Yesterday saw a welcome break from the norm – I made an actual, correct diagnosis. The patient, a gentleman in his late 40s with a curious blurring of vision in his right eye, kindly gave me excellent practice. He had a fixed stare, had already had his pupils dilated with special drops, and last but not least, his eyes were huge.
Years ago, in the daydream land of lectures, examining the eye sounded pretty straightforward. Basically you hold up a little instrument called an ophthalmoscope (or fundoscope – basically a magnifying glass with a torch) to the patient’s eye and try to peer at the retina. There’s little extras, like adjusting the lens, darkening the room, and awkwardly squatting down to the patient, but that’s the gist.
Nonetheless, despite having actually lost count of the number of times I’ve done this, it all too often feels like I’m just so focused on following the procedure that I’m not actually looking at what’s in front of me. It was tempting in most clinical exams to learn them like plays, making the right noises and tapping the right parts, but being more interested in your examiner’s pen-strokes than actually seeing what the patient’s body is showing you.
With this patient however, I was determined to try and actually work out what was going on. From the brief bits of history I’d managed to take, I knew his loss of vision was sudden, and that sometime beforehand, he had been struck in the eye. Trauma is an important thing to ask about, as the eye is made up of a lot of delicate parts that don’t respond well to things flying at them.
I had a suspicion of what was wrong, but it was important to try and see for sure. For a while it was the usual blurry mess. Eventually the vessels came into view, and then the optic disc (where the optic nerve enters the eye). It all looked fairly normal compared to a lot of eyes I’d seen – there were no haemorrhages (blood spills) or exudates (leaked fat) that you might expect from diabetes or hypertension.
Then, I saw a strange speckling that I presumed at first was a problem with my kit. It persisted, and I remembered hearing about a sign called ‘tobacco dust’: basically, these are small pigmented dots visible after a part of the vitreous (inner jelly) of the eye detaches from the retina – a posterior vitreous detachment. It commonly causes a full-blown retinal detachment with it, too.
With my face still practically touching the patient’s, I craned back to look at the retina again. Sure enough, just to the side of the optic disc, there was a little lightened segment that looked a little bigger than the rest, somehow. This was the piece of retina that had been pulled when the jelly had shifted, causing the man’s loss of vision.
The man was scheduled for an operation to repair the retina, solving a condition that would otherwise have meant permanent loss of vision. I think the biggest lesson I’m taking from the Caribbean is this skill: being able to finally recognise things instead of just politely acting examinations out. This is probably just as well with a year on the clock until graduation, though!