Staff Epidermins and Rosacea?

Staphylococcus Epidermidis May Play Contributory Role In Pustular And Ocular Rosacea.

MedWire (10/22, Albert) reported that, according to research published online Oct. 12 in the Journal of the American Academy of Dermatology, "scientists have demonstrated that Staphylococcus epidermidis is likely to play a contributory role in pustular and ocular rosacea." Researchers came to that conclusion after taking skin swabs to detect the presence of S. epidermidis "from an incised rosacea pustule, nearby cheek chin, and the eyelid margins of [15] patients with cutaneous pustular rosacea" and 15 matched healthy controls. Notably, the study authors "cultured pure S. epidermidis growths from nine pustule and four eyelid samples out of 15 in the patients with rosacea."

Keep in mind that ocular rosacea is often implicated in patient dry eye complaints. We need not overlook periocular skin lesions, especially across the bridge of the nose when a patient complains about dry Eyes.

Low Vitamin D3 Levels implicated in Diabetic Retinopathy

Patients With Diabetic Retinopathy More Likely To Have Insufficient Vitamin D Levels.

Medscape (10/22, Louden) reported that, according to research presented at an ophthalmology meeting, "patients with diabetic retinopathy, especially the proliferative type, are more likely to have insufficient serum vitamin D levels than people without diabetes, suggesting a link between vitamin D deficiency and one of the leading causes of blindness in adults." In a study of 221 patients with type 2 diabetes, researchers found that "people with diabetes had significantly lower mean 25-hydroxyvitamin D levels than people without diabetes (22.9 vs. 30.3 ng/mL; P < .001)." What's more, "people with no eye disease had the highest serum vitamin D levels (mean, 31.9 ng/mL), and those with proliferative retinopathy had the lowest levels (mean, 21.1 ng/mL)." And other diseases as well. See the Vitamin D Council for much more information on Vitamin D3.

The High Cost of Poor Service

As we move forward as an organization into using Social Media to help market ourselves it occurs to me what a powerful tool the internet can be -- to build a practice or to help to destroy what you are trying to be.

It used to be that a dissatisfied patient would tell 10 friends, relatives and co-workers. In the internet/Social media age a dissatisfied patient may post to Facebook, Twitter, Yelp, and many other sites. Their message goes viral and you can bet that those who check these sites will see the bad review. Therefore we must be more and more vigilant about both preventing poor service and fixing problems when they inevitably occur.

What I suggest is that the OD as the CEO of the practice invite ALL of his or her patients to contact them if they are ever not completely satisfied with their experience in the office. How to do this? Something like this.... at the conclusion of the examination.

"Mrs. Jones I am responsible for everything that happens in this office. We try very hard to make certain that all of the professional and optical services (glasses or Contact lenses) that we provide to you are of the highest quality and completely meet your expectations. We want you to be completely satisfied with everything that we do. However, if there is ever any reason that you feel that we have fallen short of your expectations please contact me directly."

Then hand them your business card which has on it the office number, your cell number, and your business e-mail address. Welcome interaction with your less-than-satisfied patients as an opportunity to solve their problem to THEIR satisfaction. If necessary at your weekly office meeting (you DO have weekly office meetings!) discuss the incident and, if necessary, change office procedures to improve your services and prevent a dissatisfied patient from leaving your office and posting an adverse review for all to see.

I'd guess that most issues revolve around the Optical and Billing Areas of the practice. In Optical I would suggest that each frame stylist give each patient a business card along with the wording above. A critically important function is a call from the stylist to see how the patient is doing about a week after they receive their glasses. In fact, call-backs are required of all of our Optical Staff. Failing to do so if setting the practice up for a problem that you don't know exists.

Patient satisfaction is serious business.

Vitamin D, The Flu, and Your Health

Vitamin D, The Flu, and Your Health

As a comment to last week's Professional Services bulletin on the Flu Vaccine, Jeff Sterling, OD in the Greenville, Arlington Blvd. location put me on to the importance of Vitamin D supplementation as an additional intervention.

Seems that many of us do not get the proper amount of Vitamin D and supplementation is recommended for most, especially in the winter months. There is far too much information for me to relate to everyone but Jeff included some good reference material for those of you would would like to explore this issue yourselves.

The Use of Vitamin D in Clinical Practice
The Vitamin D Council

Finally, Jeff's statement on what all of this means to him:

"You're not going to find anything that says if you take this much Vit D, you won't get the flu. But I think (and I am not alone) that it is a good idea. Lots of anecdotal evidence on the web."

Thanks, Jeff!

Does Migraine with Aura Need Cardiovascular Work-up?

Migraine With Aura Linked To Increased Risk Of Dying From Cardiovascular Disease.

Bloomberg News (8/25, Kay) reports that individuals who experience migraines with aura may be "more likely to die from stroke or heart disease, according to a study in the British Medical Journal."

The UK's Press Association (8/25) reports that investigators "examined data from 18,725 men and women born between 1907 and 1935 and living in Iceland."

The UK's Telegraph (8/25, Adams) reports that the researchers "found that those who had migraine with aura were 27 per cent more likely than those without migraines to die from cardiovascular disease, which includes both heart disease and strokes." The investigators also found that "suffering from normal migraine also increased the risk of mortality compared to those who did not suffer at all from them, but by a lesser degree." The UK's Daily Mail (8/25, Hope), WebMD (8/24, Doheny), and MedPage Today (8/24, Walsh) also covered the story.

Nexagon Gel Approved for Serious Eye Injuries

I must have been out to lunch on the Orphan Drug approval for chronic epithelial defects, especially those caused by chemical burns.

New Gel May Help Speed Healing Of Chronic Wounds, Serious Eye Injuries.

