Yesterday there was a dark cloud over our store. One of the previous staff members (a young woman who left before I joined) died last week and the funeral was that afternoon.  Just after lunch, most of the staff went to pay their respects, leaving a skeleton crew behind.

It was interesting that the patients in the morning seem to have picked up on the atmosphere. It’s usually loud and bustling and although we were as busy as usual, there was an air of sadness hanging over us.  My first patient of the day said in passing, “I think the weather is getting everyone down”, which I thought nothing of but then, later, one of my dry eye patients mentioned that we were all very quiet that day.

I reviewed a patient that morning who I’d seen on Saturday. Well, it all started with a phone call on the Friday.  This patient, G, had called to say he wanted an appointment to review a corneal ulcer. He was in Wales but coming home the next day.  The hospital had said to go and see his optometrist straight away. They’d given him some ointment and some drops then discharged him.

When I saw G, I discovered he had keratoconus (or, “Kerry Katonas” as he called it) and wore hospital-prescribed RGPs.  His IOPs were 4mmHg in both eyes and he had those little lines in the stroma caused by oedema (I always think of them as corneal stretch marks) as well as some faint central scarring in both eyes.  There was a small, healing abrasion in the centre of his right eye. It was epithelial and looked like a smaller, fainter version of those “dust trapped under RGP” photos you see at uni.  The hospital doctors hadn’t seen keratoconus before* and I think they may have seen the central scarring (which, to be fair, was under the abrasion) and thought it was an ulcer.

From history and symptoms, it had sounded like an abrasion (sudden onset, when he was in a windy environment).  The hospital had given chloramphenicol ointment and a cycloplegic and told him no RGP wear until he saw his optom.  I said he could stop using the cycloplegic – G was happy about this because it stings like mad – but I wanted to see him again before he puts his RGPs in.  So, yesterday, there he was, his IOPs scaring the optical assistants, with a fully healed cornea and no further scarring.  I asked him to pop his RGPs in and his VA was 6/6 in the affected eye.

G had googled corneal ulcers when he got home from the hospital on Friday night and was very concerned. He was ecstatic when I told him it was a scratch on the front of his eye that was now fully healed and not an ulcer.  I also explained how the doctor probably saw the scarring from the keratoconus and thought it was connected to the abrasion.

Anyway, I was the only optom testing yesterday afternoon.  The diary was full and there was a range of patients from ages four to 80.

First one was the four year old.  He had been tested a couple of months before but his mum noticed a spot under his eyelid.  And that’s what it was: a spot.  A little whitehead on his lower lid, below his eyelash line.  Still, I checked vision, did pupils and examined the eyes inside and out.  Everything nice and healthy. Just a spot.

Next was a teenager with no Rx and no problems. 6/4 N5 R&L.

My next interesting patient of the day arrived after that. He was referred in from his GP because the doctor suspected him of having giant cell arteritis.  I don’t mind admitting I got a bit of a fright when he told me that.  There were no notes on his appointment and he had been “squeezed” into a small slot.  In my head, I started thinking about the signs and symptoms of GCA (something I’ve never seen before).  Vision would be poor, optic disc would be a mess, jaw claudication (that’s the one I think everyone remembers), scalp tenderness… In my mind, I was phoning the hospital and we hadn’t even prescreened the man.

Anyway, his last eye test was 6 years ago and, back then, he only had a distance prescription.  He had been struggling to read in the last few years.  He was unable to work through depression and had slowly given up reading, the only thing that had brought him joy.  He didn’t have GCA, just in case you were wondering.  He did have a displaced pupil (inferior) in one eye and massive peripheral scarring in his right eye.  There was a large, white patch of atrophy a few disc diameters under the disc and I think this may be what the GP had seen when he used the direct ophthalmoscope because the disc itself was fine.  I found a change in his distance prescription (getting to 6/5 in the good eye) then got him to hold the reading chart.

“It’s no use. I can’t see it.  Well, maybe the really big font at the bottom.”  He tried to hand the chart back to me.

“No,” I said. “Just keep it where you would like to hold your books and papers.”

I judged his reading add quickly and popped it in to the trial frame.

“I can see that,” he said, pointing to N8.  “And that.” N6. “And the smallest.” N5.

He started reading the chart, marvelling at how clear it was.

I explained about the lens in the eye and how it changes over time.  He just need a new prescription for reading.

He sighed and looked downcast again. “Oh, I guess that means I’m getting old.”

Sometimes you can’t win.

 

* I’ve seen a lot of patients with keratoconus (and not just in my current location) so I assumed it was quite common. When I said to a colleague that I can’t imagine someone working in HES not having experience of keratoconus, he said that, like high cyls and high plus, it’s a regional thing. I wonder if there’s been a study done on that.

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