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I have been thinking a lot about autism spectrum disorder (ASD) after meeting a lovely 4 year old on the spectrum.  As mentioned previously, I’m working one day a week in practice, surrounded by a fantastic team, and they tend to save the best patients for me.

A couple of weeks ago, I saw a young boy, H, who came in with his mum, dad and brother for his first eye test.  His mum was concerned because H said he wasn’t seeing well in the distance and there was also a family history of strabismus.  When H was booked in, a note was made in the diary that he had ASD and sensory issues.  The appointment was in the middle of the afternoon, at that time when, if one or two people show up late, my clinic starts running behind.

I looked at the diary and spoke to the optical consultants about my plan for the day.  Basically, I wanted H seen as soon as he came in, I didn’t want to keep him or his family waiting in a busy, bright area, especially since I had no idea the nature or strength of his sensory issues.

As the day progressed, everything seemed to be running smoothly.  The patient immediately before H turned up quite early and everything was going well.  I’d said to the OCs that they could try and do a photo for H if he was willing but, otherwise, no pre-screening was necessary.

H quite liked getting the fundus photo taken and wasn’t put off at all by the flashes of light.  In general, he seemed a little nervous and a bit shy, like most children arriving for their first eye examination.  He was doing the “hiding behind mum” thing that young children tend to do when they are unsure of a situation.

We went into the test room and he got up on the chair.  I moved the chair up a bit until he could see the mirror and, again, he seemed fine, if a little apprehensive.  His mum was sitting under the mirror, on hand in case he needed her.

Everything started quite well.  We chatted about his t-shirt (which had Spiderman on it, his favourite superhero) and talked about his vision.  History and symptoms was going fine but H was so shy that day, he was looking down and talking into his chest.  I couldn’t make out what he was saying so I asked him if he could speak up, as I couldn’t hear him over the noise of the air conditioning in the room.  That was a big mistake.

I had drawn H’s attention to the air con.  Suddenly, he was very aware of it. “I don’t want it!” he threw his hands up to his face and his mum rushed forward.  He just wanted to be out of the room at that point.  We all went out to the waiting area which was quiet, except for my previous patient looking at glasses.

H sat down with his parents and brother.  It took a few minutes for him to recover from that bit of sensory overload but he seemed quite happy to be outside the test room, surrounded by his family.  H refused to go back in so I just picked up my pen torch, occluder, ret and budgie stick and knelt down on the floor of the waiting room and did as much of the eye test as H felt comfortable with.

His eyes were straight, motility was full and smooth (and a bit giggly) and ret showed what might be a small plus Rx.  Of course, I wasn’t able to get vision and he refused to let me have a look at his eyes with the ophthalmoscope.  His fundus photo looked the picture of health but I still needed to check the peripheral retina.

After a chat, we decided to book H in for another appointment in two weeks’ time.  We went for an early morning appointment, the first one of the day, and a note was made in the diary to switch the air con off before his arrival (this had to be done upstairs, in a part of the store I have no access to).  His brother J, also 4, was booked in for a check as well.

So I had two weeks to come up with an idea of how to make the eye test a nicer experience for H.  I ended up buying Spiderman stickers and taking my noise cancelling headphones into work.  Turns out that the noise of the fan wasn’t the issue, it was the thought of it being on that he disliked.

Anyway, I came in early that day to make sure everything was set up and the air con was off.  It was, of course, one of the hottest days of the year so that air con was on the second H had left the store.  But I’m getting ahead of myself.

H was a lot more relaxed when I saw him.  He was still using his mum as a human shield but he was peeking around her more often – I took that as a good sign.  We went into the test room, I asked if he wanted to sit on his mum’s knee (I sensed that he didn’t like the electric motor moving the chair up at his last visit) and he was quite happy with that.  I asked if I should close the door and he said “no” so I left it open.   We used Snellen pictures to get vision and I tried ret again.  H didn’t want the lights off or dimmed so I wasn’t able to do Mohindra ret as planned.  His vision was very good though and his stereo acuity was fine.  A small plus prescription in a 4 year old (similar in both eyes) isn’t worth prescribing and I didn’t want to cyclo him unless there was a compelling need.

