Gonioscopy injury

[JennyJet]

So we've learned how to do gonioscopy recently and will be tested on it next week. Pretty scary experience at first, but I finally started to feel comfortable with it as a patient and doctor. That is until today ...

Tonight while practicing and me as patient, the gonio lens suction was so strong that the lens did not come off my eye as easily as usual. (NOTE: By this time, the anesthetic was definitely wearing off and my eye was probably drying out.) Well with a lot of coaxing, it finally came off, but with a pretty loud popping sound. I was a little freaked out, but I didn't feel any pain.

3 hours later ... My right eye feels like there is some pressure on it compared to my left eye. Kind of like a sinus headache. I look in the mirror and see a red dot near my limbus that was definitely not there before. I think it's a subconjunctival hemorrhage, but no where near as large as the pictures i've seen in books and websites. The red dot moves when i move the bulbar conj back and forth.

Next week, we all have to serve as patients after we are doctors. Should i be worried about having gonio on my right eye again? Anyone else have scary gonio experiences?

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[Richard_Hom]

So we've learned how to do gonioscopy recently and will be tested on it next week. Pretty scary experience at first, but I finally started to feel comfortable with it as a patient and doctor. That is until today ...

Tonight while practicing and me as patient, the gonio lens suction was so strong that the lens did not come off my eye as easily as usual. (NOTE: By this time, the anesthetic was definitely wearing off and my eye was probably drying out.) Well with a lot of coaxing, it finally came off, but with a pretty loud popping sound. I was a little freaked out, but I didn't feel any pain.

3 hours later ... My right eye feels like there is some pressure on it compared to my left eye. Kind of like a sinus headache. I look in the mirror and see a red dot near my limbus that was definitely not there before. I think it's a subconjunctival hemorrhage, but no where near as large as the pictures i've seen in books and websites. The red dot moves when i move the bulbar conj back and forth.

Next week, we all have to serve as patients after we are doctors. Should i be worried about having gonio on my right eye again? Anyone else have scary gonio experiences?

Dear Jenny Jet,

The removal technique needs to be reviewed. You could have gotten an abrasion.

 

[Opii]

When I was initially learning Gonio I used to use gonak. The person I was practicing on one time got an immediate allergic reaction and you could see the side of the conjunctiva swelling up into the mirror while still checking the angles. That was scary! I never ever touched gonak again. Celluvisc is the way to go.

 

[stevec]

You think you had a bad experience? On Wednesday in theory lab, my partner took the gonio off my eye, and it felt like something was stabbing me in the cornea. The pain kept getting worse. The doctor in clinic sent me home with an eye patch, some antibiotic, and an NSAID. Once the anesthetic wore off the pain was a 9 out of 10. I could not open my eyes. Even if I opened my good eye, it would make the bad eye move, and I'd feel the sharp stabbing pain. I was basically blind and in chronic pain. I think he should have given me something better for the pain, but with the anesthetic I'd received in lab and clinic, I don't think he fully grasped my predicament. At lunch time (somebody had taken me home), I literally had to feel my way along the wall to the kitchen and rip open a pack of crackers for lunch. I could not prepare anything, and my roommates were at school. That night I think I fell asleep for at least a few minutes with a bag of ice balanced on my head. It was one of the worst days of my life.

The next day the staff doc said it was one of the worst abrasions he'd seen in years. It was about 6-8mm wide on my central cornea. He gave me some homatropine (which still hasn't fully worn off), some antibiotic ointment, and another eyepatch. I went back to the clinic later because the eye patch was torture. I still had an exam to take the next day and begged for a contact lens. I needed to function. It's been getting better, and I'm finally without the contact lens today. I just have a slight foreign body sensation now.

 

[Richard_Hom]

You think you had a bad experience? On Wednesday in theory lab, my partner took the gonio off my eye, and it felt like something was stabbing me in the cornea. The pain kept getting worse. The doctor in clinic sent me home with an eye patch, some antibiotic, and an NSAID. Once the anesthetic wore off the pain was a 9 out of 10. I could not open my eyes. Even if I opened my good eye, it would make the bad eye move, and I'd feel the sharp stabbing pain. I was basically blind and in chronic pain. I think he should have given me something better for the pain, but with the anesthetic I'd received in lab and clinic, I don't think he fully grasped my predicament. At lunch time (somebody had taken me home), I literally had to feel my way along the wall to the kitchen and rip open a pack of crackers for lunch. I could not prepare anything, and my roommates were at school. That night I think I fell asleep for at least a few minutes with a bag of ice balanced on my head. It was one of the worst days of my life.