The AP (8/12, Cheng) reported that scientists have developed a new gel called Nexagon. Although it "has only been tested on about 100 people so far, experts say if it proves successful, the gel could have a major impact on treating chronic wounds, like leg or diabetes ulcers, and even common scrapes or injuries from accidents." It "works by interrupting how cells communicate and prevents the production of a protein that blocks healing," essentially allowing "cells to move faster to the wound to begin healing it." The gel has already "been granted approval by the Food and Drug Administration for serious eye injuries."


Company preparing to initiate Phase 2 clinical trial

May 11. 2009 - CoDa Therapeutics, Inc. today announced that its lead drug product candidate, Nexagon® , has received Orphan Drug Designation from the U.S Food and Drug Administration for the treatment of persistent corneal epithelial defects. The Company initiated a Phase 2 clinical trial for this indication in April 2009.

Persistent Epithelial Defect (PED) is a condition where the epithelium (thin layer of surface cells) covering the cornea of the eye fails to re-grow over a defect within the expected time period. PED is extremely difficult to treat and a common occurrence after traumatic abrasions and chemical injury. If unresolved the outcome for patients can lead to severe visual impairment or even blindness in the affected eye.

"Receiving orphan drug designation for Nexagon® for the treatment of PED is an important milestone for CoDa and provides meaningful benefits as we move our lead program through clinical development" commented Bradford J. Duft, President and Chief Executive Officer of CoDa.

"In acute eye injury from chemical burns a successful outcome for patients is often challenging. In recent cases of PED from ocular burns, where we received compassionate use approval from New Zealand regulatory authorities, we have seen dramatic improvement in epithelial re-growth and a positive result for patients following treatment with Nexagon® "commented Professor Charles McGhee, Director of the New Zealand National Eye Centre, University of Auckland. "This designation will assist CoDa’s clinical advancement of Nexagon® which has the potential to significantly improve clinical outcomes in patients with PED."

Orphan Drug Designation is granted by the FDA Office of Orphan Drug Products to novel drugs or biologics that treat a rare disease or condition affecting fewer than 200,000 patients in the U.S. Orphan Drug Designation entitles CoDa to seven years of market exclusivity in the treatment of PED patients in the event of market approval for this indication. Additional incentives for orphan drug development include tax credits related to development expenses, reduction in FDA user fees, and FDA assistance in clinical trial design.

What's Coming in EHR's

Don't hold your breath but, one day..........

Newly Developed Program Automatically Sifts Through Patient Charts To Provide Diagnosis, Treatment Suggestions.

The Milwaukee Journal Sentinel (8/9, Ghose) reports "University of Wisconsin-Milwaukee researchers have developed a program that reads patient charts, then automatically sifts through thousands of medical studies and condenses the key findings to suggest diagnoses and treatment." In most cases, "the system, called AskHermes, does as well as doctors," according to the study, published online in the Journal of Biomedical Informatics. "Doctors could one day use the program to cross-check their conclusions, identify rare diseases or optimize their treatment regimens," the paper adds.

Who Knew?!

Some Open-Angle Glaucoma Patients May Benefit From Reduction Of Pressure Within The Eyeball.

HealthDay (8/9, Preidt) reported that, according to a study published online Aug. 9 in the Archives of Ophthalmology, "patients with glaucoma who have more rapid visual field change than other patients may benefit from a reduction of pressure within the eyeball." During "the study, 216 patients with open-angle glaucoma were given standard treatment for controlling intraocular pressure...and were followed up with re-examination every four months." The study authors found that "reducing intraocular pressure appeared to slow the rate at which some...patients experienced declines in visual field."

All I can say is WTF!

Is "Touch" on your Checklist?"

Other than an handshake are you "hand's on" with your physical exam?


Not on the Doctor’s Checklist, but Touch Matters
By DANIELLE OFRI, M.D.

A new patient comes to my office, a healthy middle-aged woman. The medical assistant has already documented her normal blood pressure. Of our allotted 15 minutes, I spend more than two-thirds talking with her.

I ask about her personal medical history, her family medical history. I inquire about her lifestyle: what kind of work she does, whether she smokes, how much she exercises, whether she eats five servings of fruits and vegetables each day. I review her “health maintenance”: whether she’s up to date with her mammogram, Pap smear, vaccinations.

I press into the remaining minutes, counseling about calcium, sunscreen, seat belts. I screen for depression, domestic violence. I remind her about flu shots and colonoscopies. I pull out brochures about healthy diet and exercise, and we talk about ways to squeeze in exercise during her sedentary job.

And then I compliment myself on a job well done. I’ve covered all the relevant screening topics. I’ve touched all the bases of preventative medicine for a healthy woman. And I’ve even managed to finish on time, so I won’t have to keep the next patient waiting.

But my patient has a quizzical look on her face. Is that all there is, she seems to be asking.

In fact, through our extensive discussion (and the initial blood pressure check), we have fulfilled all of the medical interventions that scientific evidence has validated as helpful for a healthy patient. But my patient is clearly dissatisfied. A doctor’s visit is not a doctor’s visit until a stethoscope has probed the inner rhythms of the heart, and a set of medical hands has palpated the belly. Research has shown that patients expect a physical exam.

But is there any research to show that a physical exam — in a healthy person — is of any benefit? Despite a long and storied tradition, a physical exam is more a habit than a clinically proven method of picking up disease in asymptomatic people. There is scant evidence to suggest that routinely listening to every healthy person’s lungs, or pressing on every normal person’s liver, will find a disease that wasn’t suggested by the patient’s history. For a healthy person, an “abnormal finding” on physical exam is more likely to be a false positive than a real sign of illness.

