So, I started my new job last week and, as I’m now under a different health board, I’ve been adapting to the changes in referral protocol as well as getting to know my new team.  I feel that I haven’t quite hit my stride in the new practice and for the last two days both my clinical and communication skills have been tested to the limit.

The first challenge was examining a 40 year old man with floaters and a “veil” across his vision.  The twist was: the veil was in one eye and the floaters were in the other:

H attended with several complaints. Reduced vision, floaters, a white curtain across his vision (which moved with eye movements) and a long history of eye issues.

He had been born with congenital cataracts.  These were removed when he was a baby, leaving him aphakic in both eyes.  To correct his vision, H attended HES (in another country – having recently moved to Scotland, he had yet to be referred to HES here) for RGP contact lenses. During a fight at New Year, he suffered a blow to the right hand side of his head, knocking his right RGP out and leaving his eye bruised and swollen.  

History and symptoms was difficult as he kept jumping from one topic to another and his symptoms became muddled into one big mess of information.  I left him to talk for a few minutes then went back to the start and confirmed all the information I’d taken down.  It was at this point, he told me that the “veil” was in one eye (the right) while the increase in floaters was in the other.  I was thinking about the chances of a bilateral retinal detachment at this point. On dilation, I found that there was indeed a retinal tear in the left eye.  A small, very peripheral tear.

In both eyes, the lens capsule (empty, white and looking like a piece of tissue that had been formed into a circle) was visible just behind the iris but in the right eye, the zonules had loosened at the top, leaving the upper part of the capsule floating in the middle of his visual axis.

I called the local HES and left a message.  The wonderful ophthalmic nurse and I then played phone tag for an hour or so before H was bundled into a taxi and sent straight up to the hospital.

A couple of hours later, I welcomed my last patient of the day into my test room.  He usually attended another optician but had been unable to get an appointment with them at short notice.

Before J had even sat down, he launched into a very detailed description of his eye health.  He was a healthy man in his mid-forties who had been diagnosed with macular degeneration when he was in his late thirties.  He had had anti-VEGF treatment in one eye (two rounds, privately) at that time and since then, he was seen regularly by his optician.  He self-monitored with an Amsler grid and had noticed something wrong in one of the lower corners of the grid.  He did not describe distortion or a scotoma, just saying that “something was wrong”.

Vision was 6/5 in one eye, 6/12 in other.

We had a good chat while the 1% Tropicamide did its job.  J was very nervous and had had a bad experience with his eye care in the past (which prompted him to go private for his treatment).  We spoke about macular degeneration.  He seemed very down.  I urged him to talk to his GP about counselling – J was still coming to terms with his diagnosis and did not want to speak to his family about how he was feeling.  I also mentioned the Macular Society* and their local support group.  I spoke to him about having a good support network in place now instead of waiting until his vision worsened.

On dilated fundoscopy, I found that there was a raised area just above and to the side of the macula, which corresponded to the area of the Amsler chart that the J had reported as looking weird.  This was my first case of wet macular degeneration.  I told J what I had seen and showed him the fundus photograph, pointing out the raised area.  There was scarring in the other eye but everything was flat.

I explained that I would write and fax the referral straight away and that he would hear from the hospital in the next week or two. J seemed quite touched that I’d taken time not just to examine his eyes but also to talk to him about how he was feeling.  I even recounted the story of the first macular degeneration patient I had seen (when I was in my final year of university) and how she was examined at hospital, told she had macular degeneration then handed a leaflet for the RNIB.  She was devastated and had ended up at the Low Vision clinic although her vision was 6/6 in each eye. J’s experience was strikingly similar.

* I love the Macular Society and would urge everyone to join.  They have a fantastic selection of (free) leaflets and Amsler charts (both on-line to download or they’ll print them and send them to your practice).  It’s also good to know where and when your local Macular Society support group meet.