“My blood pressure was so high that I could have had another stroke or a heart attack”
Patient Robert Adams, 75, and optometrist, Iain Milne, from Ellerker Opticians, a Hakim Group practice in Shrewsbury, on identifying signs of a stroke
15 March 2021
Before you went for a sight test, had you experienced any symptoms and how had this affected you in day-to-day life?
Patient, Robert Adams (RA): It started quite innocuously. I was sitting calmly in my chair, but once I stood up it was as if I was hit by something, even though I hadn’t banged my head or anything. My eyesight, especially my right eye, suddenly became blurred and it was almost like a foggy black area around my vision. I put up with it over the weekend, but I was fairly concerned by the Monday, although I thought it was probably just a migraine.
In the following days I went to two doctors, as well as A&E and hospitals, but the only medication I was given was some antibiotics, as they thought it might be linked to an ear allergy, but that didn’t help. It wasn’t until I was able to get an appointment at the opticians, a week after I first noticed my symptoms, that I found out I had actually had a stroke.
How has COVID-19 changed the way you accessed the services you needed from your optometrist?RA: I wasn’t able to come into practice without first contacting them, so everything prior to the appointment was done over the phone. In the practice everyone was wearing personal protective equipment (PPE), there was a lot of sanitation and everyone was socially distancing, so I felt very safe.
What did the optometrist find, and how did they explain the next steps to you?RA: I had a visual fields test and Iain explained that, due to my results, it was very serious and that I needed to immediately go to A&E. Iain arranged a meeting at the hospital and told me I wasn’t allowed to drive. I went to the hospital clutching the printout of the test results that Iain had provided me. Those results were crucial to convincing doctors that I had had a stroke.
The doctors on the stroke ward really stressed that there is an important relationship between the eyes and having a stroke
Can you describe how you felt during the referral?RA: Prior to the eye exam I had not received a concrete answer about the problem, but I knew it was serious. Once Iain reiterated that I needed to go to hospital immediately, I was actually relieved that someone was agreeing with me that it was urgent. I had seen two doctors and no-one had recognised it. It was doing those tests at the opticians that immediately showed that there was something wrong.
Did you have to undergo further treatment and what has been the outcome?RA: Doctors at the hospital confirmed that I had had a stroke, so I was then transferred to the stroke ward in Telford. I had to stay over the weekend, during which time I was given three sets of medication to lower my dangerously high blood pressure so I didn’t have another stroke and to reduce any blockages in my arteries. I’ve been told I will be on these tablets for the rest of my life. I’ve had some more appointments at the hospital, including some intensive rehab and eye exercises, but thankfully my vision has vastly improved since then.
Before I retired, I was an artist and I continue to do it now as a hobby, so when this first started I was absolutely devastated as I thought I would never be able to use my eyes properly again
Have your views on the importance of sight tests and eye care changed as a result of this experience?RA: Absolutely. The doctors on the stroke ward really stressed that there is an important relationship between the eyes and having a stroke, which I was completely unaware of. It’s one of the main indicators that you have something very seriously wrong with you. I would recommend anyone to do what I did and get their eye sight tested, especially if they were having similar symptoms.
During that week of seeing different doctors until finally going to the opticians I had exceedingly high blood pressure, and there is a possibility that I could have had a heart attack if I was not seen in time. Without Iain, I wouldn’t have gone back to the hospital and I would have just put up with it, as I had tried everything. That could have been really dangerous, as my blood pressure was so high that I could have had another stroke or a heart attack – anything could have happened.
It was Iain’s intervention and his tests that enabled me to get treatment, and without the medication that followed I could have been on the cusp of something more serious.
How has the experience affected you?RA: You could definitely say that going to the opticians saved my life. It was so important that Iain recognised the fact I needed treatment straight away. Up to that point I wasn’t aware something like this could be seen from problems with my eyes.
Before I retired, I was an artist and I continue to do it now as a hobby, so when this first started I was absolutely devastated as I thought I would never be able to use my eyes properly again. There is a chance it could come back, and I could have another stroke, but thankfully things are now getting back to normal and I’m back in the workshop again.
