This article is best viewed in a PDF Format.
|
|
We first saw this patient many years ago, for both spectacles and gas-permeable contact lenses at our previous practice.
When we moved our practice, she decided to visit another practitioner nearer her home, but was not happy with the service she received. She found us in our new practice via the internet, and decided that she would prefer to pay for her check-ups to be done again by us.
When she arrived for her refraction on October 7, she said that she wasn't 100 per cent happy with her eyes she felt that something was wrong, but she was unable to describe it to me. As is usual in our practice, we recommended the Optomap retinal exam, so she and I could look at her eyes together in great detail. Her spectacle Rx at this time was:
R. -5.50/-1.00 x 180 6/6-
L. -5.00/-1.25 x 165 6/6 Add +1.75 N5
The Optomap image (Figure 1) showed a distinct tear and detachment on the temporal side of the right eye, which explained why she was finding difficulty describing the problem to me it would appear that the position of the tear corresponded to where her nose was in the field of view. The diagnosis was confirmed with the ophthalmoscope. Also visible in Figure 1 is the faint line extending across the fundus, barely 1.5DD from the macula at one point, indicating just how much of the retina was involved at this moment.
While she was having her contact lens check with the contact lens optician, I set out to try and locate the correct rapid referral track, not so easy, as our practice is not within the area covered by her PCT. Eventually, I managed to talk to an ophthalmic triage nurse, who was still on duty after 5 o'clock in the evening. An appointment was made for 10am the next day, and the patient was sent away.
She attended the hospital the next morning, where the junior doctor was unable to locate the detachment at all. She was assured that there was no defect visible, but to come back to the normal clinic in two weeks' time, just to confirm. She phoned to let us know, saying the hospital felt it was only a posterior vitreous detachment, why were we so worried?
By the time she returned to the hospital a fortnight later, the detachment was very obvious, and was diagnosed at once. She was sent to Moorfields and had the operation immediately. Unhappily, she had to cancel her Italian holiday, but felt her sight was infinitely more important.
Unfortunately, in December her retina detached again, and she had a second operation, which involved filling the eye with silicone oil, to be kept there for three months. She was warned at the time of the operation that she would definitely develop a cataract in that eye. The silicone oil altered the refraction of the right eye, as shown here:
R +0.75/-0.50 x 100 6/12-
L -5.50/-1.25 x 165 6/7.5+
Add +2.00 N5
She survived the three months wearing only one contact lens.
We warned her that, when the oil was removed, the eye would probably return to myopia again, but she had her cataract removed at the same time as the oil, and her refractive results from June 13 are as follows:
R +1.25/-0.50 x 60 6/12-
L -5.50/-1.25 x 165 6/7.5 +2.00 N5
The Optomap was carried out again, when she returned after all her treatment was finished, and the results are shown. (Figure 2) The scarring from the cryotherapy is extensive, but covers a smaller area when compared to the original detachment (Figure 1). She reports that Moorfields are pleased with her progress, and she has hopefully only one more visit before discharge.
She is now wearing one CL and is determined to have an Optomap retinal exam every year, to ensure her eyes remain healthy.
Conclusion
Several things come to mind while thinking about this patient. The first is that I am so glad she came to see us when she did. She could so easily have decided to wait and see us when her next check was due in a year's time. She has no memory of any trauma which could have caused the tear in the first place and finds this worrying, but we have assured her that all we can do is keep an eye on everything.
The hospital offered to remove the crystalline lens from the left eye at the same time as the right, but she wasn't given time to consider the advantages, and decided she could see no point in removing a perfectly healthy crystalline lens. Perhaps the problems of anisometropia should have been explained to her. It will be interesting to see how she gets on with her new spectacles!
We are able to see the fundus at greater magnification, and so is the patient. She is so grateful to us and Optomap as she realises just how close she was to losing the sight of her right eye. ?
? Lis Lowe partners a practice in Gillingham, which has used the Optomap system since August 2008