As you may remember, I started the Independent Prescribing course all the way back in 2015.  At the time, I was working in a multiple, I had the opportunity* and thought that being an IP optom was a natural progression for me.  I loved the idea of being able to provide treatment for my patients with straight-forward eye problems without sending them to their GP or the hospital.  Sometimes, I would ask a GP to prescribe something only to end up playing phone-tag with them over the details.  When I worked in Lanarkshire, I became LENS qualified – this allowed me to supply chloramphenicol, fusidic acid, hypromellose, cyclopentolate, aciclovir (later, when they had problems sourcing that, it was replaced with ganciclovir) and other preparations for minor eye-related ailments.  I thought this was a wonderful system and really missed it when I left that health board to work closer to home.

You might be wondering why, two years down the line, I’ve only got one module (out of three) under my belt.  Well, in 2015, I couldn’t get the time off work to attend the second module and then, I re-registered in 2016, only to find out that I’d booked a holiday (for a special birthday) at the same time as the module exam**.  Ooops.

So, here I am, in 2017, two years after starting the course and I’m just over half-way through the process.  The exam for module two was on Friday and this weekend we had a selection of lectures and tutorials.

For anyone thinking about the IP course, it’s a bit of a strange experience.  Instead of having a weekly class, the teaching happens in three short bursts, followed by a couple of months of self-study.  Each module has coursework and then an exam at the end of it.  The first module concentrates on common anterior eye complaints, the second is focused on glaucoma and the third is mainly about systemic drug interactions and adverse drug reactions.  The course work is a case report (for module 3, it’s two case reports) and each exam is a three hour affair which includes multiple choice, short answer questions and a VRICS style section.

While the material is quite straight-forward, in the beginning, it can feel overwhelming.  Once you realise that, as IP optoms, there are only a few types of drugs we will be using, it becomes much simpler.  If you have a BNF, a quick look at Section 11 (the eye bit) will show you every drug and preparation that you might possibly use, excluding the intra-ocular drugs (although I’m all for continued professional development, I think I’ll leave the Lucentis injections to the ophthalmologists and ophthalmic nurses).

Overall, it’s been an interesting experience and I would urge anyone thinking of getting IP qualified to do it sooner rather than later.  When I was a pre-reg, I was advised by a wonderful locum optom to do the IP course as soon as I could – she said, the longer you are qualified and out of the habit of studying, the harder it is to get back into the swing of it.  This is especially true for the IP course where, as well as working, you will have to do a lot of independent study: revising for the exam, preparing the coursework and reading articles on such diverse (and sometimes desperately boring) areas such as pain management, clinical governance, laboratory investigations and anti-microbial agents.

So, fingers crossed that I have passed the second module.  Still, I have another two pieces of coursework, the module 3 exam, twelve days of hospital experience and the final College of Optometrists exam to sit before they let me loose with a prescription pad.

 

* NHS Education Scotland sponsors optoms based in Scotland, which is yet another reason I’m lucky to be practising here.

** As the course happens around the same time every year, this week I spent my birthday studying for/panicking about the exam the next day.

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I thought I would write a post on what I do in practice and why.  This started out as a quick post but has turned into a bit of a monster so I’ll separate it into a few parts.  This post deals with the first part of the eye test, up to refraction.  The next part will be on refraction and the final part on the health check and management.

So, without any further ado, my routine:

Each working day, I arrive at my practice with some time to spare.  I usually get there 15 minutes early to set everything up – this involves little things like switching on the computer, test chart and slit lamp console.  While the computer is booting up or logging in, I lay out all the things I’ll need.

Chef’s have a thing called mis en place, which is having all ingredients prepared before service.  It’s what happens in Jamie Oliver’s TV kitchen before the cameras are turned on: every ingredient is peeled, chopped, weighed and set out in a logical and accessible place before the cooking begins.  Like chefs, we have time limits.  No-one wants to wait an hour for their meal because the chef has to hunt high and low for each ingredient and no sane patient would leap at the chance of spending double the time in the test room because their optom was inefficient.