My wife Isobel recently went into the practice and told Iain how thankful I am. I was helped there after not being helped anywhere else, and it really was so important what they did. Hopefully Iain, especially, knows how grateful I am.
Given that he was admitted on the spot and found to have suffered a stroke I don't think it's hyperbole to say it may have saved his life
How has COVID-19 affected your practice, and how did you adjust your services/approach to be able to meet the needs of your patients, such as in this case?
Iain Milne, optometrist director at Ellerker Opticians, a Hakim Group practice in Shrewsbury (IM): Initially COVID-19 had a huge impact. After the first lockdown had been established, we had a period of many weeks when we were unable to see patients face-to-face. As with other Hakim Group practices, we remained ‘open’ throughout, being contactable via telephone. We gained access to the NHS teleconsultation software, which allowed me to handle minor eye complaint episodes remotely. Any ‘red flag’ symptoms, such as a veil-like scotoma or complete visual loss, were referred directly to the local eye casualty.
By the end of May it became apparent that this approach was limited, particularly in differentiating anterior uveitis from blepharitis and for investigating posterior vitreous detachment. Acquiring the correct grade of PPE was difficult but, once we had a reliable supply established, we took the decision to start seeing patients with minor eye complaints face-to-face. I was acutely aware that contact time should be minimised, so we adapted the consultation process with history and symptoms conducted via telephone and a locked-door policy, with patients encouraged to arrive on time.
We have had OCT since 2011, and it has really come into its own in establishing an excellent assessment of macular health with minimal contact time. Following the College of Optometrists’ guidelines, we have prioritised essential and emergency care over the pandemic which means for cases like Robert’s, we were actually better placed than ever before to see him.
How did you interact with the patient and carry out the sight test? Have you introduced any technologies or systems that have helped you during COVID-19?IM: Because of the necessity to minimise contact time, we obtain a lot more information now before the patient even enters the room. We have a telephone triage system in place which establishes the reason a patient requires an examination – whether there is an urgent or essential eye care need, or simply a routine health screening.
In this case we had already established the nature and duration of Robert’s symptoms before he entered the practice. We have the freedom to perform only the tests that are clinically necessary or appropriate and to exercise our professional judgement on a case-by-case basis, without fear of recourse.
What did you identify during the sight test and what was your reaction?IM: Robert had been experiencing a loss of vision to his right-hand side. His acuity and ophthalmoscopy were normal but visual field testing revealed a homonymous hemianopia, suggesting a neurological pathology. I had suspected such a result whilst we were discussing his symptoms. My reaction was deep concern, but I also took solace in the knowledge that whatever underlying pathology was present would be properly investigated and managed.
How do you approach explaining what you suspected you had identified?IM: It was an interesting situation because the patient had already mentioned this to his GP but hadn't gotten anywhere. I showed him the results of the field test to explain that the missed points matched with his symptoms. I explained the significance of the presence of the same defect in both eyes and impressed upon him the potential seriousness of my findings. It is always difficult to strike the correct balance between alerting a patient to the gravity of an urgent pathology without causing undue distress, particularly until the underlying aetiology is confirmed.
What were the next steps that you took, and what was the significance of these steps to this case?IM: One of the differential diagnoses of the findings was a cerebrovascular accident so I instructed the patient to go immediately to A&E with a covering letter. Given that he was admitted on the spot and found to have suffered a stroke I don't think it's hyperbole to say it may have saved his life.
Iain’s three tips on making a referral during COVID-19
- Put yourself in the shoes of the person receiving the referral. Will they be able to determine what symptoms the patient is noticing, what signs you have detected and why the patient has been referred?
- Spell out your instructions – who do you want the patient to be seen by and by what point? If you are writing to a GP surgery, the admin staff simply want to know who to send the referral onto, ideally which sub-speciality and under what priority
- Get to know your local referral protocols. Your Local Optical Committee is very useful in this regard. Having a solid knowledge of the onward patient journey following a referral will give a much better insight in how to word your referrals.