Tuesday, 12 June 2018

Polyopia

Myopia is short sightedness, hyperopia is long sightedness and diplopia is double vision, so what is polyopia? Polyopia is seeing more than one image, typically more than two (otherwise would just be classified as diplopia). It can be ocular, ie caused by a problem in the eyes so problem can be partially resolved by closing one eye or cerebral, caused by problem in brain.

I saw a lovely lady, aged 44, earlier in the week who had cerebral polyopia after having a stroke 14 years ago. If you looked at her eyes there was nothing wrong with them, normal discs, healthy maculae, clear media, everything was as it should be. Retinsocopy showed a minimal prescription of +0.25/-0.50x180 RE and +0.50/-0.50x180 LE so nothing significant there either. However the patient's vision and VA were 6/120 right, left and binocular and that was at a push. The problem was as the patient described it "I can see 24 images, 12 from right eye, 12 from left eye and they are all moving". So the problem wasn't that the eyes couldn't see, it was that the patient was seeing multiple moving copies of the image and wasn't sure which one was real. So the real test wasn't what could I do to improve the patient's sight, it was what I could do to reduce all the dancing images.

As the vision was poor, conventional methods of binocular vision assessment such as Maddox rod, Mallett fixation disparity won't work so it was purely subjective as to what felt best for the patient. As the issue was cerebral it wasn't as simple as just trying prism in one eye and then splitting for cosmesis, I needed to do each eye separately, and with no guide it was just purely a case of putting prism in different directions and finding out if patient found it was better or worse. In the end we found that 9 prism dioptre base in RE and 4 prism dioptre base in LE seemed to pretty much stop the movement in both eyes, which patient was amazed by and really pleased with.

Next up was reading, with any low vision patient this is always a compromise between clarity and comfort for working distance. Starting with +4.00 add we found this wasn't enough magnification for what the patient wanted so we starting increasing it. At the end we found a +12.00 add worked best for the patient which then meant we needed to increase the prism to help with the eyes converge.

The final problem is frame selection and getting some lenses to look good, but in my store that's for the dispensing team so I took my leave and left patient with our dispensing optician.

Thursday, 31 May 2018

Lightning strikes twice

About a year ago I saw a 59 year old gentleman for a routine sight test, in fact it was his first proper sight test. Unsurprisingly he needed a pair of glasses to help with close work, whilst his distance was pretty good - just a little bit of astigmatism in one eye. What was more remarkable was a longstanding retinal detachment in his right eye inferiorly, it had sealed pigmented edges and was out in periphery so wasn't affecting his vision or likely to but in need of a referral. So after checking what I was seeing was what I thought I was seeing with a colleague I called the on-call ophthalmologist at the local hospital eye casualty and arranged an appointment to check it in a few days.

Fast forward a year and the gentleman comes back in noticing a line like floater in his vision in the right eye, no shadow or cobweb over vision and no flashes. The referral from last test had resulted in a check and a lot of cancelled follow-ups but no treatment. Having a check undilated I noted a Weiss ring showing a posterior vitreous detachment but also a faint silver line temporally so dilation was definitely indicated (I'd have dilated even without this just to check periphery). After a brief wait (and seeing another patient in mean time) I called patient back in to have a look. Most of the periphery was flat and normal, previous scar present and unchanged and then the silver line was a horseshoe shaped tear in temporal peripheral retina. So it was onto the phone to chat with the on-call ophthalmologist and explain the situation before writing a letter and sending the patient on their way to the hospital, after answering the obligatory "is this serious?" question. Answer - where it is currently no, but if it spreads and your macula comes off then yes, very.

So my total for retinal tears/detachments moves onto 2 in  almost 3 years of practice so I'm slightly ahead of the average 1 every 16 months, although not sure if 2 in the same eye of the same patient should count as 1 or 2. Either way proof that lightning can unfortunately strike twice.

(For reference having a retinal detachment in the eye does make you more likely to have another one in same eye and the other eye).

Wednesday, 9 May 2018

Vision overseas

In the UK we are lucky enough to have a very good eye care system with a vast array of multiple and independent optometrists who offer private sight tests for a range of fees and NHS sight tests for those with entitlement, including under 16s, over 60s, certain income related benefits and those deemed to be at risk (or everyone in Scotland). There are enhanced optical services, chargeable in some parts of England, free in Wales and Scotland, for acute eye problems and further investigations to aid referrals to the hospital eye service. The NHS hospital eye service provides treatment free at point of use for all manner of eye conditions from routine procedures such as cataracts (although maybe not within correct timescale) to emergency appointments for uveitis, foreign bodies or papilloedema. There is also private hospital eye service for people with insurance providing extra cover for orthoptics, cataracts and other routine procedures. However the same is not the same worldwide, even in America you need insurance to cover the cost of the sight test and any prescription glasses you might need - myopes really have it tough; and that's another first world country, it's much worse in the developing world.

A few days ago I saw an article from the New York Times (high brow I know) about eye care in the developing world, in particular India. This section really struck me:
More than a billion people around the world need eyeglasses but don’t have them, researchers say, an affliction long overlooked on lists of public health priorities. Some estimates put that figure closer to 2.5 billion people. They include thousands of nearsighted Nigerian truck drivers who strain to see pedestrians darting across the road and middle-aged coffee farmers in Bolivia whose inability to see objects up close makes it hard to spot ripe beans for harvest.
 It seems such a simple thing but even according to the World Health Organisation up to 75% of blindness in the world could have been avoided. 60% of the the cases of blindness in 1996 were due to either cataract or refractive error. This could be prevented or cured with a simple 30 minute operation or a pair of glasses but isn't due to lack of care or money.

