12. Contact Lenses + an Extremely Rare Condition

My final day here at LV Prasad Eye institute has come to an end, marking the end of an incredible and insightful journey across the last fortnight into the world of ocular-related pathologies. What a ride it has been, the clinical exposure has been phenomenal and far better than I had anticipated before I travelled overseas. It’s actually quite sad to think today was the last time I’ll spend running around in a white coat through this incredible centre of excellence. I certainly hope that one day in the not too distant future to return here, once I have enhanced my knowledge in the field of optometry further, and endure a more hands on clinical experience, perhaps seeing patients of my own through another pre-arranged placement. Until then I’m sad to say goodbye, but thankful for the unparalleled opportunity to develop an understanding of many ocular-related conditions that I may never come across again, at least not in the frequency I’ve been exposed to them here.

For my last day of placement, I was posted in the contact lens department, where I was lucky enough to be exposed to one exceptionally rare genetic condition that I will discuss in further information below. The majority of patients I saw today were either being fitted with contact lenses for the first time or attending contact lens after care check-ups. This was fairly similar to that of the contact lens appointments that occur at the optical practice I work at in the UK, with the only exception being that almost every patient was diagnosed with keratoconus. For those of you who know me personally or have read my other blogs – you’ll know I also have been diagnosed with keratoconus, which is a condition that effects the cornea of my eyes. The cornea is the superficial transparent layer that forms the front of the eye, which normally has a rounded shape – however in keratoconus the cornea becomes more ‘cone’ shaped, resulting in non-ideal image formation leading to visual distortion and blurring. Note to all; Please don’t stare keep staring at my eyes every time you see me now, attempting to try and see this ‘cone’ of a cornea yourself – as its not visible with the naked eye, only at a microscopic level or using specific imaging machines designed to map the contours of the cornea.

Most of the consultations I observed today included the fitting or review of rigid gas permeable lenses (RGPs), which are ‘hard’ contact lenses that ultimately apply some pressure to the cornea, essentially forcing it back into a more suitable shape. The use of these lenses results in a much better quality of vision for individuals in general, but especially those with high astigmatism and keratoconus. I was actually amazed how much the visual acuity in these individuals improved with the use of lenses, with some of them not even able to view the test chart without the contact lenses but able to read down to the 6/7.6 or even 6/6 line (bottom line of the normal test chart) with them in. At the moment I currently have no corrective lenses for my own eyes, with my left eye being the only eye that’s really poorly effected as my right eye received treatment at a very early stage. I am however under the care Moorefield’s Eye hospital, where I have a contact lens fit arranged for the end of January, which I am extremely excited for now after my time in the contact lens department today. The idea of being able to regain near enough 6/6 visual acuity in my left eye again is something I desperately long for and can’t wait to hopefully achieve this.

Now, I would like to talk about the amazing and informative experience I had today, simply by being fortunate enough to find myself in the right place at the right time! I was able to sit in on a consultation with an 8-year-old male patient, who had been diagnosed with GAPO syndrome, an extremely rare genetic condition. To put into perspective how rare this condition is, only 38 known cases of GAPO syndrome have been recorded around the world since the year 1947. The abbreviation GAPO;

-       G = Growth Retardation (Patient was 8 years old but appeared to be the height and build of perhaps a 4/5-year-old, with small hands and feet, short limbs)

-       A = Alopecia (Hair loss or baldness – The patient was completely hairless)

-       P = Pseudoanodontia (The clinical absence of teeth, due to failure of eruption)

-       O = Ocular Manifestations (In this specific case, the patient presented with retinal detachment in his right eye at the age of 5, and complete blindness in his left eye)

