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REVIEW
Therapeutic Topics
Wise Choices for
Ocular Diagnoses
A look at the value and utility of a range of diagnostic
techniques and technology for anterior segment disease.
Mark B. Abelson, MD, CM, FRCSC, FARVO, and James McLaughlin, PhD, Andover, Mass.
key part of the many debates
A over health care is the idea of
providing the best possible care with
increasingly limited resources. This
attention to spending has amplified
the interest in more cost-conscious
medicine. A 2012 report in the Journal
of the American Medical Association
identified six areas of medical
waste and, among these, overtreatment
(including superfluous testing,
treatments or hospitalizations) was
the biggest of the offenders, with estimates
of $150 to $225 billion wasted
by such activities in the United States
annually. 1 Lost in these arguments, at
times, is that no matter the dollar figures
involved, such activities are often
bad medicine as well as bad economics.
So perhaps a silver lining that may
emerge from the chaos that is healthcare
reform is the reaffirmation that
in medicine, as in many other avocations,
less is very often more.
An example of this is the Choose
Wisely campaign, 2 an effort spearheaded
by the American Board of
Internal Medicine that has recruited
more than 50 specialty societies, including
the American Academy of
Ophthalmology, to identify tests and
procedures that are overused, provide
little clinical benefit and, in some cases,
may even be obstacles to achieving
the best possible patient outcomes.
These groups identified five or more
suggested practices based upon the
latest in evidence-based assessments.
One of the AAO recommendations
states, “Don’t perform preoperative
medical tests for eye surgery unless
there are specific medical indications.”
So unless the patient has a
history of heart disease, for example,
a preoperative EKG is unnecessary.
Some of the Choose Wisely recommendations
run counter to established
practices, but in a sense, that’s
the point: They are a way of rethinking
standard operating procedures in
light of 21st-century economics and,
most importantly, 21st-century medical
evidence.
In this month’s column we examine
selected front-of-the-eye diagnostics
and standard operating procedures
and ask how these procedures hold up
to a “choose wisely” inspired evaluation.
Our strong bias in this discussion
is that patient history and examination
remain the most valuable sources of
information for diagnostic inquiry.
Which Conjunctivitis?
Acute conjunctivitis presents with
a spectrum of features that will often
provide all the diagnostic data needed
to determine the underlying etiology. 3
What we like to refer to as “Abelson’s
diagnostic triad” states that if it’s itchy,
it’s allergy; if it’s sticky, it’s bacterial;
and if it burns it’s dry eye. Clear discharge,
visual impairment, photophobia
and ocular pain are other features
that can be useful in whittling down
the diagnosis. 4 Viral conjunctivitis can
have a variable presentation, but a
key to remember is that it’s typically
follicular, so swollen lymph nodes (especially
periauricular nodes) can be
diagnostic. These initial assessments
can be followed up by additional testing,
exploratory therapeutics or both.
While a test dose of a topical antihistamine
is probably the most efficient
way to confirm a diagnosis of
allergic conjunctivitis, other forms
of conjunctivitis may require further
investigation. Another of the AAO
recommendations in the Choose
Wisely campaign is “Don’t order antibiotics
for adenoviral conjunctivitis
(pink eye).” Despite this, recent
50 | Review of Ophthalmology | February 2014 This article has no commercial sponsorship.