Dr. Mai's Optometry Blog

In case you did not realize it, optometry is quickly expanding its role in primary care as a healthcare profession. I’ve seen it in action at the IHS hospital and Veteran’s Affairs clinic I’ve worked at and patients are definitely better off because of it. Strange asymmetric optic nerve cupping, CRVO’s, suspected ocular ischemic syndrome have all been reasons for referrals on our part for carotid ultrasounds.

Recently I stumbled across this article in review of optometric business by Dr. Kathleen Andersen. (you’ll have to create an account to read the article but I think it’s very worthwhile to read some of the other great articles on that website). Dr. Andersen has introduced vascular health screenings along with her comprehensive eye examinations and I think it’s fantastic. By evaluating the carotid intima media thickness, optometrists can get a good indication on an individual’s vascular health.

Myself, I’ve recently started working with HeartSmart’s EyeCare division. Basically our goal is to expand optometry’s role as a primary health care provider by offering patients vascular health screenings. Millions of eye exams are conducted each year. In fact many Americans go see their optometrist more often than even their primary care physician!

If you think optometrists should play a bigger role in keeping patients healthy, like us at http://www.facebook.com/HeartSmartEyeCare

I have the pleasure of working at the Children’s Hospital of Orange County on Fridays. We do pediatric examinations for underprivileged children in the area. It’s a great overall experience. The kids come in a little shy but we generally have them smiling (except when we put in the dreaded eye drops) at the end of the day.

During my time there I get to work with Dr. Monique Nguyen, a residency trained doctor who owns a private practice in Ladera Ranch. It’s refreshing to talk to her about vision therapy and how she runs her private practice.

Working at CHOC is an awesome reminder of why I joined this profession. You have these children who are struggling in school because of significant myopia but cannot afford glasses. And many children rarely complain, quietly struggling through academics for years just because they have poor vision and can’t see what the teacher is working on in front of the classroom.

So it’s rewarding to break ground and give them their first pair of glasses. One patient (not at CHOC) but who I am following at the Eye Care Center who has a +9.50 DS Rx in both eyes proudly yelled at my last amblyopia continuing evaluation.

“I LOVE MY GLASSES!!”

Awesome.

Besides blog.drmai.info I am also a featured guest blogger for the AOSA and have also been asked to contribute to optometrystudents.com

In case you did not realize, the AOSA and AOA both have blogs where leaders post their thoughts and experiences. Here is my first blog as an AOSA blogger. I think I am the only non-former AOSA trustee or cabinet member to be invited to blog so I feel very honored!

How to refract like an OD and not a student. I realize that many optometry students and optometrists are masters at refraction, but hopefully some of my insights can help!

http://www.lrc.ky.gov/record/11rs/sb110.htm

Kentucky has followed in Oklahoma’s footsteps to pass a bill allowing optometrists to perform laser surgery. (SLT, LPI etc)

Here is a video of optometrists and ophthalmologists arguing whether or not optometrists should be allowed to train for laser procedures.

http://www.ket.org/cgi-bin/cheetah/w…tdir=&template

The KOA president, Ben Gaddie, has been to SCCO multiple times to discuss practice management. It was great to see him representing the profession.

There is evidence that the prevalence of myopia is increasing significantly over just the past few decades.

Rate of myopia increasing rapidly.

Looks like decent future job security for optometrists in the United States. The article (written in 2009 by Susan Vitale) states that 1999-2004 rates were 41% versus 25% when done in 1971-1972.

Interesting indeed!

This is the first of many optometry clinical encounters where I learned something.

1. Very first patient ever in my life. (I don’t count seeing classmates/friends as first time experiences). 66 year old male contact lens patient who wants multifocals CLs. But he’s doing a modified monovision of sorts where he has a multifocal in one eye and a distance toric lens in the other. I fit him with the CIBA Air Optix Aqua Multifocals in his non-dominant eye and the CIBA Air Optix Toric Lens distance contact lens in his dominant. He LOVES the vision, reads happily and can see distance great and the over-refraction (loose lens in multifocal eye, and the distance I did a sphero- cyl OR through the phoropter) was about plano-ish in both eyes.

The clinical pearl is that modified monovision can be an excellent option for patients with a little bit of astigmatism (he had 1.25 D of cyl.) Especially if the patient loves the feel of a particular contact lens multifocal but a toric multifocal option isn’t available.

