?Ocular Emergencies?

Had a young lady in recently who had slept in her contact lenses a day or three previously. She had been to her GP, who prescribed an antibiotic eye drop, and advised her to go to casualty if her symptoms deteriorated in the next few days – she was suffering with a very painful, and light sensitive eye.

I have never seen her before, so obviously she gets her contact lenses elsewhere.

Slit lamp examination showed a mid peripheral corneal infiltrate – a collection of white blood cells, with a slightly staining (damaged) overlying epithelium – the outer coating of the cornea was slightly damaged. I advised her that because she has a keratitis, I really should send her to an eye department in Dublin, but that as she was being treated by her GP, and it did look to be a sterile ulcer, I would be willing to leave her a day or two, and have another look at it.

A Sterile Ulcer can occur because the cornea releases chemicals to say that it is under attack – it is part of the immune reaction, but this can sometimes be triggered by bacteria on a non mobile contact lens releasing toxins which cause the reaction, but without there being an infection. The contact lenses were either very poorly fitting, which I think unlikely, as I know who fitted them, or stopped moving because she slept in them…. (eyes dry up when you are not blinking, and you do not blink when asleep – the lens sticks to the eye, stops moving and hey presto….)

She has thus far not returned.

I had another chap in this week with a similar issue, with multiple infiltrates in the upper part of one cornea only. He admitted to not changing his soft lenses as often as he had been instructed, and that his wife bought his contact lens solutions. She had bought a different one of late, and he was unable to tell me the name of the solutions, or even if it was a multipurpose solution (to disinfect contact lenses) or perhaps it was just a saline solution, which is suitable only for rinsing… (It was a green bottle, but that is little help!) He also did not know what type of lenses he was wearing.. Again his issue seemed to be sterile, and again I advised him that as he has a keratitis, that it was above my pay grade to determine the appropriate course of treatment, if any – he should go to casualty, and again he declined to do so.

A keratitis (corneal inflammation) is an ocular emergency, until proven otherwise.

In both of the previous corneal issues, a referral to the eye department would probably have resulted in an observation, followed by a repeat check in 3 or 4 days, with a common antibiotic, just to cover the possible risk of infection. As Optometrists in Ireland are not allowed to prescribe antibiotics, the best I could advise the gent was an antiseptic, to try to ensure that no secondary infection took hold. It is unfortunate that an eye problem in these parts requires a visit to the Eye and Ear Hospital, or the Mater Hospital in Dublin, but that is the way “specialisation” works in Ireland.

I have seen so many clients, who had to be seen by me THAT DAY, as they had an eye issue, who later either refused to go to casualty when advised to, or agreed to go the “next day”, and then did not – One man promised to go to casualty the following morning (it was very late in the day that I saw him), but then he went about a week later, having ensured the weeding, grass cutting, lawn edges and hedge trimming were up to date – this despite me advising him to go home and lie on his left side to ensure his retina fell “on” rather than “off”. His retina was successfully reattached with no apparent (to him) loss of vision.

Another Saturday special refused to go, but stated that he would go on Monday, if he felt it was no better. As I was 99% sure he had a retinal detachment, I advised that it would not get better, only worse. I wrote him a letter, and advised him that I was writing it on the presumption that he was leaving my premises and immediately going to Dublin.

Monday came and went, but by a week and a few days later – the next but one Wednesday, he did take the day off work to go to the eye department. Unfortunately, by that time, he could see very little as the retina had undergone a macular detachment – he could see nothing by that stage. It was “successfully” reattached, but he could read the smallest line on the chart when I saw him – now after the macula was reattached he can get a distorted half way down the chart, slowly – he can see letters 4 1/2 times bigger now than before, with a struggle.

He is aware he should have gone when I told him, and the only consolation I could offer is that he would have been able to nothing at all had he not gone when he did.

I am always amazed at the number of people who want to be seen the same day with an eye problem, but then refuse to take the advised course of action – why come to me/us if you are not going to accept that you really DO have an issue!?

I have had a lady refusing to go to hospital, as she had just had her hair done for that evening’s dinner party -a phone call to her GP put her right on that – retinal surgery the following morning! If she had not been so late for her appointment, perhaps I might have been able to tell her to cancel the hair appointment over at Edel’s before spending (though I doubt Edel would have been pleased!) – I seriously suspected an issue, but put in drops to dilate her pupils (to get a better view), and only confirmed the problem after her hair appointment. Her hair was lovely, but probably not so much after a day or two in a hospital bed?

We also a young lady who nearly refused to go to casualty when advised – to be fair she was in for a routine test, with no complaints and no problems. Fortunately she did go (she was sent to the GP with a sealed letter to have her “blood pressure” checked, but advising a trip to A&E,) She was released with medicine which will hopefully control her brain issue about a week later…

I saw a young girl a few years ago with a condition called papilloedema – Swollen optic Nerves, which must be considered very suspicious (of a space occupying lesion in the brain – possibly a brain tumour  – until proven otherwise). Fortunately most cases of papilloedema can be explained with less serious causes. This young girl had brain surgery the following evening.

Still the problem in itself can be serious – there is a court case in the UK, where an optometrist has been convicted of missing a case of papilloedema. She has been found guilty of “Gross Negligence Manslaughter”. She will be sentenced in the next week or so… She faces up to life imprisonment!  Sometimes, papilloedema can be subtle, but a close examination of the optic disc should show signs of it. Both of the cases I mention were obvious and unmissable, but I have personally also had another three or four of late which were less obvious. Personally I had thought that my first one – the young girl, would be the only one I found in my career, but unfortunately, I have had another four since her… To me, this condition seems to be becoming more common, but it is more likely that I have just been rather unfortunate….

Your local Optometrist should be the first port of call for any eye related worries, especially in contact lens wearers, though you should return to the place where you get your contact lenses – they know your eyes best, and most often details that you will not be able to supply (they are soft and circular!?! and the box is blue/white/peach). If you purchased off the internet, ask the internet to look at your eyes! only joking, but equally…. if you are not willing to accept the optometrist’s advice, perhaps you should not go to them at all??

We are aware that a trip to Dublin ruins the rest of your day, or longer, but we will not advise you go there unless we really think you need to! Oh, and tell us what drops the GP put you on – I have seen so many case where things got worse after the drops – are you sensitive to the drops, or the preservatives in the drops? Hard to tell 3  days later when you complain, and do not know the name of the drops!

Equally, in the case of all of the papilloedema, only the young girl was showing any signs of an issue, which caused her parents to book her for a test – she had a wandering eye -(why would a completely blind eye point in the same direction as its buddy?). All the other cases, bar one had no complaints at all – they were all routine tests. The “bar one” was a very young man who had had all of the treatment he could for his very aggressive brain tumour. He had sadly come to Ireland to be with his parents for his last few months. Only in his case were swollen optic nerves not a surprise. The young man wanted a pair of glasses, as I was able to improve his vision, but unfortunately, he passed before they were ready.

Life was so much easier in Glasgow, where there were 4 or 5 casualty departments who would deal with eyes in the city centre, 3 or 4 within reasonable walking distance…

We do understand your reluctance to go, but you do leave us in a difficult situation!

Local eyecare for all the family

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