“It was pretty evident that there was an issue”

Whilst on holiday in Scotland, Steve Coombs noticed he had reduced sight in his right eye. After contacting Eyeglass Opticians in Largs, North Ayrshire, his concerning symptoms led to an emergency appointment and an urgent referral. OT heard more from Steve and the practice team.

What led you to have an eye test? Before you went for a sight test, had you experienced any symptoms and how had this affected you in day-to-day life?

Steve Coombs (SC), patient: I have always had regular sight tests with my usual local practice. I am short-sighted, wear glasses, and occasionally daily contact lenses. I had noticed a slight degradation in my vision for the past few weeks and had booked an appointment to check all was okay and, if necessary, adjust my prescription. At this point there was no major issue and no change to my day-to-day life.

Whilst on holiday, I noticed I had really reduced sight in my right eye and a large circular blind spot on the left-hand side of my vision, as well as reduced peripheral vision. It was pretty evident that there was an issue. Of course, I Googled, which led me to a basic Amsler grid. This showed that I was unable to see any of the left-hand side of the grid.

Not being local to the area, we searched and attended Eyeglass Opticians in Largs, Scotland, to hopefully get some assistance.

What did the optometrist find, and how did they explain the next steps to you?

SC: The optometrist quickly discovered that I had a retinal detachment (macula off) in my right eye and that further hospital treatment was required.

It was explained to me what a detachment was, what might cause it, as well as the possible next steps, and that urgent care was required to provide a positive outcome. It was late afternoon by this time, and I was more than an hour away from any hospital.

I had Tropicamide 0.5% in both eyes and was made aware of how this would affect my sight for the next few hours. I was also advised at that point to sleep on my right-hand side until further investigation to try and reduce further damage.

The optometrist contacted a specialist eye hospital in Glasgow (Gartnavel General Hospital) and arranged an urgent appointment for me the following morning, explaining in detail what my symptoms were. I was provided with directions as we were reliant on public transport, along with a copy of detailed letters that had been sent to the hospital in advance. A letter was sent to my local GP of the findings. High-res scans of my eyes were also emailed to me so that I could provide them to the hospital staff.

Can you describe how you felt during the referral?

SC: I felt comfortable and in very good hands during my optometrist appointment. Space was made immediately available for me to have my sight checked and a variety of tests were performed. Each one was explained to me and any questions I had were answered honestly.

The referral was handled excellently. The process was very efficient due to them already having much of the detail. It was explained clearly what the next steps should be, and I felt at ease with the options presented. Surgery was required and the post-operative treatment was imperative for a good outcome.

I felt comfortable and in very good hands during my optometrist appointment

Did you have to undergo further treatment? What has the outcome been?

SC: I live close to London but was on holiday in Scotland. My appointment at Gartnavel was on a Saturday and they confirmed that the earliest I could have surgery would be Monday. We discussed the options with the hospital and decided that it made sense to travel home to London on the Saturday afternoon and attend Moorfields Eye Hospital on Sunday. Even if surgery was still on Monday, it would mean far less travel post-operation: one hour compared to 10.

Thankfully, I had the operation on Sunday morning, which was almost pain-free. The staff were excellent, very professional, with a little humour to keep me at ease. The first week was unpleasant with the posturing needed. My vision was almost zero for around 10 days, then it gradually improved as the gas bubble started to reduce in size, finally disappearing from view around 30 days after the operation. [At the time of interview] I’m at around 40 days post-operation and do have vision, although still quite blurred using that eye.

By all accounts, it can take several months before I can be confident of stable vision. I will have another hospital check at the eight-week stage.

Have your views on the importance of sight tests and eye care changed as a result of this experience?

SC: Having regular eye tests was always part of my life, and so I would wholeheartedly recommend this. What has changed, is that if anyone does have a sudden change in vision – be that reduction of sight, floaters, dull patches – then they should be checked quickly. If your regular optometrist isn’t able to accommodate these emergency checks then seek one that will.

How has the experience affected you?

SC: Short-term effects have been the cancelling of holidays and general events due to not being permitted to fly, and not being confident enough to drive yet. The post-operative posturing was difficult and did affect my ability to work and exercise.

Longer-term effects could be a reduction in my vision and the likelihood of further problems such as cataract issues. I’m hopeful that my vision does return fully and so the longer-term effects should, thankfully, be minimal.

I firmly believe in good clinical training of all optical staff and with this, any patient presenting with symptoms can be appropriately triaged and appointed according to the urgency of their symptoms

What did you identify during the sight test and what was your reaction?

Lynn Maclaren (LM), independent prescriber optometrist and partner inEyeglass Opticians: On presentation, I discovered poor central and nasal vision in the patient’s right eye. Right nasal field loss including macula, and on dilation, a retinal detachment was identified temporally in the right eye.

These findings were as predicted after a thorough triaging by Anne Allan, our dispensing optician, and Rachael Merrilees, trainee dispensing optician. Steve, who was on holiday from the Stansted area, attended the practice with concerning symptoms. He was aware of the symptoms of a detached retina as another family member had suffered with this condition. The patient had taken the initiative to check an Amsler chart online.

Following that, he contacted our practice where we prioritised him over a routine appointment. Emergencies must always take priority. I firmly believe in good clinical training of all optical staff and with this, any patient presenting with symptoms can be appropriately triaged and appointed according to the urgency of their symptoms. This allows us to triage optical emergencies as time can be of the essence. Fortunately, our front of practice staff are qualified dispensing opticians with good clinical knowledge. This allowed us to recognise how important it was for Steve to be seen and referred urgently.

How did you approach explaining what you had identified?

LM: I explained that Steve had a detached retina that was likely due to his short-sightedness, which can cause thinning of the retinal tissues. As the patient had noticed his vision getting slightly blurred over the previous two weeks, the likelihood was that the retina had been slowly detaching over that time. Steve’s vision had worsened when the central macula had detached that morning, prompting him to seek advice.

What were the next steps that you took, and what was the significance of these steps to this case?

LM: I performed slit lamp bio-microscopy and a 3D retinal scan which confirmed a temporal retinal detachment with macula off. We performed a central visual field test on both eyes. Fortunately, his left eye retina and visual field test were intact. Doing these tests confirmed the diagnosis and allowed for a visual representation for the ophthalmology team I was referring to.

I called the hospital triage to try and organise an emergency ophthalmology appointment – of course, it was half past four on a Friday. A phone call was made to the on-call ophthalmologist who agreed to examine Steve the next morning.

When did you hear about the results of your referral and how have you been involved since?

LM: Steve was assessed the following morning and was told he would require an operation to repair the detachment. It was agreed that he would travel home by train, where he would be operated on the following day at the local specialist hospital, allowing him to recover at home. Recovery from this operation takes around six weeks. Steve kept in touch with the practice in the days following the operation, and informed us of all that happened. We will hear from the hospital in due course.

What would be your three top tips to other practitioners when making a referral?

1. In Scotland most referrals are completed online, allowing for inclusion of all relevant information which should be concise and accurate. Fields, retinal scans, and fundus photographs can be included to give a full visual representation. Due to the urgency of the referral, the patient was asked to bring a copy of all our findings in paper form. We emailed the necessary technical information to Steve for easy access at his appointment
2. When a patient has a retinal detachment it is important to inform the patient to lie on the affected side as much as possible until they are seen by the ophthalmologist. Keep in touch with the patient to ensure they have been assessed, treated if required, and to ensure they are recovering well
3. Inform the GP of all relevant findings, including a copy of the original referral.