“It was quite easy to put it down to a migraine”

What led you to have an eye test? Before you went for a sight test, had you experienced any symptoms and how had this affected you in day-to-day life?

Julie Brook (JB), patient: I thought I had a migraine. I had a visual image appear on my right-side peripheral vision. It was a round opaque shape. As I got up in the morning it seemed to be there on the right-hand side. But then, as I went about my normal day it disappeared, so I didn't really think much more of it apart from the fact that I felt quite sick. I've had migraines before and I don’t get a headache; I just feel really sick and get a visual effect, so it was quite easy to put it down to a migraine.

The following day, I woke up with the same visual effect, but again it seemed to go during the day. That evening, I had a rising sensation at the front of my body that made me feel very sick. That made me think it might be a heart-related issue.

I rang 111, and they suggested I go to A&E. I explained the visual effect and the nauseous feeling, and they decided to check my bloods and my heart. The bloods were okay, there was no heart issue, but they advised me to go to my GP and get referred for an in-depth eye examination. The GP gave me a list of three opticians to try but after calling a few, decided to ring my own optician and booked an appointment.

What did the optometrist find, and how did they explain the next steps to you?

JB: Nikita, the optician, did a scan and everything looked okay initially. Then she had a look inside the eye and discovered I had a tear in the very top part of my right eye. Perhaps that is one of the reasons why it didn’t exhibit itself much during the day.

At that point Nikita explained that this was an emergency and I needed to go to hospital. She told me she was sorry to give me bad news, but that now we had found it, the key thing was to get medical assistance quickly. The practice team were really kind to me. The ladies brought me a cup of tea to cope with the shock while I rang my husband to pick me up.

Nikita tried to get me into the local hospital but because it was the end of the day on a Friday, they referred me to another hospital.

Can you describe how you felt during the referral?

JB: At the hospital, they confirmed I had a tear that needed to be treated, but said I needed to go to Liverpool. Sadly, they couldn’t get hold of the hospital, and so we decided to go straight to Manchester Royal Eye Hospital, which has an emergency walk-in.

I’m very grateful to Nikita for identifying it and making me realise that I needed to get treatment fast.

Did you have to undergo further treatment and what has the outcome been?

JB: I had a vitrectomy at Manchester with a lovely surgeon who put my mind at rest, because I was petrified.

I'm very grateful for the operation, which has saved my sight. I’m curious as to how things will be going forward. At moment my vision is very good. The first few days and weeks after the operation are quite scary because you have a gas bubble in your eye and posture face down. I had a two-week bubble in my eye. As that was lowering, I was discovering that my sight is very good. I’m delighted with that outcome, because I wasn’t sure that was going to be the case.

The practice rang me to find out how I was and how the operation went. They were genuinely concerned about making sure I got the right treatment. If the referral process had worked straight-away, that would have been perfect.

Have your views on the importance of sight tests and eye care changed as a result of this experience?

JB: I’ve always had regular eye tests, because I’m short sighted, and have regular checks for contact lenses too. This was between the regular checkups, and the scary thing for me is that it didn't appear to be a problem at first – until I felt quite poorly and made the decision that I needed to get checked out in the interim.

It has made me much more aware that migraines can be a bit of a red herring, and the importance of understanding your own body and making sure that you do check out anything that changes need to check out.

How has the experience changed your life or affected you?

JB: It’s not something that I ever thought would happen to me. I feel very aware of potential problems. Even now I'm waking up in the night worrying. At this stage of the recovery, I’m possibly a little bit paranoid. I think longer-term it will make me a check out my eyes very often. I wonder whether there is a way of doing it more frequently as we get older because the reason this has happened to me, is I understand, due to age and the vitreous gel tugging on the retina, and because I'm short-sighted the likelihood of me having this problem is higher than for others. Bayfields did a great job of finding this for me.

It’s always tricky to have those conversations

What did you identify during the sight test and what was your reaction?

Nikita Patel (NP), optometrist at Bayfields Opticians and Audiology in Macclesfield: From hearing what Julie’s symptoms were, I thought it could have been a number of conditions. We had a look in her eyes using the slit lamp and using a lens to check the back of the eye as a starting point. I was quite surprised to see that she had a retinal detachment.

Julie had a small tear in the retina which had an associated detachment. The detachment was in the superior retina, and so gravity is not on our side because fluids can get under the damaged retina and pull the retina away from the eye further.

Once I found out that she had the retinal detachment, very quickly the wheels start turning and you realise you've got to get a referral started because it's something that does need to be sorted quickly.

How did you approach explaining what you had identified/suspected?

NP: It’s always tricky to have those conversations. I think the best thing to do is explain what you've found, and then talk briefly about the implications of what you found, so both you and the client are on the same page, and then go through the next steps as well. With Julie, that's what I tried to do. I discussed what a retinal detachment was, and that due to its location we needed to make a referral and try to get some treatment for her for quite swiftly.

What were the next steps that you took, and what was the significance of these steps to this case?

NP: With the retinal detachment that Julie had, specifically its location, it did need to be seen to quickly. I tried to make the referral by contacting our local hospital, but unfortunately because it was the end of the day on a Friday, they weren’t able to see her and advised that I call a second hospital. I had to wait 45 minutes before they started accepting calls. When I got through, the hospital agreed that they would be able to see Julie, so I advised that she made her way over.

To make the referral, I had to speak to the on-call ophthalmologist, explain the symptoms and what I found. Then I gave Julie the referral letter and sent her across.

When did you hear about the results of your referral and how have you been involved since?

NP: When I was back in work on Monday, I asked one of my colleagues to give Julie a call to see how everything went. We were surprised to hear that she wasn’t at the hospital I referred her to, and she was actually at the fourth hospital that had been involved in her care. I think when we gave her the phone call, she was sat in the waiting area to go through for surgery.

It was frustrating, but mostly because whilst I had been trying to make the referrals, I knew that Julie was sat in the waiting area, concerned about the health of her eyes. I tried to get things done as swiftly as possible to make it as easy as possible for Julie, but sometimes it's out of your hands and it means that Julie went through a trickier time than perhaps she could have done due to it being out of hours.

What would be your three top tips to other practitioners when making a referral?

1. The first thing we're trying to do with referrals is to be as concise as possible, which is easier said than done when you're trying to involve all the relevant details, and then stating the urgency of the referral. But try to get that all into one concise letter
2. When making out of hours referrals, I always give the client a paper copy of the referral that I've made because I've found in the past that sometimes on-call ophthalmologists or staff members don't have access to the email accounts or the ways that we would normally process referrals in working hours. Feedback from previous clients is that they've found having a paper copy quite helpful
3. Chase emergency referrals to find out if the condition was what you thought it was, and finding out if the client needed treatment, so then you can add it to the record and keep everything up to date, but also just find out how things went for that person.