Woman Raised in Australia Whose Eye Growth Is Blurring Her Close Work — Free SCA Practice Case

Character Overview: You are Georgia Pellow, a 34 year old dental hygienist. You grew up on the Queensland coast in Australia, on a beach most weekends, and moved to Bristol at 22 for work. You live with your partner in a flat and cycle about 25 minutes each way to the practice. You are brisk, organised and a bit impatient, used to booking things in and getting them done. You do not wear sunglasses and never really have. You are on the phone from your car at lunchtime, and you are not distressed, just keen for a plan. Your father still lives in Queensland.

Opening Sentence: "Hi doctor. I've got this growth on the inner corner of my left eye that's got bigger over the years, and now my close work's gone a bit blurry. I'm hoping to get it removed before my new loupes get fitted next month."

History if Asked (Data Gathering Phase)

• ●How long and how it has changed: "I first noticed a little pink bit in the corner maybe six or seven years ago. It's crept slowly, there was never a sudden change. In the last year or so it's got noticeably bigger and it's now reached the clear part of the eye, the coloured bit. It's a triangle shape, with the point heading towards the middle of my eye, if that makes sense."
• ●Colour and surface (if asked about colour, dark patches or bleeding): "Pink and veiny, a similar colour to the rest of the corner, no dark patches or white patches. It's never bled. It looks the same shape as it's always been, just bigger."
• ●The vision: "Only the left eye. Close work is smudgy, like a slight blur or a ghost image on the edges of things, mostly by the afternoon. Distance is fine, I drive without trouble. It doesn't come and go minute to minute, it's just a bit off. No double vision, no flashes, no floaters, no curtain."
• ●How the eye feels (if asked about irritation or pain): "Gritty and a bit red, especially after I've cycled in, and worse on windy days. By the evening it settles. It isn't sore, it doesn't hurt and it isn't sensitive to light. No sticky discharge. It waters a bit in the wind."
• ●Itch and hay fever (if asked): "It's not itchy. I get hay fever a few weeks of the year and my eyes itch then, but this is different, it's the one corner and it's gritty, not itchy."
• ●Contact lenses, injury, chemicals (if asked): "Never worn contacts. No knocks, no chemicals, no dust in my eye. I wear a visor at work and the loupes protect me."
• ●Sun exposure over the years (if asked): "I grew up in Queensland until I was 22. We lived near the beach. I was in the surf club as a kid, mornings on the sand and afternoons in the water, and nobody wore sunglasses. I played beach volleyball as a teenager. We did slip slop slap for skin later on, but not for eyes. In Bristol I cycle and I don't wear anything on my eyes."
• ●Father's eye (if asked about family): "Dad had one on his eye. He had it taken off in Australia about fifteen years ago, and it grew back a couple of years later. I'm not sure what they did the second time. He's fine now, just keeps a hat on."
• ●The right eye and optician (if asked): "I had an eye test about a year ago for my work. The optician pointed out a small yellow patch on the white of my right eye and said it was harmless. She mentioned the left one was there but small and to keep an eye on it. It's grown since. The right one hasn't changed and it doesn't bother me."
• ●Features of concern (if asked about skin cancers, immune problems, previous eye surgery or steroid drops): "I've had a couple of moles checked and they were fine. No skin cancer. No immune problems, no HIV, no steroid drops, no eye surgery."

Ideas, Concerns, Expectations

Gating note: Georgia does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

• ●Ideas: She thinks it comes from the sun when she was growing up. "I reckon it's a sun thing from my childhood. Everyone I grew up with had something taken off their face or eyes by thirty." She does not know if the blur and the growth are linked, but suspects they are.
• ●Concerns: She is worried it will keep growing across her sight and that it might be a skin cancer on the eye. "Where I'm from, a growing lump on you is skin cancer until proved otherwise. I keep thinking, is this one of those?" She is also worried her father's regrowth means hers would regrow.
• ●Expectations: She wants it removed as soon as possible, ideally before the loupe rep comes in about four weeks. "I'd love to get it dealt with before the loupes are refitted, because they'll be made to my eyes as they are now." She expects the surgery to be done by the NHS, and would think about paying if the wait is long.

