As a dispensing optician (DO) who has worked in practice for more than 30 years, being informed that someone has suddenly developed diplopia and advising them on the appropriate actions to take, is not an unfamiliar scenario. It was a very different experience, however, when the person reporting it was my own mother.
I am sharing my account of what happened, not as a case study, but to highlight a disease that many of my colleagues in practice were not aware of – but one which can have a devastating impact if undetected.
Mum, 77, has generally been in good health other than some dental issues but had declined suddenly complaining of back pain, loss of appetite and fatigue. She had also experienced an episode where her legs felt heavy, and she lost the strength in her arms and fell.
Her GP conducted blood tests and referred her for an endoscopy and colonoscopy, which subsequently didn’t reveal anything of concern. Mum also mentioned her right ear felt blocked and uncomfortable. On examination, she had a perforated ear drum and was prescribed antibiotics. I live 200 miles away but went to be with her to help where I could.
“I can see two cars” – was how (as a passenger) Mum reported horizontal diplopia to me at 5.40pm on a Bank Holiday Friday night.
An appointment with a local optometrist showed a myopic shift in both eyes due to early cataracts. Vision was worse in her right eye and, more importantly, nine base out due to a new sixth nerve palsy. Visual acuities were R: 6/12 and L: 6/5. She was referred to the hospital eye service and the transient ischaemic attack (TIA) stroke clinic.
TIA was ruled out and the ophthalmologist confirmed sixth nerve palsy, which he believed to be due to diabetes. Blood tests six weeks earlier had shown Mum to be borderline pre-diabetic. I highlighted the ear pain, but this was dismissed because if there was a link, Mum would be very ill indeed. An orthoptist assessment was advised and a review planned in two weeks.
The pain in Mum’s ear increased, so the GP referred her to ENT and for an MRI as there was no sign of an infection to explain the perforation, which was from the inside spreading outwards.
I attempted to help Mum adapt to the diplopia by using micropore to cover the right lens, which she removed at times. I was tempted to contact my colleagues and order a Fresnel prism, but the ophthalmologist said the diplopia should resolve.
A few days later, Mum mentioned that the vision in her right eye had “gone dark”. Trying to differentiate between a sudden drop in acuity, and her being more aware of the reduced vision due to the cataract, was tricky. When later that evening Mum began to decline, grasping her head in pain and wanting to be in bed, I felt that something was not right. But she attributed her symptoms to ear and dental problems, and fatigue.
It was then that I started to suspect that Mum may have something called giant cell arteritis (GCA). But was it a case of a little knowledge combined with ‘Dr Google’ being a dangerous thing? I decided to consult with an optometrist colleague who agreed that this did need investigating – and that an erythrocyte sedimentation rate blood test be carried out immediately. GCA was confirmed and Mum was prescribed steroids.
Unfortunately, this and the subsequent emergency admission to hospital for several very high dose steroid infusions were not in time to prevent loss of vision and hearing in Mum’s right eye and ear. Her right eye visual acuity is now no light perception. But it was in time to save the vision and hearing in her left eye and ear – and potentially her life.
I am convinced that the skills I gained during my time in practice enabled me to identify a potential crisis and act. This experience has reminded me to listen for incidental comments made in conversation by patients. As a relative, I have learnt to encourage my Mum to state all new symptoms and advocate for her when necessary.
I would like to thank my colleagues for their support and advice, and my Mum’s wonderful GP who listened and, more importantly, acted.
Symptoms of GCA
Please do familiarise yourself with the symptoms of GCA:
• Headaches, tenderness over the temples and scalp
• Thickening and tenderness of the blood vessels at the temples
• Pain in the jaw or tongue when chewing
• Flu like symptoms
• Sweats
• Weight loss
• Double vision
• Loss of sight, which can occur suddenly. This may be partial but sometimes it’s total. It’s usually temporary in the early stages
Find out more about GCA here.
Abbie White FBDO works as a dispensing optician for Bell & Stenton Opticians in Yatton, North Somerset.