The Spiderman stickers went down a treat and during his brother’s eye test, I put a little Spiderman on my nose as a near fixation target (when he wasn’t looking).

“Your nose!” J said.

“Is there something on my nose?” I asked, looking puzzled.

“Yes!”

“What is it?” I tried to look at my nose (esophoria for the win).

“Spiderman!”

“Oh, he’s tickling my nose, what’s he doing?”

“He’s jumping!”

“Where’s he jumping to?”

… and this went on for as long I needed for the cover test.

At the end, I discussed my findings with H and J’s parents and they were all just about to leave when their mum said to H, “That was okay, wasn’t it?”

H turned to me, looking as serious as a 4 year old can, and said, “Yes, but Michelle is very silly.”

I’ll take that as a compliment.

Lots of interesting things have happened since February.  I left my regular locum role in an independent to try “proper” locuming (where I travelled the length and breadth of the central belt*) for a month before starting back at university.

My experience of locuming has been mainly positive.  I went back to the company (and, indeed, the practice at one point) where I spent my pre-reg.  Except this time, I was earning more in a single day than I was getting for a week’s work.  I really liked the flexibility of locuming but I found myself going back to the same practice over and over because I liked the store, the patients and the staff.  It makes such a difference when you are part of a team who works well together.  Having went to various stores, both busy, city centre practices and out of the way, shopping centre ones, it is amazing how different they are even though they are all owned by the same company.

Some practices, I was treated as part of the team and between patients, I chatted with the optical consultants and in others, I was pretty much told to stay in my room! One even had a pretty passive aggressive “locum” folder which put me right in my place.

I’ve ended up with a regular day in the store I liked the best.  It’s a little out of the way for me but I don’t mind driving for a little longer in order to work with such lovely people.

The main news is that I’m back at university studying for a PhD.  This is something I’ve wanted to do for some time but I was waiting for the right project to come along.

Anyway, this was a quick update.  I’m going to try to put aside an hour a week to blog because I’ve got so many stories to share.

 

 

* Slight exaggeration as the furthest I went from home was Fife but after 1.5 hours of driving in the snow, I felt like I was in another country.

What you might not realise is that for every blog post that you see, there’s a couple of failed ones.  Ones that I start and then I run out of steam or time.  Sometimes these posts sit in my “drafts” folder for years.  This is such a post, where I was originally going to tell the story about two patients that were very different in age and lifetyle, both affected by vision loss.  What happened was that I’d gotten half way through, saved the draft and promptly forgotten about it so here it is, edited because I can’t remember the rest of it.

At the beginning of the month, I saw B.  He is a 25 year old guy whose first words to me were: “I’m going blind.”

He said it in a different way from the usual overly-dramatic patients (the ones who are -0.50DS and declare that they are blind without their specs).  His tone was flat, serious.

“What’s causing it?” I asked, setting up the autorefractor.

“Diabetes.” And that was it, no further information.  I nodded.

During my pre-reg, I had seen a young woman with diabetic maculopathy.  It had left one eye 6/60 and the other with exudates very close to the fovea.  I was reminded of her optimism that her bad eye would somehow heal over time and how I had to break the news that, after so long, her vision was not going to improve.  B didn’t sound optimistic – he’d already had that talk with someone.

So we go through to the test room and we chat about life.

At his first eye test (in July last year), my colleague took one look in his eyes and called HES.  B was seen the same day and that was the start of a very difficult 9 months for him.

He’s lost his job as a forklift driver because he doesn’t meet the visual requirements.  He’s now on Job Seekers’ Allowance.  As B struggles to control his diabetes (he was diagnosed as Type 1 when he was in nursery), he is struggling to find a job that would accommodate his unpredictable healthcare needs.  He had been in and out of hospital several times since the New Year and, in fact, the next day he had an appointment with an ophthalmologist.

B’s a smart guy.  He’s read up on his condition and he realises how close he is to losing his sight.  He knows that the ophthalmologist might laser his peripheral retina to save the macula.  B asks a few questions about the procedure: how does it work? Will it hurt? Will he be able to drive?

