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Always sweat the small stuff



San Diego-It was standing room only in the Optometry’s Meeting course, Ten Diagnoses Not to Miss, presented by Andrew S. Morgenstern, OD. Dr. Morgenstern took attendees through a list of ten symptoms-many of them seemingly insignificant or common-and emphasized how important it is not to jump to simple conclusions.

  • Vague visual blurring. How often do you encounter patients who report a little blur, but when you check the glasses, you find the patient is corrected to 20/20? Don’t assume the patient is just being too particular. Perform a visual field, said Dr. Morgenstern. In one of his patients, it turned out to be a pituitary adenoma.

  • Transient vision loss. You think it’s dry eye. Ask the patient to point it out. If the patient is 78 and she points to her temple and says it’s here, it’s temporal arteritis. Consider all of the possibilities. It could always be giant cell arteritis or MS.

  • Skin lesions. The adnexa is part of our job, said Dr. Morgenstern. Non lid skin is important too. “You can get sued for not picking this stuff up,” he warns. Cancer starts out small. Look carefully for basal cell carcinoma and pay attention to freckles, including those on the lid margin.

  • Odd facial sensations. Dr. Morgenstern saw a 60-year-old female who said she had an irritated tingle on the side of her face. “Ask her to explain where it comes from and where it goes,” he suggested. In Dr. Morgenstern’s patient, it was early zoster. A little tingle can turn to zoster the next morning.

  • Droopy lid. “Everybody thinks they have one,” said Dr. Morgenstern. “There are lots of hypersensitive patients.” Take a history. Does the patient also get headaches? One of Morgenstern’s patients was ultimately diagnosed with a carotid dissection.

  • Itchy, burning eyes. “We see this constantly,” said Dr. Morgenstern. “If somebody says dry eyes, don’t forget thyroid eye disease. This is much more prevalent than you might think,” he said.

  • Red eyes. A seemingly simple case of red eye, even a subtle one, can be much more serious. In one case Dr. Morgenstern’s saw it was carotid cavernous fistula. Pull the eyelids and compare them, he suggested. Is it symmetrical? Don’t just say, “That looks injected.” Instead, ask how torturous are the vessels. Ask yourself a litany of questions. Also consider choroidal melanomas.

  • Red, swollen eyes. “If it’s red, consider TED (thyroid eye disease),” he said. If your patient is not getting better, that may be it.

  • Double vision. Again, this could be TED. It could also be the 3rd or 6th nerve.

  • Facial dissymmetry. One of Dr. Morgenstern’s patents seemed to have one elevated brow. He had a melanoma. Another of his patients, who was only 39, looked a little “not right.” Sometimes it’s hard to do, but practitioners need to ask patients about facial features. Request a photo from a few years back. One of Dr. Morgenstern’s patients who fell into this category wound up having a melanoma.

Bottom line: You’re not going to get into trouble by not doing the right thing on the first try, said Dr. Morgenstern. But you need to keep trying. “You get into trouble by doing nothing,” he warned. “Do your due diligence.”ODT

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