Yesterday everyone had hayfever, me included. I quite like it when faced with allergic conjunctivitis because I know exactly what to do.  I’ve talked about allergic conjunctivitis before so, instead, I thought I’d share a couple of stories about comfort.

I’ll start with a gentleman, C, I saw a few days ago.  Last week, he had been in work when suddenly his left eye turned out and down and his upper eyelid started to droop a little.  There was no trauma, no headache, no history of diabetes or any other health issues.  This lovely, 40 year old man had randomly developed a third nerve palsy.  His only symptom was diagonal double vision, which was making it difficult for him to navigate life.  He went straight to the hospital and they did a CT and an MRI but couldn’t find anything that would have caused the palsy.  He was referred to the orthoptist via his GP and given an eyepatch to cover the affected eye.

When C came in, it was just for a chat rather than for a specific reason.  He wanted to find out more about what had happened and what was causing the double vision – his GP was a bit rusty on his ophthalmology so had suggested C speak to an optometrist.

I started my history and symptoms that same way that I do for all problems, “So, tell me what’s happened.”  This is a great open question that, nine times out of ten, will elicit not only the symptoms but the chronology and also any little details that the patient feels may be important.  For the other 10%, this question is interpreted as “Please tell me your life story” which is, you’ll find, as good a place to start as any because it builds rapport.  Most people like talking about themselves but, as you have only a finite amount of time for the eye test, you need to be confident enough to jump in when they are going off topic and guide them back with an eye related question.

Anyway, back to C.  When the incident first happened, he had a whopping LXOT, LhypoT and a bit of ptosis.  The next day, the deviation wasn’t as marked but he was still experiencing double vision.

When I saw him, there was maybe a 10 degree LXOT and an even smaller vertical deviation.  It was noticeable to an optom.  I did a quick VA check, motility (which was actually not too bad but not full, obviously) and cover test (no movement).  The ptosis seemed to have resolved itself as I didn’t notice any.

He mentioned that he felt himself turning his head to the right as a way of lining up the images.  When he was walking or driving, he used the eye patch the hospital had given him although, he said, he was worried about covering that eye in case it damaged it in some way.  His daughter had occlusion therapy for amblyopia and he’d remembered what the orthoptist had said about covering an eye for too long.

I reassured him that the eye patch wouldn’t do any harm.  He looked at it for a moment and said, “It’s also a bit sweaty and it started off as a bit of a joke but now I’m getting tired of people asking about it.”

I had an idea. C was a contact lens wearer (small -ve Rx, something like -1.00 DS R&L) and he had a current EW fit (Biofinity) on the computer system and I just happened to have a Biofinity fitting bank in my room.  I explained that, by giving him a contact lens in the wrong power (in this case, +2.00DS), I could blur the image in the left eye so much that it would be easier for him to ignore it.  He knew a little bit about suppression (the orthoptist his daughter had seen must’ve been a great communicator because he was really well informed on the ins and outs of BV) and I told him that, by blurring the image, it’s making it easier for his brain to suppress the left eye.

I must say, he was a bit skeptical.  That is, until he put the lens in his left eye.

Immediately, C said, “This is much better.” And he started covering one eye and then the other.  “So, I won’t be able to see at all?” he asked.

I showed him the reading chart, “You will be able to see with that eye up close, so” – and I guided the chart towards him until it was 30cm away – “you might still have some double vision when you are looking at things that close but it should be fine for driving and for the computer.”

He left, happy that he had an alternative to the eye patch.

Again, on the theme of “comfort”, I saw an elderly lady on the same day who was troubled by styes.  She had come in for a routine eye test and I had noticed that the temporal part of her upper left lid was a little swollen and inflamed.  She didn’t mention this during history and symptoms so, I prompted her, “I see your left eye looks a little sore, just at the top there…”

“Oh, yes, I’m very prone to these wee spots on my eyelids.  I’ve had this one for a few days and it’s not sore as much as annoying.  It’s red and a bit warm.  I went to my doctor about them years ago and he said that I just had to keep them until they were better.”

“Did your doctor tell you how to treat them yourself?” She shook her head. “Or about how to avoid them in the future?” Again, she signalled “no”.

I refracted her, checked her eyes both inside and out and the stye was the only abnormality.  I told the patient that I could remove the lash from the stye and that would help it heal.  No anaesthetic was needed, just a good pair of tweezers.  I did warn her that it might nip for a second when I removed it.  I asked her to look down as far as she could, and positioned the tweezers near the top lid before looking through eye piece of the slit lamp.  From there, it was easy to move the tweezers into place and grab the lash.  It came out with a satisfying lump of yellowy-white mucous.

I explained about lid hygiene, warm compresses and lid massage and told her that, if it happens again, she could come back and I would have a look.  She seemed really surprised that there was a way to alleviate her symptoms after being told by a GP to “keep it until it’s better”.

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