Patient case for September 22, 2023

A 20 year old Persian female came in for her first eye exam in the states last week and was complaining of blurred distance vision with her current pair of glasses as well as some itchy eyes for the past three months. She’s systemically healthy, isn’t taking any medications, and has no medical allergies.

All confrontation testing was normal.

Incoming VAs with glasses were:

OD: -3.00 -3.25 x 031  20/400, pinhole 20/40
OS: plano -2.50 141  20/40

Refraction results were:

OD: -6.00 -3.00 x 037  20/40
OS: -0.75 -3.50 x 150  20/40

Ocular health showed some trace papillae and otherwise myopic looking discs that were obliquely inserted, right>left.

For the ocular allergies, we recommended OTC allergy drops to be used as needed.

In terms of refractive error, this certainly looks like refractive amblyopia, which is what the student was leaning towards when she came in for the final consultation. However, what questions would you ask to help confirm this diagnosis or rule it out? What other testing could you do as well? Are there any other differentials for her decreased visual acuity given an unremarkable dilated ocular health exam?

Happy thinking!

Pink smoothie

This one was super filling and very tasty. Plus it was just so pretty to look at! The only downfall? All the little seeds made it surprisingly gritty. I guess I could have blended this one longer but all good. Definitely worth remaking this one in the future!

  • 1/2 cup soaked oats
  • pomegranate
  • apple
  • beet
  • 4 asparagus stalks
  • 2 Tb neutral oil (I had to mix avocado and coconut oil here because I ran out of the former)

Blended together, it came out to this:

Beware! Your pee may have a pink tinge to it after drinking. All normal!

The art of letting go

Seeing patients means establishing a relationship with them, getting to know them, becoming invested in their eyes and health and over time, their lives. You will share good times, not as good times, major milestones, and more, all while doing your job and duty of making sure they see to their fullest potential and their eyes are taken care of.

That being said, remember, it is your job and duty to educate your patients on what is their best interest for maintaining good ocular health and vision.



Be a resource if they have questions.

If applicable, lead and demonstrate by example.

But do not get caught into caring more for your patients’ eyes and health more than they are willing to care for themselves.

Yes, some patients will require you to advocate for them. For example, there will be plenty of individuals who have limited funding for glasses or optical devices. Your finding alternative resources for them will continue to solidify your relationship with them.

Some patients will hear your recommendations for different treatments or care with other specialists and defer or decline. As an example, one of my students was telling me of an elderly patient who they recommended cataract surgery for. That patient declined the recommendation because he wanted the money to go towards his family instead, raising his grandkids, explaining that he’s already lived a good life and he can just make do.

One of the patients I saw during residency had severe NPDR and CSME in one eye and I was recommending he see the ophthalmologist for injections. He refused because he’d had injections in the other eye already and shortly afterward lost vision. He just wanted new glasses and could not understand that glasses wouldn’t help. He left furious when I said I couldn’t help him the way he wanted – he’d already seen all the other providers in the department and we had all said the same thing. I’ll also mention he was, by this point, already a double leg amputee from poor diabetes control. And he was only in his early 50s. One of my mentors casually mentioned that this patient probably didn’t have good chances of living another 5 years considering his health status. That hit me hard.

I’ve given a recent example of a patient coming in with hypertensive crisis who wasn’t entirely convinced of the need to go to the emergency room or ophthalmology same day. A couple weeks ago, we had a different patient coming in with a painful eye that was already blind but who had a new corneal ulcer. Her caretaker wasn’t entirely convinced they needed to go right away for ophthalmology follow up and management because, “What’s the point? [The patient] can’t see out of that eye anyway”.

There will be times when you’ll want to do everything you can for your patients. Short of physically driving your patients to the emergency department, purchasing glasses for your patients out of your own pocket, joining them for all the recommended exercise sessions or dietary classes to help  manage their overall health – in the end, the patients will have to make their own informed decisions to follow and take your advice or not.

