Clinical conundrums in practice

Optometrist, Scott Mackie, outlined his approach to a series of rare clinical cases in practice during his 100% Optical presentation, It may be rare but it’s in your chair.

The first case Mackie discussed involved a man with a swollen eye, who he saw while working at the vaccination centre during the pandemic.

“You notice people’s eyes more when they are wearing a face mask,” Mackie observed.

After Mackie vaccinated the man, he suggested that he come see him in practice.

Mackie initially suspected episcleritis and prescribed fluorometholone drops and carbomer gel.

However, when he reviewed the patient a week later, he was experiencing severe chemosis and congestion with reduced visual acuity and elevated intraocular pressure. The patient’s eye movement was also restricted.

Mackie shared that following referral to the hospital eye service, the 67-year-old man was diagnosed with a left indirect carotid cavernous fistula requiring surgery.

Reflecting on his initial decision to take action after observing the patient’s swollen eye, Mackie observed: “My wife said, ‘Why did you diagnose someone when you were injecting them?’ With this man, I thought it was the right thing to do.”

The next case Mackie discussed involved a 22-year-old man with a swollen left eye.

Mackie shared that while there was no reduction in vision, he decided to call the emergency department because of how poorly the patient reported feeling.

The man tested positive for neisseria meningitidis and received five days of intravenous antibiotic treatment in hospital.

Mackie then outlined the case of his friend’s 12-year-old son, who suddenly started experiencing blurred vision and seeing a grey blob in his right eye.

He shared that optical coherence tomography scans revealed elevation of the sensory retina and some blot haemorrhages.

The patient was referred to hospital for a series of tests to exclude a range of conditions, including large vessel arteritis, Behcet syndrome and Takayasu's arteritis.

He was prescribed a low daily dose of aspirin before being discharged from hospital care after two years.

“It all went back to being OK. That is a common thing in medicine – unknown aetiology. You don’t always find out what the cause is,” Mackie explained.

The next case Mackie discussed involved a 55-year-old woman with a local business who experienced a fleeting loss of vision.

Mackie recalled how the patient described her loss of vision to him.

“It was like a curtain coming down and then coming up,” he said.

The patient was found to have blood pressure of 191/101 and was referred to the local stroke pathway.

Mackie then described the case of an 88-year-old woman who began experiencing issues with her visual perception.

She would overfill her water glass and lose track of her pen when doing the crossword.

The patient told Mackie that she was seeing people walking about as if they were fragmented.

After referral to neurology, the woman was found to have posterior cortical atrophy.

During his presentation, Mackie reflected on the importance of having a network of colleagues to seek guidance from when unusual clinical cases arise in practice.

“When you’re working in hospital there is always a support network, but you might not have that in your practice,” he highlighted.

“My advice is to get yourself a pal,” Mackie emphasised.