Optometric Physician

Vol. 22, #37   •   Monday, September 27, 2021


Off the Cuff: What Makes a Good Clinician Good?

Like many of you, I spend most of my life in the doctor’s seat, but today the roles were reversed. For a change, I became the patient. The doctor had a great CV and an impressive number of well-framed diplomas on the exam room wall. Despite an icy front desk staff that didn’t even bother to make eye contact, I had great hopes that the visit would be productive. Sadly, the front desk experience was just a harbinger of things to come. To put it simply, the doctor had the personality of a dead fish. There was no real dialog or appearance of interest and, more importantly, no human connection.

As Shannon and I reviewed and dissected the experience—hoping to at least get something useful that would help us in our own practice—the conversation turned to a patient I saw earlier this week. It was a very complicated case that had been referred to me by an astute local colleague. The patient had congenital cataracts removed fifty years earlier and was aphakic. A surgical mishap left him essentially blind in his right eye, and the left was failing. He reported having dry eyes, which were worsening, increasing contact lens intolerance, and a number of disturbing odd visual problems with his “good eye.” Despite all of this, he held a very high position at a national company. Perhaps because he was a fellow NYer, I immediately connected with him. As I explained my findings and how I was going to approach managing them, I told him not to worry. I would do everything possible to take care of him.

What he couldn’t quite articulate, but what was clearly evident, was his near panic at the prospect of losing his remaining sight. After what he had already been through, the mere thought of that made me angry. I see a lot of desperate patients with complex issues, but one thing I’ve come to realize is, the more challenging and complicated their problem, the more determined I am to help them.

As we continued to discuss the patient, Shannon offered a brilliant bit of clinical insight that I had overlooked. I noted it’s funny how often we talk about our patients and seek each other’s perspective and how our patients really benefit from it. She smiled and said, “Somehow, I doubt the doctor you saw today ever talks about her patients or their problems.” I said, “I think you first have to care about the patient before you have anything to say about them.” As it turned out, we did confirm something we already knew. If you want to be a good clinician, give a damn about your patients.


Arthur B. Epstein, OD, FAAO
Chief Medical Editor

Want to share your perspective?
Write to Dr. Epstein at artepstein@optometricphysician.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.



Accuracy of Perceived Glaucoma Risk by Patients in a Clinical Setting

Researchers conducted a cross-sectional survey with a final study population of 1203 individuals from two medical centers in Taiwan between January 1 to June 30, 2019, to determine whether patients attending the ophthalmology department underestimated their glaucoma risks. The "high concern" group was defined as the set of patients who rated themselves as having low risk but who had been rated by physicians as having medium or high risk of developing glaucoma over the next year.

Approximately 12% of the respondents belonged to the "high concern" group. For those with education at the college level or higher, the interaction term was estimated to be 0.294 (95% CI=0.136 to 0.634). Marginal effect calculations revealed significant sex-based differences in the effect of knowledge at specific age intervals.

A considerable proportion of patients attending the ophthalmology department underestimated their glaucoma risks. Misjudgment of glaucoma risks can lead to delays in seeking medical attention. Glaucoma education should be designed according to each patient's education level and sex, as its effect is not consistent across different education and sex clusters.

SOURCE: Hou CH, Lee JS, Lin KK, et al. Accuracy of perceived glaucoma risk by patients in a clinical setting. PLoS One. 2021; Sep 16;16(9):e0257453.


Severe Optic Disc Cupping Following the Methanol Toxicity in a 20-Year-old Man: A Case Report

In April 2018, a 20-year-old man with a history of methanol intoxication from an alcoholic drink two years earlier when he was 18 years old, was referred to Nikookari Eye Hospital in Tabriz, Iran. The patient was admitted to the emergency service and underwent eight hours of hemodialysis at the time of poisoning. His past medical history was negative, and he did not take any medication after discharge. The patient had a driving license and never experienced any visual problems before. At presentation, his visual acuity was 160/200 in both eyes with the main complaint of visual field deterioration. Other neurologic exams and brain magnetic resonance imaging (MRI) were reported normal by a neurologist. Optic disc cupping was near total in both eyes with a very narrow remaining rim. Optic disc cupping was very similar to glaucomatous cupping. Intraocular pressure was checked several times via Goldmann tonometry and was 13 mmHg. There was no history of refractive surgery leading to the thin cornea. Based on this case, methanol poisoning can mimic glaucomatous optic disc cupping. This is the first case report of methanol toxicity-related optic disc cupping from Iran.

SOURCE: Hassanpoor N, Niyousha M. Severe optic disc cupping following the methanol toxicity in a 20-year-old man: a case report. Iran J Med Sci. 2021 Sep;46(5):395-8.


