For this exercise, you were asked to consider the following scenario:
A seven-year-old boy attends your practice with his parent. They are new to your locality, having previously lived in another part of the UK, and the boy has broken his spectacles on the first day at his new school. His parent presents the following prescription for a replacement pair of spectacles. This had been issued from a hospital some 14 months previously.
R: +5.50/-1.25 x 180
L: +6.75/-1.00 x 170
His parent says he needs the glasses ‘as soon as possible’ as they help to control his ‘squint’ (a very apparent left convergent strabismus) as well as improving his vision. They also remember that the hospital had ‘used drops’ for his last test and hope this will not need to be done again.
You were asked to discuss the following;
What would be the best course of action in your practice to help this boy?
Most discussions covered the several areas of interest here. Firstly, the need for an immediate eye examination. Most correspondents felt this was important and to be done as soon as possible. Fourteen months for a child with a binocular vision anomaly (in this case what appears to be an accommodative convergent strabismus) is too long without a further refraction. Answers included comments such as ‘As the child has no current spectacles it is our opinion that a replacement set should be supplied as soon as possible.’ ‘Although it may be possible to supply a replacement pair on a GOS4, we consider that given the prescription is 14 months old, it would be normal procedure to re-test to obtain a current to date prescription.’
There was much debate around the need for a cycloplegic refraction, something most would rightly advise in such a case, and the possibility of having the child retested at a hospital department. One discussion in this area went as follows; ‘We both had slightly different opinions as to how to deal with this. My colleague works in a practice where the next available appointment has a three-week wait. So she would do a repair voucher, and get spectacles straight away. She would then discuss with parents if they are still under the hospital. If so, she would ask them to contact the hospital to arrange a refraction [presumably a cycloplegic]. I would book the patient in straight away if they aren’t under the hospital and reconfirm the refraction.’
A very few respondents felt little action here was needed, such as the following response; ‘I wouldn’t need to cycloplegic. If the squint is controlled and the acuity OK, I wouldn’t feel I need to refer back to the hospital. I would probably send a letter to the GP for information.’ This does assume somewhat complete confidence in the cover test with the non-cycloplegic correction in place and most would recommend a cycloplegic and full plus correction in cases of hyperopes with esotropia of seven years of age.
This was nicely outlined in the following response. ‘Given the nature of the prescription and the convergent squint, it would be normally necessary to determine the maximum plus Rx. This is best done with cycloplegic refraction, although the parents may be concerned about the use of cycloplegic drops. They should be advised that it is in the best interests of the child to determine the most accurate Rx, and is normally the test method of choice.’
Though many were aware that the child was reaching an age where they might well be discharged from the hospital for ongoing community practice management, most rightly felt the details of previous hospital care and the need for possible future hospital management, whether maintenance of care or simply confirmation of discharge, were needed. ‘My optometrist colleague advised that the hospital eye service tend to discharge children at their seventh birthday. Her opinion was to phone the previous hospital and request a discharge letter to be faxed. If the child has not been discharged, then to refer him ourselves to the hospital via the GP [would be appropriate] but this obviously means the child is left without spectacles which is not ideal.’
Others felt a re-referral at the new locality was appropriate, such as ‘The child should also be referred via the GP for further orthoptic assessment given the nature of the squint, and that this was probably on-going at the previous hospital and there is no reference to the child been discharged. Prior to the referral, we would consider it appropriate to contact the previous hospital department to obtain case notes as necessary, to aid in the referral notes and to have on file for possible future appointments.’
So the key points recognised were:
- The need for a new correction as soon as possible and to include a cycloplegic refraction.
- To establish the hospital care in place, whether discharged or the need to re-establish in the new area.
One final point for consideration – the fact that the child had their glasses broken on the first day at a new school might have suggested at least one careful question about the exact nature of this – remember our duty for safeguarding vulnerable children.