The next day the staff doc said it was one of the worst abrasions he'd seen in years. It was about 6-8mm wide on my central cornea. He gave me some homatropine (which still hasn't fully worn off), some antibiotic ointment, and another eyepatch. I went back to the clinic later because the eye patch was torture. I still had an exam to take the next day and begged for a contact lens. I needed to function. It's been getting better, and I'm finally without the contact lens today. I just have a slight foreign body sensation now.

I'm quite surprised that your treating doctor used a pressure patch. PK Kaiser (A Comparison of Pressure Patching vs No Patching for Corneal Abrasions due to Trauma or Foreign Body Removal, Ophthalmoloy. 1995. 102 (12) 1936-1942)reported that abrasions healed better unpatched than patched.

I also offer a case I treated with an abrasion of equivalent size without a patch or a bandage contact lens being used.

Richard Hom OD FAAO
http://www.geocities.com/rchom/

 

[sco1styear]

You think you had a bad experience? On Wednesday in theory lab, my partner took the gonio off my eye, and it felt like something was stabbing me in the cornea. The pain kept getting worse. The doctor in clinic sent me home with an eye patch, some antibiotic, and an NSAID. Once the anesthetic wore off the pain was a 9 out of 10. I could not open my eyes. Even if I opened my good eye, it would make the bad eye move, and I'd feel the sharp stabbing pain. I was basically blind and in chronic pain. I think he should have given me something better for the pain, but with the anesthetic I'd received in lab and clinic, I don't think he fully grasped my predicament. At lunch time (somebody had taken me home), I literally had to feel my way along the wall to the kitchen and rip open a pack of crackers for lunch. I could not prepare anything, and my roommates were at school. That night I think I fell asleep for at least a few minutes with a bag of ice balanced on my head. It was one of the worst days of my life.

The next day the staff doc said it was one of the worst abrasions he'd seen in years. It was about 6-8mm wide on my central cornea. He gave me some homatropine (which still hasn't fully worn off), some antibiotic ointment, and another eyepatch. I went back to the clinic later because the eye patch was torture. I still had an exam to take the next day and begged for a contact lens. I needed to function. It's been getting better, and I'm finally without the contact lens today. I just have a slight foreign body sensation now.

Who treated you? And be sure your theory teacher knows about the incident - they will probably want to supervise whoever performed gonio on you for a while.
Steve - the next time you have such a problem (even after hours) call the clinic. After hours there is always someone on call that will meet you up there to see you.

Richard: And I thought one advantage and reason some people patch was to minimize pain? Does it not seem to really make a difference in that regard?

 

[Richard_Hom]

Who treated you? And be sure your theory teacher knows about the incident - they will probably want to supervise whoever performed gonio on you for a while.
Steve - the next time you have such a problem (even after hours) call the clinic. After hours there is always someone on call that will meet you up there to see you.

Richard: And I thought one advantage and reason some people patch was to minimize pain? Does it not seem to really make a difference in that regard?

Again, patching is practically an obsolete technique and is frequently still used only by emergency room or primary care doctors. Realistically, it should be a pressure patch but the pressure is no longer a pressure patch if the patch is removed by the patient to reinstill topical medications.

The realm of patching I suppose may be helpful if you have no bandage contact lens available. In the photo and case I submitted earlier in this thread, the simple use of ointment is as useful as a patch. I give a lecture on this topic.

 

[sco1styear]

Thanks for the info.
The other day a young boy was brought into our clinic. The day before he had been stabbed in the eye with a pencil by a classmate. It went all the way through to his lens and he was rushed to the ER. They gave him some antibiotic ointment, patched him, and sent him home!!! Scary stuff!

