Today’s blog post is, as you can probably tell from the title, a bit of a mixed bag. These are my highlights from the past few days.

Yesterday, I was just about to go on my break when I was approached by one of the girls from the pharmacy.  She was asking about antihistamine drops for a patient who was complaining of a sore, watery eye.  I decided that it was probably a touch of hayfever and that I’d bring the patient into my room for a quick look.

I did a very brief Hx & Sx and jumped on the slit lamp, fully expecting to see some papillae under the upper eyelids (px reported a foreign body sensation on blinking and had been given antihistamine drops for a similar issue previously).  I was a little surprised by a large whitish ulcer on her superior cornea.  I popped some FLUO in and discovered that it was not only pretty large but it was dendritic (my first dendritic ulcer!).  There were little end bulbs on the dendrites so it was pretty clear that it was Herpes Simplex.

On questioning, the patient told me that she’d been to the hospital for a similar problem a while ago but last time she hadn’t had anyone look at it – she was just given Otrivine and some other drops (I think hypromellose, although she wasn’t sure) and it seemed to resolve on its own.  It seems that, although she had been referred to HES the first time, the patient had then relied on pharmacists knowing what she meant by a “an itchy, watery eye”.

Now, yesterday was a bank holiday so I called the emergency eye clinic but there was no answer.  I then asked the pharmacist if we could issue a written order to get some acyclovir ointment for my patient but he said “no”.  In the end, the 5 minute look at this lady’s eye turned into a 30 mins referral nightmare, at the end of which I had to send her to the out of hours doctor at a local health centre in order to get a prescription to then come back and get Zovirax eye ointment.  ARGH.

Sometimes the way we do things seems so unnecessarily complicated. Anyway, I told the patient to come back in 48 hours so I could review the ulcer (she’s coming in tomorrow evening).

Today, I had a young woman with a congenital cataract in her right eye.  Here’s a (rather rubbish) pic:

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Basically, it looked like a little explosion with flecks of cataract coming out from the centre of the lens.  Her vision wasn’t affected by it but, worryingly enough, she’d had her eyes tested a few times and no-one had ever mentioned it to her.

My saddest moment of today was testing a lady who is being investigated for retinitis pigmentosa.  She has no family history of RP and her symptoms sounded pretty normal to me – she reported finding it difficult to dark adapt in places like cinemas, etc, when going from bright light to dim conditions.  She reported that her night vision was fine, once she adapted.

She’d been referred into HES by another chain of opticians after she missed some points on the visual field test.  When she went into the hospital, they repeated fields and then told her that they would do a further test (ERG or VEP).  The doctor then, quite bluntly, told her that she could have a gene screening for RP but that, if she was in the patient’s position, she wouldn’t want to know since RP means going slowly blind.

I explained that she would still need to go to HES for the next test as it’s quite a specialised one.  I sat as a patient for our ERG and VEP labs at uni so I was able to describe in detail what happens when you are being tested and, more importantly, what it feels like.  I told her about my eyes being anaesthetized and having a large contact lens placed on my eye.  How it wasn’t sore but I could feel the pressure of it being there.  She seemed reassured.

When I looked in her eyes, at the end of the test, she did have flecks of pigment all around the periphery (so peripheral that none showed up on the fundus photo).  She also had very thin blood vessels.  I explained what I had seen and told her that the only way to be sure was to have the screening and the VEP/ERG but there were signs on the retina that were indicative of RP.  She’s going to let me know how she gets on at the screening and, at that point, I might be in a better position to advise her.

I’ve come home just now and spent ages Googling RP, trying to find a leaflet I can download and print out or, even better, order.  Does anyone have any ideas?

 

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