Author Archive for: ‘Ian McLeish’

2016 03 31 00.33.21

25% OFF – Most anything – today only.

Kingscourt Craft and Trade Fair 2016

 

Purchase anything to do with spectacles or Opticians today ONLY from Victoria, at the Kingscourt Craft and Fair Trade, today, and receive a 25% discount!

Vicky is also displaying her Stella and Dot Jewelry range – the main reason for her being there.

The fair is open from 11.00 am until 6.00 pm.

Any purchases will be eligible for a 25% discount.*

*Offer excludes Corporate Eyecare, anything else is eligible – today only.

Happy Halloween

Bank Holiday Weekend Closure

Happy HalloweenPlease remember that it is a bank holiday this weekend, so as usual our practices will not be open on Saturday 29th , or Monday 31st, but will be open as normal on Tuesday.

Have a great weekend!

 

 

 

 

 

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!

?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!

Clip Art Pokemon 508076

Pokemon Go (Away)

A Pokemon, but not the one we caught I think

Sandra in Kingscourt caught a Pokemon sitting in the middle of our Kingscourt premises earlier today. It was completely in the way, and anyone could have tripped over it! Luckily she ?caught it, (by throwing a ball at it a few times??) and it is now “gone”-  wherever one of them “goes” when they are “captured”. I guess she will need to train it, but I will have to advise her that she will not be getting overtime for doing that!

What is this latest craze? idiocy? I am too old to be interested, but I would rather Nintendo et al would prevent their POCkEt MONsters from coming in to us, as they could be a bit disruptive!

I will not be installing the app, but I will ask my Bailieborough stand-in receptionist (Grace – Neasa is off after her wedding) to do so, to ensure both premises are free from these little trip hazards.

Well, perhaps I might install it (just to have a look at what it is all about, you understand) – everyone else has after all?

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