What would you do if someone came into your office with something penetrating their eye (such as a pencil). Do you call an ambulance to take them to the ER? And then what..? Hope there is an ophthalmologist on hand to give them the proper treatment after it is removed?

 

[Richard_Hom]

Thanks for the info.
The other day a young boy was brought into our clinic. The day before he had been stabbed in the eye with a pencil by a classmate. It went all the way through to his lens and he was rushed to the ER. They gave him some antibiotic ointment, patched him, and sent him home!!! Scary stuff!

What would you do if someone came into your office with something penetrating their eye (such as a pencil). Do you call an ambulance to take them to the ER? And then what..? Hope there is an ophthalmologist on hand to give them the proper treatment after it is removed?

I have stabilized such patients and get about 1-2 / year of children being stabbed or scratched in the eyes by a pencil. I've also seen patients who have been assaulted where they have suffered a global rupture.

In fact, it is incumbent upon optometrists who see trauma cases as part of their acclaimed repretorie that they understand the algorithm necessary to determine the existence of a ruptured or penetrated globe.

In the case of the global rupture, sealing the wound is essential. In many cases, the wound if small will self seal with the iris possibly prolapsing through the wound. The important thing is to keep the anterior chamber intact. A flat anterior chamber is a big risk. IN times past, I have temporarily sealed corneal wounds with surgical grade cyanoacrylate (super glue) topped with antibiotic ointment and place on the wound until the patient can see the surgeon.

 

[stevec]

Who treated you? And be sure your theory teacher knows about the incident - they will probably want to supervise whoever performed gonio on you for a while.
Steve - the next time you have such a problem (even after hours) call the clinic. After hours there is always someone on call that will meet you up there to see you.

Richard: And I thought one advantage and reason some people patch was to minimize pain? Does it not seem to really make a difference in that regard?

I think the patch was a waste of time. It immobilized the eye somewhat, but it wasn't enough. I still ended up holding my hand on the patch most of the time to keep the eyelid still, so I might as well have not had a patch and held my eyelid with my own hand. I was told to remove the 1st patch the next morning before I put any drops in or anything, but at the advice of my dad over the phone (also an OD), I removed it that evening, went ahead with the antibiotic, and put some ice on it to try to kill some of the pain and get some sleep. He doesn't agree with using patches either.

The contact lens definately decreased the pain by leaps and bounds. Sure, it probably didn't heal as fast, but when you're in severe pain and have stuff to do, it's a godsend. With a contact lens on there it didn't feel like glass grinding in my eye every time I blinked.

 

[Richard_Hom]

'...The contact lens definately decreased the pain by leaps and bounds. Sure, it probably didn't heal as fast, but when you're in severe pain and have stuff to do, it's a godsend. With a contact lens on there it didn't feel like glass grinding in my eye every time I blinked.

The silicone hydrogel lenses should get most people's attention on this. See R Arora, et al, Efficacy of continuous wear Purevison contact lenses for therapeutic use, Contact Lens and Anterior Eye, 2004, 27:39-43. for a study on the use of these lenses for corneal pathology.

 

[stevec]

The silicone hydrogel lenses should get most people's attention on this. See R Arora, et al, Efficacy of continuous wear Purevison contact lenses for therapeutic use, Contact Lens and Anterior Eye, 2004, 27:39-43. for a study on the use of these lenses for corneal pathology.

Could you sum up what you're trying to say with that article? Most of us are probably not going to get around to looking that up right now.

 

[JennyJet]

You think you had a bad experience? On Wednesday in theory lab, my partner took the gonio off my eye, and it felt like something was stabbing me in the cornea. The pain kept getting worse. The doctor in clinic sent me home with an eye patch, some antibiotic, and an NSAID. Once the anesthetic wore off the pain was a 9 out of 10. I could not open my eyes. Even if I opened my good eye, it would make the bad eye move, and I'd feel the sharp stabbing pain. I was basically blind and in chronic pain. I think he should have given me something better for the pain, but with the anesthetic I'd received in lab and clinic, I don't think he fully grasped my predicament. At lunch time (somebody had taken me home), I literally had to feel my way along the wall to the kitchen and rip open a pack of crackers for lunch. I could not prepare anything, and my roommates were at school. That night I think I fell asleep for at least a few minutes with a bag of ice balanced on my head. It was one of the worst days of my life.

