Melissa Valdellon

Patient case for July 28, 2023

A 51 year old Hispanic female came in for her annual exam. She mentions she has some blurred vision after two hours of looking at her phone or doing close work. She closes her eyes to rest them and that makes things better. She doesn’t currently use glasses, though she has had them in the past.

Health wise, she is healthy without any medical conditions, has no allergies, and is not taking any medications.

Initial confrontation testing is all normal. She is correctable to 20/20- in each eye with a mild prescription of hyperopia and astigmatism. An appropriate add allows her to see 0.4/0.4M.

Anterior segment shows some mild interpalpebral staining and mild nuclear sclerosis in both eyes. IOPs are 18/18.

Peripheral posterior segment is unremarkable but posterior pole segment findings are seen as below.

Is anything remarkable here looking at the nerve, the blood vessels, the macula area?

The following are photos from an earlier visit in 2019.

Are there any differences?

I hope you can appreciate the significant loss of rim tissue in the left eye with the associated nerve fiber layer defect. Historically, this patient had been monitored for her large C/D’s over the years. Pachymetry is 456/450 nm, gonioscopy is open in both eyes, and a couple of 24-2 visual fields were clear. IOPs have ranged from 13-19 OD, 15-19 OS. She also had a drance heme of the inferior rim in the left eye in 2022. OCT progression analysis shows no statistical change in the right eye over the last 4 years, but significant thinning of the left inferior rim in that same period.

How would you manage this patient? If you are to medically treat, what’s your eye drop of choice given the monocular presentation of this condition? What’s your plan for the next follow up and moving forward?

Tomato arugula salad

When it’s tomato season, I can’t help myself but get a bunch and then figure out what I want to eat with them later.

For this recipe, I got a packet of arugula sprouts – grown arugula has that warm, spicy bite to it that I know some people can’t take. It’s such a different tasting green though, it’s worth a try. If using in a salad, I definitely suggest starting with small amounts mixed in with other green leafies and then increasing the amount over time as you desire the taste.

Also, with the baby sprout version, there is still some of that peppery kick but not as much.

  • half packet arugula sprouts
  • 1.5 large tomatoes, chopped
  • 1 Tb or so of sun dried tomatoes
  • 1 Tb avocado oil
  • salt and pepper to season
  • 1 Tb hemp seeds to top

Super easy to put together in under 5 minutes and easy to take with you too for maybe a picnic snack outside. Enjoy!

How to manage a difficult refraction

One of my students recently brought up a good case of discussion. She was working with a 65 year old Asian female who came in for her annual exam reporting that her vision was not as clear anymore.

She had last come into our clinic in 2021 and due to cataracts, was best correctable with the following:

OD -3.00 -0.50 x 060  20/40
OS -1.25 -0.75 x 120  20/50

This is in comparison to refraction results from 2019:

OD -4.00 DS               20/40
OS -0.75 -1.75 x 120  20/40-2

Both times, she’s been noted to have moderate mixed cataracts in both eyes but she wasn’t ready to pursue cataract surgery.

When she came in for this year’s exam, however, she was wearing something completely different:

OD plano -2.00 x 090  20/200
OS plano -2.00 x 093  20/50

The student also did auto-refraction before bringing starting her refraction and got this:

OD -5.00 DS
OS -3.00 DS

Afterwards, the student let me know that with all the different data, she didn’t know where to start her refraction so she had started with a random one and tried to work with them all to see if she could get anything better.

Her final refraction ended up being:

OD -5.00 -1.00 x 120  20/40–
OS -3.50 -2.50 x 156  20/40–

The patient was told about her cataracts again and she was now ready to pursue surgery since we mentioned that we’d have to change her prescription a lot for minimal gain in clarity.

After the patient left, the student and I discussed how she could have had a smoother refraction, and it relates to simply asking a couple extra questions:

The patient had mentioned her vision was more blurry. Where were things clearest? With the pair of glasses she brought in today, with an older pair she got from us previously, or without glasses at all?

The student recognized how getting this extra info could have directed her to a better starting point for refraction. She already knew that the patient’s cataracts were affecting the best visual acuity for a number of years now and that refraction was unlikely to yield anything better, but it would have saved her time knowing which direction to start from.

