Just before Christmas, I tested a lovely man, Mr F. He was in his 60s and had broken his specs on the same day he received a recall letter from us. Kismet, really. After the test, I helped him choose his frames and then we chatted about holidays for a while before he left. As the door clicked shut, my optical assistant, G, turned to me and said, “He’s so nice… wait until you meet his wife.”
G then went on to explain that his wife, Mrs F, was difficult. So difficult, in fact, that the optical assistant that had dealt with her last year (who still worked for the company but in a different practice), left instructions not to tell Mrs F her current location.
Now, as you know, I’ve dealt with challenging patients before and usually, I find G is a little more worried about these things than I am so I didn’t think much of it.
Anyway, I was on holiday for two weeks in January (when Mr F said his wife would be in), so I assumed that I’d missed her (gosh darnit). But no, she waited until February to come in for her test.
To say that Mr and Mrs F were like chalk and cheese would be wrong. They were more like chalk and an abstract feeling of existential dread.
I was writing a referral letter in my room, with the door open, while Mrs F was being pre-tested by G. I wasn’t paying much attention to the conversation in the pre-screen area, concentrating more on spelling “hypercholesterolemia” correctly (I’m not convinced I did but I’m sure the GP knew what I meant).
Suddenly, I became very aware of the battle of wills that was going on a few feet from my door.
Mrs F: “And what, EXACTLY, is this and why do I NEED to have it done?”
G: “It’s a puff of air that checks for glaucoma.”
Mrs F: “HOW does it check for glaucoma? I have NO history of glaucoma in my family. Why am I REQUIRED to have this done?”
G: “Everyone gets this check as part of the eye test. It doesn’t hurt but it can startle you.”
MRS F: “I just don’t understand why I am REQUIRED to have it done.”
G: “As I said, it checks for glaucoma by measuring the pressure in your eyes. If you are unhappy to have it done then -”
Mrs F: “I’m NOT unhappy. I just want to be CLEAR why these procedures are being carried out and to make SURE they are COMPLETELY necessary.”
I’ll spare you the rest of the conversation but, eventually, Mrs F submitted to non-contact tonometry. As an aside, I’ve told my optical assistants not to worry too much about not getting NCT done as usually I can convince them in the room when I offer them contact tonometry instead.
After G handed Mrs F over to me, I heard a muffled “thud” coming from outside my door, which I assumed was G hitting her head off the wall.
Mrs F seemed to fill the entire room. Formidable was the only way to describe her.
“Can I put my things here?” she demanded, pointing to the chair next to the slit lamp.
“We’ll use that later on but -”
There was no point in continuing as she’d already heaped the chair with her coat, bags and what seemed like a whole layer of clothing.
Before I could start history and symptoms, she launched into a rant about her current glasses. They weren’t very good. She’d paid a lot of money for them. They weren’t comfortable. The metal was coming off the frame. They were causing glare at night. She couldn’t see well with them. She’d been disappointed with that girl who used to work here. The list went on and on.
I looked at her specs and the nose pads had widened to such an extent that metal of the lens rim was resting against her nose. Over time, her sweat had reacted with the coating, leaving the base metal visible where it touched her skin.
She wanted me to say that they weren’t fit for purpose but they were several years old and I’m sure they hadn’t been fitted with such splayed pad-arms. I realised I’d have to be very careful about what I said because she seemed to be listening strategically, waiting for me to say something wrong. She had a strange, almost goading quality when she spoke.
We got through history and symptoms with minimum fuss then vision, OMB, pupils and motility. At that point, I asked if she was driving that day (she wasn’t) and if she was happy to have the drops.
“WHY? Why do I REQUIRE drops?”
I explained that they were used to dilate the pupils so I could get a better view into the back of the eye. I told her that it was part of the health check for over 60s and, given her prescription (which was around -10DS R&L) and the issues she’d described, I would like to make sure that I could get as good a view as possible.
Reluctantly she agreed. I warned her that they are a little nippy when they went in and that they would blur her vision for a few hours afterwards. Then I popped open the Minim.