The next day the staff doc said it was one of the worst abrasions he'd seen in years. It was about 6-8mm wide on my central cornea. He gave me some homatropine (which still hasn't fully worn off), some antibiotic ointment, and another eyepatch. I went back to the clinic later because the eye patch was torture. I still had an exam to take the next day and begged for a contact lens. I needed to function. It's been getting better, and I'm finally without the contact lens today. I just have a slight foreign body sensation now.

OK, you definitely win the worst gonio experience. I just have a slight headache on my right side and the hemorrhage is a little bigger and not as distinct. I can't believe you still had to take an exam the next day. I hope you did well despite the pain.

Of all the procedures we've learned so far, gonio has caused me the most anxiety both as a patient and a doctor. We'll see how I do on next week's practical.

P.S. Love your O RLY owl avatar. Whenever someone says "O RLY?", I always shout in my head "YA RLY!" and think of the mean scowling owl. Hmmm ... you've inspired to use an avatar.

 

[Richard_Hom]

Could you sum up what you're trying to say with that article? Most of us are probably not going to get around to looking that up right now.

The new silicon hydrogel lenses are excellent bandage lenses! One of the things in medical care is the ability to be well read and being current. THis is sometimes difficult for the practitioner who is independent or in a commercial setting. I'm hopng that where ever a graduate ends up that they do n ot forget about being current. It is surprising how obsolete you can be in 1 year. Even going to CE lectures isn't good enough. I know, I'm on the circuit myself and see this first hand.

By the way, could you private message me the name of your school? THanks

 

[Richard_Hom]

Dear threaded posters,

If you do not know how this injury occured, it is possible that the you as the recipient might also create a similar result in your own patient.

There is one entity called epithelial basement membrane disease which can cause abrasion with the slightlest provocation.

By the way, if you're using a Goldmann three mirror with a fluid interface, I think the flange either entering or leaving the eye or a stray finger nail probably caused the injury. It is much easier to create an injury with the Zeiss four mirror or the Sussman four-mirror than the Goldmann three mirror.

 

[JennyJet]

On a slightly different note, what is the advantage of getting a non-flanged vs. a flanged gonio besides lid stabilization? What gonio lens do you guys use and what do you like about it?

 

[stevec]

Dear threaded posters,

If you do not know how this injury occured, it is possible that the you as the recipient might also create a similar result in your own patient.

There is one entity called epithelial basement membrane disease which can cause abrasion with the slightlest provocation.

By the way, if you're using a Goldmann three mirror with a fluid interface, I think the flange either entering or leaving the eye or a stray finger nail probably caused the injury. It is much easier to create an injury with the Zeiss four mirror or the Sussman four-mirror than the Goldmann three mirror.

What really caused it is still up for debate. In lab we did 3 mirror first and then 4 mirror. I didn't actually feel any pain until the 4 mirror was taken off. The size of the abrasion has led most people to believe that it was the 3 mirror (it was a circular area about 6-8mm wide with spk). It's plausible that I just didn't feel it right when it happened because my partner had instilled proparacaine just prior to 3 mirror. If that's the case, the 4 mirror probably aggravated it. In fact I had a slight foreign body sensation the first or second time after taking out the 4 mirror. The last time it was really bad though.

 

[Richard_Hom]

What really caused it is still up for debate. In lab we did 3 mirror first and then 4 mirror. I didn't actually feel any pain until the 4 mirror was taken off. The size of the abrasion has led most people to believe that it was the 3 mirror (it was a circular area about 6-8mm wide with spk). It's plausible that I just didn't feel it right when it happened because my partner had instilled proparacaine just prior to 3 mirror. If that's the case, the 4 mirror probably aggravated it. In fact I had a slight foreign body sensation the first or second time after taking out the 4 mirror. The last time it was really bad though.

Stevec,
The 4 mirror has always been the more common culprit since the lens rides on your tear prism. On the 3 mirror, the lens is designed to completely vault the globe and have a gonioscopic or other viscous solution as an interface. I suppose that an injury is also possible if no solution was added, but I guess that would have been obvious.

