My name is Jim and I am a physician who owns 2 very busy urgent care centers. Need to get 2 very user friendly slit lamps to use for FB removal and rust ring removal. Which brand and model would you advise? Thanks a bunch!
My name is Jim and I am a physician who owns 2 very busy urgent care centers. Need to get 2 very user friendly slit lamps to use for FB removal and rust ring removal. Which brand and model would you advise? Thanks a bunch!
Dear doctor,Originally Posted by gorejr@bellsouth.n
The standard, of course, is a Haag Streit. Even the early basic 900M model will work very well with the 10X oculars. The spare parts are plentiful and most everyone knows how it works. The nice thing also is its converging optics which older users may benefit.
I also like the Kowa handheld SL15. Some patients I have seen in the Emergency Department may be (1) oversized; (2) supine (3) or being attended below the neck by other physicians. With the SL15, battery operated slit lamp, you can attend to the foreign body at the head of the patient without disturbing anyone else. It is wireless.
Do you prefer to remove foreign bodies with a sterile needle, spud or Alger brush?
I use a sterile 18 gauge needle attached to a long q-tip and use a rust ring drill. I used to be a dentist and learned about using good purchase points for stability when drilling.
Dear Doctor,
- Do you feel that there might be less scarring with a different sized-needle?
- What is your post procedure medication or mechanical cover etc
What size needle and post sx. med would you recommend? We usually patch the eye and follow up in am. Seems to work well but if there is something that would benefit patient more I would like to know.
Current thought follows along the notion that a smaller needle, although requiring more careful debridement / dissection, produces a smaller corneal scar, something of relevance as the wound site approaches the visual axis. I often use a 25 gauge needle. It's small but it is very good at fine debridement.
Something that isn't oftne mentioned is the removal of the debris after removal of the FB. I try to capture it and tape it to a paper portion of the chart. Sometimes, I use a CTA with a small dap of erythromycin oph ung and dab it on the fb or debris and it is easily lifte off
The post procedure management is dependent to somewhat the environment of the intruding fb. I consider all fb's as being potentially infectious. Therefore, many authors no longer will recommend pressure patching as first choice. It has been found that pressure patching can incubate any residual bacterial and makes the recovery 1-2 days longer.
My own strategy is to prescribe the following: Cyclopentolate, 1%, 1 drop, QID follwed 2 mins later with Erythromycin oph ung, QID into the eye with the last application at bedtime. The ointment mimics a "living bandage of the eye". Some ophthalmologists and optometrists may even recommend a topical NSAID like Ocufen or Acular LS or a bandage contact lens if the debrided area is large or there is signifcant symptamology, but I have never found this to be necessary because the Cyclopentolate, being a cycloplegic, provides significant pain relief.
I like this approach, because no oral analgesics are needed and there is little chance of incubating a pathogen under a patch during the night.
Do you need intraocular pressures prior to dilation? Somehow I remember years ago at Univ. of Fla. opth. rotation to be careful with pressures with steroids, dilating eyes, because of exacerbating closed angle glaucoma or
something along those lines. I rarely use steroids or dilating drops because of this. Sorry for such a basic question on an optho forum but I will start dilating if this is best for the pt. Thanks again!
The actual "danger" of the short term use topical steroid (that means less than 14 days ) isn't the glaucoma risk as much as the reactivation or aggravation of subclinical herpes simplex infection of the corneal epithelium (HSK - Herpes Simplex Keratitis). HSK or other viral or fungal infections are actually much more prevalent than steroid response, although not remote.
The golden rule of thumb is 14 days for steroid response, formation of posterior subcapsular cataract as and steroid rebound. Most often these 3 enitites will not occur in less than 14 days of use.
Therefore, I tend to ask patients to return at least in the next 48 hours to see if the reactivation or aggravation of an occult viral or fungal infection is a possibility if I am using a topical steroid.
I think I might have been misperceived. I advised cycloplegia rather than myddriasis. Cycloplegia is much less likely to spur a ACG attack than mydriasis. In cycloplegia, I'm only paralyzing the ciliary body. Thus the dilator effect is much less. In mydriais, you are paralyzing the constrictor muscle of the pupils (tropicamide) or activitating the pupillary dilator (Phenyephrine) which creates a more profound effect on angle depth and pupil location.
HTH
Your reply was excellent. I will relay this to our providers. Our one clinic is open 7 days a week and sees over 60k pts. a year. Second one opens in 3 months. Should also be very busy. If you are ever near Griffin Ga. look us up. Family Medical Center. Thanks again! Jim
Do you have a reputable vendor to buy slit lamp amd optic supplies from?
Try Lombardt Instruments. I'm sure you can find them on the web.
Any slit lamp will do. Since it will get some abuse in the ER you may want to consider a used one. Also, since no one in the ER will be able to use the Goldman tonomoter on the slit lamp I would make sure to get slit lamps without tonometers (that will save you about $800 per machine). Otherwise, doesn't really matter.
Before starting to remove the foreign body I would place a drop of Zymar and Acular in the eye. Zymar is a broad spectrum 4th generation cephalosporin and Acular is a topical NSAID. Acular does wonders on the cornea for controlling pain. I would remove the FB using a 25 gage needle mounted on the head of a qtip as previously described. The rust ring can be removed with a battery operated burr (very inexpensive and useful to have). It is critical when using a needle near the eye that you know what you're doing. If you have any doubts you may want to try removing the FB with a jewelers forceps or 0.12 tip and then drill the remaining portion out. If you use the needle make sure the head is always flush up against the slit lamp (so that it doesn't move forward and take the needle through the cornea). Always work tangentially or bend the needle so that you don't poke it through the cornea. After the foreign object is removed you will have an epithelial defect left behind. If it is small you can send the patient home on either antibiotic drops or ointment along with Acular for pain. If the defect is large you may also need a cycloplegic drop like cyclogyl and a bandage contact lens to cover the defect until it heals (I use the Focus Night and Day plano lens). If you don't want to use the contact lens then make sure you use the ointment tid and have the patient see an Eye M.D within a few days.
Sorry, I forgot to mention that before starting any of this you should use a topical anesthetic (either tetracaine, proparacaine, Fluoress, Xylocaine 4% etc). In cases where the patient is in a great deal of pain and there is no immediate access to ophthalmology or a bandage contact lens, you can try "comfort drops". This should be used exceedingly sparingly because when abused it can be quite toxic to the cornea. Comfort drops are 9 parts sterile preservative- free BSS (balanced salt solution) to 1 part anesthetic (eg:tetracaine). Therefore, one tenth the strength of regular tetracaine. The patient can be given a little of this in a dropper bottle and told to use it every 4 hours prn pain until he sees an eye doctor. This should keep him quite comfortable and pain free for a day or so. IT is completely safe as long as it is not used for more than a couple days. USE THIS SPARINGLY.
Ilan,
As an "eye MD" you should know that Zymar is a 4th generation fluoroquinolone, not a cephalosporin.
Yours truly,
"Eye OD"
Quite right. I stand corrected. Zymar is, of course, a fluoroquinolone and not a cephalosporin.
Also, Acular can retard corneal healing...and you know how some patients abuse drops that are supposed to relieve pain.
Although, true, it is appropriate to relieve pain with topical NSAIDS as it is indicated for post-operative surgical pain. If the patient is seen with 1-2 days after the procedure, then I think the chance of over use is minimized.
You can also try Marco or Topcon, they make great products. Don't bother with a used slit lamp unless your budget is tight or unless the used equipment is fairly new. Expect to pay around $3500-$5000 for new depending on how many bells and whistles you need to have. PM me if you want the name of any distributors or have some other questions.
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