Wednesday, November 2, 2011

Eye Pain in a 20 Year Old Patient

I walked into the urgent care clinic exam room at about 6 pm one evening,  to see a new 20 year old obese African-American patient.  She was there with both of her parents. 
“Hi, I’m Sharon, how can I help?” I asked.
TaRhonda stood there leaning against the exam table with her hand over her left eye.  She moved her head up a little bit and mumbled, “my left eye hurts again and I’ve got this green stuff on my eyelids.”
“Okay, when did this start?”
“Last night,” replied TaRhonda. 
“You’re protecting your eye, which tells me that light hurts your eye?” I asked.
TaRhonda nodded her head ‘yes.’
“What about your sight, are you having problems with it out of your left eye?”
TaRhonda mumbed, “it’s blurry.”
“How bad is the pain in your eye?”
“It’s a constant hurt on this side of my face, “ TaRhonda replied as she gently stroked her left side of her face with her right hand.
“Can you take your hand away from your eye so that I can see what’s going on?”
TaRhonda moved her right hand towards the light switch and with a few flicks of her free hand up and down, motioned for me to turn the overhead light off.
“You’re telling me you need the light off?” I confirmed.
TaRhonda moved her head up and down with a positive nod. 
I turned the overhead light off,  afterwhich TaRhonda moved her hand down, and using the wall mounted welch allyn otoscope’s light I shined it on TaRhonda’s lower left forehead so as to not shine direct light into her eye.  The reflected light showed green drainage coming from her left eye, it was very injected, red, and looked somewhat swollen.  I looked at her right eye and it was normal. 
“Okay, I’m going to give you a clean small dressing to put over your eye with some tape so that your hand doesn’t have to continue to protect it from the light.”
Hearing this, TaRhonda nodded ‘yes’ with her head.
After TaRhonda taped the dressing to her face I turned the overhead light back on. 

This patient had typical signs of scleritis, which means inflammation of the sclera, which is the fibrous outer coating of the eyeball.  Evidence of scleritis includes:
1)      Redness of the eye
2)      Pain
3)      Being light sensitive
4)      Visual changes in the affected eye

Patientts who have scleritis typically are young adults.  Many times the cause of scleritis is idiopathic, meaning ‘unknown.’  But in 50% of the cases the patient’s scleritis is a sign that they have an auto-immune disease (i.e. their immune system is attacking themselves), or they have an infection from a virus (herpes) or tuberculosis. 

“Okay, you said that you’d had this before, when was that?”
TaRhonda’s mom who had been sitting in the one exam room chair was primed and waiting for this question.  She quickly handed me a slip of paper with the name of two medications listed on it.  In a demanding tone, she said, “she’s needs these two medications, that’s all we need from you.  We came here so that she wouldn’t have to be seen by the eye doctor.”
I took the slip of paper and looked at the two medications listed on it.  One of them I wasn’t familiar with, and had to look up what it was.  After I checked what the second medication was, it confirmed what I had been thinking.  TaRhonda’s eye condition was something an opthalmologist had to take care of, she most likely had scleritis.  The second medication was an opthalmic non-steroidal medication.  The first medication listed was a mixture of steroids and antibiotics in an opthalmic drop solution. 
I turned to TaRhomda and asked her when did the first episode of her eye condition happen.
“I think about 6 months ago.”
“Who did you see for it?”
“An eye doctor near our house.  He gave me both of those medications on the list, my mom gave you.”
“Well, I’m going to give you an opthalmic eye drop for any possibility of a bacterial infection, but I need you to call first thing in the morning the opthalmologist you saw 6 months and make sure you see him tomorrow.  You have to be seen by him tomorrow, you don’t have an option about that, do you understand?”
After barely getting those words out of my mouth, TaRhonda’s mom immediately said in an irritated, inpatient voice, “all she needs is these two meds,” flipping the piece of paper in her hand.
“I’m sorry, but TaRhomda has to be seen by her opthalmologist tomorrow, she doesn’t have an option about that.  She most likely has scleritis again and that demands an opthalmology appointment within 24 hours.”
TaRhomda’s mom now yelling at me, “you don’t understand, all you need to do is give her a refill of these two meds and she’ll be fine, just like she was before!”
Turning to TaRhomda’s mom I replied in a firm voice, “I’m sorry, I’m not allowed to prescribe opthalmic steroid drops, nor am I allowed to prescribe the non-steroidal opthalmic drops.  Both of those drugs have to be prescribed by an opthalmologist.  He has to see her and follow her to make sure this heals correctly.”
Her mom replied in an angry voice, “just give us the meds, damm it!”
“I can’t, they’re out of my scope of practice.  She has to be seen by an opthalmologist tomorrow, there’s no choice about that.  I’m sorry.”

Patients with scleritis have to be seen by an opthalmologist (eye physician) within 24 hours of their being seen by their primary care physician.  The opthalmologist will then treat them with an anti-inflammatory opthalmic drop solution, or possibly steroids.  This will calm the inflammatory response down.  They also have to follow the patients for any visual changes which can occur.  After the scleritis has been treated, the patients then need to be sent to their primary care physician for a thorough work-up of any possible auto-immune disease.  If one is found, this needs to be appropriately treated. 

At this point, TaRhonda’s  dad finally chimed in.  In a quiet questioning voice he asked, “You’re telling us that she has to be seen by the opthalmologist who saw her six months ago.  Why does he have to see her?”
I turned to TaRhonda’s dad standing at the end of the exam table and explained, “TaRhonda has had a previous episode of scleritis.  Now she most likely has a second episode in her same eye.  The opthalmologist has to see her to treat her appropriately.  But more importantly he is probably going to be in contact with your family physician and get a work-up ordered for the possibility of an auto-immune disease, which this scleritis could be a sign of.”
“You think she has the same problem as she did last time?”
“Yes, I think so.”
“What sort of auto-immune disease could she have?”
“There are several auto-immune diseases that she could possibly have.  That’s why she needs to be worked up for them.  And of course, auto-immune means that her own immune system could be attacking herself.”
“My sister has lupus, that’s an auto-immune disease, right?”
“Yes, lupus is one of the auto-immune diseases.  But just because your sister has lupus doesn’t mean that your daughter has it, please understand that.”
“I understand.  Can you write down exactly what we are supposed to say to the person who answers the opthalmologist’s phone in the morning?”
“Sure.”
I took a piece of paper and wrote down exactly what was supposed to be said so that TaRhonda would be seen tomorrow and gave it to her father.  “Here, this is what you need to say, “ as I handed him the paper as well as TaRhonda’s prescription for her antibiotic eye drops.
“Thanks.  Let’s go, TaRhonda, let’s get your one prescription filled and then I’ll call first thing in the morning for you an appointment to be seen by the opthalmologist again.” 
With that, TaRhonda’s mom grumbled under her voice as she got up to leave, and TaRhonda meekly followed her father out of the exam room.
As they left, I breathed a sigh of relief.  I never liked having to deal with confrontational situations.   

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