All, in all, I think the supervision was insufficient. I'm wondering why this occurred or why was this allowed to occur?

 

[JennyJet]

Stevec,
The 4 mirror has always been the more common culprit since the lens rides on your tear prism. On the 3 mirror, the lens is designed to completely vault the globe and have a gonioscopic or other viscous solution as an interface. I suppose that an injury is also possible if no solution was added, but I guess that would have been obvious.

All, in all, I think the supervision was insufficient. I'm wondering why this occurred or why was this allowed to occur?

I agree. I'm starting to feel like we shouldn't be practicing gonio unless there is a doctor around. My injury happened after hours during open lab times. Many of us are feeling pretty anxious about having gonio performed on us, but the instructors just say to trust them to intervene if they feel the procedure is being done incorrectly. But how do they know exactly what the patient is feeling. During gonio, the pressure of the lens on my eye can be really uncomfortable, and the student doctor/classmate have observed blood seeping from my trabecular meshwork. The instructors assure us that this is normal when we're first learning. They really haven't told us how to handle abnormal situations like removing a lens that is stuck onto the eye.

 

[Richard_Hom]

I agree. I'm starting to feel like we shouldn't be practicing gonio unless there is a doctor around. My injury happened after hours during open lab times. Many of us are feeling pretty anxious about having gonio performed on us, but the instructors just say to trust them to intervene if they feel the procedure is being done incorrectly. But how do they know exactly what the patient is feeling. During gonio, the pressure of the lens on my eye can be really uncomfortable, and the student doctor/classmate have observed blood seeping from my trabecular meshwork. The instructors assure us that this is normal when we're first learning. They really haven't told us how to handle abnormal situations like removing a lens that is stuck onto the eye.

By design, a well positioned 3 mirror lens should actually stay on the eye if you remove your hands. If not in position, the lens would have slipped out of the eye (usually the lower lid is not cleared).

Jennyjet, could you please private message me where you are as a student?

 

[sco1styear]

Stevec,
The 4 mirror has always been the more common culprit since the lens rides on your tear prism. On the 3 mirror, the lens is designed to completely vault the globe and have a gonioscopic or other viscous solution as an interface. I suppose that an injury is also possible if no solution was added, but I guess that would have been obvious.

All, in all, I think the supervision was insufficient. I'm wondering why this occurred or why was this allowed to occur?

You have to keep in mind that this is not the norm. While mild spk is not uncommon upon first learning the procedure, injuries such as this are uncommon. There are lab instructors that are more than willing to supervise if you feel the need. Other than that, they more or less walk around the lab looking at everyones performance as they get to them. But, like I said, if you feel uncomfortable performing it without their supervision they are more than willing to come watch.

 

[Richard_Hom]

You have to keep in mind that this is not the norm. While mild spk is not uncommon upon first learning the procedure, injuries such as this are uncommon. There are lab instructors that are more than willing to supervise if you feel the need. Other than that, they more or less walk around the lab looking at everyones performance as they get to them. But, like I said, if you feel uncomfortable performing it without their supervision they are more than willing to come watch.

I apologize. I think I may have been a bit strong on that. But the essence is that there should always be three persons involved in tnese demonstrations. The two players are so busy with what they are doing that is difficult to monitor what is happening.

 

[Opii]

.... Once the anesthetic wore off the pain was a 9 out of 10.... .

OUCH! Just reading about it hurts.
Hope you completely recover from the experience soon.
You get the prize for worst gonio story - hands down!

 

[yOyOYoo]

I agree. I'm starting to feel like we shouldn't be practicing gonio unless there is a doctor around. My injury happened after hours during open lab times. Many of us are feeling pretty anxious about having gonio performed on us, but the instructors just say to trust them to intervene if they feel the procedure is being done incorrectly. But how do they know exactly what the patient is feeling. During gonio, the pressure of the lens on my eye can be really uncomfortable, and the student doctor/classmate have observed blood seeping from my trabecular meshwork. The instructors assure us that this is normal when we're first learning. They really haven't told us how to handle abnormal situations like removing a lens that is stuck onto the eye.

