Our practice is open late (well, we test until 8.30pm) so we have our fair share of emergencies.  Yesterday we were called by a patient (P) who had been experiencing some unusual symptoms.  She had booked an appointment with another optician for the next morning but was worried as she felt her symptoms were getting worse.  We were fully booked but we managed to rearrange the clinic a little to squeeze her in.  So, at 8pm, our patient arrived.

My supervisor was removing a rust ring from another patient’s cornea (this happens quite a lot) so I did NCT and took fundus photos.  Her IOPs were 19mmHg in each eye and the photos were completely normal.  I took the worried P through to my room.  We had a little chat and I asked about her prescription (from her specs, I could see that she was quite myopic and it turned out she was -7.50DS in each eye).  So, what had happened?

Well, P was out gardening the day before.  She suddenly noticed a lot of floaters in her left eye.  She could also see this little circle in the corner of her eye (again, left eye), it seemed to change colour and she noticed it more in bright light.  She was unsure about flashing lights – she saw something out of the corner of her eye after each blink but found it difficult to describe.  Her description of the floaters was really interesting, she spoke about seeing black streaks and feeling as if there was a layer of dust over her eye.

I’d asked her to come in with someone who could drive her home.  I checked Van Herrick’s and popped some TRO 0.5 in each eye.  I explained that I would have a look in each eye and then I would ask my supervisor to have a look as well.  I always tell patients that I’m going to get my supervisor to double check so it doesn’t worry them when I bring him in.

Anyway, after ten minutes, the tropicamide had really kicked in.  I started with a good look in the right eye and found a cluster of small holes surrounded by pigment (I wasn’t too worried about these because they looked old) in the inferior retina, well away from the macula.  It looked like lattice degeneration.

In the left eye, Shafer’s sign was absent but there were a lot of floaters behind the lens (long, stringy floaters – obviously the black streaks that P had described).  I took my time, using my 90D to have a general look.  There it was, out in the periphery, exactly where P had described it – a horseshoe tear.  It was in the inferior temporal retina (again, well away from the macula) and it looked like a little flap coming up towards me.  I switched to my 78D lens to have a better look.  This time there was no pigment.

My heart was pounding.  I was nervous about telling the patient but also, I was really happy that I’d spotted this very peripheral tear all by myself.  I always worry about missing something.  I asked the patient to wait for a moment and I would ask my supervisor to double check.  By this time, he’d finished removing the rust ring and was out on the shop floor.  I pulled him into his room and described what I’d seen in both eyes.  He’s usually quite nonchalant but his reaction was “Oh, *&@%” (censored for decency), which I found strangely reassuring.

Anyway, he came through and confirmed my findings and then looked at me. “Do you want me to stay? Or are you okay to explain everything?”

I asked him to stay.  He said that we were going to call the hospital and see if we could have an appointment for P to be seen.  As it was 8.30pm, the appointment would probably be tomorrow morning.  They would ask her to get up early (around 6am) and not eat anything, just in case she had to go into surgery (this was the bit I was unsure about and the reason I wanted him to stay).  I stayed with P while my supervisor popped into his room to phone the hospital.

I explained everything again and she mentioned that it was a really inconvenient time for this to happen – her daughter was moving house the next day and she was helping out.  I told P that I was sure her daughter would completely understand and that she’d done the right thing in coming to us tonight.  While the tear was way out to the side of the eye (I loaded up her fundus photo and showed her the macula and then pointed to where the tear was – it was off the photo, between my VDU and keyboard), we needed to get it treated because, over time, it might get bigger and start to cause problems.  I asked if she had any questions but she didn’t.

The hospital wanted her to go over that night so the ophthalmologist could assess the tear (although treatment would be the next day) so we sent her off to the hospital.  I’ve asked her to call me and let me know how she got on.