Sunday, 23 July 2017

An interesting cataract story

It appears my posting on here is getting less and less frequent but that is mostly due to being busier and busier at work. However there is one story that I felt needs to be told.

Cataracts are clouding of the lens in your eye that sits just behind your pupil and enables you to change the focal length of your eye so you can see things close up and far away. Most commonly they are caused by age but can be congenital, brought on by diabetes or steroid use, electric shocks and trauma.

In this case Mrs A, a lady in her mid 40s came in for a routine check as she felt the vision in her left eye was getting worse and seemed blurrier than her right eye. Now initially I thought this might just be a slight difference in prescription but said it had been getting noticeably worse over the past couple of weeks. Finished off history and symptoms (one point of note but that's the spoiler) and moved onto checking visions - R 6/6 unaided L HM?! Ok so this was looking a little bit more than just a slight change in prescription. Cover test fine, pupils reacted normally but whilst looking at the pupil reactions got first clue as to what the problem was.
So onto slit lamp examination, the right eye was fine, all looking healthy with no problems at all. Anterior segment of left eye, fine; onto the lens and there was a really dense cataract filling the entire lens. It was so dense that even with dilation I still couldn't get a view of the retina. Normally with that dense a cataract I would expect it to be congenital and patient to have no usable vision in that eye but the patient reported that had been fine previously (no previous record at the practice).

It's now time for the kicker - how it happened. The patient reported that a few weeks ago they had been boxing training and doing some pad work on uppercuts. The patient said they had thrown an uppercut but the pad had moved so instead of hitting a nice soft pad and stopping the punch continued and they had hit themself in the eye, which appeared to have caused a traumatic cataract to form over the space of past 3 weeks. Quite how they had failed to notice that vision was more than "a little blurry" I will never know.

Due to the history of trauma and the fact that I had no view of the retina I called the on-call ophthalmologist at the local hospital and described the situation. For normal cataract referrals we dilate and then send a letter to hospital and they are seen after a few weeks and placed on the list. For this patient I felt an assessment sooner rather than later was the best course of action and the ophthalmologist agreed to see them the following day at the eye casualty department. Unfortunately I haven't heard anything back from the hospital or patient to find out how they got on and what end result was.

Friday, 4 November 2016

Inter-linking disciplines

Whilst optometry and pharmacy have their rivalries at university; with the Cardiff Optometry/Pharmacy Varsity which pits the two courses against each other in a variety of sporting events. We also have our similarities; being public facing; analytical thinking; needing good communication skills and technical knowledge. However the biggest link between the two disciplines is that we are both involved in the primary health care sector; that is dealing with patients who present with particular problems, often of acute onset, and would like our specialist advice.

To this end it is good to foster good relationships with your local pharmacies so they know what you can supply or write signed orders for (the optometry version of a prescription). It also helps if they know a bit about the local minor eye care service (MECS) you can provide in England, or about the Eye Health Examination Wales (EHEW) which provides a similar service across all of Wales. This means that they can refer patients presenting with eye problems to you as a specialist part of primary care rather than sending them to their GP or to hospital, although this may be necessary in some cases.

As part of this for the past few weeks we have been having pharmacy students come into our practice and spend some time with us. During this time we explain the different parts of the eye care sector; dispensing opticians, optometrists, ophthalmologists, orthoptists and how we all work together to help patients. (Sorry to any contact lens opticians reading, you get lumped in with dispensing opticians I suppose). Whilst some have an idea of the different roles we all play, most have been surprised by how many roles there are and how they all come together. They sit in on a few sight tests to see how we explain ocular conditions and what side effects different medication can have on the eyes (few examples here). We also put them through the pre and post-screening we do routinely to help with their understanding of a routine test.

It's not just pharamacists that we, as optometrists, should be fostering better connections with; it's also GPs, the local hospital eye service particularly the on-call ophthalmologists who deal with everything we send from practice. This means that GPs can refer to the appropriate specialists and we can manage or refer appropriately. Feedback from all sides is important so we can all improve our knowledge and help patients better.

