My husband and I opened a practice in Kent, from scratch, back in 1985. Thirty-two years on, my husband has retired, the practice is sold, and I continue to work on a part-time basis. When I see a patient that we have cared for for 30 or more years, I feel both old and nostalgic. It is also interesting to track the aging eye. I have come to the conclusion that aging does not have a great deal to recommend it, as is illustrated by this case history.
Case study
1987
This patient was a pharmacist working for a big pharmaceutical company. At the age of 57, hyperopia and presbyopia were kicking in and he was inquiring about bifocals instead of his present readers. General health was good and he took no medication. His family history was relevant as his mother had glaucoma. Here are the relevant findings from this visit.
Refraction:
R +0.75/-0.25 x 155 (6/5)
L +1.00/-0.50 x 20 (6/9) Add +1.50 (N/5)
IOPs R13 L13 mmHg (NCT)
Friedmann fields full R and L
Discs 0.6 cupping R and L
On subsequent visits (1989, 1992 and 1995) little change of note was found.
1998
He was now reporting occasional dizziness that he was seeing his GP about and was now taking cholesterol tablets.
Refraction:
R +1.25/-0.50 x 15 (6/6+)
L+1.25/-0.50 x 45 (6/6-) Add +1.75 (N5)
Humphrey 81 fields full.
IOPs R12 L13mmHg
2000
Again, little change.
IOPs R15 L16mmHg
The images of the discs from this visit are shown in figures 1 and 2.
Figure 2: Right disc in 2000
2002
Now aged 67, the patient had attended our practice as an emergency, complaining of awareness of floaters over two previous to attendance. He was dilated and the peripheral retina examined. A left vitreous detachment diagnosed. No sign of tobacco dust, no holes or tears seen.
Figure 3: Left fundus 2003
2003
Fundus photographs are shown in figure 3 and 4. Refraction was stable and a slight lowering of IOPs was found. The patient was still aware of floaters in the left. Medication-wise, he was still taking cholesterol tablets.
Figure 4: Right fundus 2003
2004
The patient attended early as he was aware of his vision blurring. This was found to be related to his hyperopia increasing.
Refraction:
R+1.75/-0.50 x 145 (6/5)
L+2.00/-0.50 x 70 (6/6) add +1.75 (N5)
IOPs and medication as before.
Frequency Doubling fields full R and L.
2006
The patient reported occasional headaches at the back of his head. He also had noticed the occasional migrainous-type aura without headache. Refraction, medication and IOPs were the same as previously recorded. His GP checks his blood pressure and cholesterol regularly.
Humphry Full Fields 81 full.
Retinal vessels are now slightly irregular (figures 5 and 6).
Figure 5: Mosaic images of left retina in 2006
2009
The patient now reported increased awareness of floaters in the right eye for the previous four days. He was dilated and examined with Volk, and a right vitreous detachment was diagnosed. Again, no tobacco dust, tears or holes were seen.
IOPs R16 L17mmHg
Figure 7 shows the peripheral right fundus.
Figure 6: Mosaic images of right retina in 2006
2011
Now aged 77, the patient presented complaining of sporadic attacks of loss of upper vision on the right, each lasting about five minutes.
Fundus view remained unchanged, IOPs were 20mmHg R and L, and the frequency doubling fields full. Early lens opacification was seen in both eyes.
Figure 7: Mosaic view of right fundus at the time of right vitreous detachment in 2009
He was referred to his GP for investigation for possible amaurosis fugax. He had duplex scanning which showed mild blockage of the carotid. His erythrocyte sedimentation rate was normal suggesting there was no inflammatory cause. He was prescribed aspirin, blood pressure tablets and advised to continue with his cholesterol tablets.
2014
The patient reported occasional episodes of ‘shimmery vision’. He is still under the local vascular clinic and sees an ophthalmologist annually. Medication remains unchanged.
Refraction revealed his hyperopia to be increasing slightly;
R +2.00/-0.25 x 90 (6/6)
L +2.50/-1.00 x 95 (6/9+)
IOPs R 20 L16mmHg
OCT macular scans appear within normal limits (figure 8).
Figure 8: OCT macular scans for 2014
2016
The patient attended our practice as an emergency, sent by his GP via the PEARS scheme now operating in this area. He complained of ‘left blurred mauve vision’, sudden onset for one day.
Acuities R 6/9 L 6/18
Fundus examination showed a left lower branch retinal vein occlusion, with no macula oedema (figure 9).
Figure 9: OCT imaging showing branch retinal vein occlusion but no oedematous response
Disc appearance was of interest, with C/D ratios of R 0.6 and L 0.7, and there was a haemorrhage and possibly new vessels on the L disc.
IOPs were R18 and L13mmHg with NCT.
The patient was referred to the local eye rapid access clinic and was seen the next day.
I also asked the patient to make an urgent appointment with his GP for vascular work up, giving him a copy of the hospital referral letter for the GP. The hospital confirmed the branch occlusion but found IOPs as R 28 L 25mmHg. The patient was prescribed travoprost (prostaglandin analogue) drops once a day and blood checks were ordered:
- FBC – full blood count. Screens for conditions such as anaemia and reductions in blood cell types.
- CRP – C-reactive protein. Helps detect inflammation.
- ESR – erythrocyte sedimentation rate. Helps detect inflammation.
- Creatinine levels – helps confirm kidney function.
- Lipid and glucose levels.
Review in two months was arranged. I had a letter from the eye clinic summarising his care with them. He had had fluorescein angiography which showed signs of resolution of the haemorrhage. He was still on travoprost, though fields and pachymetry were arranged to assess whether that needed to be continued. Repeat OCT was also ordered for November.
Figure 10: OCT macula scans for 2017
Vision maintained
2017
The patient was still using travoprost. He reported that the vision in his left eye now seemed much improved;
R +2.00/ -0.25 x 65 (6/6-) L +3.00/ -1.50 x 95 (6/9+)
IOPs were R 13 L 12mmHg (NCT)
Lens opacities of grade 1 were now seen in both eyes. OCT scans for the maculae and discs are shown in figures 10 and 11 respectively.
Figure 11: OCT disc scans for 2017
I take some comfort in the fact that this gentleman is now 82 and still has good vision, can drive his car and read as much as he wishes, despite the ravages of age. I trust this will be the case for many more years to come, although I will probably only see him one more time before I hopefully join my husband in retirement.
Lynn Jackson works in independent practice in Kent.
