Retinal Screener

Taking a Look Behind the Screens

It's the last day of October today, and I always like to see how many patients will wish me a Happy Christmas before Halloween. This year it was two. I think one of them was being slightly ironic in the face of postal strikes, but the other was entirely serious. It makes me feel like doing my clinics in a Santa hat.

Not everyone was in a festive mood this week, however. The camera in one of our remote clinics broke down on Wednesday, and I spent Thursday afternoon in the office, phoning patients to tell them that their appointments would have to be rescheduled for early December. It's interesting the different reactions you get to this news. Some people are entirely reasonable, and take the view that 'it can't be helped', but others seem to see it as a personal slight against them, and will argue relentlessly, as though pointing out how inconvenient it is will miraculously fix our equipment.

I spoke to one such lady on the phone. Having explained our reasons for the cancellation, and apologised profusely, she immediately got uppity with me, and started ranting about how long it had taken her to arrange for someone to give her a lift to her original appointment. Now, the thing is, I understand that completely, and I actually feel a lot of sympathy for her. I had a hospital appointment a few months ago, for which I rearranged my working week, only for it to be changed with less than two weeks notice. It's the most annoyingly frustrating thing. But the difference here is that I was fully explaining our reasons. I'd informed her that our equipment had broken down, when it was going to be fixed, and the earliest available dates for another appointment. It was clear that these were circumstances beyond our control.

But the lady went on and on. I suppose it was just her chance to vent her (understandable) frustration, but I do wonder what she expected me to do about it. I offered her an earlier appointment at a location further from her home, but that wasn't good enough. She kept repeating how downright inconvenient it was, then pausing, as if she expected me to say "Oh ok then, you can keep your original appointment". Maybe she expected me to offer to come round in person with an Instamatic and take a few snaps of her eyes.

To be fair though, some of the other patients were lovely. When I apologised to one lady, she told me there was no need to say sorry, it was nobody's fault, and she thinks she gets a wonderful service from us. Then there was the elderly lady who told me that it didn't matter because she wasn't planning to come anyway. That threw me slightly.

In other news, I saw a patient yesterday who told me the amusing story of how she was first diagnosed with diabetes. Apparently her husband has been diabetic for years, and was given a blood glucose monitor for home use. The lady told me that she used to watch him test his blood every day, and then one day, whilst feeling a little bored, her curiosity got the better of her, and she decided to try it on herself. She got a reading of 18. The next day it was 19. And the day after that, she was officially diabetic. As she said to me with a shake of the head and a roll of the eyes, "I only did it because I was bored".

Dorothy Parker once said "The cure for boredom is curiosity. There is no cure for curiosity". Although in this lady's case, it turned out to be Metformin.

There are times in my working life when I have absolutely no idea what to do. Fortunately they don't occur too often or I'd probably be sacked, but I had one such moment yesterday. And I still can't work out what I should have done.

I saw a patient on Friday morning who was a lovely lady with learning difficulties. People with such challenges in their life are not uncommon in our screening programme, and I'm generally able to screen them without too much trouble. In fact, one of the most enjoyable appointments I ever had was with a patient who had the mental age of a child, and insisted on me photographing her carer too. Never has a consulting room been filled with so much laughter and carefree chatter.

This particular patient was also a cheerful soul, and insisted on shaking my hand and smiling in a friendly manner. But in addition to her learning difficulties, she was also profoundly deaf, and could only communicate through sign language. Naturally she had a carer with her who translated for me, and I carried out the VA with no problems at all. She was quite happy to have the eye drops too. In fact, the first half of the appointment went without a hitch. The problem was the photos.

Unfortunately the lady lacked the mental capacity to understand that she needed to look directly at the light. So I had to direct her. Picture the scene: I have a lady positioned with her head on the chin rest, able to see nothing but the lens of a camera in front of her, and I want to give her an instruction. She can't 'hear' that instruction unless she moves her head to look at her carer, but if she moves her head, that instruction no longer applies.

For example, I need her to look a little more to the right. So the carer taps her on the shoulder and signs the instruction to her. By which time she's looking in an entirely different direction and the instruction is no longer relevant.

