Last Tuesday I attended a peer review evening.  It was a nice, relaxed discussion that covered lots of different areas, ranging from paediatric dispensing through to ocular emergencies like retinal detachments.

It was during this CET event that I realised I hadn’t had a “proper” emergency since starting at my new job.  In the first two months of last year, I’d seen two retinal detachments, wet AMD and an array of other straight-to-HES conditions.  These last few months have been very relaxed in comparison.  I now realise that, by thinking this, I was tempting fate.

Last Thursday morning, I was testing in a different practice and everyone was running late.  My last patient of the morning appeared at 12.05pm for her 11.55am appointment, causing me to run a little over time.  When I came out of my test room at 12.30pm, the receptionist (C) told me that the receptionist from the other shop (L) had left a message for me but, as she lifted the phone to hand it to me, it rang again.  While C was dealing with the patient on the phone, I picked up my mobile to call L.  I had several missed calls, a voicemail and a text message from her.  Worried, I called her straight away and asked what was going on.

“There’s a man in just now and I think he’s had a retinal detachment,” she said.  L also told me that she’d called the practice’s owner as she couldn’t get me and he was also on his way down.

I told her that I’d be right over and to do tonometry, photos and visual fields on him while he waited.  It’s a ten minute drive between the two shops and that day it felt like forever.

When I arrived, L was just about to start the fields test.  I quickly discarded my jacket and bag and took Mr K straight through to the test room.  I planned to do a quick history and symptoms, dilate him and then ask L to do fields while I ate my lunch in record speed (this was supposed to be my lunch hour, after all).

So, Mr K had noticed a “haze” in his right eye the previous evening.  Thinking nothing of it, he’d gone to bed, only to wake up that morning with half the vision in his right eye missing.  There were no flashing lights, no floaters, no curtain across his vision.  There was no history of head trauma, no high minus Rx or previous retinal issues.  The only risk factor he had for RD, apart from age, was bilateral IOLs.  We had been discussing this on Tuesday at the peer review: a patient’s natural lens is thicker than an IOL so replacing the former with the latter creates more space – space that the vitreous can move forward into, causing a PVD and, if a patient is unlucky, a retinal detachment.

Mr K’s VA in the right eye was 6/18, previously 6/9.  I popped some TRO 1% in both eyes (you should always check the fellow eye thoroughly as patients confuse their right and left eyes all the time*) and asked L to do screening fields while the drops worked.

I looked at the retinal photos and they looked pretty normal, if a little dark.

I retired to my room to inhale a sausage roll and can of Pepsi Max.  Around then, the other optom arrived.  We went into the test room to discuss the patient and I gave him a brief run down of the history.  There was a knock at the door and L came in with the right eye field plot showing a well defined right nasal hemianopia with a slightly depressed threshold of 27dB.  Mr K was very reliable with no fixation losses or false positives.

I’m sure you are thinking the same thing as I did: that Mr K had had a stroke.  But we really shouldn’t make assumptions until we see the left field plot (which was perfect).

I set Mr K up on the slit lamp and had a good look through to Berger’s space.  There was no tobacco dust (Schaeffer’s sign) but there were lots of stringy floaters in the anterior vitreous, rising and falling as I asked him to look up then straight ahead.

On Volk**, I immediately saw the problem.  There was a small, partial Weiss ring floating above the disc.  This had created a retinal hole and fluid had leaked under the retina, lifting it up.  The macula was half raised – the other half was still attached, which explained Mr K’s VA. The detached portion was a lovely, healthy pink and the blood vessels were all still intact.  The fluid under the macula was only apparent on Volk – it didn’t show up on the first photo.

I retook the photos and managed to capture the detachment this time.

The field plot also confirmed that the macula was still partially attached, although it was probably barely hanging on at this point.

I explained to Mr K what had happened and told him that he’d done exactly the right thing in coming to us straight away.  I also explained that time was of the essence – I was going to call the hospital and get him seen that day.  He went to sit with his wife in the waiting room while I called HES.

I’ve gotten surprisingly good at writing referral letters while talking on the phone.

It rang and rang and eventually went to voicemail.  I looked at the clock: it was still lunch time.  I updated Mr K and told him I would call every 15 mins until I got through to someone, and I did.  Less than an hour later, he was on his way to the hospital, my referral in his hand.

Now, I’ve said this before: I’m very nosey and I tend to worry about people.  Before Mr K and his wife left to go to the hospital, I asked him to call me when he got home, to let me know how he got on.

He was seen that day but, because of the holiday weekend, his surgery was delayed until Tuesday morning.  When he called on Thursday afternoon, he told me this and thanked me.  I asked him if the ophthalmologist had told him to take it easy for the next four days.  No playing touch rugby, I joked.  He chuckled and asked if he could have a wee dram of whiskey that night – a plan I thoroughly endorsed.

Mr K was seen at HES on Tuesday morning and they used a bubble to secure his retina (I assume this was after a vitrectomy).  They kept him in overnight so my update came on the Wednesday afternoon.  He told me that the ophthalmologist was quite positive and that, although he could not see clearly out of the right eye because of the bubble, it was all light whereas before it had been dark at the affected side.  For the next six days, he’s to lie in a certain position and then they will review his eye.

I thought I’d share this case to demonstrate that not all retinal detachments involve flashing lights and floaters and that, although the fundus camera is an amazing tool, it will never replace a Volk lens and slit lamp.

 

* A few months previously I saw a lovely lady who had a small retinal tear in one eye.  She had been referred and had it treated.  When I asked which eye, she told me it was her right.  She had floaters in that eye now, since the tear.  On Volk, I looked all around her right eye and I couldn’t find a tear.  Thinking my Volk must be rubbish, I moved onto her left eye and almost immediately spotted the tear, which was surrounded by black pigment, where it had been lasered and had healed.

** On occasions such as these I tend to use two lenses: the 90D superfield for a general sweep of the whole eye and a 78D for a closer look at the macula, disc and anything that looks a little dodgy.

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