And you will need to take care of your own mental and emotional health and well-being by making sure you don’t ‘take these patients’ home’ with you energetically at the end of the day. In the beginning of my career, that was hard. I was super invested in my patients and wanted to make sure I was doing everything possible for them. But after months and years of hearing how these patients never ended up going to see their doctors or ophthalmologists, how they habitually forgot to take their eye drops or systemic medicines… I learned that I had to step back from being that doctor who knew what was best for my patients to understanding that my patients had their own lives they had to deal with and sometimes, whatever I had to say wasn’t the priority for them.

It took time to realize that and come to grips with understanding it, but I want to share these thoughts with you too so you won’t find yourself worrying and losing sleep over what could have been done differently, etc. Be thankful for the patients who listen to you – the majority will. And be patient with those who don’t – everyone has a choice, just like you.

Patient case for September 15, 2023

We have a 5 year old Hispanic male we’ll talk about today. His parents brought him in because they’ve noticed his eyes getting really red for the past month. There aren’t any vision concerns and no other ocular complaints at this time. It is the kid’s first eye exam ever.

The patient is systemically healthy with some seasonal allergies for which he’s taking Claritin. Otherwise, he has no other drug allergies.

Incoming visual acuity is 20/20 in each eye, confrontation pupils, EOMs, color, and fields are full in both eyes, cover test shows ortho in the distance. Dry retinoscopy shows +1.00 DS in each eye.

Eyes are white in office, but he does have about 1+ papillae in both eyes. The rest of his anterior segment findings are normal.

What allergy drops would you recommend for this pediatric patient? At what age can you start prescribing allergy drops for kids? If the parents ask, should the patient continue the Claritin? Doesn’t it cover the ocular signs and symptoms too?

Would you want to cycloplege this patient or not? He has no headaches, no eyestrain, and no eso posture.

We ended up just using tropicamide and phenylephrine for his patient. Damp retinoscopy results showed +1.25 DS in each eye.

What is your recommendation for glasses for this child? And their follow up?

Any general thoughts or questions on this case?

Tahini broccoli pasta salad

Yay for utilizing whatever I had in my pantry again!

I had leftover broccoli from another recipe that I needed to use so I just shopped the stem into slivers and roughly chopped the rest. I boiled the rest of my pasta and then made a sauce using some tahini, pasta water, freshly grated lemon with juice, salt, and pepper.

Simple, easy, and super tasty! I added some dried basil for some more seasoning but some fresh herbs would have been perfect too to go with this fresh, light pasta. Yum!

Receiving criticism

It’s that time of year when we transition from summer sessions to fall. That also means it’s quite possibly time for evaluations.

First off, let me remind you that as part of your education, you are obligated to receive feedback on what is going well with your exams and your performance, and sometimes more importantly, what areas require improvement.

I cannot stress enough how important it is to not take this feedback personally! Having been on both the receiving and giving end, it is never a pleasant experience when one has to discuss less than stellar skills.

I’ll give a personal example – when I was a fourth year student, in my last rotation before graduation, I ended up working with an attending who left me feeling stupid each day I worked with him. I felt like he was pushing me harder and treating me differently than my peers, who were getting along with him just fine. He had critiques for every part of my exam, from refraction, to slit lamp, to BIO. I felt terrible.

At the same time, one of my other attendings at the same time happened to be a preceptor of mine during my summer of third year clinic. One day working together close to graduation, he made a comment to me that hit hard – he had seen me in third year, confident, engaged, happy to be in clinic and learning. Now this close to graduation, I seemed the exact opposite – the confidence was gone, I seemed to be questioning everything… “What happened?”

It wasn’t until years later when I was watching this video of a professor giving his last lecture that I understood the feedback wasn’t about me. The lecture has since served as a source of inspiration for me, and despite his having since died of pancreatic cancer, many of his tips still resonate with me. The one relevant here goes like this:

“When you’re screwing up and nobody says anything to you anymore, that means they’ve given up on you. You may not want to hear it but your critics are often the ones telling you they still love you and care about you and want to make you better.”