He had a small minus prescription but felt that there was a change in his vision.  I refracted him and found him a little more myopic, which could be normal progression or may be the result of better diabetic control.  As he was seeing the ophthalmologist the next day, I had his specs glazed for him straight away and gave him a copy of his prescription with VAs on it for the ophthalmologist to see.

I’m always surprised when we see patients with diabetes who don’t attend their retinal screening and/or get regular eye examinations.  It’s especially strange since those with diabetes are entitled to a “free” eye test* every year.  I wonder if it’s denial, lack of education, lack of understanding or a combination of many things.

* Paid for by the NHS so free at point of delivery.

Just before Christmas, I tested a lovely man, Mr F.  He was in his 60s and had broken his specs on the same day he received a recall letter from us.  Kismet, really.  After the test, I helped him choose his frames and then we chatted about holidays for a while before he left.  As the door clicked shut, my optical assistant, G, turned to me and said, “He’s so nice… wait until you meet his wife.”

G then went on to explain that his wife, Mrs F, was difficult.  So difficult, in fact, that the optical assistant that had dealt with her last year (who still worked for the company but in a different practice), left instructions not to tell Mrs F her current location.

Now, as you know, I’ve dealt with challenging patients before and usually, I find G is a little more worried about these things than I am so I didn’t think much of it.

Anyway, I was on holiday for two weeks in January (when Mr F said his wife would be in), so I assumed that I’d missed her (gosh darnit).  But no, she waited until February to come in for her test.

To say that Mr and Mrs F were like chalk and cheese would be wrong.  They were more like chalk and an abstract feeling of existential dread.

I was writing a referral letter in my room, with the door open, while Mrs F was being pre-tested by G.  I wasn’t paying much attention to the conversation in the pre-screen area, concentrating more on spelling “hypercholesterolemia” correctly (I’m not convinced I did but I’m sure the GP knew what I meant).

Suddenly, I became very aware of the battle of wills that was going on a few feet from my door.

Mrs F: “And what, EXACTLY, is this and why do I NEED to have it done?”

G: “It’s a puff of air that checks for glaucoma.”

Mrs F: “HOW does it check for glaucoma? I have NO history of glaucoma in my family. Why am I REQUIRED to have this done?”

G: “Everyone gets this check as part of the eye test.  It doesn’t hurt but it can startle you.”

MRS F: “I just don’t understand why I am REQUIRED to have it done.”

G: “As I said, it checks for glaucoma by measuring the pressure in your eyes.  If you are unhappy to have it done then -”

Mrs F: “I’m NOT unhappy. I just want to be CLEAR why these procedures are being carried out and to make SURE they are COMPLETELY necessary.”

I’ll spare you the rest of the conversation but, eventually, Mrs F submitted to non-contact tonometry.  As an aside, I’ve told my optical assistants not to worry too much about not getting NCT done as usually I can convince them in the room when I offer them contact tonometry instead.

After G handed Mrs F over to me, I heard a muffled “thud” coming from outside my door, which I assumed was G hitting her head off the wall.

Mrs F seemed to fill the entire room.  Formidable was the only way to describe her.

“Can I put my things here?” she demanded, pointing to the chair next to the slit lamp.

“We’ll use that later on but -”

There was no point in continuing as she’d already heaped the chair with her coat, bags and what seemed like a whole layer of clothing.

Before I could start history and symptoms, she launched into a rant about her current glasses.  They weren’t very good.  She’d paid a lot of money for them.  They weren’t comfortable.  The metal was coming off the frame.  They were causing glare at night.  She couldn’t see well with them. She’d been disappointed with that girl who used to work here.  The list went on and on.

I looked at her specs and the nose pads had widened to such an extent that metal of the lens rim was resting against her nose.  Over time, her sweat had reacted with the coating, leaving the base metal visible where it touched her skin.

She wanted me to say that they weren’t fit for purpose but they were several years old and I’m sure they hadn’t been fitted with such splayed pad-arms.  I realised I’d have to be very careful about what I said because she seemed to be listening strategically, waiting for me to say something wrong.  She had a strange, almost goading quality when she spoke.

