Melissa Valdellon

Month: August 2023

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Minty fruit juice

This one’s full of fruit, which normally would be heavy for me but I think the wheatgrass and mint lighten it up just enough for me.
  • half pineapple
  • 4 apriums (who knew this was a thing? substitute for apricots, which aren’t in season)
  • 2 cups blackberries
  • 2 pears
  • mint
  • wheatgrass

As I said, this was surprisingly light and filling – it lasted me all day given how much I got out of it:

Fun note – don’t just dump fresh cut, wheatgrass into a juicer, especially if it’s longer than an inch. Chop it smaller – when I opened my juicer, a good amount had wound itself around the blade and didn’t get juiced. Good tip for next time…

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What’s your why?

One of the questions I love to ask my students is what their history is coming into the profession. What made them decide to pursue optometry and go through more years of schooling?

The stories have varied, of course. For some, it was a direct relative or close family friend who was in the field that influenced them to consider it. For others, it was having their own eyes examined, getting glasses, and seeing the world clearly for the first time that left such a lasting impression that it inspired them. For many, myself included, we knew we wanted to be a doctor and somehow, by a little trial and error, shadowing and volunteering and working, we found optometry as the best fit for us.

So that’s good for the initial dive in. Is it enough for the long haul? Is your why a good enough reason for you to see yourself doing this every day for the rest of your working life?

Let me be honest with you – for me, being an optometrist just for the sake of that, for seeing patients, working on the rez with some amazing people – it wasn’t enough for me. After a year of residency and two years in the four corners area, I got burnt out. And I didn’t even realize it until I saw one of my elderly grandmother patients who I love – she was thanking me and giving me a hug goodbye (different world back then pre-COVID) and I felt… empty.

The interaction was still warm and friendly. I was still smiling as I walked her out of the office room, but in that moment, I realized my joy for my work was gone.

And I did what any other person would do in that moment. I shook it off and kept working and going at it, thinking this was a fluke. I had a job after all doing pretty easy work in a stunning location.

But then a couple months later, it happened again. Another grandmother patient. Another hug. Another feeling of emptiness, and this one harder to shake off.

Suddenly, the idea of a future working the rest of my days on the rez didn’t seem right anymore. Suddenly, I was realizing that my day to day work and routine was not as fulfilling anymore.

I knew something had to change but I didn’t know what that would mean. I still had bills to pay and a good student loan to work on.

Coincidentally, at the time I was hitting my burnout, things at home were changing and I had to move back to California to be with family. Giving my resignation letter and moving back with no job lined up has to be one of the most stressful things ever, but there it was.

To keep things brief (because I know I could definitely go on longer about this – maybe for another blog post), it took a few years for me to fully fall back in love with optometry. I had to give myself grace as I ‘tried out’ different practices when I filled in, figuring out what I liked and what I didn’t like, what fit and what didn’t fit. And in the end, what fit the best and what gave me the greatest joy was going back to school and being a clinical instructor, helping the next generation of optometrists figure out how they were going to be doctors for their patients.

My ‘why’ is what motivates me in the day to day now, what helps me wake up every day and keeps me going on the days we get slammed with patients and interesting cases. It’s my reason for sharing so many of my stories, writing these blog posts and books – I want to make sure that the doctors who come after me are more than just ready for a 9 to 5 job, but that they thrive in all aspects of their lives too.

Coaches out there will always ask you, what’s your why, what’s your reason for X, Y, or Z, and now I can understand why it’s important. I didn’t get to my why until I was in my 30s, which was fine for me because I also got to figure out what was important to me and what wasn’t along the way.

Give yourself a reason to look forward to each and every day – not just the special occasions that come and go. But also give yourself time to figure out what that reason is, modifying as needed until you find the thing that really makes sense for you. Cheers!

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Patient case for August 25, 2023

A 69 year old patient was coming in for her 6 month follow up for moderate NPDR OU. She reports that there has been no vision or other ocular changes since the last visit.

