Category Archive for: ‘Clinical’

An Amsler Grid used to detect macular distortion and losses

Keep a check on your own sight!

 

Every year there is a national (AMD) week of attempting to raise awareness of the eye condition AMD (Age related Macular Degeneration).

There are two types of AMD. Neither form is curable at this time, but the vision in Dry AMD will slowly deteriorate over a number of years, and there is much evidence that eye health multivitamin supplements are very effective at slowing this condition down.

The more dramatic form of AMD is the exudative (Wet) form. This type of macular degeneration is caused by new blood vessels which grow underneath the retina. These vessels are leaky and prone to bursting. The leaking causes retinal swelling and visual distortion. The rupture of one of these blood vessels – a haemorrhage, causes the retina to be damaged into a scar which does not function. This means that the central straight ahead vision is irreparably damaged. This is the vision you require to read, drive, see the television and recognise a face, so it is a great loss to those who do not have it.

If Wet AMD is detected early enough it can be treated with intra-ocular injections of a drug which causes these abnormal vessels to “wither away”, and reduce their “leakiness”. This is likely to be an ongoing management, probably indefinitely, but it does significantly help control this condition. There are other possible treatments also, but this type is the most commonly used at the moment, as it is the most effective.

But here is the thing – A National Week of AMD awareness is not sufficient to deal with this devastating eye condition.

Neither is a regular sight test!!

Most eye conditions will be detected during a routine test, but Wet AMD can come on so rapidly that we would really need to be checking everyone every 3 weeks to exclude this possibility – obviously not possible. So you really do need to do this for yourself!

I am aware of many people who come in for a test, as they “need better glasses”, but it only becomes apparent to them (and me) that there has been a significant deterioration in their sight in one eye only. As they see as a pair, they were completely unaware of this significant drop in one – though we do not see twice as good with two eyes – 2 eyes are about 1.44 times better than one. But why really does it need the Optometrist to compare your eyes individually?

A particular gent I recall was very aware of Wet AMD as it is common in his family. He booked in not long (a couple of months) after he had had an eye test, as he had noticed that one of his eyes had changed – he noticed that a horizontal line had a very small kink in it in one eye. He was referred to see a specialist in Dublin, where the condition was unfortunately diagnosed in that eye. He had a round of three injections, and at his next scan, the specialist advised that the eye which was treated had responded well, but the condition was now also in the other eye. – It comes on that quickly!

So what to do?

Just compare your eyes! Ideally put an Amsler grid on the fridge door, but failing that, just compare the vision in the two eyes. If you can’t wink / close one at a time, use your hand to alternately cover the right and left eyes to compare them. If there is a difference between them, but there always was, (maybe you have a weaker eye), get to know what is normal for you? This way you should be able to detect the very earliest possible signs of this problematic disease, and the sooner it is detected, the sooner it can be treated, which is of the essence.

Once a week, be it the Sky guide, the Saorview guide, the newspaper or an Amsler grid, compare your eyes. I would also advise clients that they should come in if they are unsure if they have an issue – please do not wait until you are sure – this problem could be more advanced if you wait until you are sure!!

If you want to you can download an Amsler Grid Here.

 

 

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!

A child wearing a pair of Harry Potter style spectacles

Optometrists Disappointed No Alternative Offered To School-Exit Eye Screening

There has been a lot of discussion recently about allowing Optometrists in Ireland to see children – to take care of their eye care needs. Optometrists are already allowed to do most things required to deal with almost all children’s visual issues, but the sticking point is that the parent either goes (for free) to a community clinic, or goes to the local Optometrist, with no funding.

Below is a repost of a Press release from the Association of Optometrists;

A detailed pdf download is available here, but the answers is clear- it would be cheaper and more convenient to have the eye test government funded at the local Optometrist – very few children really do need to be seen in a hospital, and those that may would be seen much more quickly, if all of those children who did not need to be seen were to be examined elsewhere!

Call me a cynic, but there is a vested interest in having a very long waiting list to see the Community Ophthalmologist – what parent would wait the required year or so, when the child gets a letter home from school saying there is an issue, if they could possibly scrape together the money to be be seen much more quickly privately?

I have never personally been a fan of school screenings – I have seen many who have slipped through the net, and many more who failed, who were perfectly normal.

I used to work in Cumbria, England – there, the local health authority sent a Birthday card to every child at age Three, advising them that it was time to have their first (and free until 16 under the NHS) eye test. That is the best system I can think of, and to be brutally honest….many times a school screening is too little too late…

Some of this is recollection, but my son started at the Vale School aged 5. He started to wear spectacles in senior infants, as we found him to be short sighted. I do not think he had a school screening until second class, when he would have been probably 8 years old, and already wearing spectacles for 2 – 3 years. Perhaps he was off sick for the previous screening – I do not think so, but even if he was he should have been checked another day, where they would have found that he had been unable to see very much at all far away, though they would not know that his issue had been ongoing for 2 -3 years!! After a year waiting he may have been prescribed spectacles in the community clinic in Cavan (aged now 9). It is not good enough!