We tried this for more than twenty minutes. The carer attempted to explain that she needed to look at the light, but she struggled to understand, and once in position at the camera, she couldn't 'hear' a thing without moving her head. On a few occasions, she would look in the right direction by chance, but her eyes would be half shut. I wanted to tell her to keep looking in that direction and to open her eyes a little wider, but in order to do so, she would need to look elsewhere, and I'd lose my shot.

We tried it with the light, with my finger, and with the carer trying to point, but all to no avail. I managed to capture a few semi-acceptable images, mostly due to luck and persistence, but after twenty-five minutes, the previously smiley and relaxed patient was becoming stressed and irritable, and I felt we'd pushed her to her limits of co-operation. I decided to let her go.

So here's the question: how do you say "Stay where you are" to someone who can only hear you by moving?

I've been doing my monthly Online EQA System grading over the past couple of days. Sadly I can't reveal my results for legal reasons (and the fact that it would send my patients running for the hills in terror), but the main issue I have with the system is quite simply the amount of time it takes to complete an image set.

We were told that it should take us approximately ninety minutes a month, which sounds perfectly reasonable. In reality, however, even the fastest grader in the west couldn't get through an image set in that time. The EQA website is as slow as a ninety-year-old diabetic with bad feet, and makes you feel like you've gone back to the bad old days of dial-up. I had to shut it down and log back in more than half a dozen times yesterday after the whole thing ground to complete halt and wouldn't move.

I don't know if the answer is better servers, more bandwidth, or just a few extra hamsters on the generator wheel, but something needs to be done. It's taken me the best part of two days to get through thirty questions, and it's time I can ill afford to spare. I'm all in favour of monthly EQA tests to ensure that we're all grading to a reasonable standard, and to give us a few pointers if we're not, but at the moment the system isn't really fit for purpose.

One of my patients today was an Indian lady in her 60s who spoke very little English. Her daughter had come along to translate, but to be honest she was very little help, and the patient and I spent most of the time communicating with each other in pidgin English.

When I tried to administer the drops, the lady had great difficulty keeping her eyes open, so having placed a couple of drops on her eyelashes, I told her to keep her head tilted back and blink a few times to let them run in. She managed to follow the first bit of that instruction, but failed to comprehend the second part. From the way she suddenly started going "owww", however, I guessed the drops had successfully entered her eyes.

So I asked her to take a seat back in the waiting room. At which point she stood up, eyes still closed, and called to her daughter in another language. The girl responded by taking her mother's hand and leading her out of the room like a guide dog for the blind. I assumed it was a melodramatic reaction to the pain of the eye drops (some patients do tend to act like they've been shot in the face), and thought nothing of it.

When I went outside to collect the next patient, the Indian lady was sitting slumped in a chair, head right back, with her eyes closed. I assumed she was having a nap, and ignored it. It wasn't until I called her back in that I realised something had apparently had been lost in translation.

On hearing her name, the lady stood up, eyes still closed, and held out her arms like a sleepwalker. Her hands found the shoulders of her daughter, and they proceeded down the corridor like the world's shortest conga line. I wondered if I should say something, but to be honest, my first thought was that the longer she keeps her eyes closed, the better dilated her pupils will be, so I decided to stay silent.

Upon entering the consulting room, the lady's first words to me were "Can I open my eyes now?". I said yes. And chose not to tell her that she could have done so twenty minutes ago. I didn't want to risk her misunderstanding, and keeping them closed for another twenty minutes.

When I went to lunch, one of the ladies on the reception desk called me to one side and told me that when I'd sent my Indian patient back to the waiting room, she'd walked all the way there with her eyes closed and her body bent so far back, they'd all thought she was entering some kind of limbo dancing contest for the blind. Next time I tell a patient to tilt her head back, I'll remember to add "And now sit up straight again".

One of my patients today was an 87-year-old lady who'd been diagnosed with diabetes in August and been referred straight to us for screening. Now, I know everyone's entitled to the best care available, and I have no objection to her receiving it, but on a human level, I have to wonder whether it was really worth making that diagnosis.

