On Wednesday, it was unbearably warm in my test room (it was 27 degrees C outside and easily above 30 in our store).  My patients were wilting in the heat and I was getting more and more lightheaded as the day went on.  The heat made testing eyes a bit harder as the trial lenses kept steaming up (as did my Volk lens).  So, yesterday, I brought my giant fan in.  It was bliss but, at the same time, it was like testing in a minor hurricane: vouchers flying everywhere and my hair becoming gradually more wind swept as the day went on.

Anyway, as well as the heat, I had a run of difficult patients.  Not that they were difficult people – they were just puzzling.  Like the young boy who said he was amblyopic but who was 6/5 in both eyes last year and the year before.  Yesterday, he couldn’t read past 6/7.5 in one eye.  He hadn’t been wearing his specs (he was 15) but his stereopsis was normal on this visit whereas it was completely absent before.  So his binocularity was better but his vision was worse.  It’s a bit puzzling.  Apart from the decrease in VA, there were no other issues but he was being investigated for fainting.

I then had a run of older patients.  Now, I actually get on really well with the over 60s – even when I was young, I spent a lot of time with my gran and her brother and sister.  I’m one of those people who were “born old”, I guess.  I had a wonderful conversation with a gentleman about the London sewers and the Bazalgette pumps (if you are interested in engineering and haven’t come across this, go Google it now).  On the down side, I get told that “age doesn’t come alone” and to “enjoy my youth while it lasts” at least twice a day.

As you can imagine, because of the heatwave, most of the talk was about the weather.  In Scotland, we complain about it being too cold, too rainy or too hot.  Yesterday it was too hot and, later on, too rainy so there was a lot of moaning about the weather.

Just after lunch, I tested a lovely lady who was in her 80s.  She reported no problems but mentioned that her friend had noticed that she closed her left eye a lot.  It wasn’t sore and her vision was fine but she wondered why she was (subconsciously) doing this.

I refracted her and she was R 6/6 N6 (previously 6/5 N5 in both eyes) and L 6/20 and near vision couldn’t be recorded.  There was a very small (0.25D) change in her prescription which improved the left eye by a couple of letters.  When she was looking at the reading chart, she reported that she could see around the word she was looking at but not the word itself.  Of course, alarm bells were ringing so I got out the Amsler chart.  Right eye was normal but the left eye had a central scotoma and distortion (she described the lines below the centre as “drooping” and the lines at the side like “ripples from a stone in a pond”).

On Volk, there was a little drusen at the right macula but the colour was healthy and the macula was flat.  In the left eye, the macular area was a lighter colour and yellowish in the centre.  I made the slit beam very thin and scanned across the macula and I could see that it was raised (this is a good trick if your stereopsis isn’t great or you have a dodgy slit lamp, I also assume you can do this with direct as well although I haven’t tried).  When the retina is raised, instead of the beam being a straight line, it’s curved.

After Volk, I told the patient that I thought she was closing her left eye because of the distortion and that I wanted to refer her to the ophthalmologist to have her left eye looked at.  I explained about macular degeneration and how one type can lead to the other.  She knew she had dry AMD and was given an Amsler to self-monitor at her last eye exam.  I explained about the fluid under the retina and how this was causing the distortion.

“Is this something I should worry about?” she asked.

This is a difficult thing to answer. You need to impress upon the patient that it’s serious enough that she has to attend the hospital (and since she didn’t drive and had mobility problems, this would probably involve a lot of faff) but, at the same time, you don’t want to terrify your patient.

“It’s something that can cause blindness if it’s untreated and that’s why I really want you to go to the hospital. We have a special referral form that we fax over and the hospital will then get in touch.” I then discussed time lines.

She seemed satisfied with this politician’s answer.  I had a Macular Society AMD leaflet which I went through with her, pointing out where in the eye the problem was and showing her the difference that distortion makes to her vision then we chatted about nutrition.  In the end, I had spent an extra 20 mins with her and, although I felt this was needed, it set my clinic back for the rest of the morning.  I hate running late but in situations like that you really need to spend that extra time with your patient.

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