Oct / Nov 2016
President s Message Page 2 Did you know the average optometry student graduating in 2020 will have $358,342 in student loans and that unemployment for new ODs in Orange County will be a staggering 47.4%? You couldn't have known this because I just made those numbers up. Sorry, the current political cycle has really inspired me to make up facts! Regardless of exact details though, financial order and stability are important considerations for all ODs whether you just graduated in 2016 or are considering selling your practice after 30 years. There are many questions that we face and rarely do we have perfect answers for our particular situation. What is your tax strategy if you are an independent contractor who moonlights at two or three different offices (whether you should legally be an employee is a different discussion of course!)? Should you refinance and restructure your student loan to a lower interest rate? How fast should you pay off your student loans versus funding a ROTH IRA? Or buying a house? Statistically speaking 1 out of 4 people of today's 20 year-olds will be disabled before they retire, what's your plan if that happens to you? Are you protected from litigation? So many questions. Luckily, OCOS can provide solutions. We've got a great sponsor, WestPac Financial, that gave an introductory presentation at our general meeting last month at Dave and Busters in Orange. As a friendly reminder, our Holiday Party will be on December 13. It s going to be a great event at the Lyons Air Museum. Bring your family and please keep in touch with our OCOS family. Perceptions Orange County Optometric Society Hope to SEE you there! Thanh Mai O.D. OCOS president Editor: Ivy Lin, O.D. (714) 234-6373 andromeda313@yahoo.com Perceptions is published bi-monthly by the Orange County Optometric Society. Submit articles and ads to the editor at the above address by the 15th of the month prior to publication. The views expressed in this publication do not necessarily represent the views of the OCOS. Neither the editor nor OCOS assumes responsibility for any statement in signed articles or a d v e r t i s i n g.
Page 3 2016-2017 BOARD OF TRUSTEES President Thanh Mai, O.D. President-Elect Rachelle Lin, O.D. Immediate Past President Danny Ngo, O.D. Secretary Maggie Jan, O.D. Treasurer Jade Davis, O.D. Events and Sponsorship Chairs Rebecca Ng, O.D. Millie Liu, O.D. Membership Chair Fara Moin, O.D. Legislative Chair Justin Kwan, O.D. Public Relations Chair Steve Wang, O.D. Webmaster/Communications Ketan Patel, O.D. Student Representative SCCO: Gary Chan WUCO: Christina Nguyen Advisory Committee Eunice Myung Lee, O.D. (714) 449-7424 emyung@ketchum.edu Harue Marsden, O.D. hmarsden@ketchum.edu Editor Ivy Lin, O.D. andromeda313@yahoo.com Education Chair Trang Ngo, O.D. Cecilia Rivas, O.D. Bylaws Review Matt Wang, O.D. THANK YOU TO OUR 2016-2017 SPONSORS: GOLD George Brennan, MD, FACS drgeorgebrennan.com Orange County Eye Institute George M. Salib, MD oceyeinstitute.com Orange County Retina Timothy You, MD ocretina.net VSP Lori McKenzie vsp.com SILVER Alcon Megan Mozayeni megan.mozayeni@alcon.com Coastal Vision Medical Group : Dan Tran, MD Mylene Soriano mylenesoriano@danbtranmd. com Comfort Vision comfort-vision.com Coopervision Deana Hibbs dhibbs@coopervision.com Optos optos.com Shamir Dia Kaesman dkaesman@shamirlens.com TLC/Harvard Eye Isabell Choi, OD isabell.choi@tlcvision.com Visionary Lens visionarylens.com Vistakon Randy Campbell RCampb27@its.jnj.com VMR Institute Mimi Nankervis Mimi.n@vmrinstitute.com WestPac Wealth Partners Rod Roberto thewp2.com X-tra Lite Optical xtraliteoptical.com
Ocos Family Picnic Septe,mber 25 @ Craig Park Page 4
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The Retina Perspective: Macula or Media? Page 7 John Maggiano, MD, Director Ocular Physiology Lab Orange County Retina E ye care doctors are routinely faced with determining the cause for vision loss. Employing standard examination techniques allows the clinician to determine if visual loss is due to uncorrected refractive errors, media densities and haze or diseases of the macula or optic nerve. An example of a standard test includes the pinhole test. However, a pinhole test may yield a false negative result, possibly due to a loss of chart luminance. The mighty pinhole test may eliminate monocular diplopia, thus implicating the media as causation. In the absence of a satisfactory best-corrected improvement in acuity, the clinician may want more information regarding a macular potential estimate. Some offices possess a retinal acuity meter (RAM) or potential acuity meter (PAM, figure 1) to assist in understanding the etiology of the visual loss. By