Melissa – Page 2 – Melissa Valdellon, O.D.

September 8, 2023April 1, 2024

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.

September 6, 2023April 1, 2024

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!

September 5, 2023April 1, 2024

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?

September 1, 2023April 1, 2024

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.

August 30, 2023April 1, 2024

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…

August 29, 2023April 1, 2024

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!

August 25, 2023April 1, 2024

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.

August 23, 2023April 1, 2024

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!

August 22, 2023April 1, 2024

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:

Do you have problems with your vision in the distance or up close?
Do you use glasses for distance or up close?
How old are the glasses you are using?
When was the last time you had your eyes examined?
Do you have any headaches or eyestrain in general?
In general, how do your eyes feel? Do they feel dry, itch, or burn?
What eyedrops do you use?
And how about your general health – do you have diabetes, HTN, or other systemic conditions?
What medicines do you take?
Do you have any allergies to any medications?
Do you have any history of surgeries or injuries to the eyes?
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.

August 18, 2023April 1, 2024

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?