San Diego County Optometric Society
The San Diego View
Inside this Issue:
- President’s Message
- Retina Corner
- Tech Corner
- Eye See
- La Jolla Lasik
- Why Shape Matters: Sclera Research Influences Scleral Lenses
- CE Corner
- Volunteer Corner
- SDCOS Announcements
- Upcoming Events
The San Diego County Optometric Society is one of the largest and most active societies in the state. Our activities include supporting the political interests of optometrists both locally and on a state level, providing monthly continuing education to our doctors, and giving back to our community with our various vision screening events and the Lions Vision Optometric Clinic. We are able to successfully run all the programs we have available largely due to the support of our numerous sponsors. We are fortunate to have a healthy network of sponsors which not only provide financial support, but also extend discounts to members for using their products and provide resources to help with building practices and optometric careers. Additionally, sponsorship helps fund our public awareness projects, advocacy efforts, our website, social media, and other SDCOS social events.
Every fall, the SDCOS Board hosts an annual Vendor Appreciation dinner to thank all of the companies which give their support to the San Diego County Optometric Society. This year, the dinner is being held on Thursday, October 5th at the Braille Institute of San Diego. All of our sponsors are invited to join us for a night of drinks, dinner, and discussions about ways in which our society and the sponsors can continue to benefit from one another. As a member, I encourage you to show how much you appreciate the support of our sponsors by taking the time to sit down with them and allow them the opportunity to present ways in which they can personally assist you. It is important to support the sponsors who are dedicated to supporting our society and profession!
We are lucky to have an extensive variety of sponsors and I would like to take a moment to recognize them. Our highest level of sponsorship is the platinum level. The amazing companies who have committed to this level of sponsorship include Empire Optical/Essilor Labs, EyeCarePro, NVISION Eye Centers, VSP Global, and Carl Zeiss Vision/Carl Zeiss Meditech. Our wonderful sustaining sponsors include ABB Optical Group, Alcon, Coopervision, Gordon Schanzlin New Vision Institute, Golden State Web Solutions, La Jolla LASIK Institute, The McGee Group, Optovue, Professional Optical Laboratories, Shamir, Synergeyes, Vision West, Vistakon, and Wells Fargo. I’d also like to extend a warm welcome to our newest sponsors for 2017: Shire and Waddell and Reed, along with the return of our good friends at Westpac Financial. We also greatly appreciate an educational grant from Allergan Eye Care.
Again, I offer a warm thank you to all of our sponsors! I am committed to seeing the relationships our sponsors have with our society and its members continue to grow in the future. Thanks to the generous support of our sponsors, the San Diego County Optometric Society will continue to be one of the strongest societies in California.
Retina Rounds: What’s Your Diagnosis
By Nikolas London, MD, FACS
A quick note of news before the article…. Paul, Lon, and I are very excited to recently have Dr. Anne Hanneken join us at Retina Consultants San Diego. Dr. Hanneken is a respected leader in our field who conducts groundbreaking research in visual processing and enhancement. She is an outstanding physician and surgeon, and we are ecstatic to have her as a part of our RCSD family.
This month I’d like to present a recent patient that Dr. Andrew Fasciani and I shared. We will describe the patient as he came to us, and ask you to think about the diagnosis before we reveal what he had and discuss the disease. For the purposes of this article, we’ll call the patient Balki Bartokomous.
Mr. Bartokomous is a healthy, affluent, 55 year-old male who presented to Dr. Fasciani with a recent history of redness in the left eye. He had no visual complaints, no past ocular history, and a medical history of mild gout. His only medication was allopurinol. On exam, Mr. Bartokomous was 20/20 in each eye, and had an IOP of 20 OU. His external and anterior segment examinations were unremarkable except for a mild subconjunctival hemorrhage in the left eye. On dilated exam, however, several tufts of pre-retinal neovascular tissue (NV) were noted in the periphery of each eye (figure). At this point Dr. Fasciani referred the patient to us for further evaluation (with the correct diagnosis). Our assessment agreed with his and we obtained widefield angiography, which showed impressive peripheral retinal ischemia in both eyes with prominent leakage from the tufts of NV (figure).