Moreover, a normal physical exam cannot reassure a patient that there is no disease lurking in the shadows.

But does the physical exam serve any other purpose? The doctor-patient relationship is fundamentally different from, say, the accountant-client relationship. The laying on of hands sets medical practitioners apart from their counterparts in the business world. Despite the inroads of evidence-based medicine, M.R.I.s, angiograms and PET scanners, there is clearly something special, perhaps even healing, about touch. There is a warmth of connection that supersedes anything intellectual, and that connection goes both ways in the doctor-patient relationship.

We only have a few minutes left to our visit, but I gesture her up to the exam table. I place my hand on her shoulder and slide my stethoscope over her ribs. As I listen to the thrum of airflow that I’m 99.9 percent sure is perfectly normal, I feel both of our bodies relax ever so slightly.

I ease the bell of the stethoscope around to her heart, and though I know that there is only a small chance that I will hear anything to indicate serious illness, the familiar rhythms are comforting to my ear. As I examine her abdomen, we continue to talk, but there is a perceptible shift in the tenor of our interaction.

The polite but businesslike nature of our initial conversation has melted. No matter how we’ve come to this room, to these postures, to this connection, we are now more intimate. Even if our initial conversation had been marked by frustration or anger, the timbre of our interaction would have softened. It is almost impossible to be annoyed or curt when skin is touching skin.

Perhaps that is the crux. Touch is inherently humanizing, and for a doctor-patient relationship to have meaning beyond that of a business interaction, there needs to be trust — on both ends. As has been proved in newborn nurseries, and intuited by most doctors, nurses and patients, one of the most basic ways to establish trust is to touch.

I cringe whenever our hospital administration refers to the doctors and nurses as “health care providers.” That term always makes me feel like a soft-drink dispenser at Burger King. I’m not a “provider”; I’m a person, a doctor. And my patient is not a “customer” or a “client.” We are not transacting business.

Which is why a doctor’s visit never feels complete without a physical exam. It is a crucial part of the doctor-patient relationship that cannot be underestimated. One doesn’t need a scientific study to prove that.

Dr. Danielle Ofri is an internist in New York City. Her newest book is “Medicine in Translation: Journeys With My Patients.”

Autologous Stem Cell Treatment Restores Vision In Patients With Severe Eye Damage From Burns.

Autologous Stem Cell Treatment Restores Vision In Patients With Severe Eye Damage From Burns.

ABC World News (6/23, story 11, 2:00, Sawyer) reported, "This is big medical news. We learned today that doctors have restored sight to some people blinded by accidents" by "harvesting stem cells from their own eyes to grow new corneas."

The AP (6/24, Chang) reports, that, according to a study published online June 23 in the New England Journal of Medicine and reported last week at a meeting of the International Society for Stem Cell Research, "dozens of people who were blinded or otherwise suffered severe eye damage when they were splashed with caustic chemicals had their sight restored with transplants of their own stem cells -- a stunning success for the burgeoning cell-therapy field." In fact, Italian researchers say that "the treatment worked completely in 82 of 107 eyes and partially in 14 others, with benefits lasting up to a decade so far."

The Time (6/23, O'Callaghan) "Wellness" blog reported, "In a study of 106 patients treated between 1998 and 2007, researchers were able to extract adult stem cells from healthy eye tissue, grow additional stem cells in the lab, and secure them over the damaged eye tissue." But, "the treatment technique is limited to people who still have some healthy eye tissue and at least partial vision, as it requires extracting some living stem cells to cultivate new ones." Vision for many of the patients "was restored within mere months of treatment."

"Interestingly, the procedure was successful in some patients who had been burned years before entering the study," HealthDay (6/23, Dotinga) reported. "Patients 22, 26 and 46, for example, were nearly blind in one of their eyes, with completely opaque corneas, after suffering alkali burns; they had undergone unsuccessful surgery, respectively, 13, 30, and three years before admission to the study. The researchers were able to restore a stable corneal covering to all three, with patients 22 and 46 regaining complete visual acuity, the study reported." Reuters (6/23, Emery), MedPage Today (6/23, Phend), and WebMD (6/23, Boyles) also covered the story.

Steep Regulatory Requirements Must Be Overcome Before Technique Can Be Tried In US, Expert Says. The Modesto Bee (6/24) reports, "Despite recent successes in Italy, it's likely to be years before American doctors again try to restore people's eyesight with stem cell transplants, said Dr. Ivan Schwab, a UC-Davis ophthalmology professor who has done similar transplants in the past." Schwab pointed out that "there are steep regulatory and financial requirements for doing stem cell corneal transplants." He added, "I just don't think that these techniques are going to be available to patients in the United States for a bit...maybe a decade."

Suspect limbal stem cell deficiency in all contact lens wearers

Heck, before today I never even heard of LSCD. Read on...... from Primary Care Optometry News

Suspect limbal stem cell deficiency in all contact lens wearers

The diagnosis tends to be more challenging than the treatment.
For more, see the article on the web:

Time for Management Pays Huge Dividends

Neil Gailmard's recent Tip of the Week, number 440 got me thinking about both Customer Service and what is required of management. Those of you who have been around me for any length of time will hear me say that I believe that providing excellent care to your patients is 50% of the job. The other 50% which provides you with a dynamic and growing practice and a high compensation is managing the practice correctly. You CAN deliver great care and end up with an average or below average income.

The Tip of the Week is worth reading in its entirety -- but so is the last paragraph:


What if you don’t have time?

You simply have to make time for management if you want a successful, fast growth practice. I think it requires the practice owner in addition to a good office manager. The eye care professional/owner has a huge effect on the practice culture, so management and marketing cannot be completely delegated.

