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When I was young, I was a regular at our local opticians.  My mother is very short sighted so she made sure I never missed my annual check up.  Growing up, much to my disappointment and my mother’s delight, my eyesight was perfect.

Fast forward several years: I was driving home after dropping my parents off at the airport.  It was just after 7am and I was crossing the Kingston Bridge in Glasgow.  Suddenly, I realised I couldn’t see the speed limit sign clearly.  I’m a bit of a hypochondriac so I immediately jumped to the conclusion that I was going blind (I was 17 at the time and all about the drama).  So I drove straight to my optician and waited in the car until they opened, the whole time wondering what was wrong.

My optometrist explained that I’d been very slightly short sighted for several years.  My vision was still good so he’d not issued a prescription.  We had a chat and, at the end, I picked my very first pair of glasses.

I could still see.  I mean, I thought I could.  I was still within driving standards but I’d been reassured that the prescription would sharpen everything up – I could wear them as much or as little as I wanted.  A week passed and I went to collect my specs.  They were a small prescription and when I popped them on in the practice, I really didn’t see much of a different but when I walked outside…

WOW.  I could see the leaves on the trees, the individual blades of grass, the telephone poles in the far distance.  It was like going from VHS quality to Bluray (showing my age a bit there).  I’d been wandering around, missing all this detail for years: I’d become accustomed to the blur.  Now, when I wore my specs, my brain realised that this is how I was supposed to see the world – in all its high definition glory – so when I took my glasses off, I was more aware of the blur.  I tried to wear the glasses just for driving but kept forgetting to take them off when I got out of the car.  I got used to that clarity and sharpness so I started wearing them all the time.

Now I’m hovering around the -2.50DS mark in both eyes (built in reading specs for when the time comes).  I’m okay when I wake up in the morning if I don’t have my lenses in.  I can get through my morning routine, have breakfast, even use the computer but if I tried to do all that in the evening, after removing my lenses, I can’t.  So, when my patients say that they feel their specs are making their vision worse, I can completely sympathise.

I tell everyone the truth: glasses won’t make anyone’s eyes deteoriate but they will get your brain addicted to seeing better.

Sometimes you have to overcome someone’s preconceived notions about their vision, especially those pesky middle aged hypermetropes.

I tested a lovely man a while ago.  He was a mature student and, when he came into my test room, he told me he’d been unable to read the last exam paper he’d sat, a few days previously.  He had to move it around to get it to focus.  As a medical student, he’d spent hours revising for each exam and, come the final one, his eyes just weren’t working the way they should.  He’d never had specs before and said that, usually, his eyesight was excellent.

Unsurprisingly, I found he was slightly hypermetropic in both eyes (around +1.50DS).  Starting VAs were 6/5, ending at 6/4.  A small improvement in the distance but, when I handed him the near chart, he immediately commented on how quickly it came into focus.

I explained that he had always been a little long-sighted and that, usually, his eyes were able to compensate for this but, after spending weeks pouring over his medical text books, past exam papers and on-line journals, he’d pushed the system to its limit.  I recommended a pair of specs that could be worn full-time or just for reading.

He asked if he really needed specs.  I told him he still met driving standards so he didn’t need to wear them to drive but they would help with the long periods of studying.

“But I don’t really need them, do I?” he repeated.  He picked up the near chart, holding it further and further away until it was almost touching my nose.  “I can see the bottom one fine.”

“Where would you hold your books usually?” I said, as he moved the near chart from about 70cm to 30cm and back again.

He frowned. “I just don’t know if I need specs.”

I looked at him for a second.  We’d established a bit of rapport and, as a medical student, I thought he’d like a bit of candour.  I gestured to his trainers, “Well, technically, you don’t need shoes.”

He laughed and nodded.  It had finally clicked.

When I was at uni, we had a variety of clinics in our final year.  There was a general clinic where we spent upwards of two hours giving unsuspecting people the most thorough and chaotic eye examination of their lives.  There was a contact lens clinic where we would take turns as patients for our partners and where, almost every week, someone would tell me I wasn’t suitable for lenses.  We had low vision clinic, colour vision clinic, visual stress clinic and finally, special needs clinic.

In uni, when you are still forming as an optometrist, testing someone with special needs is daunting.  It’s even more terrifying when your patient is non-verbal – how will you know if you are improving your patient’s vision if they can’t tell you? Are you upsetting them with your dithering? Is your ret really as bad as you think?

