Fluorescein, TBUT and Lid Eversion Procedures

I.    Fluorescein
  A.    Strips
    i.    Avoid spilling onto patient or yourself
    ii.   Difficult to remove stain from clothing
  B.    Opening Strip by Parting Halves
    i.    Parting Halves
    ii.   Tearing 1/4 into cover and "Popping" cover
    iii.  Folding wide strip into "L" shape
      a.    Avoid limpness
      b.    Delivers more fluorescein to eye
  C.    Short Strip wetting demonstration
  D.    Long Strip wetting demonstration
  E.    Wetting strip
    i.    Perform over wastebasket to avoid staining carpet or floor 
    ii.   DO NOT contaminate saline bottle tip
    iii.  DO NOT use anesthetic as substitute for saline
      a.    Wasteful of drug
      b.    Inadequate anesthetic
  F.    Placing drop into eye
    i.    Pull lower lid away from globe with thumb or index finger 
          while patient looks upward
      a.    Lower palpebral conjunctiva
      b.    Lower bulbar conjunctiva
    ii.   Pull upper lid up toward brow with thumb while patient looks 
          at table or toward his feet
      a.    Upper bulbar conjunctiva
    iii.  DO NOT "Paint" -- just dab tip of strip onto eye
    iv.   DO NOT place "Edge-wise" onto eye
  G.    Fluorescein stays in eye for 2 to 10 minutes (average = 5 min.) 
    i.    Delay wearing soft contact lenses for 1/2 hour after 
          instillation 
      a.    Can speed up process with irrigation 
            (to be covered in another lab)
    ii.   Persons wearing rigid contact lenses can use immediately 

II.   TBUT
  A.    Biomicroscope
    i.    6x to 10x magnification is adequate
    ii.   1/2 width of cornea beam of light at full height
    iii.  Light co-axial or any angle to illuminate cornea  
          (not critical) 
    iv.   Focus on tear film  (critical)
    v.    Must use cobalt blue filter
  B.    Position patient in slit-lamp
    i.    Make all adjustments prior to instilling fluorescein
    ii.   Look at lower lid conjunctiva using while light
      a.    Look for fluid filled vacuoles
      b.    Look for concretions
      c.    Look for combination
  C.    Measuring procedure
    i.    Three FULL blinks to distribute dye
    ii.   Instruct patient to hold eye open as long as possible
    iii.  Scan across cornea -- focused on tear film and epithelium 
    iv.   Should take about 1 second to scan each direction
    v.    Count number of seconds until first "black" area forms
    vi.   DO NOT hold light steady in one position
    vii.  Average 3 separate TBUT estimations
    viii. Record average --  TBUT:  xx seconds
  D.    Interpretation
    i.    < 5 seconds:  patient will probably have dry eye complaints 
          and probably should not be fit in contact lenses
    ii.   5 to 10 seconds:  patient has marginal tear film (may or may 
          not have complaints)
    iii.  > 10 seconds:  patient has normal tear film
    iv.   > 15 seconds:  record as TBUT greater than 15 seconds

III.  Lid Eversion
  A.    Use Q-tip (shorten if necessary)
    i.    Place temporal to lid to be everted
    ii.   Lift lashes slightly and grab at base of lashes
  B.    Move Q-tip to lid fold near top of tarsal plate
  C.    Pull lid out and up with fingers while pushing lid in and down 
        with Q-tip
    i.    Pull out on upper lid only 2 to 4 mm
    ii.   Push in and down gently on upper lid with Q-tip
  D.    Trap upper lid with thumb against upper orbital bone to 
        maintain eversion
    i.    Slide Q-tip temporally and remove from area
    ii.   Do not leave in place during examination
  E.    Look at lid
    i.    Inner lid margin of everted lid
      a.    look just above everted lid
      b.    look also in profile at everted lid margin
    ii.   Palpebral conjunctiva
    iii.  Determine extent of "bumps"
      a.    None      - (0)
      b.    Trace     - (1)
      c.    Mild      - (2)
      d.    Moderate  - (3)
      e.    Severe    - (4)
      f.    Note extent of bumps from everted margin toward lid lash 
            margin
        1.    three zones (described more in contact lens course)
    iv.   Use fluorescein and cobalt blue light
      a.    Note extent of "cobble-stone" appearance as tear fill 
            "cracks" between bumps
    v.    Use white light to determine amount of injection
      a.    None, Trace, Mild, Moderate and Severe
  F.    Restore lid to normal position
    i.    Use thumb to fold lid back to normal position
    ii.   Have patient "squeeze" blink to restore lid to normal 
          position 
  G.    It is possible to evert lids using fingers only 
        (not using Q-tip)