Most practices actually see accelerated growth when the ECP schedules more time for management. And that is the best way to correct the hundreds of little flaws that exist in every practice. Schedule time for it. Of course, no practice is ever perfect, but we must keep trying to reach perfection. You may naturally be concerned about reduced productivity if you take a day or two for management. In my experience, most practices are extremely inefficient and if you began a new plan to delegate more and speed up the exam process (without sacrificing quality or stressing out the staff) you could compress all the patients you currently see in five days into three or four days.

If you have unmet patient demand of more than a week or two, hire an associate optometrist to see some of the patients so you can work on management!

One of my favorite quotes is by Zig Ziglar and it sums up this philosophy very well: “You can get anything you want in life if you just help enough other people get what they want.”

Medical Group Praises "Meaningful Use" Rule, Warns Of Challenges In EMR Compliance.

American Medical News (8/2, Silva) reports that the American Medical Association praised the final rule on "meaningful use" of electronic medical records, but warned that some challenges still remain.

"The AMA says physicians still face several challenges in becoming compliant in time. There is no EMR system on the market now that offers the capabilities needed for physicians to become meaningful users. Federal officials expect such systems to become available this fall, which would give practices only a few months to install and test the technology before the Jan. 1, 2011, start date of the incentive program." Also, "Physicians who already have invested in EMRs now must upgrade their systems to meet certification criteria."

What a radical idea!

Massachusetts Doctor Cuts Waiting Time By Accepting Same-Day Appointments, Walk-Ins.

The Boston Globe /Kaiser Health News (7/14, Arnst) reports that a Worcester, MA, family physician, Dennis Dimitri, runs an "unusual" practice: most of his "patients call in the morning and are assigned a time slot later that day." He accepts few appointments in advance. Dimitri's "open access" system works, because it "reduces the number of patients who don't show up for their appointments or who call in with an emergency and plead to be squeezed into an already full schedule," the story notes.

Administration Unveils Free Preventive Services Under Healthcare Law.

Preventive Services Recommended By Task Force Would Be Covered Fully Under Healthcare Law. Kaiser Health News (7/15, Weaver) reports, "Under the new healthcare overhaul law, insurers will be required to pay fully for services that get an 'A' or 'B' recommendation from the US Preventive Services Task Force, a volunteer group made up of primary care and public health experts." This is "good news for patients, who will no longer face cost-sharing for these services, but it puts the group in the crosshairs of lobbyists and disease advocates eager to see their top priorities -- including routine screening for Alzheimer's disease, domestic violence, diabetes, or HIV -- become covered services."

The above will apply to some vision services as outlined in the Agency for Healthcare Research and Quality's Guide to Preventive Services

FDA Leaves Avandia on the Market. What you should tell your patients.

Statement Warns Against Stopping Avandia Use.

The Los Angeles Times (7/15, Maugh) reported, "Diabetics taking Avandia [rosiglitazone] who are concerned about the drug following Wednesday's decision by a Food and Drug Administration advisory committee to allow it to remain on the market should continue taking the drug until they can make arrangements with their physician to receive alternatives, three groups of physicians who treat diabetes said Thursday." Notably, "the Endocrine Society, the American Diabetes Assn. and the American Assn. of Clinical Endocrinologists issued a joint statement saying that the risk of stopping the drug abruptly is greater than any potential risk of cardiovascular disease that might be caused by the drug."

According to HealthDay (7/15, Gardner), "'Patients should continue taking all currently prescribed medications unless instructed otherwise by their health care provider,' Dr. Robert A. Vigersky, immediate past president of the Endocrine Society, said in the statement." The statement also pointed out that "reports regarding the cardiovascular safety of rosiglitazone...have not been definitive."

Reuters (7/16, Fox) also quotes Dr. Vigersky, who stated, "Stopping diabetes medications can cause significant harm and result in higher levels of blood glucose that may cause severe short term health problems and could increase the risk of diabetes-related complications in the long term."

CNN (7/15, Rice) provided an "explanation of the pros and cons of other treatments to lower blood sugar for people with type 2 diabetes," including metformin, metformin with sulfonylureas, metformin with insulin, Actos [pioglitazone], DPP-4 inhibitors, and diet and exercise.

New Healthcare.gov Site

New HHS Website Helps Consumers Determine Health Coverage Options.

The Christian Science Monitor (7/2, Grier) reports, "Healthcare.gov is up and running -- and that should be good news for the many US citizens who are trying to understand the brave new world of US healthcare following this year's passage of sweeping reform legislation." Notably, the site "is mandated by the new law, as is its July 1 start date. It is intended to be both a one-stop-shopping site for individuals looking to see what their insurance options are, and a central repository for news and information about the health bill's rollout." According to HHS Secretary Kathleen Sebelius, "Healthcare.gov will take some of the mystery out of shopping for health insurance."

CBS News (7/2, Hunter) says on its website, "The most interesting part of the site may be the search tool," which "allows people to click on their state, then choose responses to questions about their family and medical status. A program processes the data and then spits out the best insurance options available."

Ezra Klein said in his Washington Post (7/1) blog that this is "a slick, easy-to-use site, which may be the best thing out there for seeing both the public and private health-coverage options for people in your situation in your area." The Wall Street Journal (7/1, Adamy) "Washington Wire" blog and Kaiser Health News (7/1, Galewitz) also covered the story.

