Optometrist Perspective by Harvey Yamamoto, OD

Harvey Yamamoto, ODHAPPY NEW YEAR to everyone!  The entire staff at C&E joins with me in wishing each of you, your staff and your family a fruitful and abundant year.

WHAT’S NEW FOR 2011? For 6 months, my practice has been serving as a beta testing site for a new program which C&E Vision asked us to look into.  I don’t wish to bore my readers with a long explanation as we all have better things to do with our time.  This new and innovative company calls itself, Lifestyle Eyecare Centers.  So, what is so different about Lifestyle Eyecare Centers?  Like so many of my readers, we have limited or no capitol to invest into new practice management ideas.   Having said that I knew, in my heart that if our practice was to improve upon itself for now and for the future, we could not do it ourselves.  After all, we had tried everything from soup to nuts.  Two years ago, we got involved with Medical Coding/Billing only to discover that our reimbursements were being pared down by over 20% by our government.

When I signed up for Lifestyle Eyecare Centers they told me that they could improve our sales and add to our bottom line.  How you ask? (The same question which I asked.) They sent us beautiful literature that we put in our dispensary.  It became a good idea when our staff noticed that patients began taking the literature pieces off the rack to take home.  Little by little the office forms began to arrive which gave us the time to settle into their program at our slow pace.  Soon table tents, wall posters, etc, began to arrive – you get the idea.  They were marketing for us without us having to lift a finger. Now I really can buy into something like that!  My personal lifestyle is so busy with administrative duties & lab maintenance that I don’t have time to be bothered by such things.

The good folks at Lifestyle Eyecare Centers began to mail out postcards to my immediate community which began to drive in potential patients to our office.  Patients began to ask about promotions that they had received via mail.  Fortunately they saw similar promotions hanging on our walls and in the literature rack.  I was like, “What is going on?”  Here is what I thought: “Some new company is actually driving in patients through our doors.  How neat can that be?”  We also noticed that most of these walk-ins were a cut above our average patients. They were very knowledgeable and wanting information on new products, frames, etc.  We felt like we were the black widow spider waiting for our next victim to arrive.  One by one, they began to filter into our office and make purchases of not one but two and yes –even 3 frames.

After 6 months of becoming an affiliate practice of Lifestyle Eyecare Centers, I felt that it was the perfect time to share this good news with my readers.  After all, this is 2011 and a new beginning. Why not start off the year with a bang.  Have fun!  Feel free to contact them at 800-874-3706 and let them know Harvey sent you.  You will get a free affiliate membership and 50% off your first order.

Smoking is bad for your eyes.  I just finished examining a patient who had been a long time smoker.  Here is his story.  A few years ago, he was struck in the eye with cement while doing masonry work.  To make a long story short, he ended up having a corneal transplant.  The transplant was successful but his dominant eye was left blind (BVCA = CF @ 3’).  That left his left eye to carry on.  He was brought in to our office by a patient of ours to see what we could do for him.  He is applying to SSI for blind aide.  Could we help?

His uncorrected acuity in his left eye (good eye) = 20/70.  No history of glasses other than store bought reading glasses.  We found the following Rx: +1.25 -1.00 x 60 = 20/50.  We took digital photos of his left eye and we saw a series of Drusen in and around the macula.  My first question that I asked the patient was “Do you smoke?”  The answer was “Yes!” I asked him, “How long?” “30 years but I can quit as I’ve stopped smoking cold turkey on several occasions.”  His medical history:  Prone to strokes frequently.  Smoking related?  Most likely.  Smoking is hazardous to one’s health and eyesight.  We spent several minutes going over the importance of giving up his smoking habit combined with eating more veggies and exercise.  This scenario is all too common in our practice.  These patients come in hoping to achieve normal acuity with new spectacles only to find that there is so much more to health and eyesight restoration than a new pair of glasses.  I suppose that these types of patients will be ongoing as the cigarette industry has become a billion dollar industry by convincing these patients that smoking is fashionable.

I instructed the patient that once he gave up smoking for good to come back and we could talk about vitamin and supplement therapy for his macula.

CHOROIDAL NEVUS:  When I was informed about choroidal nevus some years ago my thoughts were “now what?”  What is the treatment?  What do I tell my patients that have choroidal nevus?  I asked my colleagues and they told me to keep an eye on it.  This is where our digital Retinal camera comes in really handy.  We have software that allows us to do an overlay of the previous pix and thus we can observe whether the nevi are becoming larger.  In spite of our technology in picture comparison, I was still in doubt about this technique.  When does the nevus become a malignant melanoma?  This is certainly an awesome responsibility on eyecare practitioners.