We got through history and symptoms with minimum fuss then vision, OMB, pupils and motility.  At that point, I asked if she was driving that day (she wasn’t) and if she was happy to have the drops.

“WHY? Why do I REQUIRE drops?”

I explained that they were used to dilate the pupils so I could get a better view into the back of the eye.  I told her that it was part of the health check for over 60s and, given her prescription (which was around -10DS R&L) and the issues she’d described, I would like to make sure that I could get as good a view as possible.

Reluctantly she agreed.  I warned her that they are a little nippy when they went in and that they would blur her vision for a few hours afterwards.  Then I popped open the Minim.

Now, I’m great at putting in eye drops.  I don’t want it to sound like I’m bragging but I get them in fast and with as little fuss as possible.  This skill I learned during my pre-reg when I tested all of the children in the East End of Glasgow.*

I have never encountered someone like Mrs F.  After the first drop, she doubled over, shrieking.  There was a second where I wondered if I’d touched her cornea with the Minim, such was the performance going on in my test chair.

“Why would you TORTURE people like that?” she gasped.

I was at a bit of a loss.  I really wanted to say, “You are a 65 year old woman, get a grip.  And, if I wanted to torture you, I’d use cyclopentolate.”**

Eventually, after me standing next to her for what seemed like an age, silently judging her, she opened her eyes.

“Well, I guess you HAVE to do the other one.”

“Not if you don’t want to.”

“No, no, you HAVE to.”

So, I popped a drop in her left eye and there was some wailing and gnashing of teeth but it wasn’t on the same level as the first eye.  After a few seconds of mild huffing, she settled down enough for me to put on the trial frame.

Refraction was a nightmare.  I used her old prescription as a starting point and she claimed she couldn’t see anything, even though I had measured her VA with her current specs before we started.  As usual, my routine was interspersed with “good”, “great” and “perfect” and this really annoyed her.

“It’s not good, is it? I CAN’T SEE.”

“This is just a starting point for us, I’m going to show you a couple of lenses and -”

“BUT I CAN’T SEE!”

The ret result was pretty much the same as her old prescription so I knew that there wasn’t that much of a change.  I soldiered on despite a steady stream of despair with a hint of accusation.  I’d blinded her with the drops, apparently.

Anyway.

The time finally came for the health check.  We moved onto the slit lamp (after much faffing about with bags, scarves, gloves, coats, earmuffs, balaclavas) and the only significant finding was a mild nuclear cataract in both eyes with a moderate cortical cataract in her right.

I told her about the cataracts and said that this may explain the issues she’d been having with her vision.

“Do I stay in this chair or move back to the other one?” she asked, starting to get up.

“Well, we can go back outside now, if you want.”

“NO, I WANT to hear more about these cataracts.”

“Ok, you can -”

And she moved back into the main chair.

I took the opportunity to double check VA with her current specs and it was unchanged from the start of the test (just in case I had blinded her with tropicamide).

I described cataracts to her.  What they were, how they started and progressed and what the symptoms were.  I talked about a haze, about patients constantly cleaning their specs because they felt they were dirty, and muted colours.  I told her about glare and how that could cause problems at night, I talked about contrast and things just not being as “black and white”.  I recounted all the information that my brain holds on cataracts, including new research and historical facts.  I just talked and talked and talked.  I do this when I’m nervous.

She was looking at me very intently, like she was waiting for me to make a mistake.  I was being scrutinised and it was taking me back to my pre-reg when my confidence was pretty much an illusion.  I felt like I was being assessed by her.

After what seemed like hours, I ran out of things to say so I just stopped talking.  She stared at me for a few seconds.

“I want to hug you.”

I really wasn’t expecting that.

“No, really, you’ve just described EXACTLY what I’ve been experiencing.  I was SO worried about it all and you… you hit the nail on the head.  So it’s cataracts.”

She then hugged me.  I wasn’t sure what was going on so I just kept very still.

“So, what do WE do about the cataracts?” she asked, settling back into her chair.