Systemically, she has DM2 with a latest HbA1C of 8.1 from March, HTN, hepatitis B, psoriasis, stage 4 chronic kidney disease, hyperlipidemia, GERD, and liver cirrhosis. She is taking a lot of medications including atorvastatin, entecavir, furosemide, insulin, labetalol, and semaglutide with reported good compliance.

She came to the exam uncorrected with a VA of OD 20/70, OS 20/40, pinhole to OD 20/50 and no improvement in OS.

Anterior segment is stable to previous visits with clear PC-IOLs. Posterior segment shows stable moderate NPDR both eyes.

This doesn’t sound like anything unusual for this patient, we’d been monitoring her every six months for moderate NPDR since she first came to us in 2021. So why am I writing about her now?

For each of her prior visits, she had been able to see 20/25 or 20/30 with correction or pinhole. This was a change and decrease in vision, even though the patient herself had not noticed.

I get it. In a busy and crazy clinic like the community clinic I am in, it’s easy to just follow the plan and call it a day. But when something is different, it warrants digging a little deeper. So I had the student build the trial frame for this patient based on the prescription we found in January and her vision still did not improve.

The student was concerned that some of the hard exudates we saw were approaching the foveas and could be causing some macular edema so we took an updated OCT. At first glance, the student said everything looked fine. All retinal layers were intact and there was actually no evidence of macular edema. So if there wasn’t any edema and her refraction did not improve anything, why did this patient have reduced visual acuity?

Thankfully, when we looked at the OCT a little closer, we noticed actually a fair amount of vitreomacular traction in both eyes, enough to cause a little bit of distortion to the retinal layers, although she was correct, everything was still intact.

Now I felt a little better having a reason for this patient’s change in vision, but it got the student and I to have a conversation about how putting all this information together was important in helping us determine how to manage the patient moving forward. Did we need to refer her out to retina or could we still see her? Did we need to modify our follow up plan?

We opted to follow her a little more closely than 6 months and we’ll see how it goes from there.

Are there any takeaways or other points of discussion from you at this point? I’m always interested.

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Mushroom pasta

On occasion, I will crave something warm that will give me something more to chew on, like pasta. One of my friends recommended this brand of pasta to me after I chose to follow a gluten free vegan diet and honestly, it’s pretty tasty. It’s called Tinkyada Brown Rice Pasta and its claim to have great texture and not be mushy is on point. I usually get the elbow pasta.

Also when I’m lazy, I go for bottled tomato sauce rather than making my own. Easy enough to just pour it over my pasta once it’s done. Here, I’ve used Sprouts Organic Recipe Pasta Sauce, which is full of flavor even though it’s free of garlic and onion, which I try to minimize as much as  I can.

I added some course-chopped button mushrooms and a good dash of Italian seasoning and voila. An easy dinner put together in under 30 minutes. Bon apetit!

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The complete case history

When a patient comes in for their comprehensive eye exam, we have a few things we need to address. We need to assess visual status of each eye, binocularity and visual function, and ocular health. How does that translate to in my case history?

I have mentioned before that I have kind of developed a bit of a speech for the beginning part of my exam that helps me hit all the necessary points for a comprehensive eye exam. And if the patient brings up other topics, I re-direct them here and there to make sure we get my main questions asked, which are:

  1. Do you have problems with your vision in the distance or up close?
  2. Do you use glasses for distance or up close?
  3. How old are the glasses you are using?
  4. When was the last time you had your eyes examined?
  5. Do you have any headaches or eyestrain in general?
  6. In general, how do your eyes feel? Do they feel dry, itch, or burn?
  7. What eyedrops do you use?
  8. And how about your general health – do you have diabetes, HTN, or other systemic conditions?
  9. What medicines do you take?
  10. Do you have any allergies to any medications?
  11. Do you have any history of surgeries or injuries to the eyes?
  12. And in the family, does anyone have any eye problems or conditions and how are those conditions being managed?

