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.

Anyway.

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.

The new year is just around the corner and I thought I’d take the opportunity to reflect on 2016.  It’s been quite a tumultuous year in politics and the world seems a different (and sadder) place as we creep towards 2017.

At the beginning of the year, I moved from a hectic job in a multiple to a position that involves me working between several small independents.  I pretty much went from one extreme to another: from being one optometrist among many (not to mention DOs, OAs and other support staff) to being one of only two staff members in a shop.  As the sole optom, I became better at time management and my routine got faster (despite the lack of computerised records).  I am able to look at my diary and anticipate any issues in advance (this is something I really missed when working with a rolling clinic*).

I’ve also been doing some dispensing (with varying degrees of success) and I learned about glazing, which, in turn, has helped with the dispensing.  This is something I missed when I was working in the multiple – I was in my room, testing, and nothing else.  I didn’t get to see the full patient journey and, this may sound weird, but sometimes, when I’m in the middle of a test, I’ll think of the perfect frame for that patient.

Anyway, my current situation isn’t without its draw backs.  Moving constantly between shops is tiring (I go from one to another at mid-day, every day).  I’m forever catching up with loose ends from when I was last in that particular shop.  I’m constantly chasing visual fields results.  I think I’m well organised but there’s always that worry that something is slipping through the cracks.

Also, as I’m a locum, I have no real job security.  I go wherever I’m needed, sometimes at very short notice, and I’m no longer in the shop with the OCT.  There’s no career progression, no training (I asked if I could start doing domiciliary visits but I think they’ve forgotten) and, as a locum, I’ll never be a pre-reg supervisor.

So 2016 was a learning experience for me and, as always, I continue to develop as an optometrist.  It’s taken a couple of years in practice to for me to fully appreciate where I belong and what my passions are.  Next year, I’ll be focusing on what I want from a career and taking steps towards it.

See you all in 2017.

 

* A rolling clinic is one where the next available optom takes the next patient.  It’s always billed as being better for us optoms when introduced by management but, well, I’m unconvinced.

A few days ago, my colleague and I ended up talking about embarrassing moments we’d had at work.  Although I’ll never come close to beating the time an OA at my previous job told a man to “put your foreskin” against the rest, I’ve had a fair few cringe worthy moments.

The funniest involves a lady I saw a few years ago.  Her name was Mrs Dick.

In that practice, I would pick up the board from beside the waiting area, call the patient’s name and then we would both walk to the test room at the back of the shop.  The whole thing would take a minute or two and I would chat to the patient as we walked.  Usually, I’d comment on the weather or ask how they were today.

But not for Mrs Dick.  No, I decided to comment on her name.

What I meant to say was:

“I didn’t realise how common the name Dick was around here.”

What I said was:

“I’ve seen a lot of Dicks recently.”

She laughed (thank God) and I scrambled to correct myself.

“No, what I meant was: there are loads of Dicks around here.”

By this time, we were in the room and she was chuckling away.  Although I could feel the colour creeping into my cheeks, I decided to give it one last shot:

“No, I mean, [town name] is full of Dicks.”

Tears were rolling down her face by this time and her laugh was infectious.  Here we were: her bent double with laughter and me with a bright red face and tears streaming down my cheeks.  I was laughing so hard that it was painful.

When we’d collected ourselves a little, she said, “I’ll give you a laugh.  My maiden name was Wright and my mother used to joke that I should have hyphenated my name… I passed up the opportunity to be a Wright-Dick!”

And we were off again, laughing.  I don’t know how we managed to get an eye test done.

This case is interesting because there are a lot of red herrings.

Last week, a 75 year old man came to me for his first ever eye test.  He had assumed the yearly diabetic retinal screening was a full eye test so had never been to an optician before.  During history and symptoms, he described sudden vision loss in his left eye six weeks ago* (this was what prompted him to see me).

Mr C realised he couldn’t see very well out of his left eye when he accidentally covered his right while he was watching TV.  What he then described sounded like a field defect.

