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:

untitled

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).

Advertisements

This is just a quick post inspired by a lovely lady I met yesterday.  Mrs C has geographic atrophy at both maculae and is now registered partially sighted.  She popped in to see me for a chat.

Mrs C has been attending HES but, at the last visit, the doctor told her there wasn’t anything further they could do.  He had mentioned an operation (privately funded) but, at the time, she didn’t feel comfortable asking questions so here she was, on a rainy afternoon, hoping I could clear a few things up.

We spoke about the implantable mini telescope which is being offered privately to AMD patients.  She didn’t like the idea of surgery, having had right phako that didn’t improve her vision.  She also didn’t like the price (I don’t think anyone does).  I explained that it wasn’t a treatment as much as a built in magnifying lens that could also move the image out of the affected area of the retina and into an undamaged part.

Although she didn’t fancy the surgery, we had a great chat.  Mrs C is one of our patients with Charles Bonnet Syndrome but she’s unusual in that she sees buildings instead of people or patterns.  We talked a bit about that and I described some of the experiences my other patients have had (see my previous post on Charles Bonnet for details).

She also described getting a fright at the hospital when, after Volk, the consultant had turned blue.  Although he explained that it was the bleaching of the photoreceptors, she was still quite upset and wanted reassurance that it was normal.  I’ve had the same experience myself after a fundus photo, although the world turns purple in that case (at least for me).

Finally, I got onto magnifiers.  I asked if she had some and she said she just had the one.  It was a small, illuminated Eschenbach handheld magnifier and Mrs C complained that she very rarely used it, finding that she had to rest it on the paper she was trying to read (which isn’t ideal as she needs it for prices, labels, etc when shopping).  I discovered that she was using it with her reading glasses.  It had been 2 years since she’d been seen at a low vision clinic and obviously she’d forgotten that she needed her distance glasses on for it to work.

I asked her to try it with her distance specs, resting the magnifier on the paper to start and then bringing it towards her eye until the letters were clear.  That was much better.

The small magnifier is ideal for when she is out and about but we’re getting in a selection of illuminated stand magnifiers for her to try as Mrs C mentioned that it would be nice to be able to read her mail (her daughter is on hand to help usually).  I explained that the stand ones need her to use the reading glasses.  Her near visual acuity is N24 so I’ve asked for 4x magnification if possible (4x would have her reading N6 with difficulty but N8 a bit more fluently).

If you are a pre reg,  I’d recommend looking at the Eschenbach catalogue to get an idea of what is available for our VIPs – but remember that a good magnifier can easily cost £80+.

It’s become a bit of a running joke that I rarely get a lunch break. For some reason, people wait until around lunch time to seek help for problems that develop early in the morning/the night before/6 months ago. I’ve seen more emergencies around 12.30pm than any other time (excepting 9pm, the favourite time for problems during my pre-reg, but that’s only because I now work 9 to 5).

So, on Friday, I’d forgotten my sandwiches. I left one practice a little early, planning to drop my things in the other then head out to pick up lunch. As I walked towards the shop, I realised there were two people sitting in the waiting area. It was 55 mins until my first appointment of the afternoon.

When I got in, C explained that the older gentleman, Mr D, had been sent down by his doctor as the GP suspected a retinal detachment. The lady with him was his daughter.

Now, Mr D has dementia and mobility issues so I had to streamline my examination of him to limit the amount of moving around. I did non-contact tonometry (R 14 L 18mmHg) and brought him through to the test room. I explained about the eye drops and popped them in. After I’d done that, I moved onto history and symptoms.

Mr D had been looking at the TV that morning and said to his daughter that his right eye was “kaput”. 

Thinking this was a sudden loss of vision, she’d made an appointment with the GP who had a look with the direct ophthalmoscope. The GP had then referred them to us, telling the daughter that it sounded like a retinal detachment. Except, of course, there were no symptoms or signs consistent with a detachment.

On questioning, Mr D said that his eye had been blurry for a while, although he was unable to give an estimate of duration except for stating it was more than a week.

He was new to our practice so I had no access to his previous records. Indeed, they weren’t sure where he’d been tested last. All I knew was the prescription from his current specs and the fact his vision in his right eye was CF (counting fingers). Also, Mr D was attending the eye clinic every three months but both he and his daughter were unsure as to which clinic it was.

By this time, the TRO 1% had kicked in so I had a good look in both eyes, using my 90D superfield then my 78D to look at the disc and macula. Apart from some background diabetic retinopathy and a moderate cataract, I couldn’t see any issues. There was no tobacco dust and the only alarm bell was the pressure difference between the two eyes.

I explained my findings and decided to call the hospital. After summarising the situation, I explained to the nurse that Mr D was attending HES every three months and that I had no previous recorded vision. I also told the nurse that Mr D had dementia and was unsure of the duration of this blurred vision.

