Barking up the wrong tree? The value of the Pinhole

Interesting case this.  I feel that this young man’s long journey through the hospital could have been prevented.  What do you think?

Young Asian male, 21. In excellent health.  No relevant Family History.

C/o reduction in his vision (one eye) over past 18 months.  Saw own optometrist 12 months ago who could not find a reason for his reduced Vision (4/60). No mention of pinhole, but referred urgently (to be seen within 2 weeks).  Funds signs normal

He was referred to the hospital eye department who spent 3 months worth of appointments on OCT scans, visual fields, orthoptics and two MRI scans.

At one stage, someone demonstrated an improvement in V with a pinhole.  A last!  The VA improved from 4/60 to.. Well, only to 6/36, but it was an improvement nonetheless.

So, finally, he comes to see the optometrist once more.  Retinoscopy revealed awkward split reflexes and the following results:

V 4/60    +1.50/-7.50 x 95 = 6/12 (PH = 6/9)

Given that the poor young man was under the impression that the doctors were now investigating for space occupying lesions (or worse still searching for Blinky from the Numbskulls) inside his brain, we were a little more comfortable with Keratoconus which was confirmed by the topography results above. Job done. Ten minutes. 

However, how much of this could have been prevented? An improvement with a simple pinhole acuity surely would have indicated an underlying missed refractive error.

Either way, he’s coming back for an RGP contact lens fit at the beginning of the year.  And he’s back at the GP next week for ongoing treatment of his recurring eczema.

Ahhh…  now that fits..

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