There was a two week period where everything went wrong.  I had a run of rechecks, complaints about glasses and problems with contact lenses.  Everything happened at once.  I was pretty stressed out and those two weeks culminated in my boss telling me that everything was going to be okay.  He was right.  This week has been much easier.

I had a full clinic on Thursday but there was a weather warning for snow so most of my patients didn’t show up.  Around 9.45am, an elderly gentlemen (Mr Y) came in.

To recap: Mr Y had been tested at another opticians 2 months ago, had not gotten on with the distance specs they’d given him and, when he’d went back, they’d been unhelpful.  So, Mr Y came to see us.  That was 6 weeks ago.  He had just gotten distance specs as he still felt the near ones from the previous optician were okay.

Now Mr Y is one of those patients who seems nice enough at first but has a bit of an edge to him so I can imagine why the previous opticians found it difficult to please him.  I also think he has a problem with women.

Anyway, Mr Y comes in complaining that his vision is blurred when he’s reading and that he first noticed this yesterday.  I looked out his card and saw that he only got the one pair of specs from us.  On the card, it also said he was N5 in both eyes with the reading Rx that I’d found.

As my previous patient hadn’t turned up, I decided to take him in for a quick check.  I did history and symptoms (no diabetes, no high blood pressure, only painkillers for osteoarthritis).  Yesterday, Mr Y noticed his vision was blurred in the right eye when reading.  No flashing lights, floaters or double vision.

With his current glasses, he was R 6/12 (previously 6/9) and L 6/9 (previously 6/7.5).  He had cataracts in both eyes and had been told by his previous optician that he had a “touch of glaucoma”* in his left eye.  When I’d tested him 6 weeks ago, his visual fields were full (both with confrontation and automated perimetry), his C:D was around 0.3 in both eyes with no real depth to the cup and the NRR followed the ISNT rule.  His IOPs were R 14 L 16.  He had not been referred to HES, had never been prescribed drops… weird.

I checked his near VA with the Rx I’d found and he was N5 in both eyes… but, the right eye was a bit of a struggle compared to the left.

His pupils were tiny, even smaller than when I last tested him.

I couldn’t dilate Mr Y then and there because he was driving and had a huge list of stuff to do, including a GP appointment in ten minutes time.  With the pinpoint pupils and cataracts, I could only see the tiniest glimpse of disc in each eye.  Although,there weren’t any real red flags, intuitively I knew something was off – and it wasn’t the refraction.

“I’m really struggling to get a good look at the back of your eyes, Mr Y,” I said. “Can you finish all your errands, drop your car off at home and then come back to see me?”

Okay, he said, grudgingly.  So I booked him in after my last appointment of the morning (over my lunch).

So, lunch time rolled around and Mr Y came back.  IOPs were R14 L16, as before.  I took him through to the room to pop in some TRO 0.5% and then asked L to do fields, pressures then photos while I ran out to Greggs for a sandwich and a can of Pepsi Max.

While he was getting those tests done, I ate half a sandwich.  After the photos, I took him back into the test room.  I had had a quick look at the photos so I knew what I was about to see.

Looking through his right eye: nuclear and cortical cataracts, a few stringy floaters and a small, dark floater near the disc, which was probably once a Weiss ring.  There was the disc: a little pale, perhaps a little swollen, with a small haemorrhage where the cup meets the disc.  In fact, the whole of the retina was covered in haemorrhages, including the macula.  Mr Y had a R CRVO.  The left eye looked perfect except some RPE changes.

I told him that I’d seen a problem with the blood vessels in his right eye and that I wanted to call the hospital and ask them to see him today.  Could he please sit in the waiting room while I: 1) phone HES, 2) write the referral and 3) finish my lunch.

A nurse answered straight away and I told her that I had an 80 year old px with a fresh CRVO.  Could I send him over? His vision was still good in that eye but the problem is affecting the macula.  Yes, she says, there’s a 3pm appointment if he can make his way up.

I finished off the referral, brushed off the crumbs and popped it in an envelope.

When I came out, I sit next to Mr Y.  His demeanor was prickly.  “Today, I feel as if I’ve being passed around a lot,” he said, sharply.

He’d only dealt with L and I.

I know he’s an old man.  I know he’s concerned about his vision.  I know I should just shrug this off (as I usually do) but this time I didn’t.

“Mr Y, I had a full clinic this morning.  I fitted you in because that’s what I do when any of my patients has an issue.  You came in without an appointment and you were seen straight away.  I was unable to do a full examination because of your other appointments so  I booked you in over my lunch.  I asked L to do those tests so I could have a sandwich before my afternoon appointments.  I have done a thorough eye examination, spotted the problem, called the hospital, written a referral – all during my 30 minute lunch break… and I have to be at another practice 7 miles away in just over 10 mins.”

He looked at me for a second, “I’m sorry, I didn’t realise.” He didn’t look sorry at all.

“It’s okay, as I said, I would do the same for any of my patients.  Now, when you get back from the hospital, please phone us and let L know how you get on.”

He left and I didn’t hold the door open for him.**

So, he called a few hours later and let L know that he had a blocked blood vessel in his right eye.  He, again, mentioned this “touch of glaucoma” in the left eye that apparently his previous optician*** had spotted but I had missed.

I was so annoyed by this that I asked my boss, who has 40+ years experience as an optom, to look at the photos, pressures and fields.  I know for a fact that Mr Y’s previous optician did not have access to an OCT.  My boss was also unable to see this “touch of glaucoma” which had never been diagnosed at HES and had never been treated.

So, after being accommodated at short notice, properly referred and treated with nothing but politeness and respect, Mr Y was still complaining, albeit in a passive aggressive way.

 

* This was only mentioned at this appointment and not the one 6 weeks previously.  He, rather accusingly, told me that I’d told him he had cataracts last time but I had said nothing about the glaucoma.

** I was very annoyed but I also had to grab my stuff and run to my car so I’d be on time for my afternoon clinic.

*** The one that he had stormed out of, after making a show of throwing his specs in the bin.

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