I hope this helps drive the point of asking more detailed questions when the data doesn’t make sense. It doesn’t hurt to clarify things in a way to help you understand the patient’s point of view or expectations, and it makes them feel like you’re invested in working with them to find the best solution for their needs. Win-win for all.

Patient case for July 21, 2023

Today’s case is a short one. The patient is a 38 year old Hispanic female who was last seen a year and a half ago for a diabetes eye exam. She had been correctable to 20/20-3 and 20/20-1 with a refraction of OD +0.25-2.00×005, OS plano DS. She comes in today saying she has blurred distance vision especially when driving at night and that she never filled the glasses prescription from last year and has never worn glasses ever.

As I mentioned, she has had diabetes since about 2003 with a latest HbA1c of 10.1 from 3 months ago. She also has diagnoses of anxiety and depression, migraine, vertigo, gastritis, and reports quitting smoking about 3 weeks prior. Her medications include albuterol, zyrtec and flonase, glipizide, metformin, and protonix. She has an allergy to eletriptan (she gets hives).

Confrontation testing of pupils, EOMs, visual fields are all normal. Incoming uncorrected visual acuity is OD 20/50-2, OS 20/25-2.

Retinoscopy shows OD plano -2.00 x 180, OS plano -0.50 x 180

Refraction shows OD -0.75 -1.25 x 175  20/25, OS -0.50 DS 20/25+2

Anterior segment shows some mild punctate erosions inferiorly of both eyes and is otherwise clear with IOPs of 13/13 mm Hg. Posterior segment of both eyes is clear of any pathology or DM retinopathy.

What would you prescribe for this patient? Do her visual acuities match her refraction results?

She had a myopic shift in her eyes compared to her last exam 1.5 years ago. Are you more or less willing to prescribe her glasses because of this shift?

The patient also reports her history of vertigo. Does this mean you should modify her prescription in any way? Considering she’s also never worn glasses in the past, would you modify her prescription any differently?

Let me know your thoughts!

Kale, tomato, celery, cucumber juice

This was a juice I made because I had some leftover veggies left around and I was going away on a short trip and wanted to make sure they didn’t go to waste. The juice that resulted was one of the more savory juices I’ve made. I’ll be honest, not my favorite concoction, but maybe if I tweak the combination, it’ll work out.

Still, just in case you’re interested, this is what went into this juice:

  • 4 leaves kale
  • tomato
  • 4 ribs celery
  • 2 cucumber

It wasn’t terrible, but it’s not my tastiest either so back to playing around with other juices for a bit… I’m hoping the next time I make something, I’ll be happily surprised instead.

Have you ever made a juice or smoothie that you didn’t think would work but ended up being tasty? I’d love to try new recipes if you want to share =)


Strangely, I’ve had more instances in the last month where I’ve had to deal with more urgent or semi-urgent conditions that require extra handling and management. Usually, I get these cases every few months but in just the last few weeks, we’ve dealt with a macula-on RD, a hypertensive crisis (the patient was totally asymptomatic, yet his blood pressure was 210/162 when we read it), a kid with super angry looking marginal keratitis that had been cooking for at least a month before being seen, and a couple more things that definitely put me on a good adrenaline rush as I tried to coordinate the best care possible for these patients.

How do you stay calm in the middle of the crazy storm? Thankfully, the instances where you’ll have to deal with patient emergencies is likely not going to happen frequently, but there will be other times where things are just piling up and the stress keeps building around you and you find yourself needing to face it or be swept into the crazy yourself.

I don’t know about you, but engaging in a highly charged environment with energy that matches it means I’m going to be jumping in with irrational emotions and thoughts that will mean someone or something is going to get hurt, something’s going to be misunderstood or lost in translation, and plenty can and often does go wrong because we’ve made rash judgements and decisions.

So rather than jumping in right away unprepared, I take just a couple moments to pause and focus on my breath. Now, I’ve done a lot of meditation and yoga practice so I find that it’s not that hard for me to focus on my breathing, but this may be new to you. I would invite you to check on your breathing now as you read this. When you breathe in, do you feel any sensations? What part of your body is moving when you breathe? Do you breathe into your chest or deeper so that your stomach moves too?

One of the first things that happen physiologically when we’re under acute stress is our breathing goes shallow. As a result, our brains don’t get as much oxygen in the short term to adequately process what’s going on. We’re instead going off on instinct on how to best preserve ourselves in this highly charged situation. That’s helpful when something’s about to attack you. It’s not as helpful when you have to take care of someone else’s immediate health needs.