What’s Your Diagnosis?
The differential diagnosis for peripheral retinal ischemia and NV formation includes diabetic retinopathy, vascular occlusive disease, retinopathy of prematurity, sickle cell retinopathy, ocular ischemic syndrome, familial exudative vitreoretinopathy, Eale’s disease, hypertensive retinopathy, sarcoidosis, and hyperviscosity syndrome.
In this case Mr. Bartokomous was black, and admitted on further questioning to possessing sickle cell trait, making the diagnosis sickle cell retinopathy.
Sickle-cell disease is a disorder of hemoglobin, the oxygen-carrying component of red blood cells. Depending on the specific protein chain abnormality, several variations of sickle-cell disease can arise. In each, the affected hemoglobin becomes curved and rigid in hypoxic conditions, resulting in inflexible cells. In turn, this can result in hemolysis and vascular occlusions. If the retina becomes affected we call this sickle cell retinopathy (SCR). The variants of sickle-cell disease most commonly associated with retinopathy are sickle C and sickle β thalassemia, and manifestations include peripheral vascular ischemia, NV commonly at the edge of ischemia, and vitreous hemorrhage and/or retinal detachment as a result of the NV. These are commonly termed proliferative SCR (PSR), referring to NV. Non-proliferative changes can also develop and include salmon patch hemorrhages, an oval, pinkish, retinal hemorrhage, iridescent spots from hemosiderin-laden macrophages after rupture of a salmon patch hemorrhage, and black sunbursts from RPE hypertrophy after reabsorption of a subretinal hemorrhage. Widefield photography and angiography (e.g. Optos) are particularly nice ways to document the extent of the pathology.
The proliferative stages of SCR can resemble proliferative diabetic retinopathy (PDR), with buds of neovascular tissue at the border between perfused and non-perfused retina. Unlike PDR, however, PSR has a fairly high rate of NV autoinfarction, seen in about 1/3 of all eyes. PSR can even regress completely in a small percentage of eyes. Overall, there is about a 10% risk of visual acuity loss in untreated eyes, most commonly from vitreous hemorrhage, traction retinal detachment, and/or epiretinal membrane formation.
Given the relatively high likelihood of autoinfarction, observation is indicated for the majority of asymptomatic peripheral lesions. In patients with vision loss in the other eye, with vision loss from PSR, or those eyes at risk clear for vitreous hemorrhage or retinal detachment, treatment should be considered. This includes scatter laser to areas of retinal ischemia to decrease the retinal oxygen requirement and reduce VEGF formation. AntiVEGF injections also play a role, albeit less durable, and can lead to rapid regression of NV tissue. Eyes with significant and persistent vitreous hemorrhage or those with retinal detachment often need vitrectomy.
Thanks again for reading. Please don’t hesitate to contact me with any questions.
Best wishes, and until next time,
Nikolas London, MD
Retina Consultants San Diego, Poway, La Jolla, and Coronado
firstname.lastname@example.org (personal email)
email@example.com (RCSD email)
Got Tech questions? We’ve got Answers!
THE HIPAA WALL OF SHAME
By Dave Tuckman from Golden State Web Solutions, Inc. (www.GSWS.com)
Did you know there is a HIPAA Wall of Shame?
There is, and it’s a good place to avoid.
Back in 2009, when the 2nd part of HIPAA regulations (commonly referred to as the HITECH Act), was implemented into law, one of the regulations required the Secretary of HHS to post a list of breaches that affected 500 or more individuals. This posting is what has come to be affectionately known as the HIPAA Wall of Shame.