This patient was actually from Yemen, UAE, and had flown to Hyderabad with the intention of receiving treatment for this disorder. The young boy and his father had been staying in Hyderabad for 6 weeks, as they’d had multiple appointments. He had received retinal reattachment surgery at the point this was diagnosed, around 4 years prior to the appointment today. The consultant explained how the patient had previously only been able to see hand movements, however now was able to see 6/12 with the correct spectacle prescription. I happened to find myself sitting in the penultimate consultation of the patients stay, where the child was given a contact lens purely for the cosmesis of his left eye, which had no vision at all and was completely white with no real distinguishable iris (colourful part of your eye) or pupil. It was incredibly heart-warming to see how fascinated the child was as he looked at himself in the mirror for the first time with a ‘normal’ appearance in his left eye, and the smile on his face was extremely uplifting. The satisfaction of the practitioner himself was incredibly obvious too, as he was genuinely so pleased with the positive response from the patient and his father. The father of the young boy must of taken about 20-30 photos of his son within the first 2 minutes of the contact lens being fitted and had already sent this on an array of WhatsApp groups to family back home in Yemen, including his wife who he kept attempting to video call.

This consultation was the perfect example of why I choose a career in optometry, being able to really make a difference and impact on individuals lives. Although the patient didn’t receive any treatment to give him vision in his left eye, as this is impossible even with the current advancements that we have in this field, the satisfaction he had as he left this consultation room was unbelievable and evident as ever. In general, I think so many of us only really gain an appreciation for the sense of sight when this tends to deteriorate, this is certainly true for myself as I only really valued my vision since developing keratoconus. This is something that so many of us take for granted, and today highlighted that in the most special and unique of ways. I wish the young child and his father a positive future, and I’m glad they received the management they had required, with the help and expertise of the extremely attentive LVPEI staff.

So that’s it! That’s the end of my placement here at this incredibly special centre of excellence, and an experience that I will forever treasure and hold close. I relish the opportunity to return, gain more experience, more exposure of clinical cases, and really go on to add value to and make a difference in the field of optometry. I will do a final blog tomorrow whilst I’m on the flight home, about my reflections on my time here. Until then, it’s time to pack as I’m leaving for the airport at 6am!

11. Cataracts

My eyes opened half an hour before my alarm was due to ruin my slumber, I only have the constant horning to blame, which starts in the early hours of the morning and continues throughout the entirety of the day. I don’t know how I haven’t adjusted to the loud noises that originate from the main road yet, bearing in mind back home I live just around the corner from Heathrow airport and directly under the flight path. I don’t even notice the planes fly over anymore, almost as if I’ve developed a niche type of selective hearing – with the only exemption being when the back-garden door is open, and the thunderous sound of the passing plane disrupts any ongoing conversations and completely over powers the sound of the television. Knowing my alarm was going to go off 30 minutes later made it near impossible to fall back asleep but didn’t stop me trying. My efforts were unsuccessful, in case you were wondering, so I lay in bed and thought about how Jose Mourinho was feeling after being sacked as Manchester United manager – though I’m glad this has finally happened as change was very much needed!

I’m starting to notice how much more energised I am in the mornings and throughout the first half of the day as a result of the large breakfasts I’ve been consuming on a daily basis. For about 2-3 years I’ve typically skipped the first meal of the day, which results in abnormally loud rumbling from my abdomen as midday approaches. By not having breakfast, I also normally find myself in a rather lethargic and tired state throughout the morning until I manage to get a meal in. On reflection, perhaps I should try and employ a more regular and healthy eating regime for 2019 – new year, new me or something like that. Today I am posted in cataract clinics, which is commonly known as a ‘cloudy lens’ in your eye that develops slowly over time and results in poor vision. Patients with a cataract often describe their vision as looking through a frost or fogged-up window, and this can eventually intervene with simple daily tasks such as driving, recognising faces and the ability to read.