Of course, depending on the patient’s response, I would go into more or less detail on some of these points. Obviously, I wouldn’t ask about glasses if I actually know this is a child’s first eye exam after failing a vision screening. I would ask a diabetic patient what year they were first diagnosed, what’s the highest and lowest blood sugar reading they’ve had over the past month, their latest HbA1c if they know it, and how closely they’re being monitored by their PCP or endocrinologist. And if it were a patient I have been monitoring for an ocular condition, like glaucoma or macular degeneration, I would follow up about their compliance with eyedrops or supplements and Amsler testing if needed.

And as a reminder, I spread out my questions to the appropriate part of the exam so it doesn’t feel like an interview right at the beginning of the exam. In the example questions above, you can see I have them grouped into vision and visual function questions for the first part of the exam and health questions for the second half.

Over the course of my practice, I have found these pointed questions to be more helpful in getting the best information out of my patients than asking open-ended questions. But what about you? Are there any you would add or subtract? I’d love to know.

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Patient case for August 18, 2023

Recently, we worked with a 55 year old black female who came in for her annual eye exam with no new complaints except she wanted to check on her eyes and get refills for her eye drops. She has been diagnosed with mild POAG both eyes and was scheduled to return for a visual field last year but no showed, so this is her first visit in about 1.5 years.

Systemically, she has a chronic hepatitis C infection with cirrhosis, arthritis, chronic back pain, and insomnia. She is taking latanoprost, timolol, cyclobenzaprine, diclofenac, melatonin, and trazodone.

The patient is correctable to 20/20 in each eye. Pupils, EOMs, and FDT visual field screener were clear today. She has some mild nuclear sclerosis and otherwise clear anterior segment. Posterior segment is also clear except for nerves with a C/D of 0.75 round in both eyes.

Historically, her max IOP was 16/18. In office today, IOP was 15/15.

Pachymetry is 517/518, gonioscopy showed open angles 360 OU.

An HVF 24-2 was last performed in 2021, which showed possible superior and inferior nasal steps both eyes after clear visual fields in 2019.

OCT of the RNFL both eyes showed thinning in the inferior-nasal quadrant for the right eye, thinning in the superior-temporal quadrant of the left eye.

Looking back at her visit history, she has had quite a few visits where she had cancelled them or no showed. At the end of the exam, she mentions she is always traveling and that’s why she can’t always come in. She also mentions that she skips a couple days’ worth of using her eyedrops when she’s waiting to pick up her new bottles from the pharmacy.

Given her appointment history and her IOPs, what would be your course of managing this patient next? I know I want to repeat her visual field for sure and check her IOP again. Is it worth it to consider adding another drop or change to a combo drop at the next visit? Is it worth it to refer her over to glaucoma to consider other interventions if her IOP still doesn’t go down?

What would you want to do for this patient?

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Apple pie smoothie

If you happen to be a fan of apple pie, this recipe is for you. I am not a huge fan personally so this is one I won’t be repeating myself.

Pro though, this one’s super easy to put together. All you need is

  • 1.5 tsp soaked rolled oats
  • 2 cups almond milk
  • handful greens (I used a spring mix)
  • 1 apple (green in this recipe)
  • 1 tsp ground cinnamon
  • 1 tsp ground ginger

This smoothie was definitely filling, but it just took me awhile to get through because of the taste. Ah well, time to think about a new recipe to try…

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The art of pre-charting

I can laugh now, looking at the days when I would show up to early and pre-chart for every patient that was on my schedule for the day. Yes, it gave me an idea of what kind of day to expect, if there were any challenging patients to look forward to or if I was going to be able to catch up with some of my favorite patients. I inwardly chuckle now when I see my students doing the same thing.

When I was working on the Navajo reservation, however, I quickly came to realize that my schedule always changed. Forces outside my control would mean patients would miss their appointments and follow ups. Sometimes, that would be because of lack of transportation. Other times, there would be work they could not get time off for. It did not matter of the weather was rainy or snowy or sunny – the show rate varied all the time. And then we would get a lot of walk in patients who were okay waiting to be seen if no one showed up or urgent care patients needing a red eye treated.