The nurse checked on the system and discovered Mr D’s right eye VA had been CF for some time. He was also due back at HES in two weeks. The nurse said that it was difficult for dementia patients with visual loss because they often forget they have an issue. Luckily, Mr D didn’t seem upset, just a little bemused at what was going on. His daughter, quite rightly, had wanted to get everything checked so was the driving force (figuratively and literally) behind his visit.

After thanking the nurse, I hung up and went into the waiting area. I told Mr D and his daughter that Mr D’s vision was the same as when he was last at the eye clinic and that he would be receiving an appointment soon. They were both quite pleased with the result.

As they left, my first appointment of the afternoon arrived…

During my penultimate year at uni, I tested a student who was unrefractable.  He was in the year below me and he couldn’t tell the difference between +1.00DS and -1.00DS.  He was 6/6 at +10.00DS and 6/6 at -10.00DS (fixed chart, if you are wondering).  At the end of the clinic, I was frazzled and thinking about qualifying in a profession that didn’t involve other people.  My supervisor took me aside and said, with a smile, that she was glad I’d had that particular patient as, being well known at uni as a perfectionist, I had to realise that sometimes you can’t get it 100% right.  You just had to do your best and use your common sense (hint hint, focimeter their current specs or use your ret result).

You learn to check vision at each stage in the refraction and stop giving a patient plus just because they’ve said the chart looks “the same” for the last few dioptres.  In reality, it should look better then the same then worse.  There’s only +0.50DS difference between better and worse, in my experience, so if your patient is stuck on “the same” for a while, check their vision – nine times out of ten, you’ve overplussed them and their VA will have reduced.

Sometimes you’ll need to think critically about what you are being told.  You will come across patients who answer “yes” to every single question.

Flashing lights? Yes. When? When I’m in bed at night, before I go to sleep.

Floaters? Yes. When? When I turn out the downstairs light.

Double vision? Yes. When? When I’m trying to read and not wearing my reading glasses.

Family history of glaucoma? Yes. Who? My mother/father but they had an operation to have the glaucoma removed…

Children are particularly bad for answering “yes” to everything but, on questioning (using the LOFTSEA approach), you’ll be able to separate true headaches from made-up ones.  The made-up ones only happen on Tuesdays and affect a one cubic centimetre area of the head for exactly 10 seconds.

There’s also a bit of external filtering that needs to happen.  Like the 12 year old, S, whose father had grudgingly brought him in for an eye test.  The father had never felt the need to get an eye test and he was sure S was making up his visual problems.

“His pal’s just got a pair of glasses and now he’s saying that he can’t see the board at school,” was the dismissive answer from his father when I asked S if he was having any problems with his vision.

In the room, away from his dad, S was more talkative.  He’d been gradually moved down to the front of the class but he was still having to copy his neighbour’s work because he couldn’t read the teacher’s writing.  It was embarrassing to S – both not being able to see the board and being accused of malingering by his family.

It just happened that his friend had got a new pair of specs recently* and that had prompted S to ask if he could go for an eye test.   No-one else in the family had specs – none of them had had an eye test before so this was, in itself, quite brave.

After a thorough history and symptoms, I suspected S was a little short sighted.  We moved onto vision and he was CF R&L, 6/60 binocularly.

I did ret and got approx -3.50DS R&L.  When I removed the working distance lenses, S was amazed. He could see the second bottom line (6/6 on my chart) and he was smiling for the first time since he walked into the practice.  A few minutes later, he was reading 6/5.  His eyes were perfectly healthy and I explained that being short sighted meant his eyes were a bit too powerful and that the glasses had lenses in them to take away some of the power when he was looking through them.

When we walked out of the room, S went back to being quiet and the smile slipped from his lips.

His dad had bounded up to him. “Nothing wrong with you, eh?”

I asked my optical assistant to help S look at the frames while I had a word with his dad.  I took the man into my room and sat him in the patient’s chair.

“S could barely see that top letter,” I pointed to the 6/60.  “He’s quite short sighted which means his distance vision isn’t that good but he’s fine with reading things up close.  Today, with the lenses I’ve prescribed, he can see the bottom line.”

“I can’t see the last three lines.”

“Then I think you might need an eye test.”

We glazed S’s specs then and there so he had them for school the next day.

 

* S had tried his friend’s specs on and they didn’t make his vision any better, which is not surprising since his friend was +6.00DS R&L (I also tested him).

One of my colleagues came to see me as he wanted a second opinion.  That morning, a woman had called and asked for an appointment for her mother as her mum was experiencing flashing lights and floaters.  My colleague (who does domiciliary visits) had gone to see her that day as he suspected a retinal detachment but when he arrived, the truth was a bit… well, stranger.

The lady, who was battling cancer and had limited mobility, described seeing vases with arms and disembodied heads wearing hats.  Her daughter had invented the flashes and floaters, apparently.  She wanted her mother seen as soon as possible and, I think, also suspected we would think her mum had a touch of dementia if she’d told us the truth.