Even now, when my students come to me for consultations and they’re a bit flustered because their data doesn’t make sense or patients seem upset or something has shaken them out of their routine, I will stop the student and tell them to breathe. And I will breathe with the student a couple times just to get them more centered before letting them continue.

Those couple moments can be enough to reset the mind and make it aware that things are ok, there is no imminent danger, and now you can think a little bit more objectively about the situation at hand. If I’m in the middle of a high tension environment and I can’t step outside to collect myself, I do try to keep part of my focus engaged on my breathing even then, just to help  me stay more calm and grounded. I wrote more about breathing and its relation to stress in my book, Remembering to Breathe – there’s helpful information in there on how to build and maintain and healthy work/study-life balance.

Taking a few breaths for yourself is just as important as what you do next afterward. Get in the habit of periodically checking in on your breath throughout the day. Set your alarm to go off every hour for the next couple days as a reminder to check in on your breathing. Even if you don’t regularly practice meditation (and I don’t anymore, just to let you know), this practice of paying attention to your breath can be the way to begin practicing mindfulness, which is a skill that can translate into other areas of life.

Happy (deep) breathing.

Patient case for July 14, 2023

And now for something a little different. Today, let’s talk about a 47 year old Hispanic male who came in for a second visit. We first saw the patient 2 months prior for his diabetes eye exam. At that visit, he had reported blurred distance vision, OD>OS, and he doesn’t normally wear glasses.

He’s had DM2 for about 11 years and his latest HbA1c was 6.3 in March of this year. Systemically, he also has hyperlipidemia. He takes Flonase and Claritin as needed for seasonal allergies, metformin for his diabetes, and simvastatin for the hyperlipidemia. He has no allergies to medications.

Pupils, EOMs, confrontation fields are all normal. He is correctable to 20/20 with a mild prescription in each eye. Anterior segment is unremarkable and IOPs are 15/17 mm Hg OD/OS, respectively. Posterior segment findings are in the photos below:

As you can see, there’s no evidence of diabetic retinopathy, but there’s a significant hemorrhage on the rim of the optic disc of the right eye.

Given that this patient is only 47 years old, is this optic nerve hemorrhage likely related to glaucoma or not? What are some other causes of optic nerve hemorrhages? Does he fit the profile for any of these other differentials?

At the second visit, we obtained the following information:

Pachy: 619/620
Gonioscopy: CB 360 with 2+ pigment and normal approach OU
IOP 16/14 mm Hg
HVF 24-2:

Based on all the data you have after these two visits, now do you think this patient has glaucoma or no? How would you manage this patient? I’m looking forward to a lively discussion here. Thanks!

Summer salad

Summer time means it’s time for lots of fresh produce in northern California. What follows is a loose take on a fiesta bowl and making it into a salad version without the rice.

  • 2 tomatoes
  • 1 avocado
  • 1/2 cup corn kernels
  • 1/2 cup peas
  • sprinkle of cumin, salt, and pepper
  • splash of avocado oil

Now, normally I make a tomato and cucumber salad but when I went to Sprouts to get groceries, the avocado was calling out to me more this time. Mm, mm, mm… Especially when I used tortilla chips to help spoon this salad into my mouth. So yummy!

I thought about adding some hemp seeds as a topping later but was already almost done by the time I thought about it. Next time!

What are your go-to summer salads? It’s nice to have variety of lighter foods when it’s sunny and hot out and you don’t want to turn on the oven or cook anything. This one was good in that it’s light and fresh, yet left me feeling satisfied due to the avocado adding some good fats in. I hope you enjoy!

Directing Your Patients

Your time is valuable. Your time with each patient is valuable. You need to be able to connect with your patients and guide them along the exam as efficiently as possible.

So for me, that means I generally ask more pointed questions rather than leaving things too open ended and broad. Even as I sit patients in their exam chair, one of my first questions is “how is your vision doing in the distance and up close?” If they start going into how their eyes are feeling or anything else, I acknowledge their points but redirect them, informing them that there are two parts to the exam, the vision part and the health part, and that I want to check the vision part first.

Most patients respond favorably to that and voila, you’re back in control of an exam that could have led you down a strange rabbit hole. At this point, I’ll ask my vision related questions and do my initial confrontation testing. Here, I have found that holding the cover paddle myself means I make sure the patient’s eye is appropriately occluded and they can’t push the paddle up against their own eye. It gives them less change to fumble too. Typically, I only let a patient handle equipment during pinhole testing.

