Clinical Hints & Tips
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  1. Making Pilocarpine 0.125% for Adie Tonic Pupil Test.
    To test a patient for Adie's tonic pupil, the optometrist needs to instill pilocarpine 0.125% into both eyes and check the miosis. A genuine Adie pupil is supersensitive to parasympathomimetics, and there will be a noticable miosis in the tonic eye compared to the normal eye.

    The problem is obtaining pilocarpine 0.125% just when it is needed. Although the local pharmacy will be able have this strength made up, it will not be readily available when it is needed.
    The practitioner needs to have saline Minims® 0.9% and pilocarpine 2% in his drug cabinet. The pilocarpine needs to be diluted in the ratio of 1 drop of pilocarpine to 15 drops of saline. The inside casing of a Minim® makes an ideal mixing bowl.(As above figure. It is sterile until opened).
    One drop of pilocarpine 2% and 15 drops of saline are mixed in the well. The saline dropper is emptied, and is used to stir the mixture, and then to be refilled with the mixture ready for patient instillation.


  2. The "O" sign presentation of a lost rigid contact lens

    Srinivasan Subramaniam FRCOphth ,Naresh Joshi FRCOphth and Luke W Membrey FRCOphth
    Reproduced with kind permission of Contact Lens and Anterior Eye

    A 47-year-old lady was seen with a swelling of the right upper lid of 4 months duration. She was a rigid gas permeable contact lens user. Examination revealed a smooth lump in the right upper lid. Eversion of the lid revealed a small opening in the conjunctiva; nothing could be seen within the opening

    Under anaesthesia, the right upper lid was everted and the conjunctival opening extended. A contact lens was expressed along with mucopurulent material
    No organisms were cultured from either the mucopurulent material or the contact lens. The patient made an uneventful recovery.

    Periocular migration of hard contact lenses is well recognised.1-4 The finding of a hole in the conjunctiva, the '0' sign over an embedded contact lens has also been described.5 Patients presenting with an upper lid lump and a conjunctival defect '0' sign should be questioned regarding contact lens wear.

    REFERENCES

    1. Roherts-Hany, T.j., Davey, C.C. and Jagger, J.D. Periocular migration of hard contact lenses. Br. J Ophthalmol., 76, 95-97 (1992).
    2. Benger. R.S. and Froeh, B.R. An upper eyelid cyst from migration of a hard contact lens. Ophthalmic Surg., 17,292-294 (1986).
    3. Homblass. A. and Kass, L.G. Contact lenses in the upper eyelid masquerading as lid masses. Ophthalmic Surg.,18, 438-440 (1987).
    4. Beyer-Machule, C.K. and Shapiro, A. Eyelid penetration of a hard contact lens, simulating a neoplasm. Ophthalmic Surg.,17, 101-102 (1986).
    5. Bellan, L. anrl Buffam, F. The ."0" sign clue to a lost contact lens. Can. J Ophthalmol., 25,348-350 (1990).

  3. A "5 second" rapid dry eye test

    This method is a simple alternative to checking the tear meniscus for a dry eye. The period of 5 seconds is critical because it is short enough to obtain a useful wetting of the strip, but seldom produces a reflex lacrimation.
    As follows:-

    Bend a Chauvin Sno*strip at the neck, and place the bulb end into the lower fornix. Remove after 5 seconds. A healthy eye will wet all of the bulb end as shown on the figure left.

    Please note, this test measures the amount of tear fluid in the lower fornix, NOT the tear flow. Five seconds is short enough not to irritate most eyes, and therefore gives a very good indication of how dry an eye may be.

    I have found leaving a strip in the eye for 5 minutes very impractical as most people reflex lacrimate profusely.

    N.B. If you prefer to estimate the tear meniscus. Using a very minimal amount of fluorescein greatly aids in viewing the meniscus.