projecting a high contrast image through the media, these devices often yield better predictive value than the simple pinhole. Other helpful psychophysical devices include Heine retinometry, blue-light entoptoscopy Figure 1 and macular microperimetry. We routinely perform the four tests as a battery (RAM, PAM, BlueLight, Heine retinometry). The best result of the four is usually closest to true (post-operative) macular potential. These subjective tests rarely overestimate macular potential, but may greatly underestimate macular potential due to dense media, patient inattention or malingering. Thus, objective testing may be indicated. Additional assistance in elucidating macular and/or optic nerve disease versus media issues is obtained with objective testing. A general test of retinal function, such as a Ganzfield ERG with a selective B-wave decrease, strongly suggests vascular disease of the central retinal vessels and/or choroid. Likewise, a poor flash VER (figure 2) strongly suggests macular and/or optic nerve disease. Comparing both flash and pattern VER with Ganzfield and multifocal macular ERG often yields a highly significant conclusion which may validate poor psychophysical testing or conversely demonstrate the subjective testing to be falsely negative for excellent macular potential. These same devices also assist in accurately predicting post-operative cataract, corneal transplant or posterior vitrectomy results, and give both physician and patient a clear understanding of expected benefit. If there is variation among the tests, a range of expected results may be considered, along with a probability estimate. Also, these devices may be employed to follow and manage patients with co-morbid disease, such as cataract and macular degeneration. Other testing may also be helpful in macula vs media considerations, (Continued on page 8)
Page 8 (Continued from page 8) Figure 2 including fluorescein angiography and B-scan ultrasonography. In the case of a poor post-operative outcome such predictive tests show both due diligence and informed consent, acting to thwart an aggressive malpractice attorney and convince a future jury of an excellent standard of care. The Physiology Lab in our central Santa Ana location contains a wide array of psychophysical and electrophysiologic testing equipment to aid in the diagnosis and treatment of retinal, optic nerve and visual disorders. The concentration of sophisticated retinal testing and clinical expertise to make sense of difficultto-explain vision loss is a unique resource available to doctors in the area. Orange County Retina s Physiology Lab offers many diagnostic tests in addition to next generation procedures. Every patient who is seen in our offices benefits from a thoughtful, thorough approach by an experienced retinal physician with the goal of obtaining the highest visual outcomes. Our approach to retina is not a one-size-fits-all. The success of the past 40 years in our community is based on the commitment of providing the best retinal care for patients. Should you wish a four-page description of our Physiology Lab testing devices or have an interest in learning more about the Lab, contact Chellie in our Santa Ana office at 714-972-8432. John Maggiano, MD, Director, Ocular Physiology Lab Sanford Chen, MD Timothy You, MD Rajiv Rathod, MD, MBA Eugene Chang, MD, MBA Millie Liu, OD Margret Yu, OD Offices: Santa Ana/Tustin; Newport Beach; Fullerton; Laguna Hills; San Juan Capistrano (714) 972-8432. www.ocretina.net
Page 9 Retina Unknown RETINA UNKNOWN FROM LAST ARTICLE 60 year old woman with metamorphopsia after retinal surgery. Seen in our offices for a 2 nd opinion. Vision is 20/30 in the right eye. What has caused the patient s symptoms? Fundus photos show multiple small blisters in the retina of the right eye. OCT shows subretinal cysts. ANSWER: Thanks to all who responded. There were many close answers including gas bubbles, artifact, and retinotoxic drug. The correct answer is retained perfluoron, (ALCON) a liquid used to repair retinal detachments. The medication got trapped underneath the retina at the time of surgery. Unlike a gas bubble, the perfluoron does not resorb and may not have to be removed unless it is creating problems.??? RETINA UNKNOWN??? Case: 72 year old woman with headaches reports blurred vision in the right eye. She has been tested negative for diabetes mellitus. She has a history of kidney disease. Fundus photo of the right eye shows an area of retinal hemorrhaging with lipid exudation. The first doctor to email the correct answer gets a special prize. The winner and the correct answer will be announced in the next newsletter. Email: Dr. Timothy You, tyou@ocretina.net.