The lady was in good health, not overweight, required no tablets and had no sign of retinopathy in her eyes. That's the good news. The bad news is that in her 88th year, this sudden diagnosis of diabetes has caused her all kinds of stress. She told me that she'd had a routine blood test for something else, which had led to her being told that she's diabetic. Before she knew it, she was being referred for retinopathy screening, and worrying about everything from her eyes to her feet.

She was even panicking about what she should be eating, and was desperate for information on the kind of diet she should be following. When I gave her a few basic details, the relief was visible in her face. Her response was "That's what I tend to eat anyway".

Maybe she has slightly high blood sugar levels, and maybe she'd benefit from bringing them down, but at the age of 87, is it really worth giving the lady two months of stress just to achieve it? I think that in this case, maybe no news would have been good news.

As a general rule, I like screening teenagers. They usually don't need eye drops, their vision is good, and they can follow every word you say without a hearing aid. In my experience, they tend to be well brought up too, because the ones with bad parents don't bother turning up to retinal screening appointments.

Of course there are bound to be exceptions, and I met one today. I don't know if St Trinians have opened a branch nearby, but the 15-year-old girl I screened this morning was straight out of the films. Bizarrely, her mother was lovely, and just how a parent should be: polite, respectful, interested in her daughter's health and concerned about the results. I can only assume the girl takes after her father.

Things started badly when I attempted to do the VA, and the girl immediately started taking the mickey out of me to my face. To my astonishment, she informed me that I have a "stupid posh voice", and that I sound funny. I was tempted to say "see how funny you find these eye drops", but sadly she didn't need any. So I went straight for the photos, with her throwing a strop between each one, and refusing to remain seated at the camera.

Her mother did her best, but the girl was in no mood to take any notice. So when it came to pointing out the problems with the girl's retinas, I addressed the information to the mother. Like a toddler trying to get her parents' attention, she then tried to break the external light off the camera. When that failed, she wiped her fingers on the lens. Naturally I moved the whole thing away from her. So she grabbed my mouse and started clicking randomly on the screen.

Now, learning difficulties and behavioural problems I can understand, but this girl was fully aware what she was doing, and simply didn't care. Her helpless mother even told me that she'll be going off to college next year, and university two years later, and that she's terrified she'll stop taking her insulin. She has good reason to be worried: apparently her daughter was hospitalised last year after refusing to take it while away from home.

We have a section on our patients' notes where we can add a warning for next year's screener, in case of a difficult patient. The moment she'd left the room, I opened it up and started typing. And then I stopped and deleted it. I wouldn't want anyone judging me on the person I was when I was fifteen, so I decided to give her the benefit of the doubt. There's a world of difference between fifteen and sixteen, and with a bit of luck she'll be a changed person in twelve month's time. Here's hoping, anyway.

One of the things I love most about my job is the people you get to meet. A complaint I hear quite often from other screeners is that the job can get repetitive, and whilst it's true that you're essentially doing the same things over and over again, what keeps it fresh for me is the fact that every patient is different. And at least once a day you can guarantee that you'll meet one like no other.

My favourite from this week was a 70-year-old chap who walked in carrying a briefcase, and immediately told me that he used to be an optician. This news put me on the back foot slightly, as I assumed his ocular knowledge would be far in advance of mine, and I'd have to end up admitting that compared to him, I know nothing. It was a similar story when I screened a retired GP a couple of months ago. I felt very self-conscious giving diabetes advice to a qualified doctor.

Fortunately I needn't have worried. To be honest, my suspicions should have been aroused by the man's demeanour alone. He was a lovely chap, but he spent the whole time grinning like a Cheshire cat, and had the manic, wild-eyed look of... well, not of a retired optician, that's for sure. But I took him at his word, especially when he started talking about Atropine, and asking if we ever use it.

Things took a turn for the weird during the VA. He told me his vision was a little worse in his left eye, and he assumed he'd probably got "a bit of a bleed" in that one. I didn't quite know what to say to that. But I decided to reserve my judgement on his ophthalmic credentials until I took the photos.

When he came back in, he said that as an optician, he'd be very interested to see the images for himself. To be honest, I show them to most patients anyway, but I was happy to oblige for a fellow healthcare professional. The conversation went something like this:

Patient: What's that dark thing there?
Me: That's the macula.
Patient: Oh. And that thing?
Me: That's the optic disc.
Patient: Really?
Me: Yes.