In the clinic the majority of consultations I was able to sit in were centred around patients who were being referred for cataract surgery, or patients who were having post-operative check-ups to ensure prior surgical intervention was successful. One of the post-op consultations I observed was 72-year-old gentleman who was able to conversate in English extremely well, which made my understanding of the appointment a lot more comprehensive. He had recently received surgical treatment for his cataract, with the exact name of the procedure being phacoemulsification with the insertion of a foldable intraocular lens. From my understanding, this refers to the fact that the ‘cloudy’ lens was emulsified using an ultrasonic handpiece and aspirated from the eye. The fluid which has been removed is then replaced with a balanced salt solution to maintain the anterior chamber of the eye. During this procedure a foldable intraocular lens was placed to replace the faulty lens, which would allow a level of vision to be restored in the patient. The lens of our eye typically helps contribute significantly to ensuring light rays that enter our pupil are focused on the retina, to allow an image to be formed that resembles the object we’re looking at. The issue in cataracts is that the cloudy lens can obscure the light rays or cause them to reach the retina in a way that is undesirable – resulting in a blurred image. In this patient, the surgery was a success and he now had relatively good vision without the aid of his spectacles. On examination, the use of spectacle lenses of correct prescription did improve his vision further, allowing him to read what we describe as 6/6 or 20/20. The patient expressed his concerns that his current glasses that were prescribed over 2 years ago no longer really helped him, and he found vision was somewhat blurrier with them on. The optometrist explained this is completely normal following surgery, and a new prescription was issued – the patient was referred to the dispensing optician to choose new frames and have his new prescriptive lenses fitted.

Each of the cataract consultations were fairly similar, and in all honesty there’s not really too much more to write about. The only other thing that’s worth a mention is that I was lucky to have the opportunity to view some patients under the slit lamp myself, which was a valuable learning experience as I was able to see how a cataract appeared. The reason this was beneficial is because at University we currently only practice on each other, so although we gain theory of common eye conditions, we don’t actually get to physically see them. The consultant I was with today took aa particular interest in the fact I was an optometry student from London, and he took time to explain a number of things to me about each patient which enhanced my learning and understanding.

The highlight of my day was probably visiting the innovation centre. I can’t say too much about it, as I am sworn to secrecy having signed a form stating that I will not share any of the information I witnessed today. Some of the products that had been designed by the engineers to tackle common issues faced in optometry, were phenomenal and effective at performing the desired tasks. I would absolutely love the opportunity to re-visit LVPEI and spend a large proportion of time working in this department, helping develop current ideas further or even working on any ideas that I may be able to propose myself.

10. Surgery and Glaucoma

I woke up this morning to number of thoughts circulating around my mind, with the first being I can’t believe it’s only a week until Christmas. It feels like only a few weeks ago I was celebrating New Year’s Eve and welcoming 2018, yet here we are already on the final stretch with less than 2 weeks left as the year draws to an end. I can certainly say my time and experience at LVPEI will be one of many personal highlights from this calendar year. It’s getting increasingly difficult to wake up as the days go by, with the cumulative effect of fatigue taking its toll on my body, however I was extremely excited this morning as I had the opportunity to visit the operating theatres and witness surgeries. As I showered and got ready for my day, I felt my mind was distracted by a wave of anxiety that was battling with my excitement, as I couldn’t help but feel nervous for my placement today. I think there are many factors that contributed to this, with the main one being horror stories I’ve heard over the years of people passing out whilst observing operations. One of my best friend’s passed out unexpectedly whilst witnessing a surgical extraction not long ago, and he has quite a high tolerance for these sort of things – so I was worried and concerned that I might wake up to see all these bodies leaning over me as I regain consciousness. Stories my mum had told me about the number of times she’d passed out following injections or the sight of blood, as she suffers from a phobia of both needles and blood, were consuming my mind also. Determined to not let it affect me and prove my self-doubts wrong, I made my way to the operating rooms (somewhat hesitantly).

