I can’t believe that it’s been four years since I started this blog.  

Looking back, pre-reg was just the beginning of the journey.  The amount of learning that takes place each day in practice is amazing – every patient and every eye has a different story.  Even the most routine of eye examinations can turn into something else.

This December was unusually busy in our practice.  When people want an eye test on New Year’s Eve, you have to wonder.  Anyway, I had a full clinic but it was mostly plano children so I was flying through the appointments.  At one point, after testing a family of four kids who couldn’t even muster +0.50DS between them, I was 45 minutes ahead of the diary.  Just then, a man in his fifties came in looking for an appointment.  He had already been turned away from a couple of other opticians although one of them had, helpfully, advised him he really should see someone today.

I was in my test room and heard him giving the details to one of my colleagues.  He hadn’t had an eye test for years, didn’t need glasses, vision was fine except yesterday afternoon, he noticed that he couldn’t see anything at the bottom of his left eye.  There was also a little red dot on his left sclera.  He thought it was an eye infection.

The optical consultant knew straight away that this was an emergency and there just happened to be the perfect sized slot in the diary.  After he was booked in, we did fields, photos and pressures.  Pressures were normal, the photo looked generally okay except for some nipping and copper wiring of the retinal blood vessels.  The fields showed a complete loss of sensitivity in the lower hemifield of the left eye.  I immediately suspected a central retinal artery occlusion.

When he came into the room, he told me that he’d never had any issues with his eyes and said, “It’s just an eye infection, isn’t it?”

Looking at the field plot, I told him that I suspected it was a problem with one of the major blood vessels in the eye.  I explained that I was going to check his vision and have a good look at the back of his eyes but, given his symptoms, I would want an ophthalmologist to see him today.  I think this shocked him.  I wonder if I gave him too much information before we’d even sat down in the room but I was aware of the timescale.  A CRAO is treatable in the first 24 hours and he had first noticed the issue the afternoon before so we were coming up to the end of the 24 hour window fast.

History and symptoms were unremarkable, except for the fact the patient hadn’t ever had his blood pressure or cholesterol tested.  I checked his vision and it was 6/7.5 in the right eye and 6/38 in the left.  He reported he couldn’t see the lower half of the chart with the right eye covered, as expected.  Pupils showed a left RAPD.  I assume this was new, given the symptoms described.

I then dilated him and, while the drops took effect, refracted him.  VAs ended up at R 6/5 N4 and L 6/38 N12, no increase with pinhole.  He had a very small prescription, a little bit myopic, which helped with his reading.

On Volk, I couldn’t see any emboli in the central retinal artery, although the vessels were twisted around each other when exiting the disc.  The retina itself looked pink and healthy both superiorly and inferiorly.  I explained to the patient that I couldn’t see any blockages in the arteries but, given the signs and symptoms, I did believe there was an embolus blocking blood flow to his superior retina.  I was going to call the hospital and ask if the ophthalmologist would be able to see him that day.

As the patient waited outside, I phoned the on-call ophthalmologist and gave her a run down of the situation.  She was surprised at his VA, expecting hand movements, and asked about how long it had been since onset.  I could only give a vague estimate – the patient was at work and had noticed the issue but hadn’t noted the time (why would he, really? He thought it was an eye infection, not an episode of 24).  She asked me to send him up to the hospital straight away so I gave him a referral letter and his daughter agreed to drive him to the eye clinic.

I was a bit annoyed that such a time sensitive issue was passed from practice to practice.  In our store, we have a policy of calling other opticians in the area until an appropriate appointment is found for a patient presenting with pain or loss of vision.  If all else fails, we advise patients to go to A&E.

I think we’re getting the healthcare/retail business balance wrong – patients with high prescriptions and a taste for designer frames are slotted into clinics routinely while those with a problem (and, therefore, no dispense at the end) may be turned away by optical assistants and managers with the excuse that they are “fully booked”.

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