Call the specialist?

Flashes, floaters and that sinking feeling

Mid-60s is the highest age peak for a retinal detachment

IN THE FIRST OF A NEW SERIES looking at the types of conditions seen in optometric practice that might warrant a referral to a specialist, one-time optometrist now consultant vitreo-retinal surgeon, Stephen Lash, looks at flashes and floaters...

We have all been there, myself included all those years ago as a locum optometrist working weekends to pay for medical school. It’s a busy clinic, the pressure to ‘convert’ (profit is the requisite of business not the purpose) and you’re running behind. The next patient (squeezed in as being flagged with a potential problem) presents with textbook (or perhaps Google searched) symptoms of flashes and floaters, and has them down so well you are sure they have rehearsed.

I am not being disrespectful to patients; history has to be teased out and refined –that is our job as professionals – using Occams Razor but ensuring Procrustes does not get hold of it (indugle me). This is a perfect storm and it means a late/no lunch, frustrated/delayed patients until closing, and the danger that this patient could lose their sight and you your career. Litigation in this area is second to none. So, how can I help? Firstly, let’s get a handle on the likelihood of a problem – before we reach for our Volk lens.

LOOK, ASK, EXAMINE Look at them. Posterior vitreous detachment (PVD) occurs in 25 per cent of 50-year-olds and 80-90 per cent of 80-90year olds. It is more common at an earlier age in myopes. You fear retinal detachment (RD) and although the background risk is around one in 10,000, there is a bimodal profile with the highest peak in the mid to late 60s: 6.00D of myopia = 6x the risk.

Ask them. What are the flashes like? Thunderbolts or shimmers? It is a classic misdiagnosis. If it shimmers for around 20 minutes in both eyes, you can ‘relax’. If there are thunderbolts, you cannot. With floaters, ask if there are lots of distinct ‘bits’. A patient once told me she had ‘black rain’, which is a perfect description of muscae volitantes – or ‘flying flies’ for the non-Latin speaker. Are the flashes and floaters related? If your patient presents with a very short history (24 hours) of flashes and a shower of floaters, they are much more likely to have a retinal tear.

The risk of a tear is between five and 10 per cent. Tears in the acute situation have around a 50 per cent chance of progressing to a RD. Finally, ask if the floaters have coalesced into a fog such that the patient cannot see. A fundus obscuring vitreous haemorrhage (VH) has an extraordinarily high risk of a tear – up to 75 per cent – and they need to go to eye casualty. Of course, if they reveal that they are losing vision from an edge (I’ve never really understood the curtain thing – mine pull in from both sides) then get your receptionist to start looking up eye casualty’s number.

Examine them. This is obvious but critical, especially if detachment follows. Is there a relative afferent pupillary defect? Check the pressure; low might be RD, high might mean Schwartz syndrome with photoreceptors clogging the trabecular meshwork (I have been caught out by that). Cells in the anterior chamber and flare in RD? I know you are itching to pick up that Volk, but leave it alone and look at the lens.

Pseudophakic? One piece in the bag –uncomplicated surgery – but a higher risk of RD (1.7x). A three-piece lens in the sulcus suggests complicated cataract surgery, which has an even higher risk (44x). Leave that Volk alone, now look at the anterior gel and get the patient to look up and down and stop. Look for pigment cells (apologies to Schaeffer and the tobacco industry this time).

Pigment cells are a concern, lack of them is not reassuring. Is there blood? This is an even higher concern. Now pick up your Volk, look for Weiss ring and the retina. Be systematic, work round eight positions of gaze. Supero temporal is the most common quadrant for a horseshoe tear, and inferotemporal is most common for schisis and dialysis.

After textbook history and examination, nothing. I am sure some of you have examined well, found nothing and both ended up in trouble. Document your negative findings and warn. If patients develop an increase in flashes or floaters or fading vision, they should telephone. Tears present from day one to day 30 with the average on day 11, so do not score an own goal at the last hurdle.

Having tried to allay your fears over flashes and floaters, tears and detachments – all pressing and urgent issues – next time I will move on to a key question for all those who ‘look’: what do we do when we see something? I am not talking about the Volk lens and peripheral retina lesions, but central issues revealed by the rapid increase in access to OCT scans. Do you refer or not? We will go through some natural history and explore the variety of findings that cause heads to be scratched and referrals to be made or not.

