Officially, all inpatient consults are supposed to be staffed by a fellow or attending within 24 hours. Unofficially, there are three types of consult patients. 1. Complicated Complicated patients should be discussed or seen by the senior resident. It is our policy that faculty only be contacted by the senior resident. In these patients, the senior residents will usually contact the faculty that night and discuss staffing. Sometimes, staffing can occur the next day in the faculty s clinic. It is permissible for the first year resident to contact a fellow directly regarding the staffing of complicated patients if the first year resident has become proficient in the examination of that particular type of patient. Otherwise, they should be discussed or seen by the senior resident first. 2. Uncomplicated Uncomplicated patients can often be discussed with the senior resident over the phone. If the senior resident feels staffing can wait for 24 hours, an can be sent to the on call faculty asking if they would like to staff these patients or if they would prefer to just sign off on the note. On some services, it is standard practice to the fellow (such as the case of an uncomplicated orbital fracture) in order to ask them about staffing. 3. Really Uncomplicated On rare occasion, you will be asked to see a post-op corneal abrasion or something like a subconjunctival hemorrhage in a patient recently intubated on Coumadin. In these cases, it is often unnecessary for these patients to be staffed and also unfair for the patient to be billed for these consults. If this is the case, it is permissible to ask the consulting service not to order an official consult and to document a short note into EPIC. *Hint Progress notes do not need to be cosigned and can be used for really uncomplicated patients. C. Follow-up After receiving permission from a fellow or attending to schedule a follow up in their clinic, leave a message with scheduling by calling and leave the patient s name, MRN, chief complaint, clinic to be seen in, and time period to be seen. Alternatively, it is sometimes easier to the ophthalmology schedulers (OphthalmologySchedulers@healthcare.uiowa.edu). The nice thing about is that they generally send a reply when the follow-up has been scheduled. The bad thing is that they may not get to an until later in the morning so I would avoid this option if a patient needs to be scheduled for an appointment the same day. Inpatient follow-up can be easily documented by creating a new progress note. This does not have to be co-signed. You are responsible for follow-up on inpatients in these cases: - The inpatient did not require subspecialty care but have eye issues that need follow-up (you may be following for weeks) - The patient was unable to be dilated at the time of the initial consultation. In this case you need to contact the primary service to see when they can be dilated, then perform the DFE and document your findings as a progress note in EPIC. - The patient was seen by a subspecialty service by they requested you follow-up on issues. D. Miscellaneous - Notes should be completed shortly after seeing a patient on call. - Often notes can be started while a patient is dilating and finished shortly after performing the dilated exam. - A note will not appear in the co-signer s inbox until the note is accepted. - In general, notes should be completed before the senior resident or fellow arrives on the scene. If a note is shared, it can be viewed by the senior resident from home, prior to completion Page 12

13 - Telephone conversations should be documented under Telephone Encounters. - Medication refills should be done under Telephone Encounters as well. Refills and new medications can often be sent using e- prescribe. Miscellaneous EPIC #1 Kaleidoscope (Ophth Exam is a tool given to all Ophthalmology LIPs as part of our privileges for all active outpatient visits.) Because Kaleidoscope can only be used one time per visit, there are a few caveats to remember: You still must create visits by calling the ER for patients we are going to see directly in the clinic after hours. If you do not do this, there will most likely not be a tab for documenting the clinic visit. If there is one, it is likely from a previous visit and changes to Kaleidoscope may change the previous exam. #2 Most faculty feel that it is satisfactory to use text templates or free text for inpatients or ER consults if you do not wish to use Kaleidoscope. So until Kaleidoscope becomes available in the inpatient settings, you may for now use the consult template for seeing inpatients and ER patients without creating outpatient encounters. This way your consultants can easily find your note in the inpatient setting. In summary: Inpatient Consults 1. Template consult note 2. Attending on call or fellow cosigner 3. All inpatient follow-ups must be text templates or free text. ER Consults 1. ER attending as cosigner 2. Call scheduling or ophthalmology schedulers to schedule follow-ups 3. Consider follow up locally if patient has local eye care provider After hours clinic visits 1. Call ER to create a visit ( ) 2. Kaleidoscope or clinic note template where appropriate 3. Attending on call or fellow is co-signer 4. Call scheduling or ophthalmology schedulers to schedule follow-ups. No-man's land (consults you are called with between 7:30AM and 8AM) This is an issue that is a source of frustration for us all, as we all have clinical duties to report to, and the issue of whom your third year is and who the attending on call is sometimes become hazy when consultations are begun around 8AM. There is no official policy around these consults. Suggestions are as follows: 1. You should evaluate the patient if you think that this can be reasonably accomplished prior to the beginning of clinic at 8:45 AM. Try to be efficient and get this done so it doesn't get left for your colleagues. If there is no way you will be able to see the patient and finish your evaluation prior to 9AM, the consult should get passed off to the day consult service for inpatients, or to the general clinic resident if the patient is in the ED. 2. If the patient is unavailable (getting a scan, in the OR, etc) you should pass the patient off to the day consult service for inpatients or to the general clinic resident if the patient is in the ED. 3. The day consult service will only see patients after 1PM. If there is any question of an inpatient with a possible true ophthalmic emergency that you are called with in the AM, you should definitely see the patient regardless of your pending clinical duties (advise your clinic attending of the situation though!), or ask your third year what to do if you have obligations you cannot miss. Page 13

14 4. Staffing: If staffing is needed, first discuss the situation with your third year backup. If he/she is in the OR or unavailable, call the attending who was on overnight directly to see how he/she would like it to be handled. They may choose to request that the consult be staffed by someone else, but this decision does not involve you. If the patient will definitely require subspecialty staffing, contact the fellow on the respective subspecialty service instead of the on-call attending (after discussion with your third year). Page 14