Add the fact that you are crammed into a small room with your patient, their parent or carer, your clinic partner and your supervisor.  I would assume my patient was stressed because I was, myself.

One of the patients I saw in special needs clinic was a young girl with Rett Syndrome, whom I’ll call R.  Now, I wasn’t familiar with Rett at all.  Before the clinic, my partner and I were given a little booklet about R that her parents had made.  It told us a bit about Rett but, more importantly, it told us about R: what she liked, disliked and how she communicated.  I really couldn’t have asked for a better first (non-verbal) patient.

Since then, I’ve seen many children with special needs, most of them on the autistic spectrum.  There’s a great saying about autism spectrum disorder: when you’ve seen one person with ASD, you’ve seen one person with ASD*.  When you are testing anyone on the spectrum, you need to tailor your routine to them.  If you are lucky, their parent or carer will help you along the way.

Anyway, sometimes we forget that an eye examination is quite stressful to non-optics people – by sitting as patients for our colleagues, we’ve pretty much desensitised ourselves to the process.  We also know what each part of the test is for, how long it will last and why it is important.  Imagine, though, that you were walking in to an opticians for the first time ever:

The lights are bright and there is so much visual clutter: hundreds of frames on frame racks or shelves, the mirrors, display cases, desks, chairs, strange machines in the corner, the other patients and staff moving around.  It’s also a riot of noise: the phone ringing, lots of different voices speaking at different levels, beeps, coughs and sneezes, doors opening and closing.  Other senses are engaged: the smell of someone’s lunch, strong perfume from the lady sitting near the door, the cold, dry air from a fan or the warm air from the heater.

You wait in the chaos until your name is called then you are led to the machines and asked to put your chin here and forehead there.  Then you are in a small room with a person you don’t know, being interrogated and having bright lights shone in your eyes. **

Basically, there’s a lot going on.  There are a couple of things, though, that will really help all your patients:

  1. Think about appointment times. If someone would benefit from a calmer, quieter environment, book them in at a quiet time (perhaps first thing in the morning or on a day where there’s only one person testing in a large practice).
  2. Build a seamless patient journey. Ideally, this would involve no waiting around.  Unfortunately, this is real life so giving someone an idea of how long they will wait is the next best thing.
  3. Introductions.  Amazing how something so small can make a massive difference: taking a moment to introduce yourself to the patient.  After saying my name, I usually smile and say, “I’m the optometrist so I’m going to be having a look at your eyes today.”
  4. Sign-posting. Tell your patient what you are going to do, and why, before you do it.  This can be as simple as saying, “I’m going to ask you a few questions about your health and your eyes” before starting history and symptoms or telling someone when you are about to turn the light on or off.
  5. Giving time limits. I do this mainly when I’m doing ret or Volk.  I will tell someone when we’re half done or nearly finished with different parts of the test.  This helps with anxiety.
  6. Positive talk. Most people love positive re-inforcement: I tend to say “you’re doing great” while doing something like ret or cover test and “that’s it, well done” when I’m moving on to the next bit.  Also, if someone has great eye sight – tell them! Everyone likes a compliment.
  7. Handovers. I like to speak to the patient about their eye health and have a discussion about glasses before the handover.  It means that, when the optical assistant comes in, I can summarise what I’ve recommended and any preferences the patient has.  In the best case scenario, the same OA who did the prescreening is the one to dispense (they’ve already built up a bit of a relationship with the patient).
  8. DIY. Sometimes doing the prescreening, test and and resulting dispense yourself is the best way to support your patient.  In a busy multiple, this may be difficult but, if you’ve picked the right appointment time for that patient, it’s possible.

I’ve recently started working with patients living with dementia.  This patient group can also experience a type of sensory overload.  I will be writing another post about dementia and working in a domiciliary setting soon.

Finally, and I’ll say this loudly for those in the back, JUST BECAUSE SOMEONE IS NON-VERBAL DOESN’T MEAN YOU CAN TEST THEM SILENTLY.  Talk to all your patients, no matter how one-sided the conversation.


* Autistic spectrum disorder (ASD from now on) is a very wide diagnosis.  It’s usually seen as a male condition but affects both sexes.  In fact, researchers believe that “high functioning” girls escape detection/diagnosis through their ability to mimic their peers (and also, because of the perception that autism mainly affects boys and men).