The POWER of Optical

From an e-mail from Gil Catino in Wilmington:

Peter,

We crossed a daily sales threshold at the Porters Neck office yesterday that could not have been done without a stellar optical day. For the past 8 years since I graduated I have concentrated on the professional side of practice and have given very little thought into the optical side. After seeing first hand sales what a practice can do with a great optical, it has made me realize how important our job is to provide our patients with good quality eye wear along with their professional exam. I have made a commitment to myself, my patients, and the Bottom Line to improve and provide the best optical service I can in each office I practice. I am glad the organization is committed to providing training to each a every staff member to continue to improve our optical as a group. I am off to Washington on Tuesday ready to come back with some ideas to make our big optical days more of an occurrence. I really do see how a little of time spent in the lane giving recommendations gives huge paybacks to a practice's daily sales. I have really been missing the boat for all these years, believe me that will change.

Gil

Not Wearing Varifocal Glasses During Outdoor Activities May Lower Seniors' Fall Risk.

Not Wearing Varifocal Glasses During Outdoor Activities May Lower Seniors' Fall Risk.

BBC News (5/26) reports that, according to a study published in the British Medical Journal, "many falls could be prevented if older people do not wear varifocal glasses while out and about." In a study of "600 people aged either over 80 or over 65 with a history of falls," half of whom "were given single lens glasses for going out" and half of whom were not, Australian researchers found that those who went outdoors regularly while wearing single focal lenses experienced 40% fewer falls. Therefore, the study authors advised seniors to wear single focal glasses while performing outdoor activities in spite of the inconvenience of having to change glasses.

Great Customer Service.......

From Neil Gailmard, OD good advice:

I made the point just two weeks ago in tip # 431, but I'll repeat it here. Great customer service is very hard to deliver when the fee schedule is value oriented.

Raise your fees in general and you'll find it is much easier to let patients win these scenarios. If vision plans are very dominant in your practice, raise the fees anyway.

What are business cards for?

Speaking with Chris Padgett, OD at the Doctors meeting he shared with me what he uses his business cars for.  He gives one to each of his patients ("I go through a lot of business cards!") and asks them to refer their friends and family.  They might do that anyhow but asking may make this more successful.

I've been an advocate of giving each patient a business card at the conclusion of an examination saying something like this:

"I am personally responsible for everything that happens (or does not happen!) in this office.  And we try hard to make certain that we meet or exceed your expectations.  If for some reason we ever fail to do that I'd like you to contact me personally so that I can correct whatever it is that has occurred."

My business card has both my DVC E-mail address as well as my cell phone number.  I want any patient with an issue to be able to contact me directly.  If a patient is unhappy with anything in my office I am confident that I can correct the problem about 99% of the time.  I am not going to worry about the 1% that I can't help -- but I WILL try.

Who is the captain of your ship, the CEO of your office?

Words to Live By

"Don't tell me what my fun is."

"Don't tell me what I can afford."

Normal Macula, Normal Fundus Image = Normal Eye? Not so fast.

As I have said may times before when vision is less than 20/20 it is our job to determine the cause.  What we have grow accustomed to over the years when the macula appears normal on fundoscopy or imaging is that we can rule out the macula as being involved.  Wrong.  As Jerry Sherman has revealed over and over in Retina Revealed when vision is down and the macula looks normal we if we have no other cause that explains the reduce acuity we should get out the OCT.  Cross sectional imaging which gets below what we can see with a scope or an image will often reveal an abnormality deeper in the retina. 

A paradigm shift is necessary.  A normal fundus image of the macula does not necessarily mean  that the macula is normal.  Without another explanation for reduced acuity we should always order an OCT scan of the macula.

Zeiss Updates OCT and HFA Software

Cirrus™ HD-OCT Optic Nerve Head Analysis 
The new Cirrus™ HD-OCT Optic Nerve Head Analysis software provides automated identification of the optic disc and cup boundaries. The analysis is generated using the existing Optic Disc 200 x 200 data cube and a new proprietary ZEISS algorithm. This algorithm is designed to precisely measure the neuro-retinal rim, while accounting for tilted discs, disruptions to the RPE and other challenging pathology. Optic nerve head calculations are presented in a combined report with RNFL thickness data. Key parameters are displayed in table format. In addition, the boundaries of the cup and disc are displayed on the en face image integrated with the RNFL thickness deviation map.

“Doctors always are on the alert for improved ways of managing glaucoma,” said Douglas Anderson, MD, Professor, Douglas R. Anderson, Chair in Ophthalmology at Bascom Palmer Eye Institute, University of Miami. “Recent improvements in OCT imagery of the eye provided such an opportunity, and I was pleased to collaborate with Carl Zeiss Meditec in the development of a new method for quantifying optic nerve damage commonly seen in glaucoma.”

Humphrey Field Analyzer with Guided Progression Analysis (GPA) Software 
The world’s most widely used automated perimeter is now the only perimeter with GPA software that has received clearance from the FDA to specifically assess both change from baseline and the rate of change of visual field loss over time. With GPA, doctors can see at-a-glance whether vision has changed for each individual patient and they can subsequently identify how rapidly visual field loss is progressing. Understanding each patient’s rate of progression helps the doctor to adjust the therapeutic regimen with the goal of preserving vision throughout the patient's expected life.

Humphrey Field Analyzers are used by more eye care providers than any other automated perimeter today, and more than 60 thousand units have been sold since the first models were introduced in 1984. In addition to FDA cleared GPA software for the HFA, GPA software also is FDA-cleared for the Cirrus HD-OCT.

The Five-20 Rule for Dietary Sodium Intake

This article may be helpful for your patients -- and yourself:

Sodium Intake Could Be Managed Using Five-20 Rule.

