I’ve had the OCT for a week now.  I’ve seen, in six short days, a plethora of pathology:

  • Dry AMD
  • Wet AMD
  • Solar retinopathy
  • a man with a patch of RPE randomly missing from one eye*
  • Proliferative diabetic retinopathy
  • Diabetic macular oedema
  • Several suspected glaucoma cases

I’ve played around with the anterior camera, took an OCT scan of my cornea (complete with contact lens and a little slither of tear film in between), looked at anterior angles, the peripheral retina settings and tried out all the different disc and macula scans.  My receptionist has seen her mascara up close and personal and I think she’s gone off it a bit.  I was going to do photos and scans of each part of my eye and put them here for you to see but, well, patients happened.

We’ve been very busy for the last few weeks and I’ve had a slew of interesting and strange cases.  Today alone, I called the hospital three times – it feels like I’m back at a busy multiple, fielding problems while trying to keep track of the diary.  It’s been both exhilarating and exhausting.

Today we had a full clinic and I had a list of things to catch up on from yesterday.  I was hoping for an easy morning.  Ha.

So, we have Mrs U who is new to our practice.  She’s brought a bag full of specs with her today.  She wants us to focimeter them and tell her what the Rx is in each one.  She’d asked if we would do this when booking the appointment and I said okay, thinking she would come in with a couple of pairs of specs, not a carrier bag brimming with them.  I guess that’s my fault, really.

Anyway, history and symptoms is completely unremarkable.  No ocular problems, no health issues.  Small plus Rx and reading specs.  VA is R 6/7.5 N5 L 6/6 N5.  On Volk, there’s a touch of cataract but, apart from that, everything looks fine.  Fields were fine, photo looked normal.

As the patient was over 60, I decided to do the wide scan on the OCT (which encompasses both the macula and disc).  It starts on the right eye and automatically moves to the left.  Left scan looks fine.  I click on the right image and start moving the cross section along.  I stop.  That can’t be right.  I look back at the left eye, just to make sure I’ve not gone mad.

I set the OCT to the high resolution scan and ask the patient to pop her chin back on the chin rest.

I was a macular hole.  A completely asymptomatic and seemingly invisible-to-the-naked-eye macular hole.  It’s a stealth hole.

So, I call the hospital and arrange an appointment.  I’m now running late so I ask Mrs U to pop back to pick up the referral letter around lunch time*.  She sees the appointment as an inconvenience because she has a previous engagement and, grumbling a bit, leaves with her (untouched) giant bag of specs.

The next few patients are quite straightforward, except they are all very talkative so I never really catch up that time as I’m too busy chatting.  Everyone seems happy enough to wait an extra ten minutes for their tests.

There’s an unexpected break when one of my patients doesn’t show up so I take the opportunity to sit down and write that referral.  I’m just learning how to export the reports from the OCT, which takes longer than expected and involves ferrying the images from the computer connected to the OCT to the main practice computer so I can then print them.

About half way through this faff, the no-show turns up.  He’s late, thinking his appointment was 25 minutes after the true time.  As there’s nothing in the diary after him, I don’t see any issue.

Now, Mr J has just turned 60 and was last tested at our practice 2 years ago.  He’s struggling with his reading specs but thinks his distance ones are still fine.  History and symptoms is quite straightforward except the fact Mr J is amblyopic and is being investigated for diabetes (and apparently has been “borderline” for a while now).  He also has poor mobility and some other, non-eye related health issues.

I found a small change in both eyes (a change of +0.75DS in the left, +0.50DS in the right) which explained the reduced near vision.  With the new Rx, Mr J was R 6/7.5 N5 (previously 6/9 N5) L 6/24 N18 (this is the amblyopic eye).

Again, dilated fundoscopy is unremarkable and, after the macular hole, believe me, I’m really looking hard at the macula.

I do the wide scan on the OCT and I can’t believe it.

It looked like diabetic macular oedema, affecting both eyes but the right more so than the left (at the bottom scan of the left eye, I could see the foveal pit wasn’t very pit-like).

So, I’m back on the phone to the ophthalmologist (who is starting to recognise my voice) and Mr J is booked into the macular clinic on Monday.

These two patients have shaken me a bit.  We rely on a combination of clinical skills, common sense and gut instinct.  Usually one of the three will set an alarm bell off but not today.  Without the OCT, I wouldn’t have spotted these two issues at such an early stage.  It’s truly an amazing piece of kit.

 

* Answers on a postcard: both the Topcon technician and I were/are at a loss.

** If you are wondering, “lunch time” never really happens for me.  I should be a lot thinner.

 

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