I think calling it a “spectrum” is a bit of a misnomer.  When I think of a spectrum, I think of a line, a change in colour from blue to red.  It’s a two dimensional thing.  If you think of the line of ASD, does it go from few autistic traits to many? Or does it go from “high functioning” to “severely impaired”? I’ve always questioned the term “high functioning” since someone can be fine in one situation yet severely impaired in another. There’s a lot of interesting articles on autistic identity so I’m not going to delve into that here.

** The National Autistic Society released a video at the beginning of April 2017 to try and show what sensory overload looks and feels like (  They’ve missed out the sound of high heels, which is probably the worst sound in the world.

It’s been a few years since I sat my OSCES, although the trauma is still fresh (only kidding).  I’m now in a position where I’m assessing students, not as a College examiner but as part of my teaching commitment at uni.  

The first thing I wanted to say was: I get as nervous about assessments as the students I’m assessing.  I was telling a colleague who is an actual College examiner (and all-round nice person) about this and they said that they feel the same way.  So just remember, when you walk into that OSCE station, the examiner is hoping to give you good marks.  They want you to succeed.  It’s painful to watch someone struggle, especially if you know that it’s down to nerves rather than a lack of knowledge or ability.

So, here’s my top five OSCE preparation tips:

1. try to get as much OSCE practise as possible.  Go to OSCE preparation courses and take turns testing and timing your friends doing ret or history and symptoms.  I was lucky enough to attend a full blown (16 stations) OSCE preparation course run by NHS Education Scotland in addition to the OSCE course (which I think was around 10 stations) that the company I was working for had arranged for us.

2. identify any areas where you need to improve.  This is quite difficult and requires you to honestly think about your skills and knowledge.  Of course, we all like practising the stuff we are good at and try to put off doing things we are unsure about.  Sit down with the College competency lists for Stage 1 and 2 and look through them point by point, highlighting any areas you think you need to work on.  Also, avoid the temptation to just “work on everything”, because you’ll end up spending a long time going over things you are actually good at.  Get your supervisor involved as well – ask them what they feel you might need to improve upon and press them if they say “nothing”.  There’s always something you could be doing better.

3. don’t personalise failure.  If you are struggling with something, it doesn’t mean you are/will be a bad optom.  It might be that you haven’t had much experience in that area.  If you are really unsure of something then don’t be afraid to talk to your colleagues, friends or supervisor about it.  You are learning just now so it’s the perfect time to ask questions.

4. try to visualise the OSCEs.  This is something that you might laugh at but I honestly think that sitting down, closing your eyes and visualising what it is going to be like is a great way of controlling your nerves.

Imagine standing outside the first cubicle, reading the scenario on the door, it’s something you are familiar with and you feel confident, after the minute is up, you open the door and stride in, confidently.  The station goes well and you move onto the next…

It’s like tricking your brain into having a positive memory of something that hasn’t yet happened.  I think a lot of nervousness comes from the fact that you are in an unknown situation and that’s why my first tip was to try and experience OSCE-type exams as many times as you can before the “real” one.

5. engage brain before opening mouth.  This is something I do all the time – I start talking before actually considering what I’m going to say.  It’s especially bad when you have a time crunch.

When you are in the OSCE station and you know that time is ticking away, you feel you need to start NOW. Right now. Just start talking. Five minutes isn’t a long time.  And the silence is awkward.  Say something, that’ll relax you.  Just start talking. You can always work out what you are going to say on the fly. 

I’m here to say: resist that urge and take a few moments to breath and consider what you are going to say.  Think of this as investing 10-30 seconds on getting it right the first time.  Also, make this a habit that you carry into practice with you.  Real world patients are far less forgiving when you say something and have to completely backtrack than your OSCE actors.  Ten seconds and a deep breath are probably one of the best pieces of advice I can give you, regardless of your situation.

So those are my general OSCE tips.  If you are new to this blog, you can go all the way back to May 2014 and read my own OSCE journey (Mock OSCEs, More mocks, NES Mock OSCEs and The OSCEs)


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”.

As you may remember, I started the Independent Prescribing course all the way back in 2015.  At the time, I was working in a multiple, I had the opportunity* and thought that being an IP optom was a natural progression for me.  I loved the idea of being able to provide treatment for my patients with straight-forward eye problems without sending them to their GP or the hospital.  Sometimes, I would ask a GP to prescribe something only to end up playing phone-tag with them over the details.  When I worked in Lanarkshire, I became LENS qualified – this allowed me to supply chloramphenicol, fusidic acid, hypromellose, cyclopentolate, aciclovir (later, when they had problems sourcing that, it was replaced with ganciclovir) and other preparations for minor eye-related ailments.  I thought this was a wonderful system and really missed it when I left that health board to work closer to home.

