Day 3 of running around in a white coat feeling like I’m
featuring in an episode of House, or just about any other healthcare related
drama series on Tv! Before I get into the nitty gritty of the day, I’ll tell
you about my unfortunate run in with a bastard of a mosquito last night. I got
into bed at a decent time, glad that my sleeping pattern has now more or less
adjusted to suit the country that I’m currently residing in. Turns out I was sharing my sheet of a blanket with a
mosquito, who decided to feed on the right side of my back, waking up this
morning to what is probably best described as appearing to look like a
localised outbreak of chicken pox. That, paired with the sore throat and
accompanying cough that I seem to wake up with every morning during my time
here, led me to consider whether I should be at the hospital as a practitioner
or as a patient today. Mosquito 1, Aaron 0, wish I could taser the little
*insert inappropriate word of your choice*. After a little analysis of my back
in the bathroom mirror, drowning my organs by downing a 1L bottle of water so
fast, and having a refreshing shower listening to my ‘upbeat’ playlist – I
sucked it up, got dressed and rolled on with my day.
Today I was allocated to strabismus and squint, which
basically means that I saw patients with a ‘lazy eye’ in layman terms – this is
an issue where the two eyes do not maintain normal alignment. One of the eyes
will be deviated outwards, inwards, upwards or downwards, whilst the other eye
maintains fixation on a target – this can occur with varying levels of
severity, with some cases being a lot more obvious than others. In other cases, both eyes may deviate inwards, or outwards. Some statistics
I’ve seen online, supported by the shared opinions of many Dr’s I worked with
today, show that strabismus and squint are one of (if not THE) most common
ophthalmic issues present in individuals throughout India.
Before discussing some interesting patient cases that I saw
today with you all, I thought it would be insightful to share some differences
I’ve observed in how optometry in India is practiced in comparison to that of
the UK. Disclaimer; just to be clear for any of you who might get a bit hearty,
these are based on what I’ve witnessed with my own eyes (I was going to say my
own 2 eyes, but let’s be real – I only use one of them), and I don’t want
sweeping generalisations to be made from these few statements. I’m sure, just
as in the UK, each practice/organisation/individual have their own variations
of the way they do things.
Starting off on a more humorous note, I find that patient
comfort isn’t really something that’s taken too much into consideration from
what I’ve observed. I often see patients with their backs in all sorts of
positions as they’re positioned on the slit lamp for an examination, and the
practitioners often grab their heads and turn them in all kinds of directions
without any prior warning. Many paediatric patients that I’ve seen are often
kneeling on their chair or trying to support their body weight by propping
themselves up using the arms of the chair they’re sitting on. In addition to
this, I find it quite funny every time a patient leans forward slightly to try
and make out a line on the letter chart that might be slightly blurry for them,
only to have the optometrist push their head forcefully back against the chair
– this did make me laugh and reminded me of what it’s like to be in clinic’s
practicing on my colleagues at University. Other differences I’ve seen here in
optometry related practices include that as far as I am aware, every patient
I’ve seen has been asked to read the entire test chart from the top line down –
rather than jumping immediately to the clearest line that they can see, or the
one above that. When refracting the patients, the optometrists use a letter as
the distant target, as oppose to duochrome (the red and green circles you see
when you go to get your eyes tested) – which is something I’d unfortunately
lose marks for if I did this in my exams. The final thing I want to mention is
that the Goldmann Tonometer is the preferred machine used to test intraocular
pressure here, which is comprised of a little rod-like thing that sticks out
and actually touches the surface of your eye – you’ll be glad to know that the
patients normally have anaesthetic eye drops put in before this is done! In the
UK we mostly use the machines that blow out a puff of air and then produce a
reading – I hate those enough, can’t imagine how much of an annoying patient
I’d be if you actually tried to prod my eye, don’t expect me to return.
