So yesterday I had a run of difficult patients.  Not that they were difficult people – they were all lovely but they all had some interesting issues that had to be dealt with.  I spent yesterday morning wondering if my chart actually went past 6/9.  

My most challenging moment was the lady who came in complaining that her new glasses didn’t make her see any better.  She had been tested with us a couple of years ago and then, late last year, she had visited another famous high street optician.  She got the glasses from them and wasn’t happy – they didn’t seem to make much difference to her vision.  No problem, I thought.  I assumed that the prescription was wrong or that she had cataracts (the lady was in her 80s) or both.  

History and symptoms was uneventful, except for the fact that 2 weeks previously, she’d seen a big floater (like a fly) and then she felt she was looking through “dirty dishwater” and then she saw a big circle in her vision.  This gave her a fright but seemed to resolve within a day so she didn’t think more of it.

During refraction, she was 6/9 (previously 6/7.5) in her good eye and in her other, she had no perception of light (this was a long standing issue and she had been monocular for many years).  So she had an RAPD.  

The Rx from the other optician was very similar to the one I found and there was no increase in vision using the pinhole.

During the health check, there were, indeed, mixed cataracts (nuclear and cortical) in each eye.  The cortical cataract went right over her visual axis.  Feeling quite confident that I’d found the problem, I then moved onto Volk.

I got a bit of a fright when I looked into the right eye and the first thing I saw was blood.  Lots of dark red, black blood coming towards me.  I nearly dropped the Volk lens.  Putting on my calmest voice, I asked her to look in all directions and then, at the end, went back to the bleed and the little retinal hole causing it, just to get a better idea of size and location.

Both the bleed and the hole were in the superior nasal part of the retinal, well away from the macula.  It was probably the best place to suddenly develop a hole.

So, I calmly explained to the patient that I had seen a little hole and some blood at the back of her eye and that I wanted one of the doctors at HES to have a look at it.  I explained that I was going to phone the hospital and see if they could see her today.  She was very calm and didn’t ask any questions, even when I prompted her.  

When I called HES, they gave her an appointment that same afternoon.  I quickly wrote the referral letter and popped it in an envelope, marking her appointment time and the hospital details on the front.  I then went to sit next to her and tell her about the appointment.

Suddenly, she was unsure.  It was a long way to go on a bus.

At this point, I needed to find a way of stressing the importance of going to the hospital without terrifying this lady.  I had the feeling that, while nodding and generally looking in my direction, she wasn’t really listening.  This might have been because she was overwhelmed by the amount of information or because she was scared.

I asked her if there was anyone that could take her to the hospital.  Yes, there was her daughter.  But her daughter was always very busy.  

I asked if her daughter worked (no, she was retired).  Did she live close by? (Yes, but it would be too much bother).

At this point, I brought the phone over and asked her to call her daughter.  I sat next to her while she talked to her and told her daughter that I wanted the eye doctor to do another eye test.  I sat there to make sure that, if the daughter said “no”, I would be able to ask to speak with her to explain what was going on with her mum.  As it was, her daughter said that it was no problem to collect her and take her into the hospital.  I was relieved.

I’ve been worrying about this lady since yesterday.  I have no doubt that her daughter took her for the appointment but I haven’t heard anything else.  I asked her to call me as soon as she got home from HES and there was no answer when I called her home phone today.

Fingers crossed for a happy ending.