You might be wondering why, two years down the line, I’ve only got one module (out of three) under my belt.  Well, in 2015, I couldn’t get the time off work to attend the second module and then, I re-registered in 2016, only to find out that I’d booked a holiday (for a special birthday) at the same time as the module exam**.  Ooops.

So, here I am, in 2017, two years after starting the course and I’m just over half-way through the process.  The exam for module two was on Friday and this weekend we had a selection of lectures and tutorials.

For anyone thinking about the IP course, it’s a bit of a strange experience.  Instead of having a weekly class, the teaching happens in three short bursts, followed by a couple of months of self-study.  Each module has coursework and then an exam at the end of it.  The first module concentrates on common anterior eye complaints, the second is focused on glaucoma and the third is mainly about systemic drug interactions and adverse drug reactions.  The course work is a case report (for module 3, it’s two case reports) and each exam is a three hour affair which includes multiple choice, short answer questions and a VRICS style section.

While the material is quite straight-forward, in the beginning, it can feel overwhelming.  Once you realise that, as IP optoms, there are only a few types of drugs we will be using, it becomes much simpler.  If you have a BNF, a quick look at Section 11 (the eye bit) will show you every drug and preparation that you might possibly use, excluding the intra-ocular drugs (although I’m all for continued professional development, I think I’ll leave the Lucentis injections to the ophthalmologists and ophthalmic nurses).

Overall, it’s been an interesting experience and I would urge anyone thinking of getting IP qualified to do it sooner rather than later.  When I was a pre-reg, I was advised by a wonderful locum optom to do the IP course as soon as I could – she said, the longer you are qualified and out of the habit of studying, the harder it is to get back into the swing of it.  This is especially true for the IP course where, as well as working, you will have to do a lot of independent study: revising for the exam, preparing the coursework and reading articles on such diverse (and sometimes desperately boring) areas such as pain management, clinical governance, laboratory investigations and anti-microbial agents.

So, fingers crossed that I have passed the second module.  Still, I have another two pieces of coursework, the module 3 exam, twelve days of hospital experience and the final College of Optometrists exam to sit before they let me loose with a prescription pad.


* NHS Education Scotland sponsors optoms based in Scotland, which is yet another reason I’m lucky to be practising here.

** As the course happens around the same time every year, this week I spent my birthday studying for/panicking about the exam the next day.

I thought I would write a post on what I do in practice and why.  This started out as a quick post but has turned into a bit of a monster so I’ll separate it into a few parts.  This post deals with the first part of the eye test, up to refraction.  The next part will be on refraction and the final part on the health check and management.

So, without any further ado, my routine:

Each working day, I arrive at my practice with some time to spare.  I usually get there 15 minutes early to set everything up – this involves little things like switching on the computer, test chart and slit lamp console.  While the computer is booting up or logging in, I lay out all the things I’ll need.

Chef’s have a thing called mis en place, which is having all ingredients prepared before service.  It’s what happens in Jamie Oliver’s TV kitchen before the cameras are turned on: every ingredient is peeled, chopped, weighed and set out in a logical and accessible place before the cooking begins.  Like chefs, we have time limits.  No-one wants to wait an hour for their meal because the chef has to hunt high and low for each ingredient and no sane patient would leap at the chance of spending double the time in the test room because their optom was inefficient.

So here’s my optom version of mis en place:

I lay out my occluder, budgie stick, +/-0.25DS flippers, lens cloth (very important in my practice as the cyls don’t have handles so are always covered in fingerprints), pen torch, pen, spare pen (for when the first one stops working or a patient/staff member* steals first pen), confrontation stick and my cross cyls.  I’ll unpack my ret and ophthalmoscope and have them handy as well.  If there are children in the clinic, I’ll put the Titmus and Ishihara within reach and if someone is attending for contact tonometry and pachymetry, I’ll have both the Perkins and Accupen in my room before the start of the day.  I also make sure I have an Amsler handy and that there are enough leaflets on common conditions in my room.

On the slit lamp table, I put my Volk lenses, Wratten filter, cotton buds and the little box I keep Sterets and needles in.

