The Eyes Have It Part 1

This follows on my earlier post “The Eyes Have It - Introduction” and I hope readers will find it useful.

So, Gentle Reader, you have had your annual retinal photograph, you have survived the demon drops and - thanks to your sunglasses - the dangerous journey home afterwards.  Having almost been knocked down by an ambulance before I realised the necessity of wearing sunglasses after dilating drops WHATEVER THE WEATHER I am pleased to note that most opticians now recommend this to patients.

Now you must await the results. The all - clear received with a sigh of relief and then either a slightly smug feeling or a feeling of having "got-away with it” when any backsliding with regard to diet is recalled. The sobering feeling when you are told there are some slight retinal changes and the resolutions to do better after your 12 month reprieve.

Finally, for some unfortunates - the dreaded referral to the hospital eye clinic. The notification and appointment is received with varying degrees of anxiety. Some want an immediate appointment as they have heard that early treatment is vital. The appointment date seems ridiculously far away. Others seek an immediate appointment with their GP to demand further explanation. A great many others just panic inwardly and dread the whole process. but don't know where to turn for advice.

Except for a few, the results of this first visit may well turn out to be an anticlimax. The fact of the matter is, that in the vast majority of cases, nothing much will happen as a result of this first visit. If possible, try to regard it as a follow up to the screening - a way of getting into the system so that you may be more closely monitored by the experts. Rather than worrying about it, think of it as a precautionary measure and consider yourself lucky. A few years ago you would not have been aware of any possible problem until your vision was affected. I can only speak from my own experience but I suspect most eye clinics are organised to a similar model.

On your first visit you are asked to bring a urine sample and your blood pressure is checked. This does not happen on future visits but applies to all new patients, diabetic and non-diabetic. A nurse will test your visual acuity on the usual chart - so you must also take any distance glasses you wear. On the first visit your near vision will also be tested. You will then have dilating drops and iodine drops instilled into your eyes, prior to your eye examination by a doctor. As with any eye drops much depends on the competence of the person instilling them. The iodine drops generally sting in any case, but if the correct amount is given, it’s merely a momentary inconvenience. I have had iodine split over my clothing on several occasions, however, so be aware that this is a possibility. It does wash out but doesn't necessarily rub off easily.

It is the practice to test vision at every visit. I have certain reservations about this with diabetics, the success or failure of certain procedures is measured by as little as one letter on the chart. I know that my vision fluctuates with my blood sugar. I can guess my bg levels quite accurately by the state of my vision. In that case the only accurate measurement would surely be to have the test done at exactly the same time after having eaten exactly the same meal before each visit. Is this not taken into account? Unfortunately not. It is impossible to treat diabetic patients separately all the time, although a few diabetes clinics do endeavor to do so.

For the rest, it is the usual hospital practice of making several appointments at the same time and patients being seen in no discernible order. This doesn't mean that there is no reason behind the order in which you are seen so don't be upset or alarmed if others arriving later are seen first.

In the early days the visual acuity test does not need to be so precise and is probably a good general guide for purposes of comparison. It is only if you receive any sort of treatment that it may be worthwhile mentioning high or low blood sugar and other factors which might be affecting your vision.

When you see the doctor on the first visit you will be asked questions about your family and personal medical history and your diabetes and blood pressure control. Recently cholesterol levels have also become an issue. You will also be asked about your medication and the results of any self-monitoring your blood. The doctor will probably examine your eyes with what is called a binocular slit lamp - but again this may vary from place to place.

You will sit at one side of a table bearing the instrument and place your chin on the chin-rest with your forehead against a more flexible rest and your eyes will be examined with a bright light and/or lights of different colour. The pressures in your eyes may also be checked by means of a lens placed on your eye. An anesthetic drop will be given before this is done. The doctor will ask you to look in different directions and up and down, or to focus on a certain point during the examination. It is generally easier to keep both eyes open when one is being examined. As with everything else - some people can tolerate these examinations better than others and some practitioners are more skilled than others. Some manage to avoid causing discomfort from the glare, others don't, so be aware that if you need another examination and it is different to the first, it is not a sign of changes to your retina - more likely a reflection on the skill of the examining doctor. Of course some people have more sensitive eyes particularly if they have other eye conditions or have had previous treatment.

