Tips from The Trenches

Recently I was able to show  a health care provider two separate patients with an eyelash caught / embedded under a pterygium on the bulbar conjunctiva. I have seen this previously  simply an incidental finding. At first our optometrist thought this black linear lesion was a suture but after gently massaging the area with a phenylephrine wet Q-tip and waiting  a few minutes the lash was more obvious / more observable.

As we all know tropicamide ( Mydriacyl ) plus phenylephrine gives a quicker dilation. It is easy enough to add 2 ml 10% of phenylephrine HCl  to a 10 ml  bottle of tropicamide 1%. One can certainly teach your staff this trick for a quicker dilation.

I always put the cyclogyl drops somewhere away from the tropicamide to prevent using the cyclogyl ( or atropine ) by mistake.  Since the bottles look similar, that’s easy to happen. Our retinal photographer in Belize was using cyclogyl  for her retinal diabetic screening photos ( tele-ophthalmology ). Needless to say, there were some unhappy ( dilated ) patients for several days post-photos. You need to explain to overseas ophthalmic personnel not to use cyclogyl for routine dilation.

With a somewhat pale optic disc, sometimes looking with a red-free ( green ) slit lamp beam and a 78 D lens will help to determine the size/ shape of the cup/disc.


Pilocarpine 4% drops are often available inexpensive in the developing world and usually comes in a 15 bottle. In a patient with a brown iris, pilocarpine 4% bid and timolol 0.5% in the AM can be an effective cheap combination. Many patients in less developed countries can not afford prostanglin analogs or any combination.

A recent article in JAMA Ophthalmology (Dec. 2017; Volume 135, number 12; page 1295 by Wang, reconfirmed what many  people / organizations have stated for decades. They collected data from Jan 1 to Dec 31, 2010 from190 countries including: the age-standardized prevalence of moderate to severe visual impairment ( MSVI ) and blindness, human development index (HDI ), gross domestic product ( GDP ) per capital, total health expenditure as percentage of GDP, public health expenditure as percentage of total health expenditure, etc. Countries were divided into 4 levels ( low, medium, high, and very high ) by HDI. The five countries with the largest number of blind people ( a total of more than one-half of the world’s blind population ) are India, Pakistan, Nigeria, Indonesia, and China. As you would expect, a strong dose-response association was observed between a higher HDI and a lower prevalence of blindness and MSVI. The prevalence of MSVI and blindness appears to be closely associated with national socioeconomic indicator data. In other words, generally the poorer the country the more MSVI and blindness.  This leans more proof to what has been well recognized for years. Certainly that has been my experience, the poorer the country ( ex. Haiti )  the more advanced, severe the ocular problems, often hopeless, that you encounter. As a general rule,  advanced / severe ocular problems in quite poor countries ( ex. Haiti ) are more common / prevalent than in mid-level countries ( ex. Guatemala ).

I recently had a frank discussion with two North American baby-boomers who have lived in a developing country in Central America for many years and are both members of  a local Rotary Club. They lamented that it was quite difficult to have sustainable ( Rotary ) projects. Water projects, maintaining a newly built latrine ( outhouse ) rather than defecating in the woods, or simply adding water to a battery are local activities that may not happen. These white baby-boomers stated that visiting Rotarians from the USA sometimes have difficulty understanding a different culture ( Mayan )/ mentality. As I have stated previously a North American mentality is sometimes not helpful / wrong for the developing world. It took me several years living in Tanzania to grasp that simple fact.

When checking visual acuity do not allow the patient to lend forward. Then you are checking the vision at say 9 feet rather than 10 feet --- teach that. Use the palm of your hand and not your fingers to cover one eye.  Avoid a pin-hole affect.

Put several florescein strips in a propacaine ( tetracaine ) bottle to make your own drops for checking IOP.  

 Poverty Tourism: Recently a good friend with a lot of developing  world experience described an event that he witnessed at his church. A  lady got up at a church function to request funding for her teenage granddaughter to travel to southeast Asia to hold Bible classes for about 5 days at an orphanage. The granddaughter had had several previous trips to developing world countries for brief Bible study events. My friend ( a member of that church ) got up and stated he did not  think that was a good use of the church’s funds. There was total silence in the room. The cost of parachuting this teenage girl into southeast Asia from the States would probably have fed that orphanage for one-two months. I am certainly not opposed to Bible study but the locals might be wondering why all that money was spent on airfare, etc. for a brief visit. Of course, they are dealing with North Americans so anything is possible.

prosthesisA newly designed ocular prothesis is now available. The current prothesis often did not  match the other ( normal ) eye as the scleral  portion was too white or bright compared to the good eye ( sclera ). There is now a prothesis with a clear  transparent scleral rim and a painted ( brown ) iris central area. The shape is similar to the older protheses. Therefore when you look at the prothesis in place ( in the socket ) you are actually seeing the patient’s own conjunctiva / sclera and the painted central iris. For many patients this will probably look better cosmetically. Available at the Academy from some of the Indian vendors.

Peace, Baxter

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