Before my first patient, I’ll make sure the slit lamp isn’t on some weird setting (like 40x mag, tiny spot and green light) and go through the computerised test chart to make sure when I hit the xcyl button, it gives me dots instead of circles (weird, I know, but I prefer the dots).  We also have one of those test charts where, if you press the wrong button on the fixation setting, you end up with a terrifying clown face so I make sure that it’s on the green dot not Pennywise.

By taking a few minutes to set everything up, I’m saving myself time during the day.

The patient will be pre-screened by the optical consultants.  In my practice, they usually do a mini history and symptoms and write any concerns on the front of the record card.  They also ask about work, hobbies, driving and VDU use.  After that little interview, the patient is then autorefracted and has non-contact tonometry done.  They then complete a 24-2 screening test on the Humphrey.  It’s good to have the autorefractor result before fields because you can then choose an appropriate lens for the visual field test.

After the 24-2, the optical consultant takes a fundus photo.  I will have a moment to check the photo on my screen before the patient is brought in.  I find checking the photo before the test helpful because I do fundoscopy after refraction and if the patient is struggling with refraction, there’s a good chance I have an idea why, based on the photo.

When the patient comes in, I introduce myself and ask how they are today.  We have a bit of a chat and I tell them they can pop their bags down on the chair over there then I ask them to have a seat “in the big chair”.  If the patient is unsteady on their feet or using a cane, I’ll make sure I flip the footrest up on the chair, allowing them to get closer to the seat before sitting down, and once they are comfortable, I’ll put the footrest down.  I also like to make sure I’m close by while they are sitting down, to provide a hand if they are struggling.  I usually say something like, “I’m just here if you need a hand or something sturdy to hold onto”.

Once we are both settled, I start history and symptoms.  If they come in with a problem, I’ll go straight to that.  If they have a sore eye or a red eye, I’ll just start with, “So, what’s happened?” and the patient will usually launch into a pretty detailed account of their sore or red eye.  When they are finished, I’ll ask any other questions I need to, again, leaving the patient plenty of time to answer.

Assuming a routine eye test, after confirming their details and their reason for visit, driving etc, my usual history and symptoms goes something like this:

Do you remember your last eye test?

Do you wear glasses at the moment? What are they for? How do you feel your vision is with them? Any situations where you feel you aren’t seeing as well as you should?

Have you had to go to the hospital or GP for any eye problems? Do you ever get flashing lights in your vision? How about floaters – wee black dots or wee black wiggly lines? Do you ever get double vision?

How’s your health at the moment? Are you diabetic? Any high blood pressure? Do you suffer from headaches?

Are you taking any medicines at the moment?

Anyone in the family with eye problems that you know about? Anyone in the family diabetic?

I will then put the chart on and ask the patient, while wearing their current correction, to occlude their left eye.  I’ll hand them the occluder and 9 times out of ten they will cover the right eye and, by right, I mean left.  Ten percent of the time, they’ll cover their right eye, which is the wrong eye instead of the right eye which is the left**.  Sometimes they’ll close one eye and cover the other.  Sometimes they’ll try and wedge the occluder under their glasses.  Sometimes they won’t even use the occluder and instead cover their left eye with one hand while holding the occluder in the other.

Hopefully, at this point, they will have one eye covered and the other open.  At this point, I’ll ask them “what’s the smallest line you can read on the chart?” Eight times out of ten, they will pick a line and read it more or less correctly*** and I’ll then ask them if anything is standing out on the line underneath****.  Those two patients out of ten will do a number of things: read the whole chart from top to bottom, say random letters (maybe throw in some numbers and stars) that bare no resemblance to any line on your chart, read the line backwards or just stare at the chart for an uncomfortable amount of time before saying, “Oh, do you want me to read it out loud?”

This is repeated for the other eye and you now have an idea of how well your patient is seeing with their current correction.  I know at uni they teach you to check vision rather than VA with current Rx but there’s really no point doing that in practice – you want to know if you are improving your patient’s vision with your refraction and, let’s face it, writing down 6/60 and 6/120 doesn’t really tell you much other than your patient needs glasses.  Also, if your patient is 6/5 with their current prescription, don’t give them more minus unless it’s getting them to 6/4, 6/3 or giving them the ability to see through time itself.

After that, I’ll ask the patient to take their glasses off and give them a target to look at for cover test.

I will start with alternating cover test at distance then get the patient to look at an appropriate target on the budgie stick and do cover test at near as well.  If they report having problems with their vision while on the computer, I’ll ask how far the computer is and I’ll do cover test at that distance as well.

