iCare trip to Negril, Jamaica, part 2

So at the end of part 1 we had the clinic set up and we thought we were all set up and ready to go for the week, as a newbie how wrong were we?!

As refraction is the main part of what we do on a daily basis Heather and I started on team refraction with the aim of working out the best prescription we could for patients with the target of 20/40 (equivalent to 6/12 in UK which is the UK driving standards).

The patient journey started with crowd control and getting people into a queue then entering the church to be booked in and those at risk due to age or family history were seen at the nurses station for blood pressure and blood sugar check. Everyone then moved onto the vision station where their unaided vision, or vision with current glasses if applicable was tested using logMAR letters, numbers or tumbling Es depending on literacy and communication. After this they moved onto pre-testing where they had their interocular pressure measured, were dilated, and had auto-refraction to give us an idea of their prescription. The big station was triage where the patient had their eye health checked, retinoscopy to see if auto-refraction was right and a decision was made whether the patient needed refraction and prescription glasses, to see the doctors for a pathology check or if they just needed glasses for reading and sunglasses. (Everyone was given sunglasses to protect their eyes from the harmful UV of the Caribbean sun). The refraction station was next where a patient's prescription was checked and if needed we could also refer to pathology for a health check. The doctors in pathology were able to prescribe medication for glaucoma, refer for cataracts but also to send over to our laser team who were performing laser operations for glaucoma and diabetic retinopathy. After all this patients who needed prescription glasses were sent to the dispensary where the best glasses for the patient were found or made if needed.

For the first half of the week we also had a team who went out into local schools to screen children and refer to the main clinic later in the week. This team was made up of a couple of optometrists and a couple of students and at the end of the week we saw a few of the screened children coming through and helped them out.

Each day started with an early start with breakfast around 7:30 then meeting up with everyone at the buses at 8:00 for quick brief, making sure we had all equipment and drinks for the day then loading up onto the mini-buses for the 30 minute commute. Every morning we arrived at the clinic to find a queue of people which only seemed to increase as the day went on. Upon arrival we would organise drinks, move any tables and equipment needed, and in my case re-stick the tarpaulin covering the windows back up as it fell down every single day!

The doors opened at 9 and the queue would slowly start to filter through the stations which meant that it took about 30 minutes before I saw a patient but once they started they kept coming for pretty much the whole day. The patients varied between fairly normal hyperopic prescriptions on patients who could communicate well to patients with high prescriptions, often astigmatism, who struggled to understand the test and my accent. Astigmatism and hyperopia were definitely the trends of the week, rather than the myopes we tend to see in the UK. Lunch was cooked by a team of cooks from the other side of Jamaica who had been brought over specially for the week and you just tried to take a break in a slight lull when others from your section weren't at lunch. It was typical Jamaica fare of rice and beans, chicken and vegetables.

 
And then it was back to the grindstone of doing our best to help out as many patients as we could for the day and week. We closed the doors at around half 3 to 4 to allow the last patients to work their way through the system and be dispensed before we finished the day and had everything packed up for around 5 o'clock. And then it was back to the resort for around half five to six for a much needed cocktail and to enjoy the sunset.

The one exception was on Tuesday evening when we held a clinic for Sandals staff and we saw 65 staff within the 2 hours we had for the clinic, which was a great evening and a thank you to them for putting up with us all week.

In total our team of 49 volunteers served 2,682 patients in 5 days, performed 1944 vision exams in the clinic (not all had refraction) and 702 exams in local schools, 110 SLT laser surgeries (for glaucoma), 33 diabetic retinopathy PROP surgeries and distributed 739 pairs of prescription glasses (98 made in clinic) with 34 custom orders from the US. We distributed 1205 pairs of reading glasses and 2119 pairs of sunglasses. PHEW!

It was an amazing week and the two days of relaxation at the end were much needed before flying back to the UK and back to the routine day job. Seeing all the patients out there handicapped by simple visual problems that could be easily treated here in UK really showed how much we take our sight for granted and that there will almost always be a solution to any ocular problem we have via the NHS or private optometrists, and why it is so petty when people complain about the price of eye drops or a sight test (rant over).

Thank you to Great Shape Inc for organising the trip, Sandals for hosting us, everyone who donated to help us go and all our supporters. One love and bless up!

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.

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.