I told her that I could refer her but given that her vision was still very good, it was unlikely the hospital would do the surgery.  She was symptomatic but seemed happy to have a name for the issue rather than a solution.  We talked about the referral process and the fact that she could come back at any point if she felt a change in her vision.  Also, as there was no change in her prescription, there was no point in updating her varifocals (transition, 1.74, freeform).***

Before leaving the practice, she hugged me again.

G turned to me as soon as the door closed behind Mrs F, “What happened in that room?!”

 

 

* Exaggeration but some days it felt like it.

** Fun fact: I once sat as a patient for some student ophthalmologists.  They cyclo-ed me for that.  Over a period of three hours, I must’ve had about ten drops in each eye and that does hurt like hell.  I came out with massively dilated pupils, a taste of what prebyopia is like and a mission to buy a retinoscopy rack.

***  I ordered in a replacement frame for her so we could just swap over the lenses.  Mrs F was well known to my boss who kind-heartedly waved the cost of the replacement frame.

The new year is just around the corner and I thought I’d take the opportunity to reflect on 2016.  It’s been quite a tumultuous year in politics and the world seems a different (and sadder) place as we creep towards 2017.

At the beginning of the year, I moved from a hectic job in a multiple to a position that involves me working between several small independents.  I pretty much went from one extreme to another: from being one optometrist among many (not to mention DOs, OAs and other support staff) to being one of only two staff members in a shop.  As the sole optom, I became better at time management and my routine got faster (despite the lack of computerised records).  I am able to look at my diary and anticipate any issues in advance (this is something I really missed when working with a rolling clinic*).

I’ve also been doing some dispensing (with varying degrees of success) and I learned about glazing, which, in turn, has helped with the dispensing.  This is something I missed when I was working in the multiple – I was in my room, testing, and nothing else.  I didn’t get to see the full patient journey and, this may sound weird, but sometimes, when I’m in the middle of a test, I’ll think of the perfect frame for that patient.

Anyway, my current situation isn’t without its draw backs.  Moving constantly between shops is tiring (I go from one to another at mid-day, every day).  I’m forever catching up with loose ends from when I was last in that particular shop.  I’m constantly chasing visual fields results.  I think I’m well organised but there’s always that worry that something is slipping through the cracks.

Also, as I’m a locum, I have no real job security.  I go wherever I’m needed, sometimes at very short notice, and I’m no longer in the shop with the OCT.  There’s no career progression, no training (I asked if I could start doing domiciliary visits but I think they’ve forgotten) and, as a locum, I’ll never be a pre-reg supervisor.

So 2016 was a learning experience for me and, as always, I continue to develop as an optometrist.  It’s taken a couple of years in practice to for me to fully appreciate where I belong and what my passions are.  Next year, I’ll be focusing on what I want from a career and taking steps towards it.

See you all in 2017.

 

* A rolling clinic is one where the next available optom takes the next patient.  It’s always billed as being better for us optoms when introduced by management but, well, I’m unconvinced.

A few days ago, my colleague and I ended up talking about embarrassing moments we’d had at work.  Although I’ll never come close to beating the time an OA at my previous job told a man to “put your foreskin against the rest”, I’ve had a fair few cringe worthy moments.

The funniest involves a lady I saw a few years ago.  Her name was Mrs Dick.

In that practice, I would pick up the board from beside the waiting area, call the patient’s name and then we would both walk to the test room at the back of the shop.  The whole thing would take a minute or two and I would chat to the patient as we walked.  Usually, I’d comment on the weather or ask how they were today.

But not for Mrs Dick.  No, I decided to comment on her name.

What I meant to say was:

“I didn’t realise how common the name Dick was around here.”

What I said was:

“I’ve seen a lot of Dicks recently.”

She laughed (thank God) and I scrambled to correct myself.

“No, what I meant was: there are loads of Dicks around here.”

By this time, we were in the room and she was chuckling away.  Although I could feel the colour creeping into my cheeks, I decided to give it one last shot:

“No, I mean, [town name] is full of Dicks.”