Anyway, onto some of the interesting patients I saw today! I
was actually more specifically working in the paediatric squint department, and
the majority of patients I observed were under the age of 10, with some of them
being only a couple of months old. Patient number 1 that I’d like to discuss
was a hyperactive 6-year-old male, whose parents had brought him in for his
first consultation as they’d spotted a slight deviation of his left eye and
were concerned. After measuring his vision using a distance letter chart and
near reading chart, his stereopsis was assessed using a wide range of
puzzle-like games, which was excellent at keeping him engaged, especially
considering his hyperactivity. Stereopsis is known as your depth-perception,
with individuals requiring visual information from both eyes to be able to
accurately perceive the depth of things. Depth perception is often an issue
with patients that have a lazy eye at a young age, as they can become
relatively one eye dependent and rewire their brains to suppress the function
of their affected eye. I thought the optometrist was excellent as keeping the
child’s attention at all times, asking him questions throughout and getting him
to read whilst he performed cover/uncover tests to assess the severity of his
deviation. In the UK we commonly quantify the level of deviation using a prism
bar, which includes prismatic lenses that gradually increase in power – but the
fact they’re in a bar means you can slide the bar along, so the patient doesn’t
have a break whilst moving from one power to another. Here however, they seemed
to have individual prisms that they use one by one, meaning the patient has
intermittent periods of a prism and then no prism in front of their eye – I
wonder how this affects the results, as I’ve always been taught to not allow
this to happen! After determining what was believed to be a suitable
prescription, the patient was given eyedrops of tropicamide and phenylephrine –
which results in dilation of the pupil and a reduction in the ability to
accommodate, which can lead to the production of an inaccurate prescription.
Accommodation refers to the patient’s ability to change the shape of their lens
in order to focus on objects at near, which is something that is normally present
in young people but is gradually lost with age (hence why the elder population
often require bifocals/varifocals to focus on things at various distances not
just the distance, and without visual correction they struggle to read things
close and hold them slightly further away). The patient’s results were then
rechecked 40 minutes later following the introduction of these ocular drugs,
which had changed very slightly, and suitable spectacle prescription was
dispensed.
Patient number 2 was a 4-year-old girl who had previously
been diagnosed with a refractive accommodative left esotropia – which means
that her left eye is deviated in towards her nose, however when she wears her
visual correction her eyes align as we would expect, and presence of strabismus
is absent. This was something completely new to me, which is why I took a
particular interest. Interestingly, the patient was examined using the same
tests as the previous patient detailed above – however her glasses were kept on
throughout, which I found strange but is completely normal procedure for this
condition. The patient was prescribed bifocal spectacles, which are comprised
of a distance prescription and a small segment that contains her near addition
to allow her to focus on things at near and maintain regular alignment and
prevent her left eye from deviating inwards when she reads. I had no idea this
was even a thing, as I’ve always seen bifocals as something the elder
population would be prescribed and would never have previously even considered
this an option for a young child. In addition, the child was also prescribed an
eye-patch to wear for 2-4 hours a day that should cover her ‘good’ eye, to
force the weaker eye to work harder and communicate with the brain, building up
strength in the currently imbalanced muscles around her globe.
Other than squints and strabismus I observed a number of
pre- and post-operative paediatric congenital cataract surgery appointments,
where young patients who had faulty ‘cloudy’ lenses were referred for corrective
surgery or had just received this treatment. The consultant optometrist who
held this clinic explained that the hospital prioritises the younger children,
typically under a year of age, and they would undergo surgery within 5 days. I
would assume this varies dramatically from standard NHS waiting times in the
UK, but I’m basing that on pure opinion rather than any actual facts – so I’m
not entirely sure. The consultant also explained that the prognosis of
patient’s depended a lot on the age that the patient undergoes the surgery,
with patients within under the age of 1 years normally having fairly good
visual acuity later in life.
The reason I found today’s clinic particularly interesting
was that it closely related with everything I have learnt so far during the
first term of my 2nd year Binocular vision module at university.
Given the opportunity to carry out a number of tests on these patients such as
cover/uncover, stereopsis tests assessments of their visual fields allowed me
to gain a greater understanding of many of the topics I’ve encountered on my
course. I look forward to taking the knowledge and experience I have gained
with me today, back to University – paired with some questions that I have for
my tutor.
So that’s another day of placement completed, day 3 out of
11 clinical days here of my placement, and I feel like I’ve gained a great deal
of knowledge so far. I’m thoroughly enjoying my experiences here and the
passion I have for the field of optometry is continuing to grow and develop. I’m
also gaining a greater appreciation for the various fields and specialisms
within this career choice, and one day would like to contribute significantly
to this field both clinically but also on a research front.
My sleeping pattern has adjusted, as mentioned earlier – but
I’m currently battling in my mind whether to stay up tonight to watch the
ManUtd game in the champions league – with the time difference it doesn’t kick
off till 1.30am here. Will let you know what I decide, fully aware that its
probably not a good decision but also aware that I most likely will stay up!
Either way, I’ll be back again tomorrow!
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