Next, I repeat that the next part of the exam is where we’ll be evaluating the patients’ vision status and needs. During refraction, I really try to keep in mind that patients’ incoming visual acuity and anticipating how much change is required to get them to see their best – if any changes are needed at all. I also keep in mind that a patient can only tolerate maybe 0.75 to 1.00 diopters or 20 degrees of change in any direction at any time from their starting point for my final refraction. With that in mind, I don’t typically keep a patient ‘accepting’ a certain direction if they keep saying it’s better after 3 or 4 options, as I know that’s usually going beyond what I’d be changing the prescription by anyway (unless it makes sense with their incoming visual acuity!).

Once refraction is complete and I have demoed their new prescription, I tell the patient that we’re switching gears and going into the ocular health portion of the exam next. This is where I’ll usually ask about how their eyes feel in general as well as their systemic health, medications, and allergies. Then I tell them I’m going to use eyedrops to check their eye pressure. When I explain that the eyedrops are necessary to help with evaluating their eye health, most patients are willing to comply. I do the same when I later go to dilate their eyes, explaining that it’s the best way for me to make sure their eyes are healthy and free of diseases like diabetes and glaucoma. For me, I have found that by explaining what I’m doing rather than making the ask if I can use eyedrops first, I find that more patients are willing to be dilated for their ocular health check. Too often, I have heard my interns ask first and their patients declining more as a result even after explaining the reasons why dilation is important.

Remember, I’m trying to get the patient to work with me. Most of your patients will want to cooperate if it’s in their best interest. They just want to be informed.

Overall, directing how your patients answer your questions can help streamline your exam. For example, when asking about headaches, rather than asking them to describe their symptoms off the top of their head, I go into specifics using questions like – Is it sharp, stinging, boring? Show me on your head where the pain is. Does this happen every day or few days? Does this happen when you’re doing something like reading or watching TV or when you’re walking around?

Of course, you want your conversations to still be in the flow and natural, and I don’t suggest that every patient response should be some kind of forced response. Incorporating more directed questions and limited patient options during key parts of the exam though can help you keep your exam moving in the direction you need it to go and uncover information that is important to your management and treatment plan.

Happy testing!

Patient case for July 7, 2023

I know we’ve been doing a lot of pediatric prescription cases lately (sorry, not sorry?), but here’s another one to get you thinking.

The patient is an 11 year old Hispanic female coming in for her first eye exam after failing a vision screening with her pediatrician. The patient reports that vision is blurry both distance and up close. She is otherwise healthy, has no allergies, and is not taking any medications.

Distance VA is OD 20/30-2, OS 20/40, and pinholes to 20/25 in each eye. Also, near VA is 0.4/0.5M-1 in each eye.

At this point, can you anticipate what kind of refractive error you’d expect here? Take a guess and keep those numbers handy.

Pupils, EOMs, confrontation fields are all normal. Cover test is ortho distance and near.

Auto-refraction results show:
OD: +0.75 -0.50 x 139
OS +1.25 -0.25 x 098

Refraction, however, yields you this:
OD: -0.75 -0.50 x 005  20/25
OS: -1.250 DS  20/30

Now what? The child is getting tired and annoyed at being here and she’s not feeling like she’s seeing dramatically better compared to when she first came in. What other testing should you do?

While the patient herself did not mention any headaches or eyestrain, a clue that this patient could have more binocular vision problems is the fact that her near visual acuities were also reduced. A minor amount of myopia or astigmatism really shouldn’t be enough to lose a whole line of acuity at near.

So we ended up checking accommodation. NPA on repetition was 8D, 7D, 5D with both eyes open. And after all that fatigue, NPC was 12cm. What are the patient’s age based norms for NPA and NPC?

We next dilated the patient with tropicamide and phenylephrine. Was cyclopentolate indicated for this exam? Would it have been wrong to use it?

Ocular health was unremarkable for both eyes.

Damp auto-refraction results were:
OD +1.25 -1.25 x 007
OS: +1.50 -2.50 x 171

What would you prescribe for this patient? What conditions are affecting this patient that you would discuss with mom about? And of course, what’s your follow up plan? Chime in below!

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