The most important message I can think of at this time is that parents must realise that it it their responsibility to to look after their child’s eye care – the state is not doing anything particularly useful for you or your child!

Here is the AOI press release;

 

Optometrists have expressed disappointment at a HSE decision to end routine eye screening of fifth and six class primary school children without offering any alternative – and called for major reform of children’s eye-care.

Primary School Principals have been written to advising them that the HSE primary school-exit eye screening service is to be discontinued with immediate effect – saying that there is a lack of evidence to support the effectiveness of the programme.

The Association of Optometrists (AOI) said it accepted that the effectiveness of the service was questionable, but removing a major part of the Primary School Children Optical Scheme and not replacing it, or reforming it, with something better is going to make outcomes worse.

AOI said that the move will further reduce eye-care services for children which are already highly compromised by waiting lists of up to five years for non-urgent cases and six months for urgent cases.

AOI’s Optometric Advisor Lynda McGivney Nolan called for commitment from the new Government to eliminate children’s eye-care waiting lists – by moving to a community based model of eye-care, similar to what has been successfully introduced in parts of the UK.

“Children’s waiting lists can be solved quickly by referring children directly from the school scheme to their local Optometrist. Under the current system in Ireland children are referred to HSE Community Clinics, or Hospital services where there are unacceptable delays.

“All children in fifth or sixth class who notice symptoms should be entitled to go to their Optometrist for an eye examination and for follow on treatment, or referral as required.

“There are 300 Optometry locations across the country with the skills, capacity and equipment to provide responsive and clinically effective eye-care.”

AOI said it understands that there have been regional variations in response to the HSE notice and that school-exit screening is still available in some parts of the country and has been ceased in others.

“This is typical of our eye-care services where there are unequal regional variations in service agreements. This further highlights the need to reform eye-care in Ireland to ensure equality of access and quality of service irrespective of where people live,” Ms. McGivney Nolan said.

The AOI said reforming to a community based model would not only eliminate waiting lists but also save the State money and improve health outcomes for children.

“On the estimation of a HSE Community Clinic examination costing €100 per visit and an Optometrist €60 per exam (plus other additional savings), annual cost savings of millions of euro can be achieved,” Ms. McGivney Nolan said.

AOI’s full position on reform of Irish eye-care, A Community Based Model for Eye-care, can be read at www.aoi.ie.

Further Information:

Association of Optometrists Ireland  (01) 4538850

Ronan Cavanagh, Cavanagh Communications: (086) 317 9731

Acanthamoeba Keratitis.

TAP WATER!! Never EVER…

I had a young man in earlier who was wearing a pair or Air Optix monthly replacement contact lenses, bought from an optician’s in Navan, from our prescription though.

He ran out of lenses about 1 month ago, so has been wearing this pair for two months now. To be fair the lenses looked in not too bad condition, but we cannot advise or condone wearing a medical device (which a contact lens is), for longer than it is designed, or licenced to be worn.

BUT…. he ran out of contact lens solutions also approximately 1 month ago, so he has been using — TAP WATER.

Tap water can commonly contain Acanthamoeba, which can cause devastating corneal infections – potentially sight threatening infection. Tap water does not kill bacteria, which will naturally be on the surface of the contact lenses – you need to clean the contact lenses and store them in an approved solution to kill off the the bugs which were not rubbed off. Acanthamoeba eat the “Biofilm” on the contact lens (the bacteria, mould spores, mucus and other contaminants which coat the lens during wear) so if there is no contamination on the lens there is less for an amoeba to eat. But if they get into your cornea, they will start eating the nerves in your cornea, which as you can imagine may “smart” a little. Often a “red flag” for an acanthamoeba infection is a very incredibly painful eye, with little sign that it should be so sore – it can take a while for the problems to begin to show up on examination.

Acanthamoeba Keratitis.Never ever ever store your contact lenses in tap water. You should not even ever allow water to get onto your contact lenses, which means thorough hand drying before handling the lenses (you did just wash your hands, didn’t you??) I gave him a new pair and told him to throw the old ones away. I also gave him some solutions to tide him over until his valuepack arrives.

This lad seems to have gotten away with it, hopefully, but I advised him (again) never to mix tap water with contact lenses. But I did advise him never to mix tap water with contact lenses when I originally fitted him, and taught him how to apply and remove them…. OK, that was a good few years ago, but just one more time…. DO NOT MIX TAP WATER AND CONTACT LENSES, AT ALL EVER!

We have a contact lens dos and don’ts on the website – it might not be a bad idea to have a quick refresher if you wear contact lenses.

 

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