One thing I am very grateful for is that over the years I have developed a sixth sense, along with good listening skills, to judge whether what a patient tells me is relevant to their examination or is influenced by a vivid imagination or sense of drama.
Patients will often have convoluted accounts of what brought to them to the consulting room or of what they have been under hospital care for. I’m sure we have all had a patient tell us they are suffering from ‘Kerry Katona’ (keratoconus).
One told me how their eye was removed at A&E after an industrial accident. The eye is back in place with a full range of eye movements and yet they insist it was placed onto their cheek while the foreign body was removed.
A high number of patients report double vision when upon further questioning it becomes clear that it is just blurred vision. I’ve had a spate of patients referred to me from the orthoptists with monocular diplopia, too, these last few months.
When I know I have a full clinic and my next patient is already waiting, I want to ignore the snippet of information that the patient in my chair has just imparted, but I know that it is always important to investigate further and elicit a little more detail to judge the accuracy of their concern.
It also makes for a much happier and loyal patient if I can give them some insight into their concerns. Too many of my patients over the years have turned out to have something more sinister than an active imagination.
There was the young teenager who returned after having a minimal prescription six months earlier. She was concerned as her vision was quite blurry. I was dubious about how much change could be there, and I observed her in the waiting area and as she entered the consulting room.
If her vision was as blurred as she was reporting, I thought that she’d struggle. She almost skipped in and then told me that her vision was blurred for distance and for close, but ok for middle distances. On looking with my Volk I found she had very subtle nasal margin disc swelling in both eyes. I was very grateful that I hadn’t dismissed her symptoms. An urgent referral revealed a large frontal lobe brain tumour, which was thankfully successfully removed.
There was the lady in her early 60s who kept returning with concerns over her new spectacles. Numerous rechecks and adjustments did nothing to help her symptoms, but she felt that inanimate objects were ‘jumping up at her’. Fortunately I had been to a lecture on dementia and the visual effects it can have due to disturbance to the visual pathway.
Something she said just made me consider that option. Sadly she did go on to be diagnosed with early onset dementia; however she has since told me how relieved she was to know that what she was experiencing was real and had a reason.
The patient from whom I learnt the most about not dismissing weird and wonderful reported symptoms was a 37-year-old who phoned to ask if it was normal for a virus to affect his vision. He was a typical, busy, successful man with a young family.
Rather than tell him to book in at his earliest convenience, I asked a few more questions, the first being in what way did he feel his vision had changed? His reply was that he could see everything, but it was like looking through a kaleidoscope of different colours.
I had certainly never come across that before, but as he wasn’t currently local to me, I suggested he saw another optometrist as soon as he could, just to rule things out.
I am forever grateful to the optometrist who listened to him, examined him, then spoke to an ophthalmologist and referred him immediately. He had suffered a brain haemorrhage as a result of a cavernoma located in between the hypothalamus and the optic chiasma – hence the visual disturbance. The reason why I am so grateful to is that the patient was my brother, who has been successfully treated and survived to tell the tale and see his family grow up.
That alone was enough to show me that while we do have to rule out and explain away a lot of insignificant symptoms, sometimes the one that sounds the most far-fetched is the one that we need to listen to most carefully.
Judy Lea is optometrist director of Specsavers, Longton, Staffordshire.