My colleague wasn’t familiar with Charles Bonnet syndrome and had popped in to ask me what I made of it all.  In the end, I went back to the lady’s house with him and explained Charles Bonnet to her, her husband and her daughter: after a sudden decrease in central vision, her brain was filling in the spaces with some weird and wonderful things.  The good news was that the hallucinations were not frightening or disturbing to this lady – she viewed them with a detached curiosity, probably because of the medication she’d been prescribed for her pain.

This experience got me thinking about Charles Bonnet syndrome and the different stories I’d heard from patients.

One of my patients told me about a day out with her father (who had wet AMD in both eyes).  They had went to the botanical gardens in Glasgow and were walking around outside.  Suddenly, her father stopped and started staring at a hedge.  My patient looked at the hedge – probably one of the most boring, rectangular hedges in the gardens.  She had asked her father what he was looking at and he replied, describing beautiful flowers that were growing out of the hedge.  The detail he gave her was astounding and she was a little concerned that he was “seeing things” but she’d went home and found information on Charles Bonnet and that put her mind at ease.

Another patient told me about her brother who is now registered blind (he is also one of our housebound patients and she’d popped in that day to get her brother’s specs fixed).  When she goes to visit, he describes what’s happening in all the rooms of the houses around him, as if he can see through walls.  There’s always something going on, a table being laid for dinner or a family playing charades.  She assumed he had a very active imagination.

Yet another wet AMD patient described to me being able to see through the wall in her bathroom, out into the street, where two young girls, dressed in old fashioned white dresses, were playing.

An older man told me about looking out his window sometimes and seeing, clear as day, his brothers (who have all passed away) looking in at him.  He told me it was wonderful to see their faces again and all looking so young!

None of the VIPs mentioned seemed distressed by these experiences.  In fact, I would go as far as to say this phenomenon is comforting for some of my patients living with central vision loss.

On the other hand, I’ve heard of people seeing strange men standing in corners or spiders covering a wall which would obviously be frightening for anyone.  The best thing we can do for those with central vision loss is to educate both them about Charles Bonnet syndrome and to reassure that, although the experience is vivid and can be distressing, it is not a symptom of mental illness.  By including the family in the dialogue, we are increasing the chances of a patient confiding in someone about the experience and feeling less alone.

The College of Optometrists advise that, on average, you will see a retinal detachment every 16 months.  Now, I’ve been practising for a grand total of 37 months (including my pre-reg) and I’ve seen 6 or 7 (I don’t know if I should count one of them because I didn’t actually see the detachment – but I’ll talk about that in a moment).

Here’s a brief rundown of the seven:

1) Towards the end of my pre-reg, late one evening, I saw a patient with a peripheral horseshoe tear.  The main symptom was a coloured circle in their peripheral vision and sudden onset floaters.  Schaeffer’s sign was absent.

2) The second was an aphakic patient who had been in a fight over Christmas.  That was eight months after the first one.  Again, no Schaeffer’s sign but the capsule of the lens was floating around in the anterior vitreous, like a wet tissue.  The detachment was peripheral.

3) A month later, I saw a completely asymptomatic detachment.  The patient’s main complaint was slightly reduced near vision.  The macula was off and the retina was a pale yellow.  Again, no tobacco dust.

4) This one looked like a stroke on visual fields as the macula was half on, leading to a very definite hemianopia.  On returning to me a couple of months ago, I found out that the outcome for that eye was poor and the patient has AMD in the other eye.

5) A young man with proliferative diabetic retinopathy.  He had recently undergone a vitrectomy and treatment for a detachment in his right eye (caused by a pre-retinal bleed) and had woken up that morning unable to see at all.  The left vitreous was so cloudy, I couldn’t see anything so I referred him straight into HES.  He lives a few minutes away from the practice and sometimes I see him on my way home, holding his white cane close to his chest.

6) A lady with a high minus prescription who had noticed a black spot at the side of her vision.  There was a small hole temporally and the retinal was raised between the hole and the optic nerve.  The detachment was lovely and pink.  Again, no tobacco dust but there was a 5mmHg difference in pressure between the eyes (with the affected eye having the lower pressure).

7) This happened yesterday.  Well, actually, it happened on Sunday but my patient (a lovely lady whom I tested 6 months ago) didn’t want to be a bother*.  She came in because she’d been experiencing a curtain across her vision, affecting her right eye (I was so happy to hear that as this lady only has one “good eye” – the left).  When she told me that, I knew immediately that it was a detachment so I popped in some tropicamide and did a thorough history and symptoms while it worked.

On Volk, there was a large area of peripheral degeneration (that I’d noted in March) which seemed to be where the problem had started.  The inferior retina had ballooned out and the macula was barely attached.  The retina was floating around making it very difficult to focus on any particular area.  I could see a black flap at the extreme periphery if I tilted the Volk and asked my patient to look as far up as she could.

I called HES and there was a bit of a discussion on what to do next.  As mentioned, the patient was densely amblyopic in the affected eye so she’d gone from counting fingers to hand movements.  In the end, the ophthalmologist decided to see her that day and I’ll hear on Monday how she got on.

 

* This is something I hear often from my older patients.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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