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!

iCare trip to Negril, Jamaica part 1

At the end of October I flew out to Jamaica with a friend and colleague (Heather) as part of the iCare initiative run by Great Shape Inc., an American charity that provides a variety of services to the people of the Caribbean including dentistry, teaching the teachers and eye care. The iCare initiative has been running for 9 years, this year was the 10th year. This year it ran two projects in Jamaica, and one in Turks and Caicos. I went to the second week in Jamaica which was based in the west of Jamaica in Negril.

After getting up very early, about 5:40, to get a 9:45 flight we were on our way to Miami for a few hours of wandering around shops and trying to buy stamps for postcards. For reference you can't buy stamps in American airports for some stupid reason! A few hours later we were on last short flight down to Montego Bay, and then another 90 minutes of transfer to the resort. By the time we got to the resort it was about 22:00 local time but felt like 4 in the morning to us! So it was quick check in, finding rooms, saying brief hello to room-mates for the week before passing out with exhaustion.

Bob Marley statue in Time Square

Our first day in Jamaica was spent acclimatising to the weather, in Heather's case the gym, in my case getting a sneaky scuba dive in and trying to recover from the jet-lag. We then went for a walk down towards the town of Negril to do some souvenir shopping, pick up some post cards and get a feel for the area. The locals were really friendly although a little confused that we actually wanted to walk the couple of miles down to town rather than get a taxi. We caught a taxi back after a successful trip round Time Square, yes the mall (collection of 20 shops) is called Time Square, so we could watch the sunset. The sunset in Negril is truly stunning.

Sunset with a photobombing pelican

Sunday morning started with a brisk walk down the beach to enjoy the weather before fighting off the birds at breakfast, they really are persistent, before heading across the road to start the induction for the week, meet everyone and be told how it was all going to work for the week. We also donated some toys which are currently being donated to kids around Jamaica as part of the Sandals Foundation toy drive. In total there were 49 of us ranging from optometrists, student optometrists, ophthalmologists, dispensing opticians, student dispensers, lab technicians. nurses and retired engineers. Most were from various parts of the United States with a few Canadians and Heather and I as the sole British representatives. A lot of people were returners with some having done as many as 7 previous trips with iCare and a few had already done the mission to Ochi 2 weeks before.

The iCare Negril team

In the afternoon we headed down to Little London, where our clinic would be based for the week. Little London is a pleasant 30 minute drive from the resort, if you can cope with the randomness of Jamaican drivers. We were based in the Fellowship Church of God and it's neighbouring church hall. We spent the afternoon rearranging the church so there was a nice flow through all the different sections of booking in, nurses, visions, pre-tests, triage, refraction, pathology, laser, sunglasses and dispensing/lab in the church hall. As you can imagine doing all this lifting and moving in 28 degree heat was a little hot and sweaty so we were all grateful when we had finished and were able to go back to the resort to get changed and relax for the evening before bracing ourselves for the week to come.

The church being set-up

Boxes and boxes of lenses

 

The church (right) and church hall (left)

Phoropter ready to go

Trial lenses

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.

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).

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.

 

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.

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).