NBC Nightly News (3/4, story 8, 2:20, Williams) reported in its "Personal Best" series that sodium "has a way of sneaking into the American diet in some of the most unlikely places," in what NBC (Thompson) called "a blizzard of salt." NBC examined how sodium is present in unlikely foods -- such as toasted wheat cereal and tomato juice -- and pointed out "an easier way to keep an eye on your sodium intake. Just remember two numbers, five and twenty. Then look at the label for the daily value or DV percentage." Barbara Schneeman, FDA Nutritional Labeling Director, told NBC, "Five percent or less of the daily value is considered low. Twenty percent or more of the daily value is considered high."

Really? No Glasses after cataract Extraction and IOL?

Long-term study confirms good results, maintenance of accommodation with IOL

BUDAPEST, Hungary — Long-term results of 37 patients followed for nearly 6 years after implantation of the accommodating dual optic Visiogen Synchrony IOL from Abbott Medical Optics showed stability of refraction, with a range of vision for distance, intermediate and near that was maintained throughout the length of the study period.

"The dual optic concept offers the potential for greater and more consistent, long-lasting accommodative amplitude. [Ultrasound biomicroscopy] and iTrace testing gave objective evidence of accommodation movements in the study," Ivan L. Ossma-Gomez, MD, MPH, of Cali, Colombia, said at the winter meeting of the European Society of Cataract and Refractive Surgeons.

All patients achieved 20/25 or 20/20 for distance and intermediate vision, and near vision was 20/25 on average.

Compared with other means of presbyopia correction, such as multifocal IOLs, the quality of vision is better because no optical aberrations are induced, Dr. Ossma-Gomez said. In addition, because of the "no space, no cell" design, the Synchrony lens has the advantage of a low posterior capsule opacification rate. "YAG rate for this cohort was 5.4% over the span of the study period," he noted.

Dr. Ossma-Gomez has personally implanted a total of 473 Synchrony lenses and has the longest patient follow-up. Worldwide, more than 1,200 lenses have been implanted.

A man ahead of his time

In the early 80's Don Bode, MD an ophthalmologist I worked with in Greenville started using Botox for his HA patients who had muscle tightness and headaches as a result of this.  A couple of Botox injections at the base of the skull on the neck and headaches often disappeared abruptly.

Read on......

Botox may help prevent some types of migraines.

Bloomberg News (2/16, Ostrow) reports, "Allergan Inc.'s Botox [botulinum toxin type A], given in the doses used to reduce facial wrinkles, may stop certain kinds of migraines that patients describe as crushing or 'eye-popping' more than other types," according to research published in the Archives of Dermatology. The company "has filed for approval with the [FDA] to market Botox as a treatment for chronic migraines...said" a spokeswoman for Allergan.

        HealthDay (2/15, Reinberg) reported that the study of 18 patients showed that 13 "saw a reduction in migraine pain," from "almost seven days a month to less than one day a month." Researchers speculated that Botox "may work by blocking pain receptors or reducing inflammation." MedPage Today (2/15, Bankhead) also covered the story.

Clean Hands without all the scrubbing

Plasma hand cleaning from the New York Times article. Interesting!

American Diabetes Association Standards of Medical Care in Diabetes 2010

Complete new standards can be found here.   Eye care standards are attached below:

C. Retinopathy screening and treatment 

Recommendations

General recommendations

• To reduce the risk or slow the progression of retinopathy, optimize glycemic control. (A)
• To reduce the risk or slow the progression of retinopathy, optimize blood pressure control. (A)

Screening

• Adults and children aged 10 years or older with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. (B)
• Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. (B)
• Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by an ophthalmologist or optometrist. Less frequent exams (every 2–3 years) may be considered following one or more normal eye exams. Examinations will be required more frequently if retinopathy is progressing. (B)
• High-quality fundus photographs can detect most clinically significant diabetic retinopathy. Interpretation of the images should be performed by a trained eye care provider. While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional. (E)
• Women with preexisting diabetes who are planning pregnancy or who have become pregnant should have a comprehensive eye examination and be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examination should occur in the first trimester with close follow-up throughout pregnancy and for 1 year postpartum. (B)

Treatment

• Promptly refer patients with any level of macular edema, severe NPDR, or any PDR to an ophthalmologist who is knowledgeable and experienced in the management and treatment of diabetic retinopathy. (A)
• Laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with high-risk PDR, clinically significant macular edema, and in some cases of severe NPDR. (A)
• The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as this therapy does not increase the risk of retinal hemorrhage. (A)
  
  

Diabetic retinopathy is a highly specific vascular complication of both type 1 and type 2 diabetes, with prevalence strongly related to duration of diabetes. Diabetic retinopathy is the most frequent cause of new cases of blindness among adults aged 20–74 years. Glaucoma, cataracts, and other disorders of the eye occur earlier and more frequently in people with diabetes.

In addition to duration of diabetes, other factors that increase the risk of, or are associated with, retinopathy include chronic hyperglycemia (291), the presence of nephropathy (292), and hypertension (293). Intensive diabetes management with the goal of achieving near normoglycemia has been shown in large prospective randomized studies to prevent and/or delay the onset and progression of diabetic retinopathy (53,57,58). Lowering blood pressure has been shown to decrease the progression of retinopathy (187). Several case series and a controlled prospective study suggest that pregnancy in type 1 diabetic patients may aggravate retinopathy (294,295); laser photocoagulation surgery can minimize this risk (295).

One of the main motivations for screening for diabetic retinopathy is the established efficacy of laser photocoagulation surgery in preventing vision loss. Two large trials, the Diabetic Retinopathy Study (DRS) and the Early Treatment Diabetic Retinopathy Study (ETDRS), provide the strongest support for the therapeutic benefits of photocoagulation surgery.

