So, after wet macular degeneration and a retinal tear yesterday, I was hoping for a nice, stress free day today.  One of my first patients of the morning was an older man complaining of floaters.

K was one of those people who don’t believe in taking medicines.  He was in his sixties and tried to avoid taking the blood pressure tablets and statins that his GP prescribed.  He confided in me that he’d gotten better at taking the pills recently but there was a time, around 6 months ago that he’d had extremely high blood pressure at a routine check and that was why he was trying to take them regularly.

The floaters had appeared in the last few days with no flashing lights or other symptoms.  It was mainly the right eye but, if he looked at the ceiling, he could spot a few floaters in his left eye too.  On questioning, K described one large floater that moved across his vision when he looked from side to side.

I dilated K and looked in both eyes.  The left one was perfectly healthy, the only notable feature was that the blood vessels were a little tortuous.  In the right eye, there was a lovely scrunched up Weiss ring which did indeed drift across the pupil with eye movement.  No Shafer’s sign, no tears or breaks.  The only other finding was a smattering of exudates across the macula but the macula was flat, the blood vessels looked normal and the exudates looked old.

At the point, I was so focussed on the posterior vitreous detachment that I didn’t think much about the exudates. They were old, the patient had mentioned his blood pressure had been a problem in the past so I ended up reassuring K, giving him the College’s “Flashing Lights and Floaters” leaflet and advising him to return if there was an increase in symptoms, if he noticed a curtain across his vision or any other changes.

It was when he’d left the room that I looked back at the previous fundus photos and discovered that the exudates were new. (in that they weren’t there at his last eye test in May of last year).  Before he left the store, I managed to get a hold of K and told him about the exudates.  I also said I was going to write a note to his GP about having his blood pressure, cholesterol and blood sugar checked.

The rest of the day passed without event until my last patient (I don’t know what it is about those 5pm appointments!).

L had been told by his GP to go for an eye test as he was having severe headaches.  He had an appointment in a couple of days time and wanted me to write a letter that he could take with him.  I said that it was no problem, after the test I could write a little note of my findings for him to take to his doctor.

L had quite an interesting eye history, having had LASIK in one eye and LASEK in the other.  The refractive surgery had left him with monovision, which suited the patient (he was R 6/6 and L N5).

The headaches had started a few days ago and they were lasting hours at a time.  The severity of the headaches seemed to vary over time and he was also getting “patchy vision” (L’s own words).  When he looked at the television, he couldn’t see the channel number which was displayed in the top left hand corner.  He reported a white space in his vision.  On questioning, he was unsure if it was one or both eyes and he gave the impression that the patch moved around.

I went through the eye test as usual.  A small Rx, which only marginally improved vision, was found.  Both eyes were healthy, discs were slightly tilted but that was all.

At the end of the test, I explained that there was nothing I could find either Rx-wise or health-wise in the eyes that would be contributing to his headaches.  We spoke about migraines but, again, the symptoms didn’t fit and the patient’s “patchy vision” wasn’t accompanied by any other aura-like visual effects.

There was one final test I wanted him to do.  I explained that the visual field test was the best way of finding out exactly what was going on with his vision.  I would skip the screening test (supra 24-2) and go straight to full threshold to save time (I tend to do this when I expect to find something as it saves time and the patient’s energy).

I explained to the optical assistant (A) who came in for the handover that I wanted full threshold fields done and I told L that it was a very long and boring test but I needed him to try his best and follow A’s instructions to the letter.

While they were getting started, I drafted a letter to L’s GP outlining the tests done and my findings.

Ten minutes later, L was switching over from his right eye to his left.  I had a quick look at the print out and my heart sank.  I had to wait, though, for the results from the other eye.  I ran upstairs and completed my letter and printed it out.  By the time I was finished, L was sitting back in the chair and A was joking that they’d have to start all over again.  L looked dismayed for a second and then they both laughed. “You’ve got some terrible patter,” he said to her, smiling.

I looked at the print out from both eyes and there was a bilateral left superior homonymous quadrantopia (pie in the sky).  It looked very like this:

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The test showed no fixation losses or false positives and, although in uni you are always taught to repeat fields, it was late and the test had taken 20 mins.  Given the reliability of the patient and the very clearly defined defect, I made the decision to refer on without repetition.  I called the hospital and they asked about VAs (which were good) and then said that they would see L the next morning.  I gave him the letter to take with him to the hospital, tucked inside was a copy of that fields test.

I asked L to give me a call and let me know how he got on at the hospital.

So, that’s my mad two days of referrals.  I was joking with the manager after the retinal tear yesterday, telling her that DOCET says that, on average, you see one every 16 months and it’s been less than a year since my last one.  She said that one of her colleagues had never seen a closed angle glaucoma in practice then had three in one day.  So, it seems pathology is like buses, nothing then all at once.

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