One day, I stumbled onto an article found in the Review written by Dr. Paul Karpecki.  He begins the article with this question, “When is a presentation just pigmentation, such as a nevus or primary acquired melanosis, and when is it a malignant melanoma? “  His question struck a note within my heart as I’ve been asking that question a lot lately.  He goes on to say that the presentations location is the most critical consideration.

Now we are getting somewhere.  Finally, someone has given me an answer to my many years of wondering, “Did I miss something?”   I wanted something more specific as to exactly where I should be looking?  I found the answer as I continued to read, “Answer: On the palpebral conjunctiva, rather than on the bulbar conjunctiva.”  To be more precise and specific: “If you see significant pigment on the upper tarsal plate or inferior fornix, refer the patient to an oculoplastic surgeon.”

One study revealed that 24 patients out of 26 that presented with malignant melanoma found on the conjunctiva, 24 were located on the palpebral conjunctiva area (including the lower fornix and anthus region as well as the upper tarsal plate while only 2 cases were found on the bulbar conjunctiva.

The importance of determining whether our patients have malignant melanoma is the fact that patients with malignant melanoma have a 28% mortality rate thus the importance of identifying these presentations as early as possible.  Thank you, Dr. Karpecki.

VISUAL FIELD INTERPRETATION: I took a 24 hour course on Glaucoma to try and understand ‘How to interpret the results from Visual Fields.’  I came away with more question marks after the session than before attending.  If Visual Fields are such an important tool to use in determining whether our patients have Glaucoma or not then why are there so many variables and tangibles involved.

I am far from being an expert in Visual Fields but I will attempt to share some of my thoughts with my readers.  I’m sure that there are many of my colleagues who feel that they have mastered the Art of Visual Fields and the interpretation thereof.  For me, I’m not so sure.  Several years ago, we purchased the Humphries 750 to be utilized as our gold standard in the determination of whether a patient needs to become concerned with signs pointing them in the direction of Glaucoma.

I listened to several lectures by Dr. Jerome Sherman who explained that a patient could have large cups and yet not have glaucoma.  He also suggested that we purchase an OCT device to help us in the evaluation of RNFL loss as well as discovering Optic nerve head Drusen.  In June of 2009, we decided to upgrade our Stratus OCT to the Cirrus OCT.

To our surprise, we have been finding many of our Hispanic patients with very large cups (.6, .7, and .8), which according to our studies, would seem to indicate substantial structural damage in the ONH.  During the extensive Glaucoma course, we were taught that there can be a number of conditions that can be mistaken for illustrating a Glaucomatous field defect or loss.  The base cause of the etiology is either pathological or non-pathological.

Pathological causes: These can be classified as AION – anterior chiasmal lesions.  Optic nerve head Drusen or anterior ischemic optic neuropathy may cause lesions that can be mistaken for Glaucoma which in turn can add to the confusion of our diagnosis.  Then there are post chiasmal lesion defects adding to more confusion in the diagnosis of glaucoma.  Then we have media opacities such as cataracts which can add adversely to the outcome while conducting visual field testing.  These defects can mimic glaucoma creating a diffuse type of depression in the fields.

Then we were told in class that one needs to take several fields before we can make the diagnosis.  Why?  Because, there apparently are many variables involved in the taking of fields.   That is another plus for the newer SD-OCT.  I won’t be surprised to see that one day in the not too distant future that OCT’s will become the gold standard of determining Glaucoma.  I know that in our practice, we are beginning to use it more and more routinely for anything that appears suspicious.

We owe a debt of gratitude for the industry in bringing us all this technology where we can make more accurate decisions based upon facts rather than assumptions.

Many of our close colleagues are yet to commit themselves in bringing these technologies into their practice.  Why?  Apparently the high cost is holding them back.  Here is how we looked at the situation.  “It is far better to invest $75,000 in new technology than to be facing a patient who went blind from our lack of technology.”

The interesting thought is that we are finding a lot more retinal pathology with our SD-OCT than we would have if we were without it.  Then there is the question of digital Retinal camera which is high on our list of must haves.  We have witnessed the changing of the guards when it comes to our eye charts.  With computerized eye charts seen nearly in every practice gone are the days of changing bulbs and dealing with not so bright images.

At the last Vision Expo I saw new technology abounding in the lab fabrication of lenses.  It was absolutely awesome and expensive. I spoke with one lab owner who went hi-tech and terminated 90% of his employee’s.  He went from 25 employees down to 5.  His first thought was: “I can’t afford that!”  Once he sat down and calculated that he could greatly reduce his workforce going hi-tech became a no brainer.

It will be interesting to see what 2011 brings – Happy New Year! Sorry that this editorial turned out to be so long  please forgive me for taking up so much of your new year.  Go Lifestyle Eyecare Centers – A company that cares about your future.

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