The DRS (296) showed that panretinal photocoagulation surgery reduced the risk of severe vision loss from PDR from 15.9% in untreated eyes to 6.4% in treated eyes. The benefit was greatest among patients whose baseline evaluation revealed high-risk characteristics (chiefly disc neovascularization or vitreous hemorrhage). Given the risks of modest loss of visual acuity and contraction of the visual field from panretinal laser surgery, such therapy is primarily recommended for eyes with PDR approaching or having high-risk characteristics.

The ETDRS (297) established the benefit of focal laser photocoagulation surgery in eyes with macular edema, particularly those with clinically significant macular edema, with reduction of doubling of the visual angle (e.g., 20/50–20/100) from 20% in untreated eyes to 8% in treated eyes. The ETDRS also verified the benefits of panretinal photocoagulation for high-risk PDR, but not for mild or moderate NPDR. In older-onset patients with severe NPDR or less-than-high-risk PDR, the risk of severe vision loss or vitrectomy was reduced 50% by early laser photocoagulation surgery at these stages.

Laser photocoagulation surgery in both trials was beneficial in reducing the risk of further vision loss, but generally not beneficial in reversing already diminished acuity. This preventive effect and the fact that patients with PDR or macular edema may be asymptomatic provide strong support for a screening program to detect diabetic retinopathy.

As retinopathy is estimated to take at least 5 years to develop after the onset of hyperglycemia (298), patients with type 1 diabetes should have an initial dilated and comprehensive eye examination within 5 years after the onset of diabetes. Patients with type 2 diabetes who generally have had years of undiagnosed diabetes (299) and who have a significant risk of prevalent diabetic retinopathy at the time of diabetes diagnosis should have an initial dilated and comprehensive eye examination soon after diagnosis. Examinations should be performed by an ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing the presence of diabetic retinopathy and is aware of its management. Subsequent examinations for type 1 and type 2 diabetic patients are generally repeated annually. Less frequent exams (every 2–3 years) may be cost effective after one or more normal eye exams (300–302), while examinations will be required more frequently if retinopathy is progressing.

Examinations can also be done with retinal photographs (with or without dilation of the pupil) read by experienced experts. In-person exams are still necessary when the photos are unacceptable and for follow-up of abnormalities detected. Photos are not a substitute for a comprehensive eye exam, which should be performed at least initially and at intervals thereafter as recommended by an eye care professional. This technology has great potential in areas where qualified eye care professionals are not available and may also enhance efficiency and reduce costs when the expertise of ophthalmologists can be used for more complex examinations and for therapy (303).

Results of eye examinations should be documented and transmitted to the referring health care professional. For a detailed review of the evidence and further discussion of diabetic retinopathy, see the ADA technical review and position statement on this subject (304,305).

The Next Frontier for Optometry?

First Oklahoma, now maybe W. Virginia. Keep in mind that WVA was the first state in the nation to have a therapeutic drug law.  NC was second.

West Virginia bill broadening optometrists' scope-of-practice advances.

The Charleston Daily Mail (2/11, Gavin) reported that on Wednesday, a West Virginia "Senate Committee on Government Affairs voted unanimously to pass a bill that would broaden the scope of practice for doctors of optometry in the state." The measure "would allow optometrists to start performing certain laser procedures but only when collaborating with an ophthalmologist licensed in West Virginia." It will also allow optometrists to give "injections that do not puncture the eyeball."

Something you can sink your teeth into

Only a bar a week?  

Consuming one serving of chocolate every week may reduce stroke risk.

USA Today (2/12, Marcus) reports, "A new analysis, which involved a review of three prior studies, suggests eating about a bar of chocolate a week can help cut the risk of stroke and lower the risk of death after a stroke." Researchers in Canada explained that "one study they looked at found that 44,489 people who ate one serving of chocolate per week were 22% less likely to have a stroke than people who ate no chocolate," while another showed that "1,169 people who ate 50 grams of chocolate once a week were 46% less likely to die following a stroke."

        The third study, however, "found no association between chocolate consumption and risk of death from stroke," WebMD(2/11, Warner) reported. Nevertheless, investigators say "more research is needed to determine whether chocolate truly lowers stroke risk, or whether healthier people are simply more likely to eat chocolate than others." Moreover, the study participants "did not identify what kind of chocolate they had eaten," the Canadian Press (2/11, Tobin) reported. HealthDay (2/11, Dotinga) also covered the study.

Becky Wartman, OD Strikes Again

Our own Rebecca Wartman, OD created this presentation of the AOA.  Thanks, Becky!




PQRI 2010 Webinar, code chart now available

The new 2010 editions of the AOA PQRI Webinar and AOA PQRI Eye Care Measures chart are both now available on the AOA Web site PQRI page (www.aoa.org/pqri).  The AOA PQRI Webinar, an online PowerPoint presentation and audio lecture, outlines how optometrists can obtain 2 percent Medicare payment bonuses for properly reporting specified quality care measures on claims.

The AOA PQRI Eye Care Measures chart conveniently lists most quality measures applicable to optometric practice, along with measure specifications and the codes to be used in reporting.  The Web site also provides convenient access to Medicare's 2010 PQRI Implementation Guide, with instructions for the establishing of a quality reporting program in a practice, as well as more than a dozen other helpful government guidance documents. Medicare's 2010 PQRI reporting period began Jan. 1. Practitioners need not register in advance to take part in the program.

Even when change isn't easy, it's often worth making.

Providing excellent patient eye care is easy.  Being the leader in your practice is hard.  I wish I had learned more about this 25 years ago.

From Time Magazine.  

Switch: How to Change Things When Change Is Hard

By Chip Heath and Dan Heath; Broadway Books; 305 pages

Whether you're a manager, a parent or a civic leader, getting people to change can be tricky business. In Switch, brothers Chip and Dan Heath--authors of the best-selling Made to Stick--survey efforts to shape human behavior in search of what works.