Sunday, 26 June 2016

Time

As I come towards the OSCEs I thought it fair to reflect on time. Time is a weird concept as Dr Who summed up:

Time comes up in several ways during pre-reg. Firstly the scheme for pre-reg is often a year, but can be extended up to 2 years depending on how the pre-registrant is getting on through the year. At first a year seems a very long time but to actually take the July OSCEs you need to have passed Stage 2 by early June, and if don't start to early August you're suddenly down to 10 months. Even when you start and you have that long it still seems relaxed until you get the date for your first assessment in 6-8 weeks. Whilst there are only 10 competencies in Visit 1 and it's more to get to know your assessor and see how you've been getting on, it is a nervous time. Then each successive visit is another 6 weeks and you're racing through the year. The trick is just to get your head down and get on with it all. If you're organised and have all your competencies planned then it's a lot easier to keep on track. 

The next part is testing time, when I first started my pre-reg I was on 1 hour for testing, then often a gap to dispense the patient or to enable me to reflect on how the test had gone, also known as what the hell just happened. This long test is needed as you may be unfamiliar with the equipment; a little (or very) nervous; struggling to remember your routine; thinking about competencies; getting your supervisor to check everything and just generally being slow. When you're sitting in your introductory talks and you hear you will be expected to be testing to 30 minutes by the end of pre-reg, you laugh and feel very afraid. When you start and your supervisor tells you, you'll be testing to 30 minutes or so by the end, you feel even more afraid, especially if you watch an experienced optom test. However, slowly and surely you learn to smooth corners, become more efficient at Volk/retinoscopy/history and symptoms and you start to become quicker. Then just as you start to feel comfortable with a test time, you get 5 minutes lopped off your test time and the panic starts all over again. I'm currently on 35 minutes and will be staying at that until qualified but it feels okay and I can test most people within that time without rushing, although there are still some patients that take a bit longer that I need to work on. Having your testing time come down is a compliment (no, really), it shows your supervisor has confidence in you and your abilities.

The last part of time is your spare time, or more likely at times the lack of it. During pre-reg you not only have to concentrate on your tests, ensuring your records are up to scratch, filling in all the paperwork for the assessments and revise for your assessments; you also need to find time to relax and switch off. Pre-reg is a daunting year but it is even worse if you are trying to think about optometry 24/7 then burn-out is inevitable and you and your patients will suffer. Take time out to continue with your hobbies, see your friends, go out; maybe even have a holiday.


Tuesday, 3 May 2016

Communication difficulties

I was originally going to call this post "difficult patients" but then I realised that the patients weren't being difficult, they were doing their best to help given their circumstances. Difficult patients are ones that are being awkward by design, either not giving helpful answers, trying to pre-empt the question and second guess what you are trying to do; or malingering and trying to get glasses they don't actually need.

The first patient, Mrs D had come in complaining of loss of central vision so mistyping letters on her keyboard. This sounds like, and is to an extent, a case of wet AMD; however the twist is that the patient was a mute and so couldn't speak. Given that a large part of the sight test involves talking to the patient and them responding it does throw a large spanner into the works. However it doesn't mean that the test is impossible, you just need to think on your feet and be flexible in how you and the patient approach the routine. In the case of Mrs D she brought a wipe clean little white board and pen with her and a pre-typed note detailing the main problems she was having. Given this and the previous record, working out the likely cause of the problem was the easy part but getting more detail was needed. So given the resources it was a case of asking the patient to write down what they could see and relying on nodding or shaking of head if things were getting better or worse. With the situation I knew subjective wasn't going to be great so concentrated on history and getting a good look at the macula to check for problems. If it had been a normal sight test then it may not have been as easy.

The other tricky patients are those who don't fully understand you, either due to not speaking English very well, thankfully I haven't had any Welsh only speakers (not far enough into the valleys); or due to dementia. In these cases you often have to rely on a relative or carer to help with history and symptoms either by telling you the problem or acting as interpreter. Performing a full subjective routine can take a bit longer and it really depends on how much the patient can understand and, in the case of dementia, respond. You really just need to play it by ear and if you can't get a response, try a different method or just rely on objective measurements i.e. retinoscopy, although this is best done using previous prescription as a starting point to help with accuracy and time. However that doesn't mean that you can't help the patient, you still need to do your best to get an accurate result and recommend what you believe is best for the patient.