Removing a gonio lens stuck onto the eye:

1. Have the patient look nasally and give a hard blink.

If it doesn't work:
2. Have the patient look nasally and give a hard blink while the examiner is pushing on the lower temporal eyelid to try to break the suction.

If that doesn't work:
3. Have the patient look nasally while the examiner uses a cotton tipped applicator to gently manipulate the conjunctiva, careful not to cause any abrasions. Have the patient give a hard blink.

This is how we've learned it in lab over at SCCO, and to my recollection, there have been no problems with gonio removal, and as for the popping sound, 50% of the time I get it, or I hear it pop off a patient. It just means you have a really good suction on the eye.

correct me if i'm wrong?

 

[4Eyes]

Wow, I've never heard of a gonio injury in lab (I understand it can happen, but so far *knock on wood* it hasn't happened in my class, and it didn't happen last year that I know of). Now I'm nervous to practice after hours! I feel really good about 3-mirror, but I haven't practiced 4-mirror in a while.

yOyOYoo, I believe you are correct. I'm sure the popping sound happens often and is completely normal. I always have the patient (student) blink hard and it pops right off. Sometimes they don't really need to blink, but at this stage in my game, I'd rather just have them blink than freak out if I get the slightest bit of resistance as I'm removing it.

 

[blazenmadison]

Who treated you? And be sure your theory teacher knows about the incident - they will probably want to supervise whoever performed gonio on you for a while.
Steve - the next time you have such a problem (even after hours) call the clinic. After hours there is always someone on call that will meet you up there to see you.

Richard: And I thought one advantage and reason some people patch was to minimize pain? Does it not seem to really make a difference in that regard?

Is this theory lab III? I wonder if the 1st years have to take it this year with the whole curriculum change. They don't tell us anything. And every professor has conflicting versions of our schedule.

 

[Richard_Hom]

Removing a gonio lens stuck onto the eye:

1. Have the patient look nasally and give a hard blink.

If it doesn't work:
2. Have the patient look nasally and give a hard blink while the examiner is pushing on the lower temporal eyelid to try to break the suction.

If that doesn't work:
3. Have the patient look nasally while the examiner uses a cotton tipped applicator to gently manipulate the conjunctiva, careful not to cause any abrasions. Have the patient give a hard blink.

This is how we've learned it in lab over at SCCO, and to my recollection, there have been no problems with gonio removal, and as for the popping sound, 50% of the time I get it, or I hear it pop off a patient. It just means you have a really good suction on the eye.

correct me if i'm wrong?

Alternatively, use your finger to push the lower lid to break the seal between the lens and the ocular surface. It should just fall out.

 

[ddown]

Although not a gonio war story I've got a pretty good procedures tale.
One of the foreign (not canadian) students in our class forgot to rinse the glutaraldehye ("wavicide") off his Goldmann tip before planting it directly on my cornea. I was anaesthetized so I didn't feel it immediately but after approx. 15 min. I was in some serious pain. I ended having a pretty serious central epithelial abrasion and was seeing about 20/80. After a few days of a bandage lens and tobradex I healed up nicely.

 

[xmattODx]

I appreciate the story. Must have been very painful but was this really a necessary component of the story?

One of the foreign (not canadian) students

 

[cpw]

I appreciate the story. Must have been very painful but was this really a necessary component of the story?

That's what I was wondering. I'm sure he/she didn't forget to wipe the iodine off because they were foreign.

Yes, my first gonio experience I discovered my eye does NOT like Gonac. I woulnd't wear contacts for about a week afterwards. Celluvisc all the way for me after that. In a pinch, Boston conditioning solution works pretty well for this too.

 

[Richard_Hom]

Relevant still, but I have successfully used Refresh Liquigel and Refresh Celluvisc for gonioscopy.

 

[r_salis]

Relevant still, but I have successfully used Refresh Liquigel and Refresh Celluvisc for gonioscopy.

Everyone at my school uses Celluvisc (unless Gonak is all that's around).

I remember there were a handful of "power gonio" injuries in my class when we were learning gonioscopy. If you're the person sitting for it, you need to speak up when you feel like the person practicing is using too much pressure on the lens -- I don't think people realize how hard they're pushing when they're first learning and trying to concentrate on holding the lens still while rotating it and getting good focus.