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.

Sunday, 26 June 2016


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.