If Asked: Medical History and Medications

Gating note: Georgia answers each of these plainly when the doctor asks.

• ●General health: "Pretty healthy. Hay fever, and cetirizine when I need it, mostly on the weekend. No other tablets and no regular eye drops."
• ●Eye drops: "I've tried a bottle of lubricating drops from the chemist a couple of times. They take the edge off the grit for an hour or so. Nothing else."
• ●Allergies: "No allergies to anything."
• ●Last eye test: "About a year ago. My vision was fine then, no glasses. They offered me sunglasses with the test but I said no."
• ●Skin: "I check my skin yearly, and the GP did a mole check two years ago. All fine. I wear factor 50 on my face."

Social History and Lifestyle Impact

• ●Work: Dental hygienist at a busy private practice, nine patients a day. She works with loupes, magnifying glasses fitted to a frame, for most of the day. The loupe company representative is booked to fit her new pair in about four weeks. They are an expensive purchase and she wants the right lens strength for the long term.
• ●Impact: "The blur is only slight, but I notice it at the end of the day, when I'm doing fine scaling. I don't feel unsafe, just a bit less sharp. I do not want to make a mistake with a patient, and I want to get the new loupes right."
• ●Home life: Lives with her partner, who is supportive. No children. Cycles to work most days, about 25 minutes each way. A couple of glasses of wine at the weekend. Never smoked.
• ●Her father: Bruce, a retired builder in Queensland. They speak weekly. He reckons she should have it sorted soon and offered to help if she wants to go private.

If Asked: Associated Symptoms

Gating note: Answers are brief. All of the following are negative: eye pain, light sensitivity, a sudden drop in vision, double vision, flashes, floaters or a curtain, discharge or stickiness, itching, swelling of the eyelids, headache, nausea, bleeding from the lesion, any change in colour of the lesion, a similar lesion on the eyelid or skin around the eyes, enlarged glands in the neck, weight loss, fever and any history of eye injury or surgery.

Responses to Management (The Negotiation Phase)

• ●If the doctor says it cannot be removed before the loupes are fitted, or that surgery depends on a hospital assessment and a wait:
  • ●Reaction: Disappointed but practical. "Four weeks isn't long, is it? Can I at least get the loupes done on my current prescription and change them later? They cost a fortune." She accepts once she hears the loupes can be made to a sight test result and that surgery is not an emergency. If the doctor mentions paying privately: "Dad offered, so I might ask what that would cost."
• ●If the doctor says it needs to be looked at in person or by an optician before anything is decided:
  • ●Reaction: Agreeable. "That makes sense, you can't see it down the phone. I can get to an optician on my day off, I'd be happy to do that first. Or I can come in to you, whichever's quicker." If asked to check it on the phone, she declines: "I can't really check it myself, the angle's all wrong."
• ●If the doctor explains that surgery can lead to regrowth:
  • ●Reaction: Tense. "Dad's came back. Does that mean mine will? Why would I bother?" She softens once told how common regrowth is, that modern surgery with a graft lowers the chance a good deal, that most regrowth happens in the first year, and that sun protection afterwards helps.
• ●If the doctor suggests sunglasses and hats:
  • ●Reaction: Doubtful at first. "In Bristol? It's grey most days. And I'd look ridiculous in a hat on a bike." She agrees if the doctor explains that UV reaches the eye on cloudy days and that wraparound glasses also protect from wind, and asks which sort she needs. "Do the clear cycling glasses count? Or does it have to be dark?"
• ●If the doctor suggests lubricating drops:
  • ●Reaction: "Are the chemist ones fine? Can I use them every day? And can't you give me some stronger drops to shrink it?" She accepts the answer that drops soothe the grit but will not shrink the growth.
• ●If the doctor gives vague safety netting such as "come back if it gets worse":
  • ●Reaction: "Worse how? What would make you want to see it quickly? Because I'm thinking about the skin cancer thing." She wants specifics, such as how fast it grows, any dark or white patch, bleeding, and when to go to eye casualty.