Breach reporting began September 23, 2009 and by the end of 2016 it listed 1,775 breaches, affecting approximately 169,839,784 individuals. In an effort to make Wall of Shame more usable/manageable, the site now only lists the last two years of breaches, beginning with the most recent. For anyone wanting to lookup breaches over 2 years old, the data is still accessible, it is just archived.
Want to see who’s on the wall? Here is the website:
AN ALARMING STATISITC
It is estimated that somewhere between 5-10% of independent Optometric practices have NOT taken the necessary steps to ensure compliance with HIPAA regulations. That means 90-95% are operating as prime targets for a breach, audit and/or possible recognition on the very wall we want to avoid.
If you are part of the 90-95% and have questions, we can help. Reach out at 619-825-4797 or info@GSWS.com. First thing we are going to do, is simply get together and discuss how the process works. There is no pressure, expectation or requirement to sign up, or any cost for an initial consultation.
written by Dr. Byron Y. Newman
SO SUE ME: DOCTORS WITHOUT INSURANCE
With the cost of malpractice insurance for medical doctors growing up to higher premiums, from about $11,000 per year to $47,000 or more, many doctors are giving up their insurance, and have no hesitancy in telling their patients about it.
“Going Bare” as it is known, or self-insuring means the insurance companies will no longer pay for judgments or settlements, and the patients may have to take less than they normally would have to settle for.
In Dade County, Florida the numbers of doctors going bare has reached 20%.
One doctor sent a letter to his patients telling them about it, and most stayed with him. The patients had to sign a form stating that they were aware of his uninsured status, a common practice. It doesn’t waive their rights to sue, but at least they’re aware of the limits of liability to be paid if they win.
One doctor was sued for $4 million. Having no malpractice insurance, the doctor filed for bankruptcy on the day the trial went to the jury, and the Supreme Court said that having filed for bankruptcy left the doctor off the hook and the plaintiff received nothing.
To protect themselves, many of the uninsured docs are sheltering assets in sophisticated trusts or partnerships, safely out of the reach of legal judgments down the road should they occur. In Florida the law protects their homes and annuities from creditors, which is one reason so many are risking “no coverage.”
And going bare is not limited to doctors. A number of nursing homes and hospitals across the country have dropped liability because of the high premiums.
What happens when patients sue a doctor without insurance? Patients often settle for less and do so more quickly before the doctor can file for BK.
Going Bare is impractical for some doctors because some hospitals and managed care organizations often have insurance requirements.
Fortunately, optometry liability insurance premiums have been quite low, due to the rarity of law suits against optometrists.
Check out Dr. Newman’s website, www.thehumorfactory.com!!!
La Jolla Lasik
For years, eye doctors and patients have cringed as patients with keratoconus and other disorders of corneal ectasia progressed from glasses to hard contact lenses to Intacs to hybrid contact lenses to corneal transplant while we remained helpless to stop the progression of the disease.
This anterior segment OCT shows the progression of keratoconus with eventual massive corneal edema and overlying epithelial bullae, and ultimately, hydrops, an acute disruption of Descemet’s membrane.
Cornea with hydrops
Corneal transplant was our only miracle. And a miracle it was, truly curing blindness. But it had its risks, including transplant rejection, glaucoma, bacterial keratitis, persistent epithelial defect, wound dehiscence, endophthalmitis, visual fluctuation, bleeding, broken sutures, cataract from chronic steroid use, and limitation of activities due to risk of rupture at the graft/host interface.
At 10 years postop, 11% of corneal transplant grafts have failed, by 20 years, 51-73% have failed, and by 25-30 years, 83-98% of grafts have failed. Given that keratoconus develops in people’s teens, the chance of needing a repeat graft in a patient’s lifetime is very high.
I’m so glad we now have a way to interrupt the march toward corneal transplant in keratoconic patients and patients with other corneal ectasias. That procedure is called corneal collagen cross-linking, or simply “cross-linking.” Corneal cross-linking forms strong chemical bonds between adjacent corneal collagen fibrils, resulting in stiffer corneas resistant to ectasia, just like rebar reinforcement in construction of skyscrapers.