Mr C is diabetic (type 2, well controlled) and was screened around 6 months ago.  There were no issues reported at the screening and he was kept on yearly recall.  He is also hypertensive but that, again, is under control.  His mum had glaucoma, which left her blind in one eye at a relatively young age.  He has a very high cyl in his left eye (+4.50DC) which has never been corrected.  He was hit in the left eye by a tree branch a few years ago and, although it was painful for a few days, he didn’t seek help.

So, we have a list of possibilities:

  1. retinal detachment
  2. glaucoma
  3. CRAO or CRVO
  4. maculopathy
  5. stroke
  6. other pathology
  7. combination/all of the above

His vision was R 6/9 and L 6/60, improving to R 6/6 L 6/36 when corrected.  He was tilting his head up and down when viewing the chart with his left eye, trying to find the best angle.

Pupils were fine – equal and reactive with no RAPD.

Mr C’s pressures were R 14mmHg and L 11mmHg.  A small difference between eyes, with the left pressure lower – something I’ve seen before with retinal detachments.  He did report seeing lots of floaters in the left eye recently.  There was no trauma (that he could remember), no flashing lights and the defect didn’t move.

The pressures were low enough to rule out acute closed angle glaucoma (and I confirmed his angles were wide open on van Herrick) so I dilated him and, while the drops were working, I did a supra threshold 24-2 fields test.  What I found looked like this:

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That’s a definite inferior defect in the left eye and it respects the horizontal midline.  His fixation was very poor, though.  I tried to redo it but then we couldn’t get a threshold at all in the left eye as he couldn’t see the central spot without moving his eye around.

Finally, I asked him to sit at the slit lamp.

Starting at the front of the eye, there was an opaque area inferior to fixation that had some ghost vessels growing into it from the limbus, there was a cortical cataract inferior nasal and superior temporal.  Berger’s space was clear of tobacco dust.  There were lots of floaters and a Weiss ring in the vitreous.  The C:D ratio was 0.2 in both eyes, the NRR followed the ISNT rule and there was little to no cupping.  A quick glance at the fundus and nothing looked amiss.  There were no diabetic changes, the macula was flat and intact and the blood vessels looked okay.

Until that point, I was thinking it was a detachment so I was using my super field 90D and concentrating on seeing as much of the retina as possible.  When I couldn’t see any breaks or tears, I switched to my 78D lens and started looking really carefully at the macula and disc.

And there it was.  A little round white blob in one of the retinal arteries, just as it exited the cup.  It could be mistaken for a reflection from the artery wall or a little bit of myelin if you weren’t paying attention.  It was an embolism.

Now that I was really looking at the vessels, I could see that both the arteries and veins were thinner in the top portion of the retina when compared to the bottom**.  The fundus was still pink, though, and there was no cherry red spot at the macula.  It was a very subtle CRAO but it had a devastating effect on Mr C’s vision.

Our HES endeavours to see all CRAO patients on the same day so, when I called, they booked him into the afternoon clinic.  I sent Mr C away, letter in hand, and asked him to call and let me know how he got on.  Hopefully I’ll hear from him on Monday.

 

*Yes, six weeks. Not a typo.

** This was so much easier to spot on the fundus photo (which I wish I’d taken after the fields test rather than right at the end of the examination).

This is just a quick post inspired by a lovely lady I met yesterday.  Mrs C has geographic atrophy at both maculae and is now registered partially sighted.  She popped in to see me for a chat.

Mrs C has been attending HES but, at the last visit, the doctor told her there wasn’t anything further they could do.  He had mentioned an operation (privately funded) but, at the time, she didn’t feel comfortable asking questions so here she was, on a rainy afternoon, hoping I could clear a few things up.

We spoke about the implantable mini telescope which is being offered privately to AMD patients.  She didn’t like the idea of surgery, having had right phako that didn’t improve her vision.  She also didn’t like the price (I don’t think anyone does).  I explained that it wasn’t a treatment as much as a built in magnifying lens that could also move the image out of the affected area of the retina and into an undamaged part.

Although she didn’t fancy the surgery, we had a great chat.  Mrs C is one of our patients with Charles Bonnet Syndrome but she’s unusual in that she sees buildings instead of people or patterns.  We talked a bit about that and I described some of the experiences my other patients have had (see my previous post on Charles Bonnet for details).

