Monthly Archive for: ‘September, 2016’

Amaurosis Fugax and other things.

I recently saw a gent in Kingscourt who complained of a sudden painless loss of vision in one eye, which had happened three times in the last two weeks, and less frequently in the past. He was sufficiently concerned to book an eye test, though his medical card refused to cover him, (once again).

Though I was unable to detect any visual loss, an onward referral to the GP, requesting that he listen to the blood flow in the gent’s neck, resulted in an almost emergency (next day) onward referral to the Mater Stroke unit, where they cleaned out his Carotid artery, a procedure called a carotid endartectomy. This treatment is not without risk, and will never be done where the risk may exceed the benefits. This gent was experiencing Amaurosis Fugax (fleeting blindness) which is/was likely to become permanent in the near future.

Though this gent may still be at an increased risk of a stroke in the future, the medics felt that cleaning out the artery (a risky procedure) was less of a risk than leaving it alone.

I only know these facts because the GP called to “congratulate me” on a “good call”, after he asked the gent “Had he let me know that my suspicion was correct?” To which he answered that he had not, (and still has not)….

It is a sad tale in Ireland that we rarely hear back about a referral, unless it is done privately, where we always receive a letter -“Many thanks for your kind referral of this pleasant elderly lady/gentleman” Usually! We never receive a diagnosis or treatment  plan from the doctors, where someone is referred through the public system. Indeed, the only time I ever received a letter about a patient referred publicly was about a lady in Bailieborough who was incredibly forgetful, who would call for an eye test, despite having only had her eyes tested a month or two previously, and had not yet collected her new spectacles. A referral about her cataracts was “stonewalled” with a statement that “she was very happy with her vision”.

I would disagree that the lady was in any way happy with her vision, but there was no way anyone could ever get “informed consent” to perform the cataract procedures she required. She called within a week of my receiving that letter, once again complaining that she could not see, but she had no recollection of any previous eye specialist investigation! She was a nice old lady who has since passed away.

I have seen three patients in the past three years, maybe 4 with a condition called papilloedema, which I have previously written about. This condition is very rare – the first one I came across, I “chalked up” that I would never see that again in my career, hopefully. There is a court case ongoing in the UK at this time, about an Optometrist who failed to detect a case of papilloedema, where the young patient died four months after the eye test. This is troubling on many aspects – the optometrist in question could face life imprisonment for “involuntary manslaughter”, actually medical manslaughter. This despite the fact that she is not a Doctor, with all of the attributes that a Doctor receives (salary) etc. Yet of the three referrals I have urgently sent onwards to the hospitals, all of which later turned out to be completely correct, have we even received a letter back saying “good call, good catch, good referral”? No.

I only know the results by having called those patients (well, one called me – the one who called for a routine test and nearly refused to go to casualty, as she was too busy at work to go, and she “felt fine” – I had to get her GP to make her go, which fortunately he did), but otherwise the referring “practitioner” would still be in the dark.

Sad that a good call doesn’t merit a letter. Even a bad call letter would be welcome – referral feedback is incredibly important as to what I should have, and should not have referred. We are all constantly learning… A number of years ago, in Scotland, I referred a young boy with a suspect papilloedema, which later turned out to be Pseudo-papilloedema. This is a condition with a very similar ophthalmoscopic appearance – it looks the same. When I received the letter, I thought s**t I had not considered that as a possibility. That improved me as a clinician, but also consoled me, as the way they differentiated his cause was to do a CT scan, where they could see calcium deposits in the optic nerves. Often these “stones” are visible when looking into the eye, but they were not in his case. The medics have many more investigative techniques than the Optometrist!

Still and all, for any eye problem, however slight the first port of call these days should be your local optometrist, though Medical Card patients may find the wait to see us unfair… We cannot see any medical card patient until they have an authorised form from the local HSE department. Imagine if you had to apply and await authorisation to see the GP….. Waiting timers are reasonable at the moment, about 2 weeks, but the gent with the Amaurosis Fugax was deemed to not be able to wait two weeks – he was operated on there and then. What might have happened if he had decided to wait for a (may have been disallowed anyway) medical card eye test authorisation – his TWO YEAR normal interval, since his last test had not yet passed.

As an HSE employee recently said to Neasa “we pay enough!”, when someone recently sought a sooner that two year eye test. That patient was complaining of a distortion in his only eye – possibly Wet AMD, but the person who stamps the forms in the HSE did not consider this sufficiently important to authorise a test.

If this gent loses the vision in his only eye, the HSE will lose significantly more money in home care, home adaptations etc. But that is another department, and somebody else’s problem….

I imagine every optician has a credit card machine, and I KNOW every Medical Card holder has a plastic card with a magnetic strip on the back – there must be a way to update our terminals to check for authorisation without all of this paper pushing?!? I am sure the HSE could save money by allowing most every eye examination, and perhaps querying why Person X has had 3 in the past year. Perhaps the Medical card strip contains no magnetic data? I am sure this would save money, though there may be a few job losses for the people who stamp the forms in the 32 regional HSE offices.

Yup, you read that correctly – I understand that there are 32 regional HSE offices which assess medical card eye test applications. I guess each office employs at least two or three staff? The one we deal with does, at least.

There is a DFSA office in Letterkenny which can assess and authorise PRSI applications for the entire country – employing (I understand) 6 staff – FOR THE ENTIRE COUNTRY!

Apologies for getting a little of topic there!

Local eyecare for all the family