Corneal cross-linking for keratoconus was approved by the US FDA on April 18, 2016. In the FDA trials, the procedure not only stabilized corneas with progressive keratoconus, it actually improved their keratometry readings, flattening Kmax 1.9 to 2.3 diopters on average, while the untreated eyes’ Kmax increased 0.5 to 0.6 diopters on average. Safety was established for patients of ages 14-65. Corneal cross-linking provides a way to arrest, and in many cases partly reverse, diseases that can otherwise decrease visual acuity, be relentlessly progressive, and end in a corneal transplant.
To perform corneal collagen cross-linking, I remove a central disc of epithelium like in PRK, and pretreat the exposed corneal stroma for 30 minutes with riboflavin drops as a photosensitizer. Then I treat with ultraviolet light at 365 nm for 30 minutes which excites the riboflavin and leads to free radicals resulting in cross-linking. Measures are taken to maintain corneal thickness greater than 400 microns to protect the corneal endothelium.
Who to refer? The incidence of keratoconus is 1 in 2,000 to 1 in 750 in the general population, but is 14.1% in people with greater than 2 diopters of astigmatism, of which 63% are keratoconic, and 7.8% are subclinical. How do we know who has it?
Detection methods for keratoconus and keratectasia include decreased best corrected visual acuity, changing refraction (sphere or cylinder), irregular keratometry, “scissoring” on streak retinoscopy, and abnormal shape (increased inferior-superior difference, skewing of steepest radial axes, area of flattening within an area of steepening). At our office, we have devices such as the Pentacam, and computer software we wrote to detect both frank keratoconus and the probability of subclinical keratoconus. Also, I can’t emphasize enough how important it is to perform the cross-linking procedure not only in the worse eye, but also in the better eye to preserve its visual potential.
The postoperative course and management after corneal cross-linking is similar to PRK with a few exceptions. Instead of gradually improving UCVA for the first three to six months after a transient decrease in vision at about day 3-5 as in PRK, the post-cross-linking patients experience about three months of transient corneal steepening and thinning, causing a variation in their spectacle refraction. Then in the majority of cross-linking patients, the vision and keratometry stabilizes or continues to improve for years. Coma and other higher-order aberrations improve. Corneal edema disappears.
We would like to get Pentacams at 1, 3, 6, and 12 months postoperatively to track the worsening and then the improvement of the keratometric measures. Long term, the patients should be followed with serial scans. They will continue with their optometrists for glasses and contacts
Postoperative issues can include:
- Ulcerative keratitis
- Corneal opacity (haze)
- Punctate keratitis
- Corneal striae
- Corneal epithelial defect
- Eye pain
- Reduced visual acuity
- Blurred vision
It’s important that we all set the expectation that the procedure is stopping a very bad disease in its tracks, but will not eliminate the need for glasses or contact lenses. Other than the 3-5 days of postoperative bandage contact lens, contact lenses should not be worn for 4 weeks postoperatively, and new contact lens fitting should be delayed at least 3-6 months after surgery due to the changing keratometry and refraction over the first year. Spectacles are a fine choice if they provide adequate vision.
Thank you again for reading. Please feel free to call or email with any questions.
Best wishes, and until next time,
Angela Nahl, MD
For more information you can also contact Matt Harnish at:
Why Shape Matters: Sclera Research Influences Scleral Lenses
Understanding of corneal shape has driven contact lenses design for decades, resulting in the development of outstanding options for vision correction. As scleral lenses gained popularity, researchers began to question how applicable their knowledge of corneal shape is when designing a lens that lands beyond the cornea.
What they discovered is that it is not possible to make assumptions about the shape of the whole eye based on the cornea. On the contrary, the anterior ocular surface is unique and, to truly optimize scleral lens design, it is necessary to integrate principles of scleral anatomy as well.