Mrs H was a patient I saw with quite advanced dementia a few weeks ago, reviewing her previous records (always a good start) I noticed that last time she had come in with a carer who didn't know much about her and the family weren't getting involved, and that we had dilated her due to fairly dense cataracts. Having seen this I admit to approaching the appointment with a fair element of dread, but had booked out next appointment in case I overran. When Mrs H arrived she had her son with her, which was good that he should know a bit more detail about her situation. Once in the test room it became clear that Mrs H couldn't hold a full conversation so whilst directing the questions to her, I was expecting (and getting) the answers from her son. It turned out she used glasses for watching TV and they had broken, hence the test; she couldn't read anymore so near vision wasn't an issue. Having established vision and current acuity as best I could with the broken glasses I moved onto ophthalmoscopy and walked straight into some pretty dense cataracts, so in went a drop of Tropicamide 1.0% to dilate the pupils. Whilst the pupils were dilating I put the previous prescription into a trial frame and moved onto retinoscopy; thinking back I could have done it without trial frame to make patient more comfortable but I always end up getting the axis wrong. After finding a small change I tried subjective using large steps and bracketing to refine it a little, but vision was still rather reduced. By this point Mrs H's pupils had dilated sufficiently for me to check there wasn't any other problem with the fundus, there wasn't and that the reduction in vision was just due to the cataracts. A quick double check with the ret and it was done. (I have found that if dilating it is always best to check ret at end as well, even if not changing prescription, just to see if you are in right ball park). I discussed my findings with her son, but he wasn't keen to proceed with the cataract surgery; which I understood, the lady was over 90, frail and would need a general anaesthetic - a very high risk patient. After documenting everything, including reasons why referral declined, I found someone to help with the dispense and briefed them on the patient's needs i.e. basic TV glasses and handed them over. All in all it only took a little longer than my normal testing time (the joys of being on 35 minute tests) and I felt quite happy (and relieved) with the results.

It is patients like these that force you to re-assess how you approach communication with patients, it doesn't just affect these types of patients, it follows through into all patients; or at least I am trying to let it follow through into all patients. Optometry is very much about communicating with patients, some are easier than others but the common factor throughout all patients is you (or me) - the optometrist.



Thursday, 21 April 2016

Wet AMD

Yes, I have finally returned to blogging after a long hiatus. Pre-reg is a busy year and it has been hard to balance work, study, trying to relax and writing this blog. The good news is that I have now passed Stage 2 of the year so it is coming to an end (at last). Just the OSCEs left in a few months, but that's a subject for another day.

This blog however is about a lovely lady Mrs D who came in to see me a few weeks ago. She had last been to the practice over 2 years ago when we had spotted she had some small haemorrhages from the blood vessels below the retina at the back of her eye and referred her off to the hospital to be treated. She came back in on a Saturday afternoon with no problems but wanted some new varifocals as current ones were a bit old and she felt vision wasn't as good as it had been. However she wasn't complaining of any of the typical wet AMD symptoms of loss of central vision or distortion. She was still under the hospital, having been seen 10 days before her sight test, although she had not had an injection on the last visit. To make things a bit more complicated she was amblyopic in her right eye, BCVA of 6/45, so her left eye was very important to her.

I had run through history and symptoms, no major problems reported and checked vision with current glasses, 6/120 with balance lens in right, 6/9 in the left. No major BV problems and given that she had IOLs in both eyes I was pretty confident that a lens opacity wasn't the problem. Being optomistic I expected a small refractive change and to send her on her way with a new set of varifocals. So I moved onto the slit lamp examination to check everything. Right eye was fine, some drusen at the macula but nothing too bad and no problems with the retina, so onto to the left. Anterior eye, fine; lens capsule, clear IOL with no posterior opacification; disc, healthy; macula... Hang on what have we here, a few small haemorrhages. The macula appeared flat but subjective showed a little hyperopic shift implying some oedema. After having my supervisor double check we agreed that she should be referred back to the HES to be seen as soon as possible so I filled in the referral form and faxed it over. However it was a Saturday so I wasn't expecting anything to be picked up and dealt with until Monday.

A few days later I had a phone call from one of the ophthalmic secretaries saying they had picked up the referral and wanted to know how soon I thought they should be seen. They were thinking of a few weeks, whilst I thought it should be sooner as existing patient, vision was reasonably unaffected at the time so a better chance of a good outcome and due to the poor vision in the other eye. After pushing back she was booked in for just over a week later.