Call me an old cynic, but I'm not sure he'd quite passed all the elements of the ABDO qualification.

Well I suppose the obvious place to start this blog is the British Association of Retinal Screeners 2009 conference, which took place in Newcastle at the beginning of this month. I have to say, I came away from this year's shindig with a slight sense of disappointment. Looking at the list of delegates who attended, it's clear that the overwhelming majority were screener/graders, and yet the conference programme seemed consistently geared towards managers. Maybe it's just me, but if I have the opportunity to spend two days with three hundred people who share my job, I want to be able to swap experiences, hear stories and learn from people in the same position as me. I don't want a dry lecture about modernising scientific careers, complete with flow charts and network diagrams.

I was hoping for talks that would relate to me and my job. Speakers who would share their techniques for administering eye drops, handling patients and grading images. Screeners who would tell me the problems they'd encountered and the methods they'd used to overcome them. Even just a few funny stories about nightmare patients or disastrous days. There was none of that. The speakers felt like they'd been booked by and for programme managers. It was all very worthy, but it wasn't for me.

Interestingly, an announcement was made at the beginning to say that this year there were no workshops taking place. Apparently people had complained that last year there were so many they'd wanted to go to, that they'd struggled to fit them all in, and had been upset to miss some. So the organisers decided to solve that problem but not holding any. It's a bit like saying that so many people want tickets to see Madonna, that we'd better cancel the concert to avoid disappointing those who can't make it.

So instead of interacting with other retinal screeners, we had two days of mostly uninspiring lectures. There were highlights, however. I particularly enjoyed the talk by Cathy Egan, a Consultant Ophthalmologist at Moorfields Eye Hospital, who outlined a few of the rarer eye conditions we might come across in our work. My only complaint is that she didn't speak for long enough. Having finally found a speaker with something to say, I wanted her to go into more detail and give me time to take notes. Next time she needs to be booked for an hour.

The segment entitled 'EQA - Where Are We Now?' was perhaps the most intriguing section of the conference. It felt like a religious revival for prodigal screeners, as a succession of individuals took to the stage to repent their retinal screening sins, give thanks for their forgiveness, and be baptised in the cleansing waters of the EQA. I've never seen anything like it. I kept expecting someone to shout "Hallelujah!" as they went back to their seat.

Dinner on the first night was our one and only chance to get to know other screeners from all over the country. And sure enough, my colleagues and I were joined on our table by a few members of another screening programme. Unfortunately I couldn't hear a single word they said. I don't know who booked the DJ for the evening, but next time, tell him not to start until we've all finished eating. The entire meal was accompanied by thumpingly loud music, and made meaningful conversation impossible. Any hopes I had of swapping experiences with a fellow screener were lost in a deafening chorus of Girls Aloud.

Day two featured an interesting lecture on screening in prisons, and an enthusiastic talk about OCT, but it was a very mixed bag. Never mind OCT, a couple of the speakers could have done with ECT just to liven them up a bit. But between Martin Harris, a Consultant Ophthalmologist, and Mr Diabetic Retinopathy himself, Professor Paul Dodson, the one consensus to come out of the conference appeared to be that we're all confused by the NSC's grading criteria. Apparently even thirty ophthalmologists locked in a room together couldn't agree on a definition of R2. So how have the rest of us got a chance? You might as well ask us to work out how many marbles were in the Medalytix jar.

Retinal ScreeningLet me say from the very beginning that I love my job. This blog is not going to be a diatribe against the NSC, the NHS, the EQA or any other three letter acronyms (although the old JVC camera units are a bit rubbish). No job is perfect, but I enjoy mine and I'm lucky to have the career I do. So whilst I may have the occasional moan about my working day, it should be taken as part of a bigger picture of overall job satisfaction. This site is not here to laser the new vessels of an imperfect system. It's just a place for me to recount my experiences and thoughts. Think of it as my ongoing quest for the perfect photo of IRMA and a clear definition of R2. It could be a long road...

About this blog

I'm a Retinal Screener and Grader currently working for the NHS as part of a Diabetic Retinopathy Screening Programme somewhere in England.
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