Corneal Shape ≠ Scleral Shape
In the past, most researchers and clinicians assumed that, like the cornea, the sclera features a curved shape. But, as they looked more closely at maps and molds of the eye, they discovered that, from the peripheral cornea onward, the sclera often continues in a straight line.
The Nonspherical Sclera
Additionally, researchers have now discovered that the ocular surface is not rotationally symmetric outside the corneal borders. Even within the same eye, scleral shape is inconsistent from one meridian to the next. Research data also suggests that toricity is more pronounced in the scleral area than in the limbal area, irrespective of the toricity of the cornea.
Introducing the SynergEyes VS Scleral Lens
SynergEyes, known in San Diego as a hybrid contact lens company, is introducing a unique scleral lens design, the SynergEyes VS scleral, that is based on the latest research on the anatomy of the sclera.
1. Proven design delivers predictability in your practice.
The SynergEyes VS scleral lens has been prescribed to thousands patients across Europe. The lens was designed by experts at the Visser Contact Lens Clinics and NKL (a Menicon subsidiary), both leading authorities in gas permeable contact lenses. Optometrist describe the lens as “very intuitive to fit” and “predictable, repeatable” and “very few adjustments”.
2. Standard toric peripheries align with the toricity of the sclera.
In a study with 3,000 lenses, 95% of the lenses required a toric periphery. Therefore, all the SynergEyes VS scleral lens and diagnostic set lenses have a toric periphery, adjustable in flat and steep meridians. The amount of toricity is consistent with the latest research data on the anatomy of the sclera.
3. The linear landing zone follows the straight anatomy of the sclera.
Research shows that the para-limbal sclera is linear or straight, rather than curved. Aligning a linear or straight sclera with a linear or straight landing zone on a contact lens distributes forces more evenly across the sclera providing a more comfortable and better aligned fit.
Prescribing specialty scleral lenses like SynergEyes VS gives your patients the latest in technology, while building loyalty within your patient base. Learn more about the SynergEyes VS scleral contact lenses at SynergEyes.com, or contact your colleague, Louise Sclafani, OD, at firstname.lastname@example.org.
 Van der Worp E, Graf T, Caroline P. Exploring beyond the corneal borders. Contact Lens Spectrum 2010;6:26-32.
We are committed to helping you fulfill your CE requirements through our local meeting with the support of our sponsors!
Featured Annual Sponsors
September 21st: 2 HR CE
Lisa M. Weiss – “Vision Therapy for the Primary Care Optometrist”
Anne-Marie Lahr – “Position of Wear & Compensated Rxs”
Continuing Education Seminars are at the Handlery Hotel 950 Hotel Circle North, San Diego, 92108.
Two-hour seminar, Thursday, 7:00 pm – 9:00 pm. Buffet meal included and served ½ hour prior to lecture.
- SDCOS Members free, COA/AOA Members $35.00, Non-Members $130.00.
Five-hour seminar, Sunday, 8:00 am – 1:30 pm. Buffet meal included and served ½ hour prior to lecture.
- SDCOS Members $90.00. COA/AOA Members, $90.00 Non-Members $325.00.