At the Orange County Eye Institute, we are proud to be Gold sponsors of the Orange County Optometric Society! We have enjoyed a great relationship with local optometrists for the past 5 years, and that is the best way we can help serve our patient population together. We have no optical shop since we closed it a few years ago in order to focus more on medical and surgical ophthalmology. We will not keep your patients after they are referred to us for surgery or consultation nor will we sell them glasses! This is our commitment to you. We specialize in cataract surgery. Surgery with basic, multifocal, accommodative and toric IOLs. S u r g e r y w i t h o r w i t h o u t femtosecond laser. We also offer istent. We differ ourselves in our commitment to the personalized care for your patients and our expertise. We are also proud to announce our newest associate, Dr. Alyson Lin, a recent Ketchum graduate!
The Most Important Person in the Room Page 12 George M. Salib, MD Orange County Eye institute S itting in my hotel room here in Chicago looking out at the beautiful skyline, I can't help but become pensive and introspective. I'm attending the American Academy of Ophthalmology annual meeting, and I wanted to share one of my revelations I came upon today. When we are seeing patients either as a practice owner or an employee, we often think very highly of ourselves and feel (and share with others) that we are the most valuable resource that the practice has, and that we are the most important aspect of the practice. I found out today that I had it all wrong, and maybe that is something many of you can relate to. In fact, what I learned should be obvious, but somehow it escapes us: the patient is the most important person in the room (and in the practice). Until we can wholeheartedly come to terms with this, we may never achieve the job satisfaction we all want. I learned this in a class that was not about customer service and how to be a caring Doctor, but rather in a class that was discussing how to make a practice efficient through the application of "Lean" processes. I was going there thinking I was going to get a bunch of pearls on what procedural steps we can take to maximize my utility in the office and how I can see the greatest number of patients possible while getting out on time. I was always under the impression that the doctor is the most important asset that the practice has, and that everything revolved around that notion. I quickly learned that I was wrong. If you are experiencing delays in the office flow, miscommunication between technicians and getting out of clinic later and more tired than you would like, then you need to pause and rethink things. First, we need to look at all of the steps involved in getting the patient checked in until they leave the office. Obviously there are many aspects of the process including signing in, waiting in the waiting room, getting called back by a technician (or the doctor) to do the initial workup/testing, more waiting while dilating, getting placed in the exam room, waiting again, getting seen by the doctor, then going outside to check out (which may involve more waiting or a trip to the optical shop). Thankfully, I don't need to worry about this last step since our practice has purposefully taken out our optical shop so that we can focus more on the medical/surgical aspects of ophthalmology while allowing referring optometrists to feel comfortable that their patients will not be sold glasses in our office if referred to us. As you can see, there is a lot of waiting that is going on in the visit. We have to consider how a patient will feel if, from start to finish, their visit took 90 minutes while the doctor only spent 10 minutes with them. I am guessing that they will not be too pleased and may not come back, or even worse, may tell their friends that you don't respect them or their time. If that occurs, your business will ultimately suffer from a decrease in your patients, an increase in employee and patient frustration, and possibly going home later and later as things become less efficient (as you spend time apologizing to patients for keeping them waiting, or as technicians slow down as their morale sinks). (Continued on page 13)
Page 13 (Continued from page 12) What do we have to do? While I don't profess to be a guru in Lean processes, the one take home from that lecture was that it all starts with the patient. We are in a service business that is meant to care for patients. We need to keep them happy so that both doctor and employee satisfaction also remains high. We need to look at all activities and steps in the visit that will add value to the patient, and which steps do not add value. If the activity does not add value (eg. waiting, walking long distances from the workup room to the exam room, having to go to multiple rooms in a visit, etc), then that activity should be modified to decrease or eliminate wasted time/resources. Once we can do that, then the patient will feel happy on