So here’s my optom version of mis en place:

I lay out my occluder, budgie stick, +/-0.25DS flippers, lens cloth (very important in my practice as the cyls don’t have handles so are always covered in fingerprints), pen torch, pen, spare pen (for when the first one stops working or a patient/staff member* steals first pen), confrontation stick and my cross cyls.  I’ll unpack my ret and ophthalmoscope and have them handy as well.  If there are children in the clinic, I’ll put the Titmus and Ishihara within reach and if someone is attending for contact tonometry and pachymetry, I’ll have both the Perkins and Accupen in my room before the start of the day.  I also make sure I have an Amsler handy and that there are enough leaflets on common conditions in my room.

On the slit lamp table, I put my Volk lenses, Wratten filter, cotton buds and the little box I keep Sterets and needles in.

Before my first patient, I’ll make sure the slit lamp isn’t on some weird setting (like 40x mag, tiny spot and green light) and go through the computerised test chart to make sure when I hit the xcyl button, it gives me dots instead of circles (weird, I know, but I prefer the dots).  We also have one of those test charts where, if you press the wrong button on the fixation setting, you end up with a terrifying clown face so I make sure that it’s on the green dot not Pennywise.

By taking a few minutes to set everything up, I’m saving myself time during the day.

The patient will be pre-screened by the optical consultants.  In my practice, they usually do a mini history and symptoms and write any concerns on the front of the record card.  They also ask about work, hobbies, driving and VDU use.  After that little interview, the patient is then autorefracted and has non-contact tonometry done.  They then complete a 24-2 screening test on the Humphrey.  It’s good to have the autorefractor result before fields because you can then choose an appropriate lens for the visual field test.

After the 24-2, the optical consultant takes a fundus photo.  I will have a moment to check the photo on my screen before the patient is brought in.  I find checking the photo before the test helpful because I do fundoscopy after refraction and if the patient is struggling with refraction, there’s a good chance I have an idea why, based on the photo.

When the patient comes in, I introduce myself and ask how they are today.  We have a bit of a chat and I tell them they can pop their bags down on the chair over there then I ask them to have a seat “in the big chair”.  If the patient is unsteady on their feet or using a cane, I’ll make sure I flip the footrest up on the chair, allowing them to get closer to the seat before sitting down, and once they are comfortable, I’ll put the footrest down.  I also like to make sure I’m close by while they are sitting down, to provide a hand if they are struggling.  I usually say something like, “I’m just here if you need a hand or something sturdy to hold onto”.

Once we are both settled, I start history and symptoms.  If they come in with a problem, I’ll go straight to that.  If they have a sore eye or a red eye, I’ll just start with, “So, what’s happened?” and the patient will usually launch into a pretty detailed account of their sore or red eye.  When they are finished, I’ll ask any other questions I need to, again, leaving the patient plenty of time to answer.

Assuming a routine eye test, after confirming their details and their reason for visit, driving etc, my usual history and symptoms goes something like this:

Do you remember your last eye test?

Do you wear glasses at the moment? What are they for? How do you feel your vision is with them? Any situations where you feel you aren’t seeing as well as you should?

Have you had to go to the hospital or GP for any eye problems? Do you ever get flashing lights in your vision? How about floaters – wee black dots or wee black wiggly lines? Do you ever get double vision?

How’s your health at the moment? Are you diabetic? Any high blood pressure? Do you suffer from headaches?

Are you taking any medicines at the moment?

Anyone in the family with eye problems that you know about? Anyone in the family diabetic?

I will then put the chart on and ask the patient, while wearing their current correction, to occlude their left eye.  I’ll hand them the occluder and 9 times out of ten they will cover the right eye and, by right, I mean left.  Ten percent of the time, they’ll cover their right eye, which is the wrong eye instead of the right eye which is the left**.  Sometimes they’ll close one eye and cover the other.  Sometimes they’ll try and wedge the occluder under their glasses.  Sometimes they won’t even use the occluder and instead cover their left eye with one hand while holding the occluder in the other.