San Diego Optometry Practice For Sale Annual Gross $575,000. Approximately $85,000 in inventory. Established in 1991. Located in busy strip center with high visibility. Doctor is looking to semi-retire and happy to transition practice over to new owner. Asking $325,000 plus inventory (negotiable). Please contact Darrin M. Davenport at email@example.com for full details. (09/17)
Optometrist (Camp Pendleton) Permanent position for optometrist with independent contractor on base at camp Pendleton Days required: Saturdays plus other days available leading to possible full-time employment. Compensation TBD Employment Type: Employees choice. (760) 763-1757 Send CV to 619-722-6389 Please contact Janice at The Family Vision Center (09/17)
Optometrist needed for part-time or full-time position at a busy well-established general ophthalmology private practice in San Diego. Job responsibilities include (but are not limited to): Patient work-ups, Refractions, Contact-Lens Fittings, Specialty Contact-Lens Fittings, Diabetic Exams, Glaucoma Care, LASIK pre-ops, and Cataract Evaluations. Leading candidates will have strong organizational skills, the desire to work in a team-based work environment, and understand the importance in responsibilities when caring for our patient’s eye health and quality of vision. Requirements: Current CA license, current Liability Insurance. Please submit cover letter and CV to firstname.lastname@example.org (09/17)
Private Office is looking for a Partnership Optometrist to join the practice, if you have interest please contact email@example.com (09/17)
Optometrist needed: in Escondido for maternity coverage, mid-November to early January. 3 days per week (1-2 days availability will be considered) with additional future 1-2 days per week possible and vacation relief dates available. Primary Care and Medical Optometry with the opportunity to learn or continue to provide specialty care in Vision Therapy and Specialty contact lenses. Email firstname.lastname@example.org with any questions and CV if interested. (09/17)
Regency Eyecare is currently seeking a motivated and caring Optometrist for our Point Loma EyeGlass World practice! This position is full time and offers a comprehensive benefits package including a competitive salary base, paid malpractice insurance, full medical benefits, vacation time, and bonus structure. We also offer a referral bonus if you know someone who may be interested. Please contact us email@example.com or at (909) 920-5008 ext 2062 (09/17)
For Sale by Owner: Established optometry office in the heart of Mission Valley. Great location with spacious and open floor plan. Has a fully equipped one exam lane and on-site edging lab with stock lenses. All furniture and display cases are custom made. Over 1,000 frames inventory. Please visit and make an offer. Contact Tammy via email firstname.lastname@example.org or call 760-670-6775 for more info Thank you!! (08/17)
Monarch School Screening
Monarch School Fall Screening: October 2nd
Monarch School Fall Exams: November 1st and 2nd
We need doctors to help on all these dates, please contact Dr. Meisel if you are interested!!
Volunteer opportunities with Tzu Chi Foundation:
- October 22nd in Mountain Empire
Please contact Dr. Bob Meisel for more information
Lion’s Optometric Vision Clinic
ATTENTION LOVC VOLUNTEER DOCTORS
FREE 5-hour CE for SDCOS Members (maximum of 2 CE’s per year)
$70 CE for Non-Members choice (maximum of 2 CE’s per year)
Flying Samaritan Optometry Clinic – Tecate, Mexico
The SDSU Flying Samaritans are asking for any optometrists that would be willing to volunteer on Saturdays and accompany other volunteers to their optometry clinic in Tecate, Mexico. It is not necessary to be fluent in Spanish, a translator can be provided. The clinic is located about 40 miles southeast of SDSU. Their goal is to provide free eye exams, glasses, and access to other free medical benefits to the underserved communities of Baja California. They are looking for volunteers for the following dates: August 19th, September 23rd, October 21st. Please contact Dr. Bob Meisel if you are interested or have any further questions!
VOLUNTEER DOCTORS needed for flexible shifts throughout the year. 9-1:00 pm. Monday -Friday 1805 Upas St San Diego, CA 92103
Can’t volunteer at the clinic? See patients in your office. Call 619-298-5273.
Please bring to a CE meeting or contact the society office at 619-663-8439 for arrangements to pick up.
SDCOS keeps a list of all doctors willing to speak in front of groups about various topics, do home visits for patients, and assist in student mentoring. ODs interested in the Speakers Bureau, Home Visits, Student mentoring, and Low Vision OD’s, please contact Nancy-Jo at 619-663-8439
- September 21st: 2 hr CE
- October 7th: SDCOS Legislative Advocacy Day
- October 19th: 2 hr CE
Phone: 619 663 8439
Fax: 800 643 8301