2. Very first primary care patient ever in my life . 83-year old Spanish speaking only patient comes in with one eye barely open. Chief complaint from his son (translator) is that his left eye is always nearly closed. 20/30 in his open (OD) eye, and light perception only (OS) in the eye that he barely keeps open.

Turns out he has a full-blown retinal detachment secondary to diabetic retinopathy that my partner Chad and I spot which our staff doctor confirms and congratulates us on. So what about the eyelids closing? The patient was able to lift that eye when he desired.

The retinal disparity caused by the retinal detachment between each eye made him voluntarily (and then just out of habit) close his non-seeing eye. This was not a case of ptosis.

3. Second contact lens patient ever. Female keratoconus in her 20s who has lost one gas permeable lens and needs a new one. Chad and I are at it again. Getting a crazy cover test of 20 exotropia in entrance testing. our staff doctor comments when we first meet with him with this clinical pearl:

“Don’t do a binocular test on an essentially monocular patient” (at this point she had just one CL on, and she can see hand motion only in the eye without the RGP.

Other clinical pearls was the patient was getting inferior dimple veiling on the cornea. To fix this we steepened the lens.

We steepened it to allow for better centration so that the lens would not slide down and we also reduced the optic zone diameter to decrease chances of air bubbles.

That’s it for now!

From optometric management

Clink on the link above to read an article about bringing a new grad into an established practice.

In psychology there is something called the self-serving bias. To quote from Wikipedia:

“A self-serving bias occurs when people attribute their successes to internal or personal factors but attribute their failures to situational factors beyond their control.” (wikipedia)

Not my fault, the DOG ate my homework!

This is prevalent in optometry school and no doubt with many other professional/graduate  schools. When it comes to test-taking, it seems to happen on every other test that there is a question that students miss yet inevitably blame the instructor for writing a poor test question.

Students sometimes start to think they’re always right, and refuse to listen and learn when they’re wrong. At my friend’s work, she laments often about coworkers who EVERYONE knows is at fault for a particular problem, yet that coworker is too prideful to admit they made a mistake and the politics of the matter makes life difficult to get things done.

So what’s the point of this post? It’s really just to say “don’t take yourself so seriously.” At SCCO they try to teach confidence in the clinic, to make a decision and stick to your guns. This is the right approach, but while learning always remain open to accept criticism for your mistakes.

One short anecdote I forgot to mention at the RAM.  My friend Denh was talking to Dr. Gordon, a staff doctor over at OCLA about ocular disease. It went something like this:

“Dr. Gordon! How much disease do you see at OCLA?!”

“Oh we see quite a bit, I guarantee you’ll learn a lot if you come here”

“Awesome! The more disease the better. We just learned about Trachoma in class yesterday, about ARLT’s line it was fun!”

:Chuckling: “A little knowledge can be a dangerous thing.”

I thought it was interesting what Dr. Gordon said, but he is right on the money. How many times do I expect to see Trachoma in the United States in my lifetime? Possibly ZERO times ever. It should very rarely be on my list of differentials. Inclusion bodies from Chlamydia, possible, but not Trachoma. So why do we learn it?

Some will fault optometry school, saying what’s the point of teaching all this “junk” information. Or mention that in a private practices someone shadowed, they never do phorometry on every single patient – so they’re mad that opt schools make us waste our time.

My opinion is that the point of optometry school is to learn as much as possible so that if I ever run across it, I can make the appropriate call. Definitely, it would be financial suicide to do 2 hour exams on all our patients when we graduate, but for now it is academic suicide to not practice all the skills we’ve been taught and to do a thorough (this is the emphasis, not speed) exam.

Most optometrists who have ever done a residency in optometry told me they were glad they did it. Many people who didn’t do one say they are glad they didn’t forfeit the extra year of earnings and that they felt adequately prepared to handle things with the training they received during optometry school.

So what should a third/fourth year optometry student to do? What are the pros and cons of doing a residency in optometry?

Let’s take a look at the pros and cons:

Pros of an optometry residency:

1. You do get paid, probably to the tune of $30-35,000. Not a lot, but that’s 2 times my current spending budget in optometry school so it’s an upgrade!