Hopefully, at this point, they will have one eye covered and the other open.  At this point, I’ll ask them “what’s the smallest line you can read on the chart?” Eight times out of ten, they will pick a line and read it more or less correctly*** and I’ll then ask them if anything is standing out on the line underneath****.  Those two patients out of ten will do a number of things: read the whole chart from top to bottom, say random letters (maybe throw in some numbers and stars) that bare no resemblance to any line on your chart, read the line backwards or just stare at the chart for an uncomfortable amount of time before saying, “Oh, do you want me to read it out loud?”

This is repeated for the other eye and you now have an idea of how well your patient is seeing with their current correction.  I know at uni they teach you to check vision rather than VA with current Rx but there’s really no point doing that in practice – you want to know if you are improving your patient’s vision with your refraction and, let’s face it, writing down 6/60 and 6/120 doesn’t really tell you much other than your patient needs glasses.  Also, if your patient is 6/5 with their current prescription, don’t give them more minus unless it’s getting them to 6/4, 6/3 or giving them the ability to see through time itself.

After that, I’ll ask the patient to take their glasses off and give them a target to look at for cover test.

I will start with alternating cover test at distance then get the patient to look at an appropriate target on the budgie stick and do cover test at near as well.  If they report having problems with their vision while on the computer, I’ll ask how far the computer is and I’ll do cover test at that distance as well.

I’ve had a few young girls recently attending with no prescription (6/5 N4 unaided) but complaining of headaches when on their phone/tablet/computer – these girls all had large XOPs at near.  A few weeks ago, I saw a patient with a very noticeable cyclophoria which was so cool and unexpected that I may have spent a few minutes just covering and uncovering her eyes, thinking “Wow”.

Anyway, next I do cover/uncover, looking for tropias.

Then I tell the patient that I’m going to dim the lights (which I do) and I test pupils.  During each test, I tell the patient what the test is for, what I’m seeing and reassuring them that the result is normal (unless it’s not, then I come back to that later).  After testing direct and consensual reflexes (three times in each eye, exerting the pupil muscles enough that if there’s an abnormality, you’ll see it after three repetitions) I move onto the swinging flashlight test.  Pupil reflexes are a bit of an art and I was worried that I would miss an RAPD but, believe me, if you are watching closely and doing the swinging flashlight test properly, you won’t miss one.

I then pop the lights back on and we move onto motility.  I always sit for motility although there’s a bit of a debate about this.  This is the part of the test where the patient is likely to start laughing.  I don’t know why, maybe it’s something about the test or maybe my look of intense concentration is hilarious, but I’ve had eighty year old men in stitches during motility.

Next is confrontation, which always involves a bit of mental agility on the part of both myself and the patient because you have to cover the contralateral eye to them to test their field in that eye.  Strangely, this isn’t as much fun for patients as motility.

So, that’s the first bit of the eye test, with a bit of an observational comedy thrown in for you.  I’ll post the next part (refraction) in a little while.

 

* You know how you are.

** Isn’t English a wonderfully clear language.

*** There is a special place in hell for those who read the whole chart using the phonetic alphabet… Oscar… Mike… Foxtrot… Golf…

**** You should always push your patients to read a little bit more because some people are quite cautious and need an extra nudge to actually admit they can see a bit better.  If we just left it up to the patients to pick a line, their VAs would be all over the place.

Those of you who’ve been reading my blog will know I’m passionate about communication. Over almost four years and in more than 100 posts, I’ve told you stories about my patients, my practise and my journey to become an optometrist.  I’ve spent a lot of time thinking about communication and reflecting on how we approach new situations.  I’ve come to realise that the worst part of our job is the unknown.  Of course, we all become more confident as we gain experience yet, at the same time, there are hundreds of scenarios that we don’t know how we’ll handle until they happen.  Not only that, we don’t know how the team around us will handle those situations either.

In the last few months, I’ve developed a card game to help optical professionals and those in the process of qualifying hone their communication skills by asking them to imagine themselves in challenging situations.  It’s called Deal with it.

I’ve been really lucky to have met a wonderful optometrist and business person, Sarah, who has helped make my vision a reality.