finishing their visit with you, will be more likely to buy glasses from you, will be more likely to tell their friends about We are in a service you and to ultimately return to see you. business that is meant to You will begin to notice that things are running more smoothly for you, for the technicians and for the patient. You will get out on time feeling good, and morale will be high. I spoke to one retina specialist who told me that he was getting so busy and things were not running smoothly after only four years in practice, and that he was feeling urges to retire! Lo and behold, he and his partner began to examine their office flow and employed Lean methodology to empower his staff to analyze the problems and come up with solutions to cut out waste. Soon his office began to have more efficient operations, wait times decreased, overall patient and employee satisfaction began to rise, and most significant to him: he felt great relief and began to enjoy his work again, and he was able to go home at a decent hour to enjoy the company of his family. You could see the joy on his face...and it all started with looking at the most important person in the room: the patient, and how to add value to the patient. care for patients. We need to keep them happy so that both doctor and employee satisfaction also remains high. That is truly a great revelation, and one that should give us all hope to achieve joy and satisfaction from our work even in the tough times, and to always focus our efforts around keeping patient satisfaction high. After all, without them, we really wouldn't have anything to do at the office! I certainly am going to look at the practice in a different light now, and I look forward to getting great reviews and many referrals from my patients while getting more time to spend with my family.
Page 15 Scleral Lenses for Everyone? An Unlikely Case Study Cindy Belliveau, MSME & Christa Brewster, GP Lens Consultant Visionary Lens It isn t a secret Scleral GP contact lenses have become a popular and successful vision correction option for patients with irregular cornea. They are perfect for irregular corneas because the lens can vault just about any abnormal shape. But wait, there s more. They are perfect because GP Sclerals have the optimal combination of design customization, excellent acuity and comfort that rivals soft lenses. There is a silent and growing realization that Scleral lenses now have all the best qualities of soft lenses and GP lenses all in one. Our head won t stop spinning thinking about the possibilities. Can we recommend Scleral lenses for regular corneas? For soft lens wearers? Is it practical to convert a soft lens wearer to Scleral lenses? That brings us to the impetus of our case study. How will Scleral lenses work on a typical soft contact lens wearer? Introducing John Belliveau. John is an ambitious 23 year old male complete with all the young man perspectives. He is the control guy that doesn t appreciate changes that he doesn t initiate. John also doesn t like to be tethered with the drudgery of routine chores, including contact lens care. Combine that with a strong dose of 23 year-old skepticism and John is the perfect person to honestly assess the feasibility of recommending Scleral lenses for existing soft lens wearers. John is a mild myopic and wears disposable soft contact lenses. He hasn t been to an eye doctor since being prescribed 10 years ago and he replenishes his soft lens supply via the internet. And, since he s the guy that uses the sniff test to determine laundry day you can bet John leaves his daily wears in a little longer than a day. He hasn t had any issues with his soft contacts with exception of them drying out on occasion. John gets a complete exam before being fitted with Scleral lenses by Dr. Heinrich. We sent John to Southern California College of Optometry s (SCCO) brand new clinic facility in Anaheim. The clinic is newly named University Eye Center at Ketchum Health and is now part of Ketchum University which establishes the clinic as an outstanding provider in the Southern California community. John was fortunate to be fitted by Dr. Colton Heinrich, a resident from the University of Houston. Dr. Heinrich has dedicated much of his residency to developing an expertise in Scleral lens fitting. Dr. Heinrich gave John a well needed thorough exam and a new prescription. But seemingly more important, or because John just wouldn t stop asking questions, Dr. Heinrich generously provided John a visual and verbal tour of the Scleral lens fitting process. This is how he explains what seems like a relatively simple fitting process. First, find yourself a fitting set with fitting instructions that makes sense to you. Experiment with lenses in the fitting set until you find one that fits the landing zone (the part of the lens that rests on the sclera). Then, keeping the same landing zone curvature, go to a lens that gives you the correct apical clearance. Lastly, over-refract to get the right power. Sound simple? Armed with his new knowledge and the excitement of being initiated as a lab rat, John was looking forward to his new adventure. However, the feeling of euphoria was replaced with another feeling at checkout time. He thought (Continued on page 16)
