I’ve been extra busy, hence the lateness of this post. 

It was a school holiday this week so my Tuesday and Wednesday was chock-full of children.  Around this time of year, the nurseries around Glasgow do a vision test on children and then send them in to us if their vision is poorer than expected or if there’s a difference between their two eyes (supposedly with a letter, although I’ve only seen one of these out of the many, many pre-school children we’ve had referred in by the nurseries).  Now, I do like testing children but seven in one day is exhausting.  I also had a two year old with a watering eye (just the one, it had been watering for three weeks) and a four year old with recurrent styes in both eyes.  I’m getting more confident with my management of random things like this (the former was referral for a blocked nasolacrimal duct, the latter was fusidic acid and review in a week).

On Thursday, despite all the flooding, I travelled down to London for a course.  On the Thursday evening, I had a sneaky look around the Fight for Sight clinic at City University.  On Friday and Saturday, I was on a Stage 2 preparation course which involved lectures, practical assessments and an endless supply of sandwiches that weren’t suitable for someone who is severely lactose intolerant.  As well as feeling ill for three days because of cheese, I also had difficulty sleeping because of the paper-thin walls in the hotel.  Needless to say, I felt underprepared for my visit three, which happened today.

Prior to disappearing to London, I had looked out all the cards I needed and had them filed, in order, in one of my drawers.  I also took a thick wad of university notes with me to study, thus taking any of the fun out of being in the big city.  I spent most of Friday night studying and then the five hour train journey home on Saturday night.  I got back home at 23.00, had dinner and then just collapsed into bed.  I got up this morning early, showered and then went into work early to hide in my test room and prepare.

Visit three was long. It felt much longer than visit two.  We had three competencies left from the last visit to cover, as well as the RGP aftercare, the RGP fit, soft lens fit, applanation tonometry (Perkins, in this case) and all the visit three competencies. 

I have struggled to find RGP patients so I fitted a friend (a fellow pre-reg) with lenses a couple of weeks ago, ordered a trial set and she has been wearing them for the last week.  Anyway, my friend turned up for the aftercare and it was obvious she was having some issues with her right eye.  A quick look on the slit lamp and I saw that the right lens was cracked, right across the centre.  It had left a lovely corneal abrasion in her right eye, in a triangular pattern.  It was like a little map that showed the movement of the lens.  Anyway, I didn’t bother checking the fit.  I just told my assessor that I was going to take the lens out because it was damaged and she seemed happy with that.  I got the lens out without it splitting in two and then checked the fit of the other lens (and put a drop of fluorescein in the right eye to look at the staining).  The fit wasn’t great (during over-refraction she’d taken -0.75DS in that right eye and -0.50DS in the left, hinting they were both too steep).

When I asked my pre-reg optometrist patient to take the left lens out, she did it like a soft lens, pinching it sideways.  Mystery solved – the steep fit coupled with the squeezing had cracked the lens.  Anyway, I didn’t see her remove the lens (she did it very quickly and I was at a difficult angle).  Unfortunately, my assessor had a great view of her poor technique.  Afterwards my assessor admonished me for not being in a position to see the patient remove her lens(es), which is fair enough but, in my head, I was like “She should know better, being an optom!” 

It was great having a friend sit as a patient because, although it wasn’t the straightforward aftercare I was hoping for, I was completely at ease.  I’ll be returning the favour for her visit three in a few weeks time so I’ve dug out my RGPs and will be building up my wear.  I have an actual reason to try RGPs, though, as I have severe dry eye.

So, the aftercare went well, except for the corneal abrasion, the steep fit and me not seeing the poor lens handling.  Sigh.  At least it gave me lots to talk about in the management side of things.  My assessor didn’t spend that long on RGP case scenarios as a result.

We went through the competencies quite quickly and my assessor seemed happy enough with my patient records.  It’s very important to make sure you have verbal consent for the records you are using.  I had a few for each competency and there were a couple where there was no consent marked on the card so they were disallowed (again, this was fine since I had added some of them in at the last minute, just because they were quite interesting).

After spending ages learning all about uveitis, my assessor spent more time on retinal detachments and PVDs than inflammation, which was disappointing.  She showed me a lovely photo of a rhegmatogenous RD and asked what type of RD it was and then asked about what I would see if it was a tractional instead.  She showed me lots of interesting photos of diabetic retinopathy, asking me to classify the stage and why.  I had a great proliferative DR photo of my own to show her from a test I’d done recently.  She asked who I would do applanation tonometry on and when I would do NCT.  I hate these “list” questions as I always tend to miss the blindingly obvious things and start going down a weird and wonderful path of “things I read about once in a paper that only three people in the world have been diagnosed with”.  

We also talked a lot about testing children.  Now, my projector chart is Snellen and has pictures.  The pictures are DOG, DUCK, FISH and FLOWER – that’s all.  A smart four year old, after a couple of lines, can make a pretty good guess at the blurred shapes on the next few.  The shapes are also up for interpretation: DOG becomes HORSE, sometimes WOLF, once a CAT. I have an interesting fixation target for the very young (a cow head on a pen that, when you bang it on a desk, lights up, flashing red and blue for a few seconds) – this captivates small children and is known as FUNKY COW.  We also have a rubber duck version of this called DISCO DUCK.*

Anyway, back to the visit.  After the competencies, we were in a bit of a rush.  There were only four people on the shop floor and I picked the worst time to bring someone in to fit with lenses and do Perkins on (one of the girls was on lunch and another was five minutes away from finishing).  The store was busy, which didn’t help.  Anyway, the girl who was finishing her shift in five minutes agreed to sit for me, even though her mum was waiting to take her home (I feel infinite guilt over this).  I then popped some OXY 0.4 in her right eye, did Perkins (she looked terrified, even though I reassured her it would be fine), popped in an RGP (again, she had a rabbit-in-the-headlights look about her during this), assessed the fit and then popped it out. So far, so good.  I then fitted the left eye with a soft lens, which seemed to be worst experience of the three for her.  She’s never had lenses before, never needed a prescription (sitting a little plus with a little minus cyl) but she did so well.  On assessing the fit, it was loose (base curve too flat, not helped by excess lacrimation) so I said that and told her I’d refit with something with a smaller base curve.  Job done.

All in all, my visit three was chaotic (which I hate) but effective.  

At some point, you just have to go limp and hope that by not struggling against the tide of little problems, you’ll be carried along instead of drowning in them.  It’s very easy to be thrown when something goes wrong but when lots of things go wrong, it’s actually quite fun.  It also is more indicative of how you perform in real practice.  If you have to manage something then it shows you actually understand what you are doing.  If everything is perfect, it doesn’t tell your assessor about your problem solving skills – for that, they have to ask follow up questions and pose difficult case scenarios.  So, in the end, a little problem is better than a complex “this happened to me once in my 40 year career, completely baffled me for a month but I eventually worked it out with the help of four colleagues, an ophthalmologist and a letter to Jack Kanski” scenario that your assessor is just dying to ask.

So, that’s me finished with Stage 1.  Stage 2 terrifies me, especially after having a mock assessment this weekend.  Good news is that I’m off tomorrow so I’ll be spending the day sleeping.


* available from John Lewis, in the pen department, for a whopping £2.50 each.