Here’s a look at the box:

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The cards have been designed to challenge players to adapt their communication style to fit the needs of patients with a variety of complex needs and conditions.

The game can be played in groups (for example, as a staff training exercise) or individually (to self test).  When played in groups, discussion and feedback become part of the game, making it a perfect training and team-building exercise for professionals working together in practice.  It can also be used as OSCE preparation or revision.

Each pack contains 56 cards: 1 suggestions card, 50 scenario cards and 5 action cards.  Each scenario card has two different conditions to explore: this generates a total of 500 possible scenario / condition / action combinations so there is plenty of scope for repeat play without repetition.  The action cards have communication tasks on them that cover the entire patient journey.  Games can last minutes or hours, depending on the number of scenario cards used.

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If you want to buy a deck of cards or just to learn more, you can visit my website: msnowball.org.uk

This post is yet another that got stuck in the “drafts” folder. It was actually written during my pre-reg and has since languished on WordPress in a half-finished state.  Today, I’ve bitten the bullet and finished it.

One of my patients today was profoundly deaf.  Now, I went to a sign language class last year and I picked up the basics (as well as colours, animals and weather… strange but true) but I still feel a little nervous about practising on someone who can sign properly.  I feel it will be like going to France and speaking French to a native for the first time, probably with a terrible accent and a lot of grammatical errors.  I once told my Russian teacher, during an oral exam, that I had problems picking up what he was saying because I couldn’t “see his mushrooms” (I meant “lips” but, well, griby and guby got mixed up somewhere between my brain and my mushrooms).

Before we get to the actual test, we should talk about what happened before it.  Making an appointment was difficult for my patient, who we’ll call J.  She’d received her recall letter and was given three options to book an appointment: 1) call us, 2) go on-line or 3) come into the store.  Now, J said the easiest way of booking was to come into the practice because using the telephone system was difficult (not impossible, you can get text phones) and the on-line system at that time worked by the patient requesting an appointment and then us calling them back (yes, facepalm).  Things have improved with this multiple – you can now book on-line properly, without having to speak to another human being.

So, J popped in with her partner (who was also profoundly deaf) and arranged her appointment.  She had a mobile phone and requested that we text instead of calling to remind her about her appointment (we would call everyone the day before to confirm) and to also advise her when her specs were ready to collect.

When J arrived for her appointment, one of the optical consultants (R, my work wife at the time) panicked a little about doing the prescreen.  She was unsure about how to adapt her routine.  Seeing her panic, I advised her how I would do it: instruct the patient while her glasses were on, tell her what the test did and how we wanted her to respond and, when the test was finished, we would tap her on the shoulder to let her know it was finished and then we would do the same again for the other eye.  Seeing that the OC was still unsure, I asked if she’d be more comfortable if I did the prescreen while she watched but she said that she felt a bit more confident and would give it a go.  I stood to the side, within the OC’s eye line so I could nip across if she had any problems but the prescreen went well and both the OC and the patient seemed quite pleased.  The visual field test was the challenging bit as we do the screening test that uses multiple points then ask the patient how many they’ve seen before we manually move onto the next presentation.  My patient and the OC worked out a system where the patient would hold up the number of fingers that corresponded to the points she’d seen and if correct, the OC would move onto the next one.  It worked really well and meant that the patient didn’t have to keep coming out of the correct position – she just stayed with her chin on the rest and forehead against the bar and held her hand up to show the OC after each part of the test.  When the OC showed my patient over to my room, they were laughing because she’d said that she had to be careful which fingers she held up for to say “one” and “two”.

There’s only one golden rule for patients with hearing difficulties: ask them how they want to communicate.  If they lip read: make sure you don’t shout (this distorts your lips) and that they can see your face clearly (keep their specs on as much as possible if they have high Rxs and don’t do Hx & Sx while looking down at your clipboard or towards your VDU).  If they are “hard of hearing”, again, don’t shout, just try to speak a bit clearer and louder and again, make sure the patient can see your face.  Some patients will ask you to shout, I try to avoid this because it wrecks my voice – instead, I use my public speaking training* and speak from my diaphragm rather than my throat (weirdly, this also makes you sound more confident so win-win**).

