“I can’t see!”
“I have terrible vision!”
These are things that I have heard time and time again, and you will too as you see patients on the wards or in clinics. This will even happen at the local restaurant or family gatherings. They are the words that are often a patient’s first volley into their hope for a fix. Those phrases, however, need to be fleshed out, parsed and hunted through. They mainly give you a sense that of visual unhappiness. Keep reading if you’d like to see some of the history points and questions you may ask to begin your hunt for an answer, or at least to know how worried you should be about the patient before you.
Go open ended right out of the box
I usually strike an engaged posture and ask them what they mean by terrible vision. The conversation will go in a whole array of directions with that, but those directions are good, great even. After they have begun to explain their symptoms you can then cone down with more focused questions.
The following things are crucial to sort out as you listen and engage them.
- Does having their glasses on make any difference?
- Is the trouble with their near vision or far vision?
- Is it there all of the time or just some time?
- Does blinking make a difference?
- Is it blurry like “looking through a shower curtain,” or dim “like someone turned the lights down”?
- Both eyes or just one?
- Is part of the vision missing? as in the top or bottom part? Left or right part?
It is not as crucial for the primary care provider to determine etiologies or to quantitate the visual level as in Snellen Acuity. It is more important that they are able to come to a conclusion on the urgency of a given situation. Does their care need moved to a specialist now or can it reasonably be delayed? That is part of this question. Also do they need to see an ophthalmologist or a neurologist? That is, are the symptoms consistent with an eye issue or a brain issue?
Let’s work through these questions
The goal is to classify whether the optical system is really dysfunctional and urgent or only perceived in those manners.
Glasses on or off?
There is a cadre of people who will volunteer that their vision is terrible, but confidently report that the glasses fix their problem. This might seem to belabor the obvious, but that getting to the bottom of problems (obviously?) no matter their complexity is your job as a physician. If the lawnmower will not start, first check the gas. If the vision is blurry first question about the glasses.
Is the problem greatest with your distance vision or near?
There are a number of issues that will alter clarity at different times or different distances. It has not come across to me as unusual for a patient to decry their vision as terrible while only meaning terrible sometimes. Remember at this point we are only dealing with history. We have not begun to examine the patient, but merely to learn how their experience is out of kilter.
At this point the answer will frequently be uncovered as many people will say they are fine with their glasses on in the distance but they cannot see up close. Here is where you interject the next question.
Is it there all of the time or just part of the time?
Does it start clear and become blurry after a few paragraphs? Many, many patients will grant you this admitting that the whole problem starts with prolonged near work, or driving a long distance or watching the television.
Once you begin to learn that their visual complaints are this way then you begin to settle toward ocular surface disease and especially dry eyes. You can also at this point ask them if blinking helps, even if just for a little while.
Many conditions effect the tear film and you can begin to sort through the situation by asking these types of questions, listening to how they answer, and then connecting the timing to other things in their life.
Blurry or dim?
This distinction is a crucial, crucial one for dim vision portends different and more urgent diagnoses. In general dim vision means there is a retinal or optic nerve issue. It is perceived as dim because there is less light getting to the occipital cortices and the higher order interpretive centers. There are many patients who will interchange blurriness and dimness so that is where you come in to sort it out. I usually will use the analogy of looking through a shower curtain for blur and lights turned down for dim.
In eyes with dim vision they often will have a preserved section and a poorer section. Horizontally it relates to the eye and vertically to the brain. Vertical loss will not dim so much unless the patient perceives it as a bilateral dimming.
So what about referral timing/urgency?
There is a smaller urgency in patients whose vision is corrected by their glasses, by blinking, or coming back in a little while, especially when only blurry. There is a greater urgency when they speak of dimness or loss of some components of their vision. These are but guidelines and if there remains concern by all means consult the ophthalmologist covering your hospital. At least by learning to parse through some of these questions you remain better attuned to your patients and even those around you who may seek answers from you. After all, they think, you are a doctor.
By learning to think these things through you also will be more conversant with the ophthalmologist providing additional steps in your grasp of diagnoses and skill sets.
Feel free to post some questions in the comments. I will try to get them answered! Happy eye sleuthing.