15 On-Call tips: Odds and Ends I. Parking On weeknights, try to get your car from Finkbine early. It is best to head straight out as soon as you can after clinic (5:00 pm) if you do not have conference or patients already coming. The Hospital Cambus schedule: Night Pentacrest Schedule: 4:45-6:00 -- every 5 minutes 7:00-8:45 -- every 15 minutes 6:05-6:45 -- every 10 minutes 9:15-12:15 -- every 30 minutes The last shuttle is 12:15 am. If your car is still at Finkbine then, you will have to walk there or call Hospital Security for a personal ride (6-2658). You can park in Parking Ramp IV (connected to Pomerantz) from 4:30 pm to 7:30 am weekdays and all day on weekends for free if you display your Finkbine card. Just write your name and card number (e.g. 1077) on you ramp ticket. If you don't have a Finkbine placard, but have parked in one of the ramps while on call, you can write the following on the back of your parking slip: the words Call Back, Your Name, Your signature. This is called the Call Back program. If you have any problems with the staff in the parking ramp questioning this, you can direct them to the following number: (parking dispatch, which is open 24-7). If you do this, you will not be charged. But if you are unlucky enough to have an early morning call patient that runs into the next clinic day, you will have to move your car or pay the regular rate after 8:00 am ($17/day). Additionally, you can park across the street from the hospital (next to Stadium) from 4:30pm to 7:30am on weekdays and all day on weekends for free (without having a Finkbine pass). If you have a quick in and out after business hours you can try to park under the glass awning (valet area) out front, but residents have occasionally been ticketed for parking there if they stayed long enough. Also, it is best to tell the patients who are coming in to park in the ramp (they will be charged). They can park under the awning out front at their own risk. II. Food Dining Dollars: Ophthalmology resident physicians can utilize their dining support monies to purchase food in the cafeterias with their ID badges. The amount of food purchased and the time of day will be at the house staff member s discretion, and if the preset amount is depleted before the annual deadline of June 30, the resident will be responsible for the cost of any additional food purchases for the remainder of the academic year. Ophthalmology Residents will receive $300 for the academic year. You must have payroll deduct activated before you can use dining dollars. When you hand your badge to the cashier, be sure you indicate dining dollars. If you do not, they will payroll deduct. The staff cafeteria and the visitor s cafeteria are the main full service food areas with the largest selection of hot and cold foods. Marketplace (first floor near Elevator C) is open 24 hours. Other options, see: Hours: Breakfast Lunch Dinner Night Weekends Main Cafeteria (1RC): 6:30-10:30 10:45-2:00 4:30-7: :30-2:00 Melrose (5PFP): 7:00-9:00 10:30-3: Page 15

16 Corneal Drawing Page 16

17 Less used now that we are with EPIC, but good to know! A. Color code used in clinical corneal drawings (see color guide in cornea exam rooms) B. Basic Outline: Left, frontal view: 1. Draw a circle about 30 mm in diameter to represent the corneal limbus (black). 2. Add pupil as a landmark (brown). 3. Indicate location of cross-section by a line through frontal view (black). Right, slit view: 4. Draw a freehand cross-section outline to show variations in corneal thickness (black) C. Pattern of corneal pathology. Left, frontal view: 5. Use sclerotic scatter and broad tangential illumination to outline all opacities (blue). Right, slit view: 6. Add a line to indicate epithelium (black), leaving defects where ulcers are apparent. D. Details of corneal pathology. Left, frontal view: 7. refine opacities into scar (black), degeneration (black), infiltrate (orange), and edema (blue). 8. Add labels if helpful. Right, slit view: 9. Draw opacities in epithelium, stroma, and Descemet's membrane at appropriate level. 10. Add labels if helpful. E. Other corneal findings. Left, frontal view: 11. Add vessels (red), pigment (brown), and posterior deposits (orange, brown). Right, slit view: 12. Add vessels (red), pigment (brown), and posterior deposits (orange, brown) F. Anterior chamber and lens. Left, frontal view: 13. Add abnormalities of anterior chamber (hypopyon, orange), iris (anterior and posterior synechiae, brown), and lens (posterior subcapsular cataract, green). Omit those that clutter the drawing. Right, slit view: 14. Show the relation between abnormalities of anterior chamber, iris, and lens. G. Vital stain Left, frontal view: Take photographs before vital staining (if desired). 15. Sketch in stain with fluorescein (green) or rose bengal (red). Make a separate sketch of needed. 16. Measure lesions with continuously variable slit height or reticle from an identifiable limbal landmark. Right, slit view: 17. Add staining with fluorescein (green) or rose bengal (red. HSV. Herpes Simplex Virus. See also: Waring GO, Laibson PR. A Systematic Method of Drawing Corneal Pathologic Conditions. Arch Ophthalmol 1977;95: Page 17

18 Symptoms as a Clue To Cause of a Red Eye Symptom Itching Scratchy Sensation Burning Localized lump or tenderness Ocular Pain Photophobia Mucoid discharge Watery discharge Purulent discharge Possible Cause Allergic conjunctivitis Dry eyes, foreign body in the eye, blepharitis Lid, conjunctival or corneal disorders Hordeolum, chalazion Iritis, keratopathy, glaucoma, scleritis, infection, orbital cellulitis, corneal abrasions, myositis, optic neuritis Iritis, keratopathy, glaucoma, corneal abrasions Allergic conjunctivitis, chlamydial infection Viral conjunctivitis, chemical irritants Bacterial conjunctivitis, corneal ulcer, orbital cellulitis The following is used with permission: van Heuven WAJ, Zwaan J. Decision Making in Ophthalmology: an Algorithmic Approach. Mosby, Page 18

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20 Superficial Keratitis - Differential Diagnosis Based on Distribution Page 20