The eye test itself was unremarkable and, at the end, when J came out of the test room, her partner came over and signed, “Do you need reading specs?”  and I signed, “Too young for reading specs” which got a laugh.

He said he had two pairs of specs and was getting fed up of changing between them.  I signed that he needed… um, v…a…r…i…f…o…c…a…l….s.  My fingerspelling isn’t that great, you can probably tell.

In the end, it was a good experience for both me and my OC.  And I was relaxed enough to try out my BSL in a real life situation***.

 

* Sadly, I used to compete in debating and public speaking competitions when I was at school.  Without bragging, I wasn’t completely awful at it.

** Honestly, Google it.

*** I didn’t/don’t tell people I can sign a little because I’m terrified of being in a situation where I need to be able to sign better than I can – which, of course, puts me in a catch 22 situation where I want to get better at it but I’m afraid to practise it in case I insult someone’s ancestors by mistake.

Of course, as part of my PhD, I’ve been doing a lot of reading about glaucoma and visual field loss.  I’m still working in practice at the weekends and I find my approach to managing patients has changed based on the papers I’ve read.

I know not everyone has a spare three four months to read up on the latest research in glaucoma so I’ve chosen five interesting facts that may help my fellow optoms, pre-regs and students with their decision making.  For those who want to read more, I’ve added references*.

1) Early glaucoma affects central vision.  Usually we think of glaucoma as a disease that causes loss of peripheral vision.  Most example field plots will show a baring of the blind spot, arcuate defects and nasal steps but only the most severe will show macular involvement.  There’s actually a reason for this – we’ve been using the wrong test.

In practice, the standard field test we use is a 24-2 which covers the central 48 degrees with a 6 degree spacing between the test points.  Only four of the points tested fall within the macular region (central 8 degrees) .  If you can imagine, the little fixation spot the patient is looking at is located at 0 degrees, then the four points checked by the 24-2 are all just over 4 degrees from fixation.  Here’s a napkin drawing to help you visualise (and to show off my mad geometry skills):

242

Considering 30% of all retinal ganglion cells originate from the macula, it makes sense that this area is affected by glaucoma, a disease that causes ganglion cell death.  Several papers have been published recently showing that, despite previous wisdom that the macula was only affected in severe, end stage glaucoma, it can actually be one of the first areas affected.  Using a 10-2 visual field pattern may pick up macular defects that are too small or not in the correct location to be detected by the 24-2 pattern.  The 10-2 test covers the central 20 degrees (10 degrees either side of fixation) with a 2 degree spacing between test points.

Optical coherence tomography (OCT) shows thinning of the retinal nerve fibre layer (RNFL) in glaucoma.  Usually, if you suspected glaucoma, you would check the disc scan but, again, the macula with its abundance of ganglion cells is a better place to look for thinning.

Further reading: Grillo L. M., Wang D. L., Ramachandran R., Ehrlich A. C., De Moraes C. G., Ritch R. & Hood D. C. The 24-2 Visual Field Test Misses Central Macular Damage Confirmed by the 10-2 Visual Field Test and Optical Coherence Tomography. Translational Vision Science & Technology, 2016, 5(2): 15.

 

2) Certain areas of the disc are more likely to be damaged first.  As clinicians, we all know the ISNT rule and anyone lucky enough to have an OCT at their disposal will see that there is a “double hump” in the retinal nerve fibre layer profile around the disc.  The two humps are the inferior and superior regions of the disc:

Humps

Anyway, these two humps (the thickest parts of the optic nerve head) are the most prone to damage.  Any lady with a large chest will confirm this**.

If you think the optic disc of a right eye in terms of a clock face (superior is 12 o’clock, inferior 9 o’clock, nasal 6 o’clock and temporal 9 o’clock) then the areas corresponding to 6, 7, 11 and 12 on the clock are the most likely to be damaged by glaucoma.  For a left eye, it would be 5, 6, 12 and 1.  Interestingly enough, disc haemorrhages are usually seen in the inferior temporal portion of the disc (around 7 o’clock in right eyes and 5 o’clock in left eyes).