Now that I am working in community clinics, it’s still the same. My patients still have to deal with transportation issues, time off from work, family obligations, and more. I’ve learned to not let that get to me. If I have a light day, great. If I have a busy day, great. The no show rate is highly variable. But what I do know is that when the patients do show up, they are serious about getting their eyes checked out and I am here to (hopefully) help them.

So what do I do when a patient actually shows up, especially if they are a return patient? I generally only look at 6 few things:

  1. When was their last visit with us
  2. What was their best corrected vision at the last visit (and put their last prescription in to the phoropter if applicable)
  3. If their vision was not correctable to 20/20, why
  4. Quick review of last chief complaint
  5. Quick review of last plan
  6. Quick review of any prescription eyedrops or medications

Any other details and specifics, I can look at again later when I’ve greeted the patient and after I have already started the testing.

This review should only take a minute or so, depending on the patient complexity. You don’t have to spend five or ten minutes going into all the details because things may have changed since the last visit and you need to prioritize the reason for today’s visit anyway, which may or may not match the last exam’s plan.

So in brief, I would suggest keeping the majority of your pre-charting to an efficient minimum so you can maximize your time with the patient in your chair.

What do you add or subtract from your pre-charting to help with your efficiency?

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Patient case for August 11, 2023

This week, we had a 54yo Filipino transgender female coming in for their first eye exam with us. They report distance blurred vision but no near problems, and they don’t have glasses.

Systemically, the patient has been diagnosed with DM2 and is s/p amputation of a toe on their left foot in July. They also have HTN, hypercholesterolemia, osteomyelitis, and history of a left sided stroke February of this year resulting in partial paresis on the right side and some residual speech difficulties. They have no medicinal allergies, and they report good compliance with medications: hydralazine, losartan, carvedilol, metformin, atorvastatin, aspirin, clopidogrel, glipizide, and insulin. Their last blood sugar was 120, but the latest HbA1c was 11.7 from February this year. They have an upcoming appointment with their PCP towards the end of this month and have been going through physical, occupational, and speech therapy since April.

Uncorrected visual acuity was OD 20/200, OS 20/125+1, with pinhole to 20/60, 20/50, respectively. Near VA was OD 0.4/1M, OS 0.4/0.63M.

Pupils, EOMs, and confrontation visual fields were full in both eyes.

The patient refracted to 20/40 OD with -2.75DS, OS 20/30 with -2.25 DS. There was no further improvement with pinhole.

Goldmann tonometry was 12/14 mm Hg. Anterior segment shows 1+ NS OU. Posterior segment was clear of any diabetic retinopathy or macular edema. There were no other remarkable ocular health findings.

What would you do in this case? The patient is certainly recovering from recent surgery still and still undergoing regular therapy for the sequelae of their stroke. Is there anything that could be contributing to this patient’s decreased visual acuity?

Would you prescribe glasses for this patient? How would you like to follow up with them?

Any other thoughts?

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Asparagus, bell pepper, mushroom, olive salad

I had leftover asparagus after one of my juices that needed to be used as well as some mushrooms. I wanted to add some color to the plate so I added a bell pepper. Lastly, I added some olives – I have never bought olives for myself in the past but after reading Fast Like a Girl, I knew I wanted to incorporate more foods that would help keep my gut biome happy among many other benefits.

Overall? I’m so happy with this simple salad. I realized too late I didn’t need to add extra salt as the briny olives were already full of it, but otherwise, just adding a splash of avocado oil and freshly ground pepper to the veggies was plenty.

  • few stalks asparagus, chopped
  • bell pepper, cored and chopped
  • couple mushrooms, chopped
  • handful olives
  • splash neutral oil like avocado
  • season with fresh pepper

I might try Italian seasoning next time with this since, you know, olives. Otherwise, this one’s a keeper!

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