She also described getting a fright at the hospital when, after Volk, the consultant had turned blue.  Although he explained that it was the bleaching of the photoreceptors, she was still quite upset and wanted reassurance that it was normal.  I’ve had the same experience myself after a fundus photo, although the world turns purple in that case (at least for me).

Finally, I got onto magnifiers.  I asked if she had some and she said she just had the one.  It was a small, illuminated Eschenbach handheld magnifier and Mrs C complained that she very rarely used it, finding that she had to rest it on the paper she was trying to read (which isn’t ideal as she needs it for prices, labels, etc when shopping).  I discovered that she was using it with her reading glasses.  It had been 2 years since she’d been seen at a low vision clinic and obviously she’d forgotten that she needed her distance glasses on for it to work.

I asked her to try it with her distance specs, resting the magnifier on the paper to start and then bringing it towards her eye until the letters were clear.  That was much better.

The small magnifier is ideal for when she is out and about but we’re getting in a selection of illuminated stand magnifiers for her to try as Mrs C mentioned that it would be nice to be able to read her mail (her daughter is on hand to help usually).  I explained that the stand ones need her to use the reading glasses.  Her near visual acuity is N24 so I’ve asked for 4x magnification if possible (4x would have her reading N6 with difficulty but N8 a bit more fluently).

If you are a pre reg,  I’d recommend looking at the Eschenbach catalogue to get an idea of what is available for our VIPs – but remember that a good magnifier can easily cost £80+.

It’s become a bit of a running joke that I rarely get a lunch break. For some reason, people wait until around lunch time to seek help for problems that develop early in the morning/the night before/6 months ago. I’ve seen more emergencies around 12.30pm than any other time (excepting 9pm, the favourite time for problems during my pre-reg, but that’s only because I now work 9 to 5).

So, on Friday, I’d forgotten my sandwiches. I left one practice a little early, planning to drop my things in the other then head out to pick up lunch. As I walked towards the shop, I realised there were two people sitting in the waiting area. It was 55 mins until my first appointment of the afternoon.

When I got in, C explained that the older gentleman, Mr D, had been sent down by his doctor as the GP suspected a retinal detachment. The lady with him was his daughter.

Now, Mr D has dementia and mobility issues so I had to streamline my examination of him to limit the amount of moving around. I did non-contact tonometry (R 14 L 18mmHg) and brought him through to the test room. I explained about the eye drops and popped them in. After I’d done that, I moved onto history and symptoms.

Mr D had been looking at the TV that morning and said to his daughter that his right eye was “kaput”. 

Thinking this was a sudden loss of vision, she’d made an appointment with the GP who had a look with the direct ophthalmoscope. The GP had then referred them to us, telling the daughter that it sounded like a retinal detachment. Except, of course, there were no symptoms or signs consistent with a detachment.

On questioning, Mr D said that his eye had been blurry for a while, although he was unable to give an estimate of duration except for stating it was more than a week.

He was new to our practice so I had no access to his previous records. Indeed, they weren’t sure where he’d been tested last. All I knew was the prescription from his current specs and the fact his vision in his right eye was CF (counting fingers). Also, Mr D was attending the eye clinic every three months but both he and his daughter were unsure as to which clinic it was.

By this time, the TRO 1% had kicked in so I had a good look in both eyes, using my 90D superfield then my 78D to look at the disc and macula. Apart from some background diabetic retinopathy and a moderate cataract, I couldn’t see any issues. There was no tobacco dust and the only alarm bell was the pressure difference between the two eyes.

I explained my findings and decided to call the hospital. After summarising the situation, I explained to the nurse that Mr D was attending HES every three months and that I had no previous recorded vision. I also told the nurse that Mr D had dementia and was unsure of the duration of this blurred vision.

The nurse checked on the system and discovered Mr D’s right eye VA had been CF for some time. He was also due back at HES in two weeks. The nurse said that it was difficult for dementia patients with visual loss because they often forget they have an issue. Luckily, Mr D didn’t seem upset, just a little bemused at what was going on. His daughter, quite rightly, had wanted to get everything checked so was the driving force (figuratively and literally) behind his visit.