Further reading: Hood, D. C. Improving our understanding, and detection, of glaucomatous damage: an approach based upon optical coherence tomography (OCT). Progress in Retinal and Eye Research, 2017, 57: 46-75.

 

3) Normal tension glaucoma is a bit different.  Obviously it’s different in terms of intraocular pressure but let’s think about what causes glaucoma.  Well, there are two main theories: 1) the raised IOP squeezes the nerves until they die (the mechanical theory) and 2) there are issues with the blood supply, starving the nerves until they die (the vascular theory).  In normal tension glaucoma (NTG), the IOP is within normal limits (there’s nothing smooshing the nerves to death) so we can assume that the vascular theory is probably more applicable to NTG.

It’s been found that NTG patients tend to present with deep, well defined visual field defects that tend to be closer to fixation than those found in high tension glaucomas.

Normal tension glaucoma is probably one of the most challenging diseases to diagnose in practice.  If someone comes in with IOPs around 30mmHg, we are immediately on alert.  But, and I came across this a few weeks ago, what if your patient has IOPs around 15mmHg, moderate cup to disc ratio, deep cupping, no sign of focal neuroretinal rim (NRR) loss, normal central corneal thickness and a family history of glaucoma? Well, you do a 24-2 (as I did) and you find no defects.  Case closed?

My optom-sense was tingling from the moment I saw a photo of the patient’s discs – even before I heard that his father was registered blind as a result of glaucoma.  So I did a 10-2 test and, yes, there was a deep defect relatively close to fixation.

Research has been done into visual field defect location and those with a defect within 5 degrees of fixation are at a greater risk of losing their visual acuity – this makes NTG even scarier! It’s certainly worth taking an extra five minutes and doing a 10-2 test if the 24-2 is unremarkable but your gut instinct tells you something is amiss.

Further reading: Cho H.-K., Lee J., Lee M. & Kee C. Initial central scotomas vs peripheral scotomas in normal-tension glaucoma: clinical characteristics and progression rates. Eye, 2014, 28: 303-311.

 

4) Glaucoma doesn’t just affect the eye.  This is something I’d never really thought about until recently but what happens when those ganglion cells die? It creates dead space in the visual cortex.

You know that glaucoma is a disease which causes a negative scotoma (as opposed to the positive scotoma that results from advanced AMD) – why? Because the brain fills in the missing areas with information from around the scotoma.  When we talk about glaucoma, we may imagine tunnel vision but that’s not actually what patients say they experience.  They have blurred bits and missing bits.  It’s like that trick we do where we draw a small cross on a piece of paper then move it across our visual field until it disappears – that’s the cortex producing a negative scotoma so we aren’t aware we actually have a blind spot.

Of course, the cortex isn’t really doing us any favours when it comes to glaucoma – it’s hiding the disease from the patient and even when diagnosed, it’s sometimes difficult to convince a patient that they have an issue with their vision (especially when it comes to something as important as driving).

So, please don’t tell your patients that they have brain damage as well as glaucoma, but maybe be more aware that the visual experience of someone with the disease is different from what you may believe.  When those patients (and I’ve had my share) come in and say “something just isn’t right” then maybe think of glaucoma as a possibility – especially if they have normal IOPs.

Further reading: Crabb, D.P. A view on glaucoma – are we seeing it clearly? Eye, 2016, 30: 304–313.

 

5) Over 111 million people will be living with glaucoma by 2040.  I’ll just leave that there.

Further reading: Tham, Y.-C., Li, X., Wong, T.Y., Quigley, H.A., Aung, T., Cheng, C.-Y. Global prevalence of glaucoma and projections of glaucoma burden through 2040. Ophthalmology, 2014, 121, 2081–2090.

 

* If you are a Scottish optometrist, you can get access to Athens through your health board so you can read these papers for free.  If anyone in Wales, England or NI knows if this is also the case, please comment.