I’ve had a few young girls recently attending with no prescription (6/5 N4 unaided) but complaining of headaches when on their phone/tablet/computer – these girls all had large XOPs at near.  A few weeks ago, I saw a patient with a very noticeable cyclophoria which was so cool and unexpected that I may have spent a few minutes just covering and uncovering her eyes, thinking “Wow”.

Anyway, next I do cover/uncover, looking for tropias.

Then I tell the patient that I’m going to dim the lights (which I do) and I test pupils.  During each test, I tell the patient what the test is for, what I’m seeing and reassuring them that the result is normal (unless it’s not, then I come back to that later).  After testing direct and consensual reflexes (three times in each eye, exerting the pupil muscles enough that if there’s an abnormality, you’ll see it after three repetitions) I move onto the swinging flashlight test.  Pupil reflexes are a bit of an art and I was worried that I would miss an RAPD but, believe me, if you are watching closely and doing the swinging flashlight test properly, you won’t miss one.

I then pop the lights back on and we move onto motility.  I always sit for motility although there’s a bit of a debate about this.  This is the part of the test where the patient is likely to start laughing.  I don’t know why, maybe it’s something about the test or maybe my look of intense concentration is hilarious, but I’ve had eighty year old men in stitches during motility.

Next is confrontation, which always involves a bit of mental agility on the part of both myself and the patient because you have to cover the contralateral eye to them to test their field in that eye.  Strangely, this isn’t as much fun for patients as motility.

So, that’s the first bit of the eye test, with a bit of an observational comedy thrown in for you.  I’ll post the next part (refraction) in a little while.


* You know how you are.

** Isn’t English a wonderfully clear language.

*** There is a special place in hell for those who read the whole chart using the phonetic alphabet… Oscar… Mike… Foxtrot… Golf…

**** You should always push your patients to read a little bit more because some people are quite cautious and need an extra nudge to actually admit they can see a bit better.  If we just left it up to the patients to pick a line, their VAs would be all over the place.

This post is yet another that got stuck in the “drafts” folder. It was actually written during my pre-reg and has since languished on WordPress in a half-finished state.  Today, I’ve bitten the bullet and finished it.

One of my patients today was profoundly deaf.  Now, I went to a sign language class last year and I picked up the basics (as well as colours, animals and weather… strange but true) but I still feel a little nervous about practising on someone who can sign properly.  I feel it will be like going to France and speaking French to a native for the first time, probably with a terrible accent and a lot of grammatical errors.  I once told my Russian teacher, during an oral exam, that I had problems picking up what he was saying because I couldn’t “see his mushrooms” (I meant “lips” but, well, griby and guby got mixed up somewhere between my brain and my mushrooms).

Before we get to the actual test, we should talk about what happened before it.  Making an appointment was difficult for my patient, who we’ll call J.  She’d received her recall letter and was given three options to book an appointment: 1) call us, 2) go on-line or 3) come into the store.  Now, J said the easiest way of booking was to come into the practice because using the telephone system was difficult (not impossible, you can get text phones) and the on-line system at that time worked by the patient requesting an appointment and then us calling them back (yes, facepalm).  Things have improved with this multiple – you can now book on-line properly, without having to speak to another human being.

So, J popped in with her partner (who was also profoundly deaf) and arranged her appointment.  She had a mobile phone and requested that we text instead of calling to remind her about her appointment (we would call everyone the day before to confirm) and to also advise her when her specs were ready to collect.

When J arrived for her appointment, one of the optical consultants (R, my work wife at the time) panicked a little about doing the prescreen.  She was unsure about how to adapt her routine.  Seeing her panic, I advised her how I would do it: instruct the patient while her glasses were on, tell her what the test did and how we wanted her to respond and, when the test was finished, we would tap her on the shoulder to let her know it was finished and then we would do the same again for the other eye.  Seeing that the OC was still unsure, I asked if she’d be more comfortable if I did the prescreen while she watched but she said that she felt a bit more confident and would give it a go.  I stood to the side, within the OC’s eye line so I could nip across if she had any problems but the prescreen went well and both the OC and the patient seemed quite pleased.  The visual field test was the challenging bit as we do the screening test that uses multiple points then ask the patient how many they’ve seen before we manually move onto the next presentation.  My patient and the OC worked out a system where the patient would hold up the number of fingers that corresponded to the points she’d seen and if correct, the OC would move onto the next one.  It worked really well and meant that the patient didn’t have to keep coming out of the correct position – she just stayed with her chin on the rest and forehead against the bar and held her hand up to show the OC after each part of the test.  When the OC showed my patient over to my room, they were laughing because she’d said that she had to be careful which fingers she held up for to say “one” and “two”.

