Melissa Valdellon

Patient case for September 29, 2023

What would you do for this patient?

A 66 year old Asian female came in for her first eye exam in the states. She reports blurred distance vision though it’s generally okay at all distances. Her last eye exam was a year ago in China, where they “measured something about 600”, but she said it caused her eyes to hurt so they reduced her current prescription.

Medically, she is taking pravastatin for her hyperlipidemia but has no other systemic conditions or medical allergies.

All confrontation testing (pupils, EOMs, visual fields) are normal.

Incoming visual acuities with her SV glasses are:

OD: -4.50 DS  20/70, pinhole 20/30, NVA 0.4/0.6M
OS: -4.50 DS  20/70, pinhole 20/30, NVA 0.4/0.6M

Refraction results were:

OD: -6.50 DS  20/30-
OS: -6.75 DS  20/40+

She has some moderate cataracts in both eyes, but her ocular health is otherwise unremarkable.

The patient is not ready to have cataract surgery done. In this case, what glasses prescription would you prescribe? How would you modify her glasses for better adaptation? How would you counsel her about her vision in regards to her daily activities?

A discussion is much appreciated.

Spinach juice

Mmm, this was the perfect green juice to break up the recent bout of ordering too much take out and restaurant food for the last week.

  • Spinach (small container)
  • Rosemary (used full stem amount)
  • Apple (Sprouts ran out of green apples so I used Fuji for this one)
  • Lemon

The original recipe called for half a lemon, which would have been perfect too. I used a full one here which added a bit of extra pucker (and I didn’t want to have just a half lemon laying around) and tartness, which again helped break the heaviness of the food I’ve been eating lately.

No, it did not produce a whole lot of juice, but it was enough to leave me feel hydrated and satiated for a few hours.


Quitting the habit of complaining

Non-optometry related, but recently, my husband and I hired a company to paint our garage. We had done work over the past year to clean it out of boxes that hadn’t been touched since my family first moved into this house and then set it up so that it was more user and storage friendly for the type of things we needed in that room – a place for my mom to do her gardening, a laundry station, some place for some crafts work, and still room for us to park a car inside.

I went on Yelp to hire a painter and ended up hiring someone who had no reviews but had left the best first impression when they came in for the consultation. They were friendly, on time, and offered a mid-range quote compared to the other companies for the work to be done of just painting our garage walls.

We confirmed the time they would arrive and confirmed that they could do the job over the course of a weekend rather than spreading it out as my husband and I both work during the week.

Well, initial good impressions aside, the rest of the work together was not ideal. They were late by almost two hours the first day. As they were leaving after the first day, they said they’d be back on Monday to finish the job and I reminded them that that was not what we had agreed to initially and referenced back to a conversation where they had stated they’d come back to back days. They arrived the second day but were again almost two hours late from the anticipated arrival time, but finished the work relatively quickly. And then as my husband and I went to move everything back into the garage, we realized that something that we had left there was missing. We asked them about it and they responded that it might have been accidentally packed away when they were cleaning up the first day and they would bring the item back.

Now, over the course of those two days, there were plenty of opportunities for me to complain and raise my concerns. We never received an apology for their tardiness, especially considering it had impacted other tasks we had wanted to take care of in the meantime. And we had to wait almost a full week for the return of the item that was taken and that was only after several reminders on my part and requests for them to return.

I know I had every right to complain. Certainly, I had considered describing all the events as part of a review for their business. They did the job I had tasked them to – paint our garage walls – but the quality of service we had received was certainly subpar, not ideal, not customer-centric, and honestly, not at all what we had anticipated or expected.

But here was the perfect series of events for me to especially practice habit of acceptance and consciously understanding where my energy should go. If I had complained or posted a negative review or reacted in any kind of negative way, I know I would have received the same, if not from them then from someone or someplace else. The cycle of negativity would have continued and no one would have been the happier or better for it.

Instead, by accepting that this was not anything for me to waste my energy on (yes, they were late but while we were mildly inconvenienced, it wasn’t the end of the world for us), I felt and knew I could let this go and just let them go when they were done. I demanded they keep their end of this business relationship without having to dictate it out loud for them. But in all the follow up I was doing, I was I holding them responsible for finishing the job on time and returning the item that had been accidentally taken. And while they were accomplishing those tasks, I was sending positive energy to them and to the situation as a whole to help it unfold in the best way possible for everyone involved.

This is not an easy practice. Not giving into complaining takes a level of mental awareness and consciousness that takes time to develop. It means catching yourself at every instance when you find yourself starting to rant or discuss or complaining about something happening. This recent event in my life is not really an isolated kind of event. There are plenty of things in daily occurrences that can make one unhappy, irritable, and in the mood to complain to any willing ear. In the optometric world or the world as a student, the difficulties of balancing work-life or student-life are not easily ignored either. But not complaining about your patient who’s half an hour late and still demands to be seen and not complaining about the difficult clinic schedule you have while you’re supposed to be studying for boards means that the energy you could have spent complaining could be channeled to something more productive, something more positive, something – anything – better than continuing the cycle of negativity.

I challenge you to taking the next 24-48 hours mentally being aware of how much of a habit you have around complaining. And once you notice, I want you to immediately start changing it. Once you’re aware of the thoughts or words coming out your mouth, I want you to stop mid-thought or mid-sentence, take a breath, and just let it go. Don’t finish the thought. Don’t say another word. Change your focus. A bonus step would be to imagine light or send good feelings to whatever’s bothering you instead, but don’t worry if you’re not there yet. Just stop the complaining first for an hour, then a day, then another, and keep up the practice.

You’ll find your energy shifting lighter and lighter over time.

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.

Skip to content