Tears were rolling down her face by this time and her laugh was infectious.  Here we were: her bent double with laughter and me with a bright red face and tears streaming down my cheeks.  I was laughing so hard that it was painful.

When we’d collected ourselves a little, she said, “I’ll give you a laugh.  My maiden name was Wright and my mother used to joke that I should have hyphenated my name… I passed up the opportunity to be a Wright-Dick!”

And we were off again, laughing.  I don’t know how we managed to get an eye test done.

This case is interesting because there are a lot of red herrings.

Last week, a 75 year old man came to me for his first ever eye test.  He had assumed the yearly diabetic retinal screening was a full eye test so had never been to an optician before.  During history and symptoms, he described sudden vision loss in his left eye six weeks ago* (this was what prompted him to see me).

Mr C realised he couldn’t see very well out of his left eye when he accidentally covered his right while he was watching TV.  What he then described sounded like a field defect.

Mr C is diabetic (type 2, well controlled) and was screened around 6 months ago.  There were no issues reported at the screening and he was kept on yearly recall.  He is also hypertensive but that, again, is under control.  His mum had glaucoma, which left her blind in one eye at a relatively young age.  He has a very high cyl in his left eye (+4.50DC) which has never been corrected.  He was hit in the left eye by a tree branch a few years ago and, although it was painful for a few days, he didn’t seek help.

So, we have a list of possibilities:

  1. retinal detachment
  2. glaucoma
  3. CRAO or CRVO
  4. maculopathy
  5. stroke
  6. other pathology
  7. combination/all of the above

His vision was R 6/9 and L 6/60, improving to R 6/6 L 6/36 when corrected.  He was tilting his head up and down when viewing the chart with his left eye, trying to find the best angle.

Pupils were fine – equal and reactive with no RAPD.

Mr C’s pressures were R 14mmHg and L 11mmHg.  A small difference between eyes, with the left pressure lower – something I’ve seen before with retinal detachments.  He did report seeing lots of floaters in the left eye recently.  There was no trauma (that he could remember), no flashing lights and the defect didn’t move.

The pressures were low enough to rule out acute closed angle glaucoma (and I confirmed his angles were wide open on van Herrick) so I dilated him and, while the drops were working, I did a supra threshold 24-2 fields test.  What I found looked like this:

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That’s a definite inferior defect in the left eye and it respects the horizontal midline.  His fixation was very poor, though.  I tried to redo it but then we couldn’t get a threshold at all in the left eye as he couldn’t see the central spot without moving his eye around.

Finally, I asked him to sit at the slit lamp.

Starting at the front of the eye, there was an opaque area inferior to fixation that had some ghost vessels growing into it from the limbus, there was a cortical cataract inferior nasal and superior temporal.  Berger’s space was clear of tobacco dust.  There were lots of floaters and a Weiss ring in the vitreous.  The C:D ratio was 0.2 in both eyes, the NRR followed the ISNT rule and there was little to no cupping.  A quick glance at the fundus and nothing looked amiss.  There were no diabetic changes, the macula was flat and intact and the blood vessels looked okay.

Until that point, I was thinking it was a detachment so I was using my super field 90D and concentrating on seeing as much of the retina as possible.  When I couldn’t see any breaks or tears, I switched to my 78D lens and started looking really carefully at the macula and disc.

And there it was.  A little round white blob in one of the retinal arteries, just as it exited the cup.  It could be mistaken for a reflection from the artery wall or a little bit of myelin if you weren’t paying attention.  It was an embolism.

Now that I was really looking at the vessels, I could see that both the arteries and veins were thinner in the top portion of the retina when compared to the bottom**.  The fundus was still pink, though, and there was no cherry red spot at the macula.  It was a very subtle CRAO but it had a devastating effect on Mr C’s vision.

Our HES endeavours to see all CRAO patients on the same day so, when I called, they booked him into the afternoon clinic.  I sent Mr C away, letter in hand, and asked him to call and let me know how he got on.  Hopefully I’ll hear from him on Monday.

 

*Yes, six weeks. Not a typo.

** This was so much easier to spot on the fundus photo (which I wish I’d taken after the fields test rather than right at the end of the examination).