There’s only one golden rule for patients with hearing difficulties: ask them how they want to communicate.  If they lip read: make sure you don’t shout (this distorts your lips) and that they can see your face clearly (keep their specs on as much as possible if they have high Rxs and don’t do Hx & Sx while looking down at your clipboard or towards your VDU).  If they are “hard of hearing”, again, don’t shout, just try to speak a bit clearer and louder and again, make sure the patient can see your face.  Some patients will ask you to shout, I try to avoid this because it wrecks my voice – instead, I use my public speaking training* and speak from my diaphragm rather than my throat (weirdly, this also makes you sound more confident so win-win**).

The eye test itself was unremarkable and, at the end, when J came out of the test room, her partner came over and signed, “Do you need reading specs?”  and I signed, “Too young for reading specs” which got a laugh.

He said he had two pairs of specs and was getting fed up of changing between them.  I signed that he needed… um, v…a…r…i…f…o…c…a…l….s.  My fingerspelling isn’t that great, you can probably tell.

In the end, it was a good experience for both me and my OC.  And I was relaxed enough to try out my BSL in a real life situation***.


* Sadly, I used to compete in debating and public speaking competitions when I was at school.  Without bragging, I wasn’t completely awful at it.

** Honestly, Google it.

*** I didn’t/don’t tell people I can sign a little because I’m terrified of being in a situation where I need to be able to sign better than I can – which, of course, puts me in a catch 22 situation where I want to get better at it but I’m afraid to practise it in case I insult someone’s ancestors by mistake.

Of course, as part of my PhD, I’ve been doing a lot of reading about glaucoma and visual field loss.  I’m still working in practice at the weekends and I find my approach to managing patients has changed based on the papers I’ve read.

I know not everyone has a spare three four months to read up on the latest research in glaucoma so I’ve chosen five interesting facts that may help my fellow optoms, pre-regs and students with their decision making.  For those who want to read more, I’ve added references*.

1) Early glaucoma affects central vision.  Usually we think of glaucoma as a disease that causes loss of peripheral vision.  Most example field plots will show a baring of the blind spot, arcuate defects and nasal steps but only the most severe will show macular involvement.  There’s actually a reason for this – we’ve been using the wrong test.

In practice, the standard field test we use is a 24-2 which covers the central 48 degrees with a 6 degree spacing between the test points.  Only four of the points tested fall within the macular region (central 8 degrees) .  If you can imagine, the little fixation spot the patient is looking at is located at 0 degrees, then the four points checked by the 24-2 are all just over 4 degrees from fixation.  Here’s a napkin drawing to help you visualise (and to show off my mad geometry skills):


Considering 30% of all retinal ganglion cells originate from the macula, it makes sense that this area is affected by glaucoma, a disease that causes ganglion cell death.  Several papers have been published recently showing that, despite previous wisdom that the macula was only affected in severe, end stage glaucoma, it can actually be one of the first areas affected.  Using a 10-2 visual field pattern may pick up macular defects that are too small or not in the correct location to be detected by the 24-2 pattern.  The 10-2 test covers the central 20 degrees (10 degrees either side of fixation) with a 2 degree spacing between test points.

Optical coherence tomography (OCT) shows thinning of the retinal nerve fibre layer (RNFL) in glaucoma.  Usually, if you suspected glaucoma, you would check the disc scan but, again, the macula with its abundance of ganglion cells is a better place to look for thinning.

Further reading: Grillo L. M., Wang D. L., Ramachandran R., Ehrlich A. C., De Moraes C. G., Ritch R. & Hood D. C. The 24-2 Visual Field Test Misses Central Macular Damage Confirmed by the 10-2 Visual Field Test and Optical Coherence Tomography. Translational Vision Science & Technology, 2016, 5(2): 15.


2) Certain areas of the disc are more likely to be damaged first.  As clinicians, we all know the ISNT rule and anyone lucky enough to have an OCT at their disposal will see that there is a “double hump” in the retinal nerve fibre layer profile around the disc.  The two humps are the inferior and superior regions of the disc:


Anyway, these two humps (the thickest parts of the optic nerve head) are the most prone to damage.  Any lady with a large chest will confirm this**.