Even before I qualified I wanted to help give back to the world with my new skills, helping patients in the UK is great but with the exception of some emergency health appointments you are rarely making a significant difference to someone's life that they wouldn't be able to get elsewhere. Some of friends have helped out in Moldova, Romania, Uganda and elsewhere. For me the Caribbean has always had a special place in my heart, after I got married in Jamaica in 2006. Whilst there is some eye care available in the bigger towns and cities, if you have insurance, there is very little in rural parts with only 2 public health eye care providers for every 500,000 Jamaicans and no public health optometrists. 43% of Jamaicans have never seen or been treated for eye health problems in their lifetime! Because of this I am volunteering to help with Great Shape Inc on their iCare initiative in Jamaica this October. I will be doing some fundraising later on and will do my best to keep you updated on progress and what happens when I'm over there.
 

Monday, 30 April 2018

Low vision

Back with another random insight into patient's lives.

Visual impairment is a very subjective thing, I've seen people with best corrected VA of 6/12 (the legal driving standard) say their vision is fine, mostly non-drivers thankfully, and I've also seen people request referral for cataract, and be listed for surgery, with VA of 6/6+ in the affected eye because they feel they are getting glare and having problems whilst driving at night. I suppose it's all to do with how much of a problem their vision is causing them, which is why the cataract referral guidelines now make no link to VA and it's based on how the patient is being affected. I still try to put off patients with 6/6 VA, particularly if it's unaided, as they may well end up with worse vision after operation if the IOL isn't exactly the right prescription.

Low vision is also difficult to fully classify as some people don't want to admit that their sight is failing and using magnifiers is the last step to losing their independence. However just because you have low vision it doesn't mean you have to be downhearted, although there is an increased incidence of depression in patients with low vision.

A little while ago (read a few months as I haven't got round to writing this up) I had a patient in who had accepted his low vision and was thriving. Mr L, a gentleman in his mid 70s, came into the store and as he was being booked in the optical assistant asked how he felt his vision was with his glasses, to which the patient replied it was terrible. At this point the optical assistant was bracing herself for a rant about how we needed to do much better but the patient just commented that it wasn't any different from normal. The patient was then pretested and brought upstairs ready for the sight test. I quickly popped out of my room and grabbed the board to have a quick scan to see what the patient was like before calling them in, saw VA of 6/45 for both eyes from last sight test, and my heart sank. I was initially hoping it was a mistype for 6/4.5 but that would probably be a bit too much to expect for the average 70 year old (I have managed it at times). So I called Mr L in and started the test, it turned out that he had extensive dry AMD in one eye and had had wet AMD in the other eye but the treatment hadn't helped, just resulting with extensive macular scarring. This had happened about 10 years ago so patient had adapted to the poor vision, and whilst they couldn't drive or see much for close work they were confident getting around, albeit steadily. The test was more to just check there weren't any changes to the back of the eye, there weren't, rather than expecting any massive improvement in his vision. The actual refraction part of the sight test was relatively quick; retinoscopy will give a much better idea of prescription compared to subjective in this situation (especially when don't have a specialist low vision chart) then a quick subjective which surprisingly enough didn't reveal much of a change and certainly wasn't improving his vision in any substantial way so we left his spectacles as they are. Chatting with him after the test had finished I discovered he was registered severely sight impaired and had regular checks with the Welsh low vision service so had a range of magnifiers at home. He knew his vision was poor and that it wasn't going to get any better but was making the most of what he had and not letting it get him down.

So the moral of the story is just to make the most of what you've got, if you can improve it then take the opportunity.

Monday, 28 August 2017

Time flies

Thanks to the joys of Facebook memories the anniversary of 2 major milestones happened this past few weeks - starting my pre-reg and passing my OSCEs and becoming fully qualified.

First up was 2 years since I started my pre-reg. Looking back at my records, confidence and test times it is easy to see that I have progressed a lot. When I started I was getting everything checked, wanted to dilate every older patient with smaller pupils, was making big unnecessary changes to prescriptions resulting in retests and remakes and taking up to an hour to test patients. It has taken a lot of practice, over 1000 patients during pre-reg alone and a lot of extra work outside of the store to keep knowledge up to date. In a timely reminder of when I started our new pre-reg has just started her optometry career after working with us for the last 2 summers on summer placements. It'll be interesting and exciting to see how she progresses and I will do my best to pass on knowledge from my experience and any tips on how to get through it.

(Edit due to delay in posting I've also had the memory that I'd had visit 1)

Secondly, and possibly more importantly, was the notification that I'd passed my OSCEs and was now fully qualified. I still remember not being able to sleep properly the night before and being awake well before the expected time of 9am for the results to be posted online. Thankfully they were up before then and I had passed. The other thing about that day was that I was off on holiday 2 days later, and so had to get all paperwork sorted and sent off to ensure it was all sorted by the time I got back. So whilst on holiday I was constantly checking my email for updates whether I had my GOC number and then getting my NHS number sorted before I got back so I could get straight back to testing upon return. Luckily mine all got sorted whilst I was away, and so unlike some friends in England waiting on Capita, I was able to carry on testing almost every patient without any problem.

Whilst I learnt a lot through pre-reg and it helped build my confidence in testing I know I still have an awful lot to learn. It is also not an experience I would want to repeat anytime soon. A lot of what is holding me back from quicker, more efficient testing is just having confidence in my own abilities and knowledge. That is one of my personal downsides that I need to keep working on but it's coming (slowly).

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.