Fast forward to last week and I see her name in my diary booked in to see me to check refraction before looking at new varifocals. She had been off to the clinic for another Lucentis injection and had noticed the improvement in her vision. I had a quick look at the fundus and although there were still lots of drusen (they aren't going to go) there was no sign of any haemorrhages. Refraction showed she had basically gone back to her old prescription. As she left the test room she thanked me for looking after her, and I advised her to return if anything felt a bit different or to call the HES to get appointment moved up.

Saturday, 19 December 2015

Loneliness

It is often said that pre-reg is the loneliest time of an optoms career. It may seem weird when you are testing up to 10 patients a day plus talking to optical assistants and the rest of your team. However these are only 45 minute conversations about the same thing and although every effort is made to get to know the patient it is not a deep and meaningful.

What "they" are really talking about is the loneliness you feel being apart from the friends you have spent most of the last 3 years studying with, going out with and in many cases living with. Now you face working full time, studying when not in work, the stress of visits, working with different people and often living away from home. I'm slightly lucky in that I am living in the same house I did throughout my course and am working in store I did summer placement and worked part time in so I know everyone there and don't have to worry about living in a strange and different place.

It's not all doom and gloom though, your team in store will soon become like a second family and can help you find all those tricky patients you need for competencies and can sit as mock patients for visits. If you're really good some may even let you fit them with RGPs. With the rise of modern communication it is relatively easy to stay in contact with your course mates via whatsapp, facebook, facetime, phone, email, skype etc. I would thoroughly recommend setting up a chat with your closest friends so you can stay in contact, swap tips and generally just let off steam.

The other time for a good catch up is on various courses either run by the various multiples or recently by the College of Optometrists. Not only do these courses give you a great chance to learn a whole host of useful information, network with people from other universities, other stores, they are also a great time to sit down and have a chat with people you haven't seen for some time.

This is not intended as a depressing post, more just highlighting that you should make the most of time with friends at uni and to keep in contact with them throughout pre-reg for academic support and to try to keep you at the same level of sanity, whether that is completely sensible or totally loony!

Thursday, 29 October 2015

Children's eye health

Testing children can be a fun, exciting and at times frustrating experience. However it is one of the few occasions, other than emergencies, when you can make a real difference to an individuals sight and life. The reason for this is that children under the age of 8 or so (although some papers argue up to 12) are still in the plastic period where they can form new connections in the brain. This means that if a child has poor vision in one or both eyes, correcting it can mean extra connections in the brain and the child having equal vision.

At times the best option is to just prescribe glasses for full time wear . Fully correcting a child's refractive error can often stop a child developing amblyopia (a lazy eye) and can correct some types of squint. If the optometrist is monitoring the child then the child may well be recalled frequently to check their vision and how they are getting on with their glasses.

In other cases the optometrist may have to put drops into the eyes to dilate pupils and allow the eye muscles to relax. These drops do sting (quite a bit) so we suddenly become very unpopular after we have put the first drop in. However it does allow us to get the full prescription and can make all the difference between monitoring in practice with glasses or referring to be treated under the hospital eye service where drops are put in on almost every visit. Children are usually referred to the hospital if the vision stays uneven between the eyes or if there is a turn that they may be able to treat.

However it is not all doom, gloom, horrible patches and stinging eye drops. Correct a child's sight and they will be grateful and at times you can really make a difference to both their future and their now.

I tested a 4 year old whose mother had a lazy eye and was worried about her son developing a similar problem because of how it had affected her. Initial investigation showed a moderately high hypermetropic prescription which put the child at risk of developing a lazy eye or a turn, this meant we had to put drops in. I went from being quite nice to being horrible in one fell swoop as far as the child was concerned. After the drops had taken effect a bit more plus came out for overall refractive error of about +9.00 with -2.00 cyls. However after he had had time to adapt to wearing the trial frame he grew to appreciate the clarity he was seeing with compared to the without, so by the time he had chosen his glasses he was happy and I got a high five on the way out! I didn't get a chance to do the collection sadly but I can only hope it was similar to the viral video of Piper, the 10 month old.