I recently saw a patient who reminded me of the importance of our job.  This man was in his early thirties and had never had an eye test.  He was in that day because he’d been in a fight the previous week and suffered two black eyes.  He wanted to check that his eyes weren’t damaged in the fight.

During history and symptoms, I asked all the usual questions and threw in a few more specific ones about pain on eye movement and other trauma symptoms.  All in all, he seemed to have been bruised and bloodied but nothing broken.  The area around both eyes was a grey-yellow colour, showing the time since the injury, and there was the ghost of a subconjunctival haemorrhage in one eye.

According to him, there was no noticeable change in vision.

When I came to ask about medication, there was a pause. I could see my patient wondering if he should tell me the truth.  I was expecting the answer when it came: methadone.  Then he watched my expression.

Now, I have worked in many economically disadvantaged areas, as you know, including the place where I was born and raised.  In my previous job, I walked past a man every morning as he waited for the pharmacy to open, saying “good morning” or stopping to chat about the weather.  I knew why he was waiting but, much to the scandal of my OA at the time, I would happily chat away with him as the pharmacy assistant pulled the shutters up.

To me, methadone is a ladder out of a pit.  It’s like citalopram or the many other medicines that exist to help people at various points in their lives.  I have tested people who have conquered their addictions, people who are in the midst of the battle and those who haven’t yet started the fight.  And they all watch for judgement when they tell their stories.  It’s at that point where you can either make a real connection or see them close up, depending on your reaction.

I wrote down “methadone” and moved on to family history.  I obviously had passed the test: my patient relaxed a little and started telling me about his life.  He was going back into education to do an access course: he wanted to be a journalist.

When I checked his unaided vision, he was 6/19 in his right eye and 6/12 in the right.  Of course, I didn’t know if the reason for the reduced vision was trauma or if it was uncorrected refractive error at that point.  On ret, he was R-3.00/+3.50×100 and L -2.00/+1.25×90.  When corrected, vision came down to R 6/7.5 L 6/6.

Apart from the bruises, his eyes were both perfectly healthy.  I took him out of the test room at the end to show him the world with his prescription and advised him about adaptation.  We chatted about dispensing since there would be a difference between the lenses and, in the end, he went for a nice pair of plastic specs that will look great when glazed.

After my patient had left, the OC asked about his prescription.  How can someone go through life with such a high cyl and not notice? How do you get to your thirties before your first eye test?

I started thinking about the reason I was taken for regular eye tests as a child – my mother is very short sighted (well, she was until she had LASEK 24 years ago, now she’s just a little short sighted).  I managed to get to 17 before I needed specs but I have memories of the opticians going back to when I was 5 or 6.  If my mother wasn’t so concerned about me also being short sighted, I might not have had a test until I was much older.

My patient may have grown up in a family where no-one needed glasses or, more likely, one where they didn’t prioritise eye tests (there are many reasons for this, including cost, access and awareness).  He wouldn’t realise his vision was poor.  If he was struggling at school because of his poor vision, he wouldn’t have realised the problem was just that: his vision.  He may have missed out on his education due to something relatively simple to fix.

While we can’t go back in time to see if a pair of specs would change the course of his life, I can make sure he goes into his access course seeing as well as he can and, fingers crossed, for the first time ever, something good may have come out of suffering two black eyes in a fight.

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