After thanking the nurse, I hung up and went into the waiting area. I told Mr D and his daughter that Mr D’s vision was the same as when he was last at the eye clinic and that he would be receiving an appointment soon. They were both quite pleased with the result.

As they left, my first appointment of the afternoon arrived…

During my penultimate year at uni, I tested a student who was unrefractable.  He was in the year below me and he couldn’t tell the difference between +1.00DS and -1.00DS.  He was 6/6 at +10.00DS and 6/6 at -10.00DS (fixed chart, if you are wondering).  At the end of the clinic, I was frazzled and thinking about qualifying in a profession that didn’t involve other people.  My supervisor took me aside and said, with a smile, that she was glad I’d had that particular patient as, being well known at uni as a perfectionist, I had to realise that sometimes you can’t get it 100% right.  You just had to do your best and use your common sense (hint hint, focimeter their current specs or use your ret result).

You learn to check vision at each stage in the refraction and stop giving a patient plus just because they’ve said the chart looks “the same” for the last few dioptres.  In reality, it should look better then the same then worse.  There’s only +0.50DS difference between better and worse, in my experience, so if your patient is stuck on “the same” for a while, check their vision – nine times out of ten, you’ve overplussed them and their VA will have reduced.

Sometimes you’ll need to think critically about what you are being told.  You will come across patients who answer “yes” to every single question.

Flashing lights? Yes. When? When I’m in bed at night, before I go to sleep.

Floaters? Yes. When? When I turn out the downstairs light.

Double vision? Yes. When? When I’m trying to read and not wearing my reading glasses.

Family history of glaucoma? Yes. Who? My mother/father but they had an operation to have the glaucoma removed…

Children are particularly bad for answering “yes” to everything but, on questioning (using the LOFTSEA approach), you’ll be able to separate true headaches from made-up ones.  The made-up ones only happen on Tuesdays and affect a one cubic centimetre area of the head for exactly 10 seconds.

There’s also a bit of external filtering that needs to happen.  Like the 12 year old, S, whose father had grudgingly brought him in for an eye test.  The father had never felt the need to get an eye test and he was sure S was making up his visual problems.

“His pal’s just got a pair of glasses and now he’s saying that he can’t see the board at school,” was the dismissive answer from his father when I asked S if he was having any problems with his vision.

In the room, away from his dad, S was more talkative.  He’d been gradually moved down to the front of the class but he was still having to copy his neighbour’s work because he couldn’t read the teacher’s writing.  It was embarrassing to S – both not being able to see the board and being accused of malingering by his family.

It just happened that his friend had gotten a new pair of specs recently* and that had prompted S to ask if he could go for an eye test.   No-one else in the family had specs – none of them had had an eye test before so this was, in itself, quite brave.

After a thorough history and symptoms, I suspected S was a little short sighted.  We moved onto vision and he was CF R&L, 6/60 binocularly.

I did ret and got approx -3.50DS R&L.  When I removed the working distance lenses, S was amazed. He could see the second bottom line (6/6 on my chart) and he was smiling for the first time since he walked into the practice.  A few minutes later, he was reading 6/5.  His eyes were perfectly healthy and I explained that being short sighted meant his eyes were a bit too powerful and that the glasses had lenses in them to take away some of the power when he was looking through them.

When we walked out of the room, S went back to being quiet and the smile slipped from his lips.

His dad had bounded up to him. “Nothing wrong with you, eh?”

I asked my optical assistant to help S look at the frames while I had a word with his dad.  I took the man into my room and sat him in the patient’s chair.

“S could barely see that top letter,” I pointed to the 6/60.  “He’s quite short sighted which means his distance vision isn’t that good but he’s fine with reading things up close.  Today, with the lenses I’ve prescribed, he can see the bottom line.”

“I can’t see the last three lines.”

“Then I think you might need an eye test.”

We glazed S’s specs then and there so he had them for school the next day.

 

* S had tried his friend’s specs on and they didn’t make his vision any better, which is not surprising since his friend was +6.00DS R&L (I also tested him).