So you’ll remember, after a lot time and paperwork, I finally found a full-time position in September.  It was a 45 minute commute at the time and, although I wasn’t thrilled about spending 3/4 of an hour on the road to and from work, I decided that it was going to be worth it for the experience (and the money).  Unfortunately, over the last couple of months, the commute has magically gotten longer and I was averaging an hour each way by the middle of December (road conditions and the volume of traffic conspired against me).  I also longed for the days when I worked 37.5 hours over 4 days.

I was offered a job in another store much closer to home (and on the right side of the city for me) where they worked a four day week, so I leapt at the opportunity.  My last day was yesterday and I’ll be starting my new job in the new year.

After a few dull weeks of routine eye tests and dreich weather, this last week has been interesting both in terms of the patients seen and also my performance as an optom.

First, I’ll talk a bit about the changes I’ve found in myself as a practitioner.

So, as my test time has reduced (seemingly by magic), I started to worry that I was not being as thorough.  How could I manage to fit everything into 20 minutes when before I felt rushed at 30? I must be taking shortcuts or missing something.  After a few days of flying through tests and worrying about it, I spent an evening reading over my routine “cheat sheets” from the start of pre-reg.  The only thing I was omitting was Maddox rod but I’m now quite comfortable with cover test so I don’t think that’s an issue.  Everything else was there, granted it was all done with more confidence.  This seems to have sped up the process.  My refraction has become very fast, although ret remains hit and miss.  I was worried that speeding up would mean, again, less accuracy when it comes to refraction but, looking back at the last three months, I have had one retest and that was from my first week, when I was doing 40 minute tests.

Another amazing thing has happened: I have internalised the mirrored/inverted nature of retinal locations on Volk.  I no longer have to sit and say to myself “that lesion in the right eye is seen when the patient looks up and to the right so it would be on the inferior nasal retina” (this part was usually accompanied by hand gestures and a look of confusion, which is never reassuring for a patient).

My history and symptoms, something that I do still spend the same amount of time on, has become smoother as I am now much better at typing while talking.  I also had my own test room for the last few weeks and it’s been great to have everything to hand.  Being able to swivel in my chair and pick up my ret or reach for the TNO has really helped the flow of my routine.  The bit where I bring the slit lamp across while simultaneously using the little height adjustment tab on my chair and the part where I pick up my Volk and bring the little fixation light over is part of my optom tai chi.

I’m also more confident when dealing with patients.

Recently, I have been managing a girl with contact lens associated papillary conjunctivitis.  She was seen by another optom who told her to discontinue lens wear for a week and use warm compresses and viscotears gel.  This did nothing (unsurprisingly).  When I saw her, she reported that her eyes felt much better and so had tried her lenses again, only to find that they became uncomfortable after two days of wear.

On everting her lids, there were large, well-defined papillae in both eyes.  It seemed she was back to square one.  I asked her to tell me about her lens wearing habits (16/24, 7/7) and how she took care of her lenses.  She was rubbing and rinsing the lenses every night and using the recommended MP solution.

I explained that the papillae were an allergic response.  The allergy was from proteins that built up on the lens surface and are then denatured during the cleaning of the lens.  When the lens goes into the eye the next day, the body attacks it as it doesn’t recognise the proteins as “self”.  These bumps on her upper eyelids were catching the lenses when she was wearing them and causing them to move too much, hence the discomfort.

I sent her over to the pharmacy for some sodium cromoglycate and strict instructions to leave her lenses out until her next appointment.  I also ordered in a set of SiHy daily disposables* (Clariti) for her to try at her next visit, if the mast cell stabiliser had worked its magic.

Last week, she returned for a review appointment and there was no sign of papillae.  I fitted her with the dailies.  On her way out of the store, I said that I was sorry to have had to get her back several times and she said that it didn’t matter as it showed that I cared.  I told her that, as a lens wearer myself, I would do everything in my power to keep her comfortable and happy in her lenses for as long as possible.

Yesterday, she came back for the end of trial appointment and was so happy that she could wear her lenses again.  I was also really happy that I was able to see this patient from beginning to end and build up a rapport with her.

* Her previous lenses were SiHy and this material is well known for problems with deposits but given the patient’s wearing time, I wanted to keep her in SiHy.  Clariti is one of my favourite daily lenses, combining comfort and affordability (I also like Total 1s and MyDays but these aren’t available to order on our store system).

This week, I also tested a lovely woman (Mrs B) who had advanced Alzheimer’s.  She came in with her husband and he was very straight forward about the situation.  He said he knew I wouldn’t be able to do much as she was non-verbal but he’d noticed a difference in her behaviour when she had her specs on (she seemed more comfortable and alert).  I explained to them that there were quite a few things we could do and that I would explain the tests as we were going along.

In cases where you have a non-verbal patient, you should always speak to them.  When asking questions, when instructing or explaining and when summarising and talking about management.  It doesn’t matter if they can’t understand you, that person is your patient, not their carer or relative.  I started off by telling Mrs B that if she was uncomfortable or didn’t like any part of the test then please let me know and we would stop straight away and move on to something else.  I then asked her husband to watch for any signs of distress and alert me (he knows his wife better than anyone so would pick up on something subtle that I might miss).  I then started history and symptoms, my complete attention on Mrs B.  Mr B stopped me within seconds.

“You do realise she can’t answer you,” he said, rather gruffly.

“I will be relying on you to answer my questions but Mrs B is my patient so I will address her throughout this eye test, as she is very much part of this process.”

He seemed surprised. “Oh, yes, right. That’s the right thing to do.  Yes.  That’s what you are supposed to do.”

After that little hiccup, the eye test went very well.  Mrs B relaxed a little and started to whisper to me, her eyes twinkling with conspiracy.  Her words were so quiet that I didn’t catch them all, only a phrase here and there.  I had her giggling when I talked to her about the eye drops (tro 0.5) as I told her, in a false whisper, that the eye drops were a bit nippy but I always found it was the men who complained about them and not the ladies.  We are made of tougher stuff.

She wouldn’t wear the trial frame so I resorted to holding the lenses.  This became a game, with her batting at them or, at one point, trying to lick one.  I laughed and said she didn’t want to lick that as I couldn’t guarantee how clean it was.  Again, she was whispering and giggling.  Ret was difficult but, in the end, I got +6.00 with a small cyl in each eye.  Checking her old specs found a similar Rx.  No wonder this lady felt more at ease with her specs on – I can’t imagine what the world looked to her without them.

In all, it wasn’t a perfect eye test.  I only managed Hx and Sx, pupils, ret and a brief look at the fundus of each eye.  Looking back, I instinctively streamlined the test, trying something and then abandoning it quickly if it didn’t work.  It was a similar routine to the one I’ve developed for small children, the key being to move fast and keep their attention.  I also am very good at having a completely one-sided conversation with myself.

Mr B shook my hand on his way out of the test room.  After they left, I felt sad that I wouldn’t be there for Mrs B’s next test.

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