** Or men, I’m not being sexist here.

I recently saw a patient who reminded me of the importance of our job.  This man was in his early thirties and had never had an eye test.  He was in that day because he’d been in a fight the previous week and suffered two black eyes.  He wanted to check that his eyes weren’t damaged in the fight.

During history and symptoms, I asked all the usual questions and threw in a few more specific ones about pain on eye movement and other trauma symptoms.  All in all, he seemed to have been bruised and bloodied but nothing broken.  The area around both eyes was a grey-yellow colour, showing the time since the injury, and there was the ghost of a subconjunctival haemorrhage in one eye.

According to him, there was no noticeable change in vision.

When I came to ask about medication, there was a pause. I could see my patient wondering if he should tell me the truth.  I was expecting the answer when it came: methadone.  Then he watched my expression.

Now, I have worked in many economically disadvantaged areas, as you know, including the place where I was born and raised.  In my previous job, I walked past a man every morning as he waited for the pharmacy to open, saying “good morning” or stopping to chat about the weather.  I knew why he was waiting but, much to the scandal of my OA at the time, I would happily chat away with him as the pharmacy assistant pulled the shutters up.

To me, methadone is a ladder out of a pit.  It’s like citalopram or the many other medicines that exist to help people at various points in their lives.  I have tested people who have conquered their addictions, people who are in the midst of the battle and those who haven’t yet started the fight.  And they all watch for judgement when they tell their stories.  It’s at that point where you can either make a real connection or see them close up, depending on your reaction.

I wrote down “methadone” and moved on to family history.  I obviously had passed the test: my patient relaxed a little and started telling me about his life.  He was going back into education to do an access course: he wanted to be a journalist.

When I checked his unaided vision, he was 6/19 in his right eye and 6/12 in the right.  Of course, I didn’t know if the reason for the reduced vision was trauma or if it was uncorrected refractive error at that point.  On ret, he was R-3.00/+3.50×100 and L -2.00/+1.25×90.  When corrected, vision came down to R 6/7.5 L 6/6.

Apart from the bruises, his eyes were both perfectly healthy.  I took him out of the test room at the end to show him the world with his prescription and advised him about adaptation.  We chatted about dispensing since there would be a difference between the lenses and, in the end, he went for a nice pair of plastic specs that will look great when glazed.

After my patient had left, the OC asked about his prescription.  How can someone go through life with such a high cyl and not notice? How do you get to your thirties before your first eye test?

I started thinking about the reason I was taken for regular eye tests as a child – my mother is very short sighted (well, she was until she had LASEK 24 years ago, now she’s just a little short sighted).  I managed to get to 17 before I needed specs but I have memories of the opticians going back to when I was 5 or 6.  If my mother wasn’t so concerned about me also being short sighted, I might not have had a test until I was much older.

My patient may have grown up in a family where no-one needed glasses or, more likely, one where they didn’t prioritise eye tests (there are many reasons for this, including cost, access and awareness).  He wouldn’t realise his vision was poor.  If he was struggling at school because of his poor vision, he wouldn’t have realised the problem was just that: his vision.  He may have missed out on his education due to something relatively simple to fix.

While we can’t go back in time to see if a pair of specs would change the course of his life, I can make sure he goes into his access course seeing as well as he can and, fingers crossed, for the first time ever, something good may have come out of suffering two black eyes in a fight.

I have been thinking a lot about autism spectrum disorder (ASD) after meeting a lovely 4 year old on the spectrum.  As mentioned previously, I’m working one day a week in practice, surrounded by a fantastic team, and they tend to save the best patients for me.

A couple of weeks ago, I saw a young boy, H, who came in with his mum, dad and brother for his first eye test.  His mum was concerned because H said he wasn’t seeing well in the distance and there was also a family history of strabismus.  When H was booked in, a note was made in the diary that he had ASD and sensory issues.  The appointment was in the middle of the afternoon, at that time when, if one or two people show up late, my clinic starts running behind.

I looked at the diary and spoke to the optical consultants about my plan for the day.  Basically, I wanted H seen as soon as he came in, I didn’t want to keep him or his family waiting in a busy, bright area, especially since I had no idea the nature or strength of his sensory issues.