Now, I’m great at putting in eye drops. I don’t want it to sound like I’m bragging but I get them in fast and with as little fuss as possible. This skill I learned during my pre-reg when I tested all of the children in the East End of Glasgow.*
I have never encountered someone like Mrs F. After the first drop, she doubled over, shrieking. There was a second where I wondered if I’d touched her cornea with the Minim, such was the performance going on in my test chair.
“Why would you TORTURE people like that?” she gasped.
I was at a bit of a loss. I really wanted to say, “You are a 65 year old woman, get a grip. And, if I wanted to torture you, I’d use cyclopentolate.”**
Eventually, after me standing next to her for what seemed like an age, silently judging her, she opened her eyes.
“Well, I guess you HAVE to do the other one.”
“Not if you don’t want to.”
“No, no, you HAVE to.”
So, I popped a drop in her left eye and there was some wailing and gnashing of teeth but it wasn’t on the same level as the first eye. After a few seconds of mild huffing, she settled down enough for me to put on the trial frame.
Refraction was a nightmare. I used her old prescription as a starting point and she claimed she couldn’t see anything, even though I had measured her VA with her current specs before we started. As usual, my routine was interspersed with “good”, “great” and “perfect” and this really annoyed her.
“It’s not good, is it? I CAN’T SEE.”
“This is just a starting point for us, I’m going to show you a couple of lenses and -”
“BUT I CAN’T SEE!”
The ret result was pretty much the same as her old prescription so I knew that there wasn’t that much of a change. I soldiered on despite a steady stream of despair with a hint of accusation. I’d blinded her with the drops, apparently.
The time finally came for the health check. We moved onto the slit lamp (after much faffing about with bags, scarves, gloves, coats, earmuffs, balaclavas) and the only significant finding was a mild nuclear cataract in both eyes with a moderate cortical cataract in her right.
I told her about the cataracts and said that this may explain the issues she’d been having with her vision.
“Do I stay in this chair or move back to the other one?” she asked, starting to get up.
“Well, we can go back outside now, if you want.”
“NO, I WANT to hear more about these cataracts.”
“Ok, you can -”
And she moved back into the main chair.
I took the opportunity to double check VA with her current specs and it was unchanged from the start of the test (just in case I had blinded her with tropicamide).
I described cataracts to her. What they were, how they started and progressed and what the symptoms were. I talked about a haze, about patients constantly cleaning their specs because they felt they were dirty, and muted colours. I told her about glare and how that could cause problems at night, I talked about contrast and things just not being as “black and white”. I recounted all the information that my brain holds on cataracts, including new research and historical facts. I just talked and talked and talked. I do this when I’m nervous.
She was looking at me very intently, like she was waiting for me to make a mistake. I was being scrutinised and it was taking me back to my pre-reg when my confidence was pretty much an illusion. I felt like I was being assessed by her.
After what seemed like hours, I ran out of things to say so I just stopped talking. She stared at me for a few seconds.
“I want to hug you.”
I really wasn’t expecting that.
“No, really, you’ve just described EXACTLY what I’ve been experiencing. I was SO worried about it all and you… you hit the nail on the head. So it’s cataracts.”
She then hugged me. I wasn’t sure what was going on so I just kept very still.
“So, what do WE do about the cataracts?” she asked, settling back into her chair.
I told her that I could refer her but given that her vision was still very good, it was unlikely the hospital would do the surgery. She was symptomatic but seemed happy to have a name for the issue rather than a solution. We talked about the referral process and the fact that she could come back at any point if she felt a change in her vision. Also, as there was no change in her prescription, there was no point in updating her varifocals (transition, 1.74, freeform).***
Before leaving the practice, she hugged me again.
G turned to me as soon as the door closed behind Mrs F, “What happened in that room?!”
* Exaggeration but some days it felt like it.
** Fun fact: I once sat as a patient for some student ophthalmologists. They cyclo-ed me for that. Over a period of three hours, I must’ve had about ten drops in each eye and that does hurt like hell. I came out with massively dilated pupils, a taste of what prebyopia is like and a mission to buy a retinoscopy rack.
*** I ordered in a replacement frame for her so we could just swap over the lenses. Mrs F was well known to my boss who kind-heartedly waved the cost of the replacement frame.