This is a classic way of how you get to decide how to look at the feedback you receive. Do you take it to heart and let it eat you up because you have failed, or do you take it as an opportunity to grow? Because your instructors are giving you feedback, they have noticed your effort and want to contribute to your growth. For those instructors who don’t offer any solid feedback and let you go on silently, well then, I might be more worried because that is a sign that they didn’t get to know you well enough to monitor your progression.

So take the feedback as what it is – a gauge on how you are doing as a student and clinician and how you can improve from there.

And if you have free time, I highly recommend watching Randy Pausch’s The Last Lecture or reading his book of the same name. I found both fun and easy to watch and read.

Patient case for September 8, 2023

Today’s patient is an 8 year old Middle Eastern girl coming in for her first eye exam in this clinic. She was referred over because she had failed a recent vision screening at her pediatrician’s. The patient is otherwise very healthy, has no allergies, and is not taking any medications.

Uncorrected, she is seeing 20/50, 20/30. All confrontation testing is otherwise normal, she is ortho on cover test, and ocular health is all normal with dilation.

Auto refraction results are:

OD: -0.75 -3.75 x 173  20/25-1
OS: -0.25 -2.75 x 180  20/25

Dry refraction results are:

OD: -0.50 -3.00 x 170  20/25
OS: -0.50 -2.00 x 010  20/25

Is it warranted to cyclo this patient?

For me, I was more concerned about getting her astigmatism correct and did not really anticipate getting more hyperopia out of her, so because of that, we just used 1% Tropicamide and 2.5% Phenylephrine.

Damp refraction results are:

OD: -0.50 -3.25 x 170  20/20-2
OS: -0.25 -2.75 x 180  20/25

What are you going to prescribe and what are you going to recommend in terms of wearing time and follow up? Look at the left eye in particular – what are your thoughts on only gaining one line of improvement after refraction?

In the middle of all the testing, she says she was prescribed glasses at the end of school last May but doesn’t like wearing her glasses so she never uses them. She did not bring the glasses with her to the exam.

Does this change your prescription and wearing recommendations? What would you say to the patient and the father present about her vision potential at 8 years old if she wears her glasses or not?

There’s no right or wrong here, obviously. I’m just curious for your thoughts.

Bok choy, eggplant salad

So I decided to play around recently and try some different veggies for a raw salad. I love eggplant and bok choy, but both are usually sautéed in some kind of really heavy sauce and I wanted something lighter.

This recipe called for 2 baby bok choy and a small eggplant to be chopped and then marinated in ginger powder and coconut aminos while I was at work. To finish the ‘salad’, I added a splash of rice vinegar, mushrooms, frozen corn, sesame and sunflower seeds, dulse, and kelp granules.

Overall verdict? Not bad. I can probably tweak the seasonings a bit more but this was actually tasty as it was. Yay for that!

The really pediatric exam

So let’s talk about those kids who are in that 3-5 year old range, where letters and numbers aren’t quite necessarily solid, left and right directions can be confused, and attention span is very, very limited.

What do you do?

I know back when I was an intern and doctor, the first thing I was told to do and followed ever since was take off my white coat before entering the room with them. For a lot of kids, a doctor’s office is really scary – who likes being poked, prodded, getting shots, and all that? It’s unpleasant enough for me now as an adult and to see it from a child’s eyes, well it can be pretty traumatizing too. So if there’s one less thing distinguishing me as a scary authority, then I’ll happily forego the white coat for these exams.

Next, I try to break the ice to see how open the kid is. That usually means asking if they have two eyes and their eyes are in their head. If I can get at least a smile, I know we’re going to be ok.

Depending on the child, I might have them sit in a parent’s lap or sit in a chair on their own – it might not necessarily be the exam chair at first! I want to get them comfortable and that has sometimes meant I bring out the color vision and stereo testing to do first wherever they are, just so they get comfortable. Then I have a handheld lea symbol guide and ask them to name each shape first when it’s super big so we all know what shapes they can grossly see under binocular conditions. Based off of those responses, then I can attempt a near VA with them either pointing to the guide or naming what they see so the child has options.