As the day progressed, everything seemed to be running smoothly.  The patient immediately before H turned up quite early and everything was going well.  I’d said to the OCs that they could try and do a photo for H if he was willing but, otherwise, no pre-screening was necessary.

H quite liked getting the fundus photo taken and wasn’t put off at all by the flashes of light.  In general, he seemed a little nervous and a bit shy, like most children arriving for their first eye examination.  He was doing the “hiding behind mum” thing that young children tend to do when they are unsure of a situation.

We went into the test room and he got up on the chair.  I moved the chair up a bit until he could see the mirror and, again, he seemed fine, if a little apprehensive.  His mum was sitting under the mirror, on hand in case he needed her.

Everything started quite well.  We chatted about his t-shirt (which had Spiderman on it, his favourite superhero) and talked about his vision.  History and symptoms was going fine but H was so shy that day, he was looking down and talking into his chest.  I couldn’t make out what he was saying so I asked him if he could speak up, as I couldn’t hear him over the noise of the air conditioning in the room.  That was a big mistake.

I had drawn H’s attention to the air con.  Suddenly, he was very aware of it. “I don’t want it!” he threw his hands up to his face and his mum rushed forward.  He just wanted to be out of the room at that point.  We all went out to the waiting area which was quiet, except for my previous patient looking at glasses.

H sat down with his parents and brother.  It took a few minutes for him to recover from that bit of sensory overload but he seemed quite happy to be outside the test room, surrounded by his family.  H refused to go back in so I just picked up my pen torch, occluder, ret and budgie stick and knelt down on the floor of the waiting room and did as much of the eye test as H felt comfortable with.

His eyes were straight, motility was full and smooth (and a bit giggly) and ret showed what might be a small plus Rx.  Of course, I wasn’t able to get vision and he refused to let me have a look at his eyes with the ophthalmoscope.  His fundus photo looked the picture of health but I still needed to check the peripheral retina.

After a chat, we decided to book H in for another appointment in two weeks’ time.  We went for an early morning appointment, the first one of the day, and a note was made in the diary to switch the air con off before his arrival (this had to be done upstairs, in a part of the store I have no access to).  His brother J, also 4, was booked in for a check as well.

So I had two weeks to come up with an idea of how to make the eye test a nicer experience for H.  I ended up buying Spiderman stickers and taking my noise cancelling headphones into work.  Turns out that the noise of the fan wasn’t the issue, it was the thought of it being on that he disliked.

Anyway, I came in early that day to make sure everything was set up and the air con was off.  It was, of course, one of the hottest days of the year so that air con was on the second H had left the store.  But I’m getting ahead of myself.

H was a lot more relaxed when I saw him.  He was still using his mum as a human shield but he was peeking around her more often – I took that as a good sign.  We went into the test room, I asked if he wanted to sit on his mum’s knee (I sensed that he didn’t like the electric motor moving the chair up at his last visit) and he was quite happy with that.  I asked if I should close the door and he said “no” so I left it open.   We used Snellen pictures to get vision and I tried ret again.  H didn’t want the lights off or dimmed so I wasn’t able to do Mohindra ret as planned.  His vision was very good though and his stereo acuity was fine.  A small plus prescription in a 4 year old (similar in both eyes) isn’t worth prescribing and I didn’t want to cyclo him unless there was a compelling need.

The Spiderman stickers went down a treat and during his brother’s eye test, I put a little Spiderman on my nose as a near fixation target (when he wasn’t looking).

“Your nose!” J said.

“Is there something on my nose?” I asked, looking puzzled.

“Yes!”

“What is it?” I tried to look at my nose (esophoria for the win).

“Spiderman!”

“Oh, he’s tickling my nose, what’s he doing?”

“He’s jumping!”

“Where’s he jumping to?”

… and this went on for as long I needed for the cover test.

At the end, I discussed my findings with H and J’s parents and they were all just about to leave when their mum said to H, “That was okay, wasn’t it?”

H turned to me, looking as serious as a 4 year old can, and said, “Yes, but Michelle is very silly.”

I’ll take that as a compliment.