Upon my arrival I was directed to the changing rooms, where I was able to change into some scrubs. If you haven’t worn scrubs before, they are definitely one of the most comfortable things you will ever come across in my own opinion. They’re incredibly light and don’t restrict your movement at all, it almost feels like you’re naked, except for the fact that you’re not. I reported to the administrative staff sitting behind the first desk I saw, and explained I was a student from London here for an observational placement – they kindly asked me to take a seat in the room next door where patients were being prepared for surgery and to wait for a surgeon to arrive. It was quite surreal watching patients being guided into the room and directed to a hospital bed where many important measurements such as their blood pressure and oxygen saturations were taken prior to their surgery. This was also an opportunity for the medical staff to administer some injections and eyedrops as necessary, dependant on the treatment they were set to receive, and answer any queries or concerns the patient presented with. Some patients seemed far more concerned than others, shaking nervously or asking lots of questions, with others just lying on their bed and waiting for calmly to undergo their procedure. I was lucky to witness a number of surgeries including retinal re-attachments, routine cataracts and corneal cross-linking to stop the progression of keratoconus. It was so strange when watching the cross-linking surgery as I’d undergone this procedure twice before, which isn’t so invasive compared to the others – but was just weird being on the other side of the table, seeing this from the view of the practitioner rather than the patient.

It was amazing to see how the members of the team work in harmony with a great understanding throughout, to ensure the operation progresses smoothly and to allow the best possible outcome for the patient. All the professionals on duty maintained a calm and collected approach, and the level of fine intricate movements was exceptional, as a display of remarkable manual dexterity was on show for me to observe. During a retinal tear operation, I witnessed the use of an endoscopic laser that is used to make small burns around the retinal tear. The result of this is development of scar tissue, which sufficiently seals the retina to the underlying tissue, helping to prevent retinal detachment. In other surgeries where the retina had already been detached, I was intrigued about the prognosis of the patients. The ophthalmologist explained that the outcome of the treatment is dependent on the severity of the case, with a better outlook favouring those who have received surgery quickly following the detachment, as the photoreceptors responsible for our vision are more likely to be maintained. Other factors contribute significantly to the prognosis, with there normally being a poorer outcome for patients with macula-involvement as part of their detachment, as this is the part of our retina responsible for central and detailed vision. Spending time in the operating rooms was a valuable learning experience, having only previously seen this through YouTube and various healthcare related drama’s on tv.

I spent the afternoon in a glaucoma outpatient clinic, sitting in on a number of consultations. Glaucoma is the second leading cause of blindness, in which there is often increased ocular pressure resulting in damage to the optic nerve; the nerve that is responsible for carrying information from your eye to the brain. The early stages of glaucoma are often asymptomatic, which is dangerous as it means that when you actually notice issues with your vision, chances are the disease has progressed to a point where vision loss is irreversible. Typically, glaucoma effects the peripheral vision first and patient’s can present complaining of a reduced field of view or the sides of their view appearing blurry, this can often be referred to or thought of as ‘tunnel-vision’. Glaucoma can be either referred to as open-angle, where the normal meshwork that allows aqueous drainage from your eye seems normal in size and appearance, or closed-angle, where the drainage angle is reduced, and this obstruction leads to inadequate drainage and therefore increased intraocular pressure.

In all honesty, I didn’t see anything that particularly stood out in the glaucoma clinic today, probably due to the fact I only spent a short period of time in this clinic as surgery occupied the majority of my day. The consultations were pretty routine and similar to one another, with gonioscopy being the only new thing I was really exposed to. The gonioscope is a small type of lens used in conjunction with the slit lamp to allow a more detailed view of the internal drainage system within the ocular tissue. This is particularly important in glaucoma as it allows the practitioner to classify and differentiate the type of glaucoma, and state whether this is open angle or closed angle type.

At the end of the day I was asked to participate in a trial for a study on colour vision, in which one of the academic staff members at the hospital was working on in partnership with a professor from my University. I was fascinated to understand how these tests worked and quantified an individual’s level of colour vision and contrast sensitivity. It’s great to see that research within this field is being conducted on a global scale, and I’m interested to know what this partnership will go on to achieve and if similar results will be obtained both here in Hyderabad, and in the UK.

Only 3 more days to go – As expected time has flown by considerably fast.