Lesson No. 1: tell people what you want them to do in a way that will make intuitive sense to them. The U.S. government's Food Guide Pyramid says adults should eat 5 to 7 tsp. of oil a day. Know how many teaspoonfuls of oil you ate yesterday or why you should care?

The Heaths find a better example of a public-health campaign in West Virginia. The message used there: drink 1% milk because a glass of whole milk has as much fat as five strips of bacon. That's specific, vivid and easy to remember when you're in the grocery aisle.

Next, engage with emotions, not just brains. Consider the ironfisted accountant at the Massachusetts Department of Youth Services who wreaked havoc on nonprofit partners by withholding funds unless forms were filed perfectly. When his boss forced him to visit some of the group homes the department funded, he saw the specific kids being helped--not to mention the pandemonium that often ruled--and started figuring out ways to work with the nonprofits instead of antagonizing them.

Or, in an example that may hit closer to home, think about how you would go about paying off a series of credit cards. Mathematically, it makes the most sense to start with the bill with the highest interest rate. Yet the Heaths argue that beginning with the one with the smallest rate is the better approach. Why? You're more likely to successfully pay it off, feel good about yourself and keep going with plan.

Finally, remember that environment helps lead people to act the way they do. When a hospital administrator in San Francisco wanted to reduce the number of mistakes nurses make in administering medication, she realized the main culprit wasn't carelessness but constant interruption. The solution: a bright-orange medication vest that told everyone, including doctors, to leave nurses alone so they could focus. At first, nurses hated the tacky vest--until medication errors dropped 47%.

Even when change isn't easy, it's often worth making.

Read more: http://www.time.com/time/magazine/article/0,9171,1960268,00.html#ixzz0f2p01A49

First Impressions Matter

A post shared with me from Ric Munz, OD.  Since 1976 Contacts have become somewhat more mundane but the lesson persists.

As a student, I visited Dr. Bob Morrison in his Harrisburg office in 1976.   I think his reputation as an innovator is well known, but not perhaps as a master of presentation.  

To introduce the first soft lenses to his patient, he had them brought into the exam room on an engraved silver tray in baccarat crystal shot glasses.

   

He held a lens up on his finger and said to the patient: "Isn't this amazing"....and let them admire the lens.

He placed it on each eye and had the patient shut both lids before saying:  "And when you open your eyes,you will be able to see without glasses."

His style was far from my own, but his immensely successful practice, being composed of movie stars & royalty, taught the value of presentation.

---He sold the sizzle.

And from Ted Watson, OD:  Words Matter, Regarding Digital Retinal Imaging.

Regardless of the wording the procedure of imaging the retina regardless of "routine" or "medical" is a very important one.

I know they are only words but how words are used have been known to start a war.

I would suggest that we start trying to change our wording of this procedure from "Routine Photos" to "Digital Retinal Imaging" instead of something like:

"Getting pictures of the back of your eye."  "We recommend getting photos of he back of your eye."  etc.
We are not Olin Mills Studios.

I would suggest that we start using terms that very specifically describe what we are doing.  I don't think it gets beyond the patient's ability to understand what we are doing but in my opinion it does seem to make a difference.  We have been using these terms in the GBlvd DVC for a few weeks, working hard to get away from the use of pictures and photos and moving more to retinal imaging, digital retinal imaging, high resolution imaging of the retina.

Small thing...but can and may make a difference.

To that end, all offices should be using the Digital Imaging Explanation.

CMS Coding Pocket Reference

I came across this handy tool while looking for something else on the Trailblazers Site.

Try it, you'll like it.

Of course to use it you will either need to understand and use either the 1995 E/M or 1997 E/M Coding Guidelines.

Every Worker Should be the CEO of Something

An article from the New York Sunday Times today that resonated with me.

If you ask your employees to state what their responsibilities are -- and what you expect of them -- and they can answer you without hesitation  I believe that you are 75% of the way toward leading them, and yourself to success.

A major problem with many companies is that employees don't really understand what, exactly, is expected of them.  If a staff member can't answer "What are you the CEO of?" its time to get to work.

Stem Cell Transplant Restores Sight

Stem cell treatment restores sight to damaged eye.

BBC News (12/22) reported that a UK man, Russell Turnbull, who "lost the sight in one eye in 1994 when he was squirted with ammonia" and "was left with Limbal Stem Cell Deficiency...a painful condition which requires constant treatment," has had sight restored in his damaged eye.

        The UK's Telegraph (12/22, Alleyne) reported that surgeons removed "a millimetre-squared section of" Turnbull's "left eye, complete with stem cells," then grew "it to 400 times that size in the laboratory." Next, they stitched "the new outer skin of the eye...onto the badly damaged cornea in place of the damaged membrane." To date, this "technique, developed by scientists and eye surgeons at the North East England Stem Cell Institute (NESCI), has been used on eight patients," nearly "completely" restoring vision for most of those patients.

        The "procedure has so far been carried out only on those who have lost their sight in one eye," the UK's Daily Mail (12/23, Sims, Hope) reports. However, "trials are already under way on patients who have damage to both their eyes -- and millions could one day benefit from the treatment," particularly those "whose eyes have been damaged by contact lenses, in industrial accidents involving thermal or chemical injuries, and by diseases." Details of the procedure are published in the US journal Stem Cells.

        According to the UK's Guardian (12/22, Sample), researchers said "25 more patients will be treated before the results are submitted to Britain's National Institute for Health and Clinical Excellence (Nice), which could approve the procedure for use in the NHS next year." The UK's Press Association (12/22) also covered the story.