2. You get REALLY good at something that might have taken many years to get good at. How many keratoconus, prosthetic eye candidates, low vision, or strabismus would you see in private practice? In a residency you’d see multiple EVERYDAY. In saturated optometry markets, carving a specialty niche can be very beneficial. Word of mouth referrals for niche specialists spreads fast which will help your bottom line.

3. Don’t have a job lined up? Don’t know where you want to set up your practice? Remember, in optometry you can succeed as long as you avoid the train-wreck. Ducking away for 1 year gives you more time to shop around for practices, interview, and network with other optometrists to find that perfect opportunity – and not being unemployed. Who knows, maybe the residency itself will help you find a job or partner who requires your unique expertise. Regardless, it’ll give you more time to more carefully examine your post-grad options without leaping for an opportunity out of desperation. Like John Wooden, the famous UCLA basketball coach said, “be quick, but don’t hurry.”

4. Less need to refer because you are better trained. This keeps life more interesting when you can manage the more interesting cases.

5. If you plan on doing academia, teaching, or working in a hospital setting, then a residency needs to seriously be considered. Not only seriously considered, it might even be required.

6. You can apply and still withdraw if you change your mind (but only up to a certain point, afterward it is extremely bad form to not honor your commitment). So it doesn’t hurt to just apply up to a point. You never know what doors could have opened if you never gave it a shot.

7. Psychologically, it’s nice to know you’ve got something going on after you graduate rather than just twiddling your thumbs and nervously looking for fill-in work or a corporate gig after graduation.

8. You can still find fill-in work maybe a couple days a month if you choose to pad your income. I know of an SCCO resident who did just that.

9. Learning is fun. One of the major draws I had to going back to school after I graduated with my BS from UCLA was that I loved learning. In a work environment, you do learn some things here and there, but it’s not your JOB to simply learn. One of the fun things about a residency is that it is still mentored education. You’ve got more responsibilities and privileges, but it is still a learning experience.

10. Board certification passed last year at the AOA meeting. If your intention is to become board certified, I believe you get to leapfrog some of the time-requirements if you complete a residency. This could potentially be a great added benefit to doing a residency if board certification is mandated or looking very favorably on by insurance.

11. It is only one year, honestly.

Cons of an optometry residency:

1. You forfeit a year of real salary. Which can be significant if you’re tired of living life on strict financial restraint.

2. Applying for a residency is like applying to school again. You have to hunt for letters of rec and interview. Could be difficult if you never fostered meaningful relationships with your current faculty.

3. You might not end up geographically where you want to be. If you have a spouse or significant other, is it worth being apart for another year?

4. Not all residencies are created equal, you may end up just being at a “5th year” of optometry school.

5. You may feel already confident with your skill set and any future obstacles can be self-taught.

6. Once you start, you can’t jump ship in the middle of the year. Say you find a can’t miss opportunity, well you might have to wait until you are done with your residency and by then it might be too late. The practice you wanted was sold, the job opening was filled etc.

It’s much more common to hear about myopia at my age and less so with hyperopia. But the prevalence of hyperopia really struck me when I volunteered for Remote Area Medical last week. What is RAM? Basically it is an event where free healthcare is given to those who cannot afford it on their own.

I volunteered in the lab making glasses as well as dispensing them. With no stretch of the imagination, it seemed at least 75% of the glasses I made were for hyperopes. Some had it bad like +4.00 with a +2.00 add. It makes me wonder how long these people, who could not afford to update their glasses, have been functioning especially at close. With that much uncorrected hyperopia at near, I can’t imagine they could have been reading all that well.

Could the inability to read presently, and the accommodative demand manifesting as eye strain in their pre-presbyopic days have been a significant impact on their current financial plight? This is debatable but I would think it could have certainly impacted their performance in school and ability to learn due to a visual problem.

To me it just highlights the need to see an optometrist regularly. Undetected vision problems can certainly impact one’s ability to learn and just function. How many of these underprivileged people that RAM served could have avoided their situation altogether if they had proper eyecare at a young age?

You’re reading your clinical medicine reader and you stumble on (page 3-18 for those in my class) when looking at near objects that “the pupils constrict and the lens becomes thicker because of relaxation of the ciliary muscle.”

And you say “wait a minute! The ciliary body actually contracts (NOT relaxes) and it’s really the ZONULES that relax to allow the lens to thicken!”

And you are even nerdier because for some unknown reason you are compelled to blog about it.