At the end of the examination the doctor should tell you of his/her findings and of what will happen next. Unfortunately, I have been told by various people over the years that this does not always happen. It is up to you to ensure that it does. Bear in mind that an examination of your retina while your pupils are dilated using strong lights in a darkened room is likely to leave you a little blurry-eyed and disorientated. You may just want to leave. Don't. Even if you are told that you will be given an appointment to return six months into the future that is not sufficient. You need to know the result of the examination.

You may be told that a letter will be sent to your GP. Your GP is not an ophthalmologist. As with everything else it is necessary to demonstrate that you wish to be involved in your own treatment. The doctor can confirm whether the scan results were borne out by the examination just completed. Can tell you if your eye pressures are within range and can explain what will happen next. Its not rocket science. They tend to err on the side of caution, which is good - so don’t panic if you are told that you will be recalled. This may even mean that there are very few signs of a problem but that they are going to see you again to double-check. If the pressures in your eyes are raised a little they may want you to undergo a field of vision test, especially if there is a family history of glaucoma. An OCT scan may also be mentioned, none of this is anything to worry about. It will probably be done on your next visit before seeing the doctor, or the field test may be done at a different time. It is possible if the doctor remains non-committal that he intends to seek a second opinion from a colleague, or superior, who is not available at the time and can't give you a timescale for your recall. The doctors you see initially are not consultants of course. The consultants are also surgeons and therefore not always available while the clinics are in progress.  At least the ordeal - which may have taken a few hours, mostly waiting around, is over and you are free to go. Because people attend these clinics with various different conditions and because there is a great deal of waiting for eye tests for pupils to dilate, for scans to be done etc - there is probably a longer waiting time at eye clinics than in others. Unfortunately you must learn to be a patient -patient. Some are not, of course, but this generally proves to be counter-productive although the person may not be aware of it. On the other hand, I have always found the staff very willing to assist in genuine cases, and some will go out of their way to do so. The time spent waiting can be usefully employed in reading notices, speaking to other patients and generally familiarising yourself with the layout and the proceedings.

In my hospital's clinic there is a great deal going on around the ophthalmology areas and often patients are confused by this. Waiting areas apart from the main waiting area are outside examination rooms. Many make the mistake of assuming that everyone in a certain area is waiting for the same procedure, or to see the same person. Some become very agitated if they think others are being seen out of turn. As most people are at least a little stressed this can become very irritating. If you are stressed and waiting in some trepidation to be seen you do not want to face an inquisition about how long you have been waiting, what time appointment had you been given etc as it has no relevance in this situation. The last straw came for me when I was practically pulled from a trolley while waiting to be taken up to the operating theatre by another patient who had been waiting longer. I suggested that notices be put up explaining the situation. This has been done in various clinics and day-care wards around the hospital and it is agreed that it has made a difference.

The procedure at my hospital is for appointments to be notified by post, so although you may be given an approximate date this will be confirmed or altered later. Even if you are not entirely reassured by your visit, or if you are now more concerned by the result of your examination and the prospect of further tests you will probably have realised that so much of the treatment and diagnosis of diabetic eye disease is a long slow process, and not in most cases a sudden trauma or something with an easy-fix solution. At least you will never face your first visit to that particular eye clinic again. Many will have paid their first and last visit to the clinic and hopefully everyone will have learned that blindness is not inevitable or imminent.

As ever, the above is just my own personal view from my own experiences as a patient. I have tried to address the main points which recur time and again in my correspondence with people on and off various places where diabetics gather. Some may seem petty and self-evident but these are the very things which cause most distress, purely because people are embarrassed to ask. I hope it is of help to anyone in this situation.

Next time I will write about the various tests and procedures which may be required before treatment.

In the meantime, as ever, you can best help yourselves by keeping those blood glucose and blood pressure figures under control. That means stable as well as low.

Kath