So it feels like forever since I had a straight forward day. The problem with working in a busy and well established practice is that we are known to the GPs in the area as somewhere they can send patients with eye problems.  As well as routine eye tests, contact lens fits and aftercares, every day we have at least one emergency. Sometimes it’s something simple like conjunctivitis. Sometimes it’s something completely baffling.

I saw a young man, L, in February who was complaining of headaches. It was his first eye test and I found that he had a bit of astigmatism in his left eye (6/10 unaided going to 6/5 corrected) while the right eye was 6/5 unaided.  His left disc was slightly raised nasally (pseudopapilloedema) but other than that, there was nothing out of the ordinary.  I recommended a pair of specs, did confrontation and automated fields and that was that.  He didn’t get specs, btw.

Anyway, he returned recently complaining of a strange spot in his vision, in the left eye.  He’d been playing golf the day before and this red spot appeared in the middle of his vision then, later, the spot went white. Since then it had stayed white.  I dilated him, did colour vision (City, monocularly, normal), VA was still 6/5 R & L, fundus exam was normal in both eyes, Amsler was fine with no scotoma or distortion.  I was completely at a loss.  I looked at the photos from that day and then back at those from February and they looked exactly the same.

I told him that the only thing I could see was the pseudopapilloedema (that had been noted in February) but that I would refer him to his GP.  He seemed quite happy with that and left.  It was only after he left that I noticed we didn’t have his GP’s name or practice.  So I called. And called. And called. A few days went by and I was getting annoyed because he’d left a mobile number and he didn’t seem to have voicemail.  I was spending 10 mins a day ringing his mobile and he was obviously ignoring the missed calls.

Anyway, one morning I came into work to find that the hospital was on the phone. L had turned up there, worried about the pseudopapilloedema.  The hospital had checked his vision and (surprise surprise) noted he had decreased vision in his left eye.  He’d told them he didn’t wear specs and that he didn’t need them*.  I told the nurse that I’d tested him recently and went through everything that I’d done and what the results were. I also told her I’d been struggling to get in contact with him since he left the store.  She asked that I fax the referral letter over, marked for her attention. I did just that and recorded the conversation in my notes.

So, a few weeks later, I get a letter from the hospital telling me L had central serous retinopathy.  Given his VA, fields, Amsler and the fact that nothing seemed to be wrong apart from this white spot in his vision, I was surprised.  I went back to those fundus photos and they looked exactly the same as the ones in February.  I asked one of my colleagues and we both stood staring at the photos for a couple of minutes.

“Don’t worry”, he said, “it’s a difficult thing to diagnose without an OCT, unless, of course, it’s severe enough to show up on Amsler and the macula appears raised.”

The upshot is: if you get someone with any weird symptoms, don’t dismiss them, refer them on.  And also, remember to get their GP’s name before they leave the store.

A few days ago, I tested a woman who seemed annoyed at the world. She was relatively young but had RPE changes superior in one eye. It was stable and she’d been discharged from HES into our care.  She was on 6/12 recall but never actually made it to 6 months before coming back.  She was very myopic and had several pairs of distance specs.  The ones she was wearing that day were fine for day wear but she had a stronger Rx for night driving.  She was experiencing a lot of glare when driving at night and wanted a tint to make her vision clearer.

I tested her eyes and found a similar Rx to the last time she was in (this was the stronger Rx that she couldn’t handle for day wear but was okay for night time). I told her that her vision was 6/5 in both eyes, 6/4 binocularly and explained about glare.  I didn’t think a night driving tint would help as much as she seemed to think. I was trying to explain all my findings but she kept interrupting me and, like she was talking to a child, explained that a man had told her a tint would help so she wanted a tint.  I said contact lenses were an option, as this would eliminate any reflections from the lenses and maybe cut down on glare but it was really a problem with pupil size.  Again, I was huffily told she had spoken to someone who had recommended a night driving tint.

I left that one with the DO.

Finally, I’ll tell you about a really frustrating incident that happened this week.  I saw a lovely lady in her seventies, Mrs S, whom my colleague had referred to HES last year for investigation. Her IOPs were in the low 30s in both eyes.  She had been seen at the hospital and no treatment was given. She was told she would be monitored and to come back in 3/12.  So three months go by and they postpone her appointment, moving it from April to June then, another letter arrives, moving it from June to October.  The final letter (she had these in a bundle and handed them to me in the test room), told her the appointment in October was cancelled and she would be contacted sometime in the future with a date.  Mrs S was exasperated.  She also had cataracts (nuclear and posterior subcapsular) and was struggling to read.  She also noticed she was getting clumsier, bumping into tables and she felt she was missing the curb a lot when crossing roads.  I refracted her, not managing to get much of an improvement in the distance but she struggled to N14 with a +3.00DS add.  Visual fields showed a clear arcuate defect inferior in both eyes.  This explained the clumsiness.

At this point, I looked back at my colleague’s records and the disc appearance hadn’t changed since last year but there was no arcuate defect back then.  I asked him for advice on how to refer.  She needed cataract surgery (and removal of the lens usually results in a decrease in IOPs) but I was more worried about getting her seen at the glaucoma clinic as soon as possible. In the end, I sent a letter to her GP asking for her to be seen at the glaucoma clinic, attaching the fields, and also be placed on the cataract waiting list.

* I don’t know why patients lie about stuff, especially to health professionals. I recently tested a young boy with a “red eye” (his eye wasn’t red at all).  Anyway, this boy was last seen for this “red eye” at another store who then faxed his details over. Everything his mum had told me during history and symptoms was different from what she’d said to the other store a couple of weeks before.  Everything.  I also discovered that he’d had three eye tests in the last month from different places.  The mother’s story continued to change during the appointment and suddenly it wasn’t a “red eye” she was worried about it was the fact that he’d lost his specs, that he’d gotten a month ago from a completely different chain of opticians that was just up the road from us.  I sent her back there for replacement specs and meticulously recorded the whole debacle in my notes and attached the faxed record to the file.