If you think the optic disc of a right eye in terms of a clock face (superior is 12 o’clock, inferior 9 o’clock, nasal 6 o’clock and temporal 9 o’clock) then the areas corresponding to 6, 7, 11 and 12 on the clock are the most likely to be damaged by glaucoma.  For a left eye, it would be 5, 6, 12 and 1.  Interestingly enough, disc haemorrhages are usually seen in the inferior temporal portion of the disc (around 7 o’clock in right eyes and 5 o’clock in left eyes).

Further reading: Hood, D. C. Improving our understanding, and detection, of glaucomatous damage: an approach based upon optical coherence tomography (OCT). Progress in Retinal and Eye Research, 2017, 57: 46-75.


3) Normal tension glaucoma is a bit different.  Obviously it’s different in terms of intraocular pressure but let’s think about what causes glaucoma.  Well, there are two main theories: 1) the raised IOP squeezes the nerves until they die (the mechanical theory) and 2) there are issues with the blood supply, starving the nerves until they die (the vascular theory).  In normal tension glaucoma (NTG), the IOP is within normal limits (there’s nothing smooshing the nerves to death) so we can assume that the vascular theory is probably more applicable to NTG.

It’s been found that NTG patients tend to present with deep, well defined visual field defects that tend to be closer to fixation than those found in high tension glaucomas.

Normal tension glaucoma is probably one of the most challenging diseases to diagnose in practice.  If someone comes in with IOPs around 30mmHg, we are immediately on alert.  But, and I came across this a few weeks ago, what if your patient has IOPs around 15mmHg, moderate cup to disc ratio, deep cupping, no sign of focal neuroretinal rim (NRR) loss, normal central corneal thickness and a family history of glaucoma? Well, you do a 24-2 (as I did) and you find no defects.  Case closed?

My optom-sense was tingling from the moment I saw a photo of the patient’s discs – even before I heard that his father was registered blind as a result of glaucoma.  So I did a 10-2 test and, yes, there was a deep defect relatively close to fixation.

Research has been done into visual field defect location and those with a defect within 5 degrees of fixation are at a greater risk of losing their visual acuity – this makes NTG even scarier! It’s certainly worth taking an extra five minutes and doing a 10-2 test if the 24-2 is unremarkable but your gut instinct tells you something is amiss.

Further reading: Cho H.-K., Lee J., Lee M. & Kee C. Initial central scotomas vs peripheral scotomas in normal-tension glaucoma: clinical characteristics and progression rates. Eye, 2014, 28: 303-311.


4) Glaucoma doesn’t just affect the eye.  This is something I’d never really thought about until recently but what happens when those ganglion cells die? It creates dead space in the visual cortex.

You know that glaucoma is a disease which causes a negative scotoma (as opposed to the positive scotoma that results from advanced AMD) – why? Because the brain fills in the missing areas with information from around the scotoma.  When we talk about glaucoma, we may imagine tunnel vision but that’s not actually what patients say they experience.  They have blurred bits and missing bits.  It’s like that trick we do where we draw a small cross on a piece of paper then move it across our visual field until it disappears – that’s the cortex producing a negative scotoma so we aren’t aware we actually have a blind spot.

Of course, the cortex isn’t really doing us any favours when it comes to glaucoma – it’s hiding the disease from the patient and even when diagnosed, it’s sometimes difficult to convince a patient that they have an issue with their vision (especially when it comes to something as important as driving).

So, please don’t tell your patients that they have brain damage as well as glaucoma, but maybe be more aware that the visual experience of someone with the disease is different from what you may believe.  When those patients (and I’ve had my share) come in and say “something just isn’t right” then maybe think of glaucoma as a possibility – especially if they have normal IOPs.

Further reading: Crabb, D.P. A view on glaucoma – are we seeing it clearly? Eye, 2016, 30: 304–313.


5) Over 111 million people will be living with glaucoma by 2040.  I’ll just leave that there.

Further reading: Tham, Y.-C., Li, X., Wong, T.Y., Quigley, H.A., Aung, T., Cheng, C.-Y. Global prevalence of glaucoma and projections of glaucoma burden through 2040. Ophthalmology, 2014, 121, 2081–2090.


* If you are a Scottish optometrist, you can get access to Athens through your health board so you can read these papers for free.  If anyone in Wales, England or NI knows if this is also the case, please comment.

** Or men, I’m not being sexist here.

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.

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.


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


“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.