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The diagnoses you shouldn’t be missing


Andrew Morgenstern, OD, shared his list of diagnoses optometrists shouldn’t be missing in the exam room during a session at Optometry’s Meeting.

Seattle-Andrew Morgenstern, OD, shared his list of diagnoses optometrists shouldn’t be missing in the exam room during a session at Optometry’s Meeting.

“When you walk out of this course, I’m going to give you a bunch of hammers, so everything is going to look like a nail,” jokes Dr. Morgenstern. “But what we want to do is slightly change the way we think. You don’t see what you don’t look for.”

Dr. Morgenstern explained a concept he calls the Trader Joe’s phenomenon. When you’re at the grocery store, do you often get up to the checkout line, only to see something in another shopper’s cart that you never spotted in the aisles?

“We have to question ourselves on what we’re missing. If we’re diagnosing the same things 90 percent of the time, what are we not picking up? My dad’s an optometrist, and what he sees in his office is not what I see when I work in his office,” he says. “If I went to your office, my diagnoses would be different from your diagnoses on a large majority of the patients because what we get comfortable with is what we do.”

Dr. Morgenstern says there are certain symptoms that may be hiding these diagnoses:

• Vague vision distortion

• Transient vision loss

• Skin lesions

• Odd facial sensations

• Droopy lids

• Irritated, burning eyes

• Red, swollen eyes

• Conjunctival injection

• Diplopia

• Facial asymmetry

Next: Vague vision distortion


1. Vague vision distortion

“When a person comes in 20/20 but has complaints, do you say to yourself, ‘This person is a nutcase,’ or do you say to yourself, ‘I really need to investigate these complaints’?” asks Dr. Morgenstern.

You’ll probably conduct a visual field. Dr. Morgenstern shared the visual field of a 28-year-old man who came in with a vague complaint about his new glasses not working for him. Based on the visual field, the audience diagnosed the patient with a pituitary adenoma.

“This is Trader Joe’s phenomenon number one. We’re trained like dogs to look at a picture and decide what the disease is,” says Dr. Morgenstern. “How do you diagnose a pituitary adenoma? MRI. But we are taught in school to look at one thing and make a definitive diagnosis about it.”

It was a pituitary adenoma.

“But don’t get caught in the trap like I caught you in the trap just now,” he says. “You’ve got to look around and see what else is going on.”

Dr. Morgenstern also says that just because a patient has 20/20 vision does not mean he is healthy.

Next: Transient vision loss


2. Transient vision loss

Dr. Morgenstern says that with symptoms like transient vision loss, most optometrists tend to jump to a dry eye diagnosis.

“If something changes with vision from blink to blink, it must be related to the tears. That’s a very logical reasoning behind it-it must be dry eye, right?” says Dr. Morgenstern. “You can’t always say that.”

Dr. Morgenstern shared a case in which an elderly woman was complaining of several seconds of “flickering” vision.

“What if she said ‘fluctuating vision,’ instead of flickering? She’s 78, maybe she’s got a tiny bit of dementia, she doesn’t know how to use her words properly,” he says. “That’s why it’s important to understand what the patients think they mean when they say something. We want to ask these elderly patients the right questions because they might not be describing their disease the right way.

“Like dogs, we’re taught key words. Who uses ‘claudication’ in their daily life? People don’t use those words that we’re cued into hearing,” says Dr. Morgenstern.

The patient was ultimately diagnosed with giant cell arteritis. He says giant cell arteritis should be considered for any elderly patient presenting with a headache, diplopia, or transient vision loss.

“In a person over 65, a headache just isn’t a headache anymore, to me-especially if they’re complaining to their eye doctor about it,” says Dr. Morgenstern.

Related: Optic neuropathy diagnosed via hypertension

When it comes to acute vision loss, you should be considering different diagnoses for a patient depending on their age.

“If a patient comes in, 18 to 40 years old with acute vision loss, you should be thinking optic neuritis, looking at the nerve, and typically, these patients have more moderate to severe vision loss. These things are usually pretty serious when you have acute vision loss in a young patient. There’s usually something serious happening pretty quickly,” he says.

“For 35 to 45 years old, anterior ischemic optic neuropathy (AION) with mild to moderate vision loss. And anyacute vision loss in a patient over 60 years old-I’m sorry, but you’ve got to go on a neurological shopping spree,” Dr. Morgenstern says.


Next: Skin lesions


3. Skin lesions

Many optometrists may not bother paying attention to skin lesions around the eyes, leaving that to a dermatologist.

Dr. Morgenstern joked that there tends to be a lot of back and forth within optometry.

“We’re systemic optometrists-we want to know about blood pressure, diabetes, and we want to get involved in every single thing. And then sometimes, we say to ourselves ‘I’m only an optometrist. I’m going to refer this out to the ophthalmologist and let him deal with the problem,’’” he says. “Skin lesions are one of those things.”

