Eye popping out

I had a very interesting experience today. I've been working with the neuro-ophthalmologist for about 4 weeks now, and I've seen some pretty shocking things, but today takes the cake.

Note: I have only linked to photographs instead of posting them directly here so that people can choose for themselves to look at them or not. You're welcome.

A patient came in today with Grave's disease. Grave's disease is a thyroid disorder that has many side effects, one of them being that your eyes may bulge out a little bit (just like this). This patient I saw was a middle-aged African-American lady who developed Grave's last year. She had some surgery on her thyroid a few months ago, but her eyes still bulge out. We see Grave's patients every day in our clinic, so it's no big deal to see someone with bulging eyes. They usually wear sunglasses because their self-conscious about the way they look.

Anyway, I was working the patient up to get her ready to see the doctor. I took her medical history, got her visual acuity, checked her pupils and eye movements, and then started to check her eye pressure. Some people in other clinics check eye pressure by doing that puff-of-air-in-the-eye test, but since that test can be pretty inaccurate we do contact tonometry. This means that I put a numbing drop in the patients eye then press on the eyeball with a blue light to find the pressure inside the eyeball (it looks like this). It was pretty scary to push on someone's eyeball the first time, but now I'm used to it. Sometimes people blink a lot so I have to hold their eye open with one hand while pushing the slit lamp into their face with the other.

This patient with Grave's that I saw today was a blinker, so I had to hold her eyelids up while I measured her pressures. I always start with the right eye, and that one went OK. It took a couple of tries because she kept saying that her "eyelid was about to roll up" and she would pull away from me real quick. I wasn't sure what it meant to have an eyelid "roll up", so I didn't think much of it.

When I measured her left eye, I found out what it meant to have her eyelid "roll up." It means that her eyeball POPS OUT OF HER FACE and her eyelid is behind it. I still cringe when I think about it. I was measuring her left eye when she suddenly said, "Oh! Oh!" and then I felt a little pop against the tonometer. I looked up and saw this lady's left eyeball protruding out of her socket with the most horrified look on her face (just like this). I'm sure my face was more horrified than hers.

I had no idea what to do. It was kind of funny because we were all joking about this happening last week and someone mentioned that there is this spoon-shaped instrument used to push eyes back in, but I had no idea where to find one or how to use it. I ended up biting my tongue to keep myself from yelling, then asked the woman if her eye hurt. She said, "Oh, yes!" I then realized it was kind of a dumb question.

I was about to get the doctor when the patient ended up fixing it herself. She pulled her eyelid out from behind the eye and pulled it down in front of bulging eye, then used both hands to push her eye back into her socket. I asked her if this sort of thing has happened before and she said that it has happened a couple of times.

After finishing up the exam, I talked to the other technicians and they all the held their hands over their mouths and gasped while I told the story. I guess they've never seen that happen before. The doctor, on the other hand, seemed totally unfazed by it. He was like," Oh, which eye did the subluxation occur in?" and I had to relive the experience over again before I could confidently say "Left eye."

And now I will live in fear of testing the eye pressure of Grave's patients. Maybe I should just keep the little eye-spoon-tool with me at all times just in case I come across a patient who can't put her eye back in.