Page 16 to himself, these lenses must be really comfortable because the sensation to his checkbook is painful. Not only that, they told him he would have to wait a couple weeks to get his lenses which crushed his instinct for instant gratification. The skeptical 23 year old mind set quickly replaced the enthusiasm. But hey, good things come to those who wait. Let s skip ahead by four weeks. (It took one round of modification to hone in on the precise power). John decided to start his Scleral lens diary on Monday. John works at a GP manufacturing lab in Southern California (was anyone surprised?) He is competent at a multitude of jobs including manufacturing, customer service and is cutting his teeth at lens design consultation. In addition, he is a student working toward a business degree. He got up early on Monday to give himself extra time to insert his Scleral lenses. He found they weren t at all difficult to insert which he attributed to his years of experience inserting soft lenses. But as soon as he put them in his first thought was he couldn t wait until the end of the day to take them out. The newness of the pressure sensation was annoying to him. At the office, John was fascinated by the clarity of everything around him especially the images on the computer screen. After a long day of work and an extra hour working math homework, John completely forgot about the annoyance he felt when he first put the lenses in. In fact, he was amazed because they turned out to be just as comfortable as his soft lenses. When asked the difference between the two, he thought about it and said the biggest difference is my eyes didn t get dry at all during the day which happens a lot with my soft lenses. On day two, John was running late for work and threw on his glasses. On day three John worked all day while wearing his Sclerals and then hustled off to his weekly softball game with his Sclerals still in place. Maybe these Sclerals are worth the price, he reported. He hit two doubles, a single and made a sweet play in right field. He added, The Sclerals are a definite improvement over soft lenses when it comes to minimizing the glare caused by the overhead lights. The ball was in better focus too. John said there was a noticeable difference in his increased ability to focus on the ball. Day four was another full day at work followed by a late night of studying. At this point he was impressed again. His common soft lens drying out problem didn t exist with the Sclerals. After a seriously long day his contact lenses didn t bother him at all. Another huge selling point for a busy person. On day five we talked to John about the extra care necessary to maintain the GP Scleral lenses versus his soft lenses. After all, he needs to clean the lenses at night. But that didn t seem to faze John and he said it really isn t much more effort - I have to soak the soft lenses anyway so an extra step to rub the Sclerals isn t a big deal. The weekend included the best round of golf in his life. John s observation was his Sclerals didn t pop out unlike his soft lenses that have a tendency to dry out while he plays sports. At the risk of making Sclerals sound magical, we ll chalk his great round of golf up to lots of practice and even more luck. Let s face it, if the Sclerals could (Continued on page 17)
Page 17 Sclerals didn t pop out of his eyes during his golf game unlike his soft lenses that have a tendency to dry out when he plays sports. (Continued from page 16) improve a golf game, we wouldn t be spending time on this article right now. After a week of wearing the Sclerals, John fell in love with them. He is especially pleased when he competes in athletics. The small annoyances of his soft lenses are gone which he believes makes his ability to concentrate better. John is completely convinced the Scleral lenses are the future for vision correction. If they just weren t so expensive and didn t take so long to get, everyone would be wearing them right now. Now let s step back from John s experience and think about his summary statement. If Sclerals are so great why aren t patients pounding down doors to get them? Is it really the pricing and the lack of instant gratification? Some of us think it is more likely the typical contact lens wearer is not aware that Sclerals even exist. We believe it is up to the lens manufacturing industry to team with practitioners to educate and promote awareness of Scleral lens advantages and benefits. Given that, we expect to see some big changes in the industry. Be on the lookout for more to come. You can follow John and his commentary regarding Scleral lens wear on Facebook /visionarylens. John said there was a noticeable difference in his increased ability to focus on the ball.