He says that any concern about lumps, bumps, or basels anywhere near the eye need to skip the dermatologist and go straight to an oculoplastic surgeon. 

“Is this a concern for optometrists? If the lesion is on the lid margin, that’s our problem, right? What if it’s just below the lid margin? Is that our problem?” he asks.

“Where does the eye stop? When we’re pushing for legislation, do you know where the eye stops? At the toes,” Dr. Morgenstern says. “When we’re in our office, writing in our charts and diagnosing stuff, do you know where the eye stops? Where the sunglass line is.

“If we’re going to be systemic doctors, we need to look at all of the other factors that could affect the body systemically,” he says.

He says that ODs commonly document other systemic conditions, so why shouldn’t they document evidence of a skin lesion, even if it’s not near the lid? He compares skin lesions to icebergs-what you can see is often a fraction compared to what lies below the surface.

Next: Abnormal facial sensations


4. Abnormal facial sensations

Dr. Morgenstern used the example of a woman in her 60s complaining that one side of her face feels strange, and her eye is irritated.

“What’s the first thing that should come to your mind? Herpes zoster,” he says. “If a 60-year-old says there’s something red on the side of her face, what’s the first thing that should to come to your differential list? Zoster. If someone says his eye is itchy or has pain? Zoster.”

Dr. Morgenstern says that anyone over 60 who complains of feeling something on the side of her face has zoster or some sort of herpetic disease until he proves otherwise.

“If you haven’t seen a case of herpes in you practice in the last five years, you missed a lot of herpes that was coming through your office because it can manifest in many different ways,” he says.

Next: Droopy lids


5. Droopy lids

It might be ptosis, but it might be something more. Sometimes, you have to start looking outside of the box, Dr.Morgenstern says.

“You have to get a hardcore history on this person. You have to ask the questions,” he says.

Related: Sagging lids and conjunctiva are an OD’s responsibility

He used an example of a man who presented with a drooping eyelid-and asymmetrical pupils. The ultimate diagnosis was Horner’s syndrome.  

“The triad for Horner’s is ptosis, miosis, and facial anhidrosis,” he says. “These patients with Horner’s deserve a neurological shopping spree, as well.”

Next: Itchy, burning eyes


6. Itchy, burning eyes

Dr. Morgenstern presented a case of a woman who was suffering from irritated eyes for weeks. Antibiotics helped a little, but the irritation returned.

“Antibiotics typically either work, or they don’t work. Bacteria aren’t like, ‘Meh-it was OK. It hurt a little bit, but I’m fine.’ You either kill the bacteria, or it’s fine,” he says, pointing out the red flag in the patient’s complaint.

The patient was diagnosed with thyroid eye disease (TED), although the eye had not begun to protrude.

“You’re allowed to have a disease that does not present normally,” says Dr. Morgenstern.

Next: Red, swollen eyes


7. Red, swollen eyes

A 50-year-old female presents with red, swollen eyes. Allergic conjunctivitis, right? Wait-her symptoms have been chronic for three months. She’s tried nearly every treatment from drops and compresses to acupuncture and meditation.

“If it’s red, consider TED, especially in a female, especially over 40,” says Dr. Morgenstern.

He says that it is very common to see patients who are on some type of thyroid medication. Yet, diagnosing thyroid disease in the optometric practice is not nearly as common.

“I think a lot of red eyes that walk through our practice are misdiagnosed or mistreated, and they may get better. But I don’t think the consideration for thyroid-related eye disease is as strong as it should be in our profession,” he says. “I personally think it is because of the machine that is dry eye in our profession that’s putting out all those articles, it’s very easy to misdiagnose it because we’re being taught to think a different way.”

Next: Conjunctival injection


8. Conjunctival injection

“Conjunctival vessel patterns are very important. When you look at these vessels, they’re telling you a story. You just have to follow them to where they start, they’re telling you where the problem is,” says Dr. Morgenstern. “You want to look at your blood vessels. They’re red, and they’re pointing right to it-could be a tumor. Pay attention to your blood vessels.” 

Next: Diplopia


9. Diplopia

TED falls into this category, too, says Dr. Morgenstern.

“If you have diplopia with any pattern of misalignment, especially when atypical, progressive, untreatable, or severe, put thyroid eye disease on the list,” he says.

Questions you need to ask:

• Is it monocular or binocular?

• Worse at distance or near?

• Is it worse at any direction of gaze?

• Is it variable, chronic, or associated with other muscular symptoms?

Next: Facial asymmetry


10. Facial asymmetry 

Symmetry is important. When you enter the exam room, sit at least two feet away from the patient and look at her face. Look for any noticeable asymmetry in her features.

Look for everything from the symmetry of the space between the eyebrow and the lid crease to the symmetry of the hair in the eyebrows. Dr. Morgenstern shared a case in which facial asymmetry revealed a man’s sphenoid wing meningioma. 

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