The patient’s confidence level can make or break this part of testing. I really try not to push an initial VA too hard because I know I still have other testing I need to do. I have them focus for a near cover test and some accommodation/convergence testing, and only after all that do I attempt a distance visual acuity, based off the child’s responses so far.

At this point, I have a couple options, I prefer free space retinoscopy with ret racks over autorefractor, although I will try to get both if I can, especially if I am concerned about any amount of cyl.

Biggest thing here is this though: do not spend more than 5 minutes total on refraction. The younger the child, the shorter refraction testing should be. Unless they are a very good, patient kid, they will lose interest and your results and their responses are just going to get worse and worse. Better to just get a rough idea and then move on to dilation.

When is a cycloplegic dilation warranted over just using normal tropicamide and phenyl? That will certainly depend on all the data that has come up so far, especially if this is the patient’s first eye exam ever – referral, chief complaint, visual acuity, retinoscopy, and refraction results. Generally, if there is some amount of plus, astigmatism, or eso tendencies, I will use cyclo for that first exam.

What if the kid has been great but then the idea of eyedrops freaks them out and they start screaming or crying before you can get near to them again? Well, there’s a few things. I can step outside and give the kid a moment to decompress and see if the parent can talk them into it after a bit (unlikely, but possible). I can try to force the kid to just take the drops and have the parent restrain their kid enough so that they hopefully don’t hit or kick you (also not ideal).

Personally, I’d rather build trust with the kid and try to not make the experience overly traumatic if possible. My goal is to make sure their eyes are healthy and they see well. If I can’t do everything at this first visit, then there will be a second visit to finish everything off. But I send the parent home with homework. I tell them to get a bottle of artificial tears and practice putting in an eyedrop in each eye every single day until they come back for their follow up. Hopefully, that few weeks’ worth of eyedrops is enough to desensitize them so that by the time they’re back, they’re okay with getting eyedrops in office and then I can perform the ocular health portion of the exam (I tell them I’m going to try to look inside their eyes so I can try to peek into their brains) and get more objective results for any needed glasses.

And that’s it. That’s my approach to a basic pediatric eye exam. I try to keep other questions light so they stay engaged – what grade they’re in, what’s their favorite subject, what’s their favorite food – and not as hyper focused on all the testing going on. And of course, giving them an end of exam sticker or two is always nice.

I hope you find this useful. Do you have any extra tips on how you deal with your peds exams?

Patient case for September 1, 2023

So recently, we had a 29 year old Hispanic male come in for his comprehensive DM eye exam with a complaint of some mild distance blur in his current glasses. We’d last seen him in spring of 2020 and had found no complications.

Systemically, he was diagnosed with diabetes just 3 years ago and has a current HbA1C of 6.2. He has also been diagnosed with a heart murmur, mixed hyperlipidemia, fatty liver disease, acne, asthma, and major depressive disorder. He is taking an inhaler as needed, atorvastatin, benzoyl peroxide, flonase, sertraline.

His incoming VAs with his 1 year old glasses were:

OD: plano -3.25 x 180  20/30
OS: plano -3.00 x 180  20/30

Pupils, EOMs, confrontation fields are all full.

Refraction results were:

OD: -0.25 -3.75 x 180  20/25
OS: -0.25 -3.25 x 180  20/25

What’s your immediate thought on his visual acuities? It certainly looks amblyogenic, right? Except last year and the year before, he was able to read 20/20 in the right eye and 20/25+2 in the left eye.

What would cause a patient to lose 1-2 lines of acuity at this age, especially given his good diabetes control?

If I tell you that his dilated ocular health exam was all unremarkable, what would you do next? Are there extra tests to do? Referrals to make?

I’m looking forward to the discussion on this one.