Stephen Lash BM, BSc (Hons), MCOptom, FRCOphth, MBA works part-time within the NHS and part-time as a private ophthalmic surgeon.

www.stephenlasheyesurgery.com

OPTINEWS Optinet FLEX: an update

CHRIS SMITH, Optinet operations and business development manager, rounds-up the latest news from Optinet FLEX

Optinet FLEX is an advanced practice management system (PMS) for independent optical businesses of all sizes, supplied by Optinet – the IT division of NEG. FLEX encompasses all aspects of the day-to-day running of an optical business – from maintaining patient records, handling eGOS submissions and scheduling appointments, to recording clinical assessment and examination results and creating patient dispense and till receipts. From a ‘back-office’ perspective, full reporting is available along with the ability to interrogate data and send communications to patients – whether it be recalls or automated email/SMS notifications.

HOSTED FLEX FOR MULTI-SITES For businesses with more than one site, FLEX can be centralised and hosted in the cloud. The benefits of centralising your business include: 1. Frequently performed tasks can be handled centrally • Viewing group diaries • Sending group recall • Planning group marketing • Stock handling across the group • Business reporting 2. Software configuration remains consistent across the group • Lens catalogues and pricing • Staff records • Document templates • SMS templates • Email templates 3. An ‘always on’ system that can be accessed from anywhere. 4. Location restrictions are removed, e.g. access diaries from other branches.

DEVELOPMENT MATTERS At Optinet, we believe in development; PMS needs to evolve – more so now than ever before. For example, one of our newest developments – FLEX Forms – was designed specifically to assist with remote triaging of patients. We always have an eye to the future, and close discussions with our Early Access Group let us check ideas in the ‘real world’ before starting any development work. Plus automatic updates ensure the software is always up-to-date. Here are some of the new releases arriving in practices right now.

FLEX FORMS FLEX Forms allow you to capture information from patients without them visiting the practice and are ideal for remote prescreening and triaging. Design and create web forms in FLEX using the simple Click2Build system; no programming knowledge is needed. Links can be sent via email or SMS and can be scheduled for automatic delivery with a diary confirmation or sent on an ad-hoc basis. The patient completes the form online and the results are securely stored before being downloaded back into FLEX for review.

FLEX MESSAGING Stay connected in practice with FLEX Messaging. Create chats that can be seen by all staff members or private chats between specific people or groups. Additional resources can be signposted by inserting web links, and patient records can be flagged by inserting patient links.

FLEX EGOS We continue to make changes to FLEX eGOS to make life simpler in practice. The latest release includes GOS5 submissions –meaning GOS1, GOS3, GOS4 and GOS5 claims can now be made directly from within FLEX. Choose from a signature pad or our dedicated Android and Apple apps (free to use) to capture the patient’s signature. Claims are quick and simple to create, with key information drawn from FLEX Records. Claims can be created in FLEX even when the PCSE systems are offline. Useful tools are included to ensure that claims do not get missed and reporting is available within FLEX.

DOCMAIL INTEGRATION We have partnered with DocMail, a leader in true hybrid mail services, to provide a seamless end-to-end system for sending letters directly from FLEX. For less than the cost of a second-class stamp, letters are printed and posted with the added benefits of the practice logo printed on a plain non-window envelope. This helps distinguish it from other mail when it arrives with the patient.

SERVICE AND SUPPORT Whilst we are committed to ongoing software development, we are fiercely proud of the service and support we offer – starting with the initial software demonstration which takes place in the practice where possible or online if preferred. By visiting the practice, we get a feel for the business, meet the owner and staff, and start to plan delivery of the software and training.

We also offer on-site training at the point of installation, helping users to get the most out of the software from the very outset. Post-installation, we offer remote telephone support, management away-days and training courses at our Worcestershire offices. Our online customer portal is available 24/7 to search FAQs and open new support tickets.

For almost 35 years, Optinet has developed software for independent practices. We understand practice needs and have the valuable experience that makes Optinet a name you can trust. If you would like to find out more about the FLEX system or the exclusive NEG free 12-month software trial, email chris.smith@optinetuk.com