Page 19 Life is Starting to get Back to Normal - 1 Month Follow Up Andrew S. Morgenstern, OD, FAAO TLC Laser Eye Centers @ Harvard Eye
Page 20 Abbott announced that the FDA has approved the Tecnis Symfony IOL, the only lens in the United States that provides a full range of continuous vision following cataract surgery while also mitigating the effects of presbyopia, according to a company news release. The FDA approval includes a version of the lens for people with astigmatism, the Tecnis Symfony Toric IOL. Coastal Vision, among the first few practices in California, has begun offering these advanced lenses. We continue our commitment to offer safe and proven technology. The lens is different from a traditional multifocal IOL in that it doesn t split light between near and distance focal points, Jason Jones, MD, of the Jones Eye Clinic in Sioux City, Iowa, and a clinical investigator for the Tecnis Symfony IOL, said in an article submitted to Eyewiretoday.com. Rather, a diffractive echelette design feature extends the range of vision, while achromatic technology reduces chromatic aberration to increase contrast sensitivity and enhance quality of vision. Patients in Symfony group were also more likely to achieve reduced overall spectacle wear and high overall visual performance in any lighting condition. Rates of adverse events did not differ between Symfony and monofocal groups. The Symfony lens is approved in more than 50 countries around the world, and has been widely studied, with data from numerous clinical studies involving over 2,000 eyes. According to AMO, in clinical studies the Symfony lens: Provided seamless, day-to-night vision Provided high-quality vision Demonstrated a low incidence of halo and glare The Tecnis Symfony Toric IOLs are indicated for primary implantation for the visual correction of aphakia and for reduction of residual refractive astigmatism in adult patients with 1D of preoperative corneal astigmatism in whom a cataractous lens has been removed. The lens mitigates the effects of presbyopia by providing an extended depth of focus. Compared to an aspheric monofocal IOL, the lens provides improved intermediate and near visual acuity while maintaining comparable distance visual acuity. Source: Abbott Medical Optics
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Page 23 Welcome New ocos Members! Jessica Bartl, O.d. Shelley miyasato, o.d. Justin burgerson, o.d. Song choi, o.d. Monica Gonzales, o.d. Scott hyatt, o.d. Jessica iida, o.d. Benjamin jager, o.d. Scott kawakami, o.d. Matthew krewer, o.d. Ngoc le, o.d. Ashley luke, o.d. Elizabeth mcmahon, o.d. Lynn messer, o.d. Melanie muprhy, o.d. Kimberly pang, o.d. Helen phan, o.d. Katelyn powers, o.d. Philip seitz, o.d. Charlene singh, o.d. Coreeliza tayong, o.d. Jeannie tran, o.d. Vincent uy, o.d. Kimberly woo, o.d. Dayna yim, o.d. Bridget zoellner, o.d.
Page 24 Adult Amblyopia Treatment Study Amblyopia is characterized by a reduction in visual acuity, contrast sensitivity, and binocular visual functions. There is very little published on adult amblyopia therapy. This is because clinicians initially believed that amblyopia could not be treated after the end of the critical period. However, recent studies have suggested that adult amblyopia can be treated. Patching combined with active, near, threshold-training tasks and continuous feedback was employed in these studies. The purpose of the current study is to use standard amblyopic therapy in addition to an oral supplementation to determine if there is an enhancement in visual performance in the amblyopic eye. Inclusion criteria/study specifics: Age > 18 years Best corrected acuities between 20/60 and 20/400 (with E-ETDRS chart) Amblyopia due to anisometropia and/or strabismus A standard amblyopic work up will be performed on all patients to determine if they are eligible for this study Visual acuity and contrast sensitivity function will be measured at each weekly visit Data collection will take approximately six months per subject Prior amblyopia therapy is not an exclusion criteria Subjects will receive amblyopia therapy at no cost Exclusion criteria: Significant cataract that affects vision Glaucoma Diabetes Uncontrolled high blood pressure Pregnant or expecting to become pregnant during the study period Ocular/systemic diseases that affect contrast sensitivity Renal impairment, liver damage If you have a potential subject for this study, please contact: Dr. William Ridder x 714 449 7494 Dr. Reena Patel x 714 992 7873 (wridder@ketchum.edu) (rpatel@ketchum.edu)
Page 25 Ocos October Meeting October 11 @ dave & buster s