Elevated Histamine Levels in Aqueous Humor of Patients With Glaucoma

Neurotransmitters (NTs) are the key mediators of essential ocular functions, such as processing the visual functions of the retina, maintaining homeostasis of aqueous humor, and regulating ocular blood flow. This study aimed to determine variations in the levels of L-glutamate and γ-aminobutyric acid (GABA), histaminergic, adrenergic, cholinergic, and serotonergic NTs in patients with primary glaucoma vs. patients with cataract. This case-control study involved three age-matched groups of patients with primary open angle glaucoma (POAG, n=14), primary angle closure glaucoma (PACG, n=21), and cataract (control, n=19). Patients' aqueous humor and plasma were collected, snap frozen at -80 °C, and subjected to ultrasensitive liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis for quantification of NTs.

Baseline intraocular pressure and the cup-to-disc ratio were found to be statistically significantly elevated in the POAG and PACG groups compared to the cataract control group. In aqueous humor, histamine was found to be statistically significantly elevated (5-fold, p<0.0001), whereas 1-methyl histamine was statistically significantly decreased (p<0.05) in POAG compared to the control group. A statistically significant increase in L-glutamate and GABA was observed among both patient groups with glaucoma compared to the cataract control group. Adrenaline was found to be elevated only in the PACG group (2.7-fold, p<0.05). No statistically significant difference was observed among the plasma NT levels between the groups.

This study demonstrated the prominent role of the histaminergic system apart from autonomic mechanisms in the progression of glaucoma. Elevated L-glutamate and GABA could be due to retinal ganglion cell death. Investigators wrote that further studies would be required to evaluate the effects of histamine on Müller cell dysfunction.

SOURCE: Gowtham L, Halder N, Angmo D, et al. Elevated histamine levels in aqueous humor of patients with glaucoma. Mol Vis. 2021 Sep 3;27:564-73.





Industry News

Essilor Launches Vision-S 700 Refraction Station

Essilor Instruments introduced the Vision-S 700 refraction station, offering three-minute refractions and concentrating a complete refraction experience into an immersive station. Consisting of a stand-alone, ultra-compact tabletop subjective refraction unit, the refraction station incorporates the patented Digital Infinite Refraction method and liquid lens module. In addition to its spacesaving feature, immersive imaging technology simulates real-life conditions for the patient. Read more.



American Academy of Optometry Announces 2021 Award Recipients

Each year the American Academy of Optometry recognizes distinguished individuals who have made countless important contributions to advancing the profession of optometry. View the 2021 award recipients.

DVI and Neurolens Collaborate to Increase Prism Specificity


Neurolens and Digital Vision (DVI) collaborated to expand the prism field from 1/8th to 1/100th prism diopter for all Neurolens designs. This enhancement will cross all DVI platforms, including VISION Lab Management System, RxWizard, web-based RxWizard, and the SEER mobile app. Learn more.

MaximEyes.com Software Integrates With Weave


MaximEyes.com, First Insight's newly designed EHR and practice management optometry software, now integrates with the Weave patient communication system. Ashish Chaudhary, Weave’s chief technology officer, said in a press release: “Integrating patient data from MaximEyes.com with the Weave platform will enable our mutual customers to better engage with their patients and help them save time.” Learn more.

Heru Reports Automated VF Testing Platform Correlates to HFA


A report by Heru indicates that visual field test results from its wearable platform, re:Vive, are strongly correlated to the Zeiss Humphrey Field Analyzer (HFA), the company said. The associated study included 47 eyes (21 healthy and 26 patients) with glaucoma and neuro-ophthalmic diseases. Researchers found strong correlations between Heru’s and HFA’s visual field mean deviation and threshold values in normal eyes, and eyes with glaucoma and other pathologies. An additional study showed similar results. Read more.

Prevent Blindness Declares First Inflammatory Eye Disease Awareness Week


Prevent Blindness declared September 27 to October 3, as the first Inflammatory Eye Disease (IED) Awareness Week, and created a webpage providing information on IED, downloadable fact sheets in English and Spanish, and resources for eye care. Shareable social media graphics will be posted on the Prevent Blindness social media channels throughout the week. Development of these resources was supported by a grant from Mallinckrodt Pharmaceuticals. Learn more.

Olleyes Appoints Dr. Mendoza As CMO


Olleyes, a medical software company focused on the development of the VisuALL Virtual Reality Platform for assessment of visual functions, appointed Carlos E. Mendoza, MD, as its chief medical officer. An accomplished neuro-ophthalmologist, Dr. Mendoza will provide leadership to clinical affairs, clinical sciences and data management in this new role. During his last few years at Bascom Palmer Eye Institute, Dr. Mendoza studied the vision loss and retinal changes seen in patients with neurological diseases including Alzheimer’s disease and Parkinson’s disease, as well as rare genetic disorders such as Familial Dysautonomia.








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