San Diego County Optometric Society
The San Diego View
Inside this Issue:
- President’s Message
- Retina Corner
- Eye See
- CE Corner
- Cross-linking: Linking the Past and the Present
- Volunteer Corner
- SDCOS Announcements
Robert Grazian, O.D.
The San Diego County Optometric Society is one of the largest and most active optometric societies in the state. In recent years, our activities have been centered on three categories, the first being the furthering and protection of the political interests of optometrists, both locally and on the state level. This strengthens the profession in the better interest of the California citizens and residents we serve. Second, our Board produces monthly continuing education meetings to educate our member doctors according to statutes set by the State Board of Optometry. Third, our Society gives back to the community by providing volunteer eye service at several locations, including the Monarch School, the Lion’s Optometric Vision Clinic, the VSP Mobile Clinic, the Richard Rex Memorial Fund, and the San Diego Veteran’s Stand Down.
We are able to successfully run all these programs largely due to the support of our generous sponsors. We are one of the few local optometric societies to have a healthy network of sponsors who 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 and advocacy efforts, as well as our website, social media, and other SDCOS social events.
Every autumn the SDCOS Board hosts an annual Vendor Appreciation Dinner to thank our fantastic sponsors. This year the event takes place during the evening of Thursday, October 10th at the Braille Institute of San Diego. All our sponsors are invited to enjoy a fun night of drinks, dinner, and lively conversation with the important goal of continuing to improve our mutually beneficial relationship. Truly, our sponsors are the best! I encourage you to show the appreciation you have by sitting down with them to hear their ideas of how to work even better with our Society in the upcoming year. It’s important to support the sponsors who are so passionate about helping our Society and our profession.
We are fortunate to have an extensive and wide variety of sponsors, and I’d like to recognize each of them. At the highest level of sponsorship—called the Platinum Level—are Empire-Essilor Labs, Eyecare Pro, NVision Eye Centers, and VSP Global. Next is the Sustaining Level, which includes ABB Optical Group, Alcon, Bausch+Lomb, CooperVision, Guardion Health Sciences, Gordon Schanzlin Institute, HEA Healthy Eyes Advantage, La Jolla Lasik, Nordic Naturals, NuSight Medical, Optovue, POL Professional Optical Labs, Shamir, Novartis-Shire, The McGee Group, Visionary, VTI-naturalVue, Vistakon, Wells Fargo Finance, and WestPac Wealth Partners.
SDCOS is committed to seeing the relationship we have with our sponsors thrive and continually improve. Thanks to their generous support, SDCOS remains as an excellent optometric society and will continue to be a positive force in the lives of our doctors and the lives of the public we serve.
I look forward to a fantastic remainder of the year!
Macular hole repair and positioning
By Nikolas J.S. London, MD FACS
Director of Clinical Research, Retina Consultants San Diego
Chief of Ophthalmology, Scripps Memorial Hospital La Jolla
One of my good friends – David Lally, a retina surgeon on the east coast – recently published an interesting article that piqued my interest and I thought I’d share it with you this month. Dr. Lally shared his results on a series of patients in whom he repaired macular holes without any gas tamponade. This may not sound like much at first, but is truly amazing and may shift the way we think about macular hole repair. Before we dive into that, I’d like to take a step back.
Macular holes are common, and present as a full thickness retinal defect at the fovea. The usually range from 200 to 400 microns in diameter, and prior to the mid 1990’s were considered untreatable. In about 1994 at one of our annual Retina meetings, Neil Kelly, a retina surgeon out of Sacramento, described a novel surgical technique for repairing macular holes, and almost overnight we went from an untreatable condition to a 95% cure rate. Dr. Kelly described a technique with a series of fairly simple steps: a complete vitrectomy, peeling of the internal limiting membrane around the hole, a full gas bubble to fill the vitreous cavity, and 2 weeks of face down positioning so that the bubble was “pushed” against the hole to help it close. Instantly, a 95% cure rate. The problem, however, is that the surgeon fairly arbitrarily picked these steps, and arbitrarily felt that the role of the bubble was to tamponade the hole closed. We now know this to be untrue, that the bubble may simply need to cover the hole to prevent liquid from entering the hole and impeding repair. We have numerous published reports to this effect. We also know that 2 weeks of face down positioning is very hard on patients, and may lead to additional morbidity. The problem is the 95% success rate. Many surgeons feel uncomfortable changing the surgical technique and risking a successful outcome. Our clinic, however, has not required patients to do any face down positioning for decades, and certainly have at least a 95% success rate. This is something we are passionate about and try hard to spread the word with numerous publications and lectures at meeting, and even a website dedicated to helping patients find surgeons who do not require positioning.
Getting back to Dr. Lally’s paper, his findings further emphasized our belief in the non-role of positioning. Dr. Lally reported on a series of 20 eyes with macular hole, 17 (85%) of which were successfully repaired with a standard vitrectomy and technique as outlined above, with zero gas bubble. Zilch. While not as high as 95%, 85% with no gas bubble is remarkable, and further emphasizes that there is really no need to force patients to position after surgery. It even calls into question our belief that the hole needs to be covered by gas, but this may account for the 10% lower surgical success rate.
As time goes by and more surgeons are willing to not as macular hole patients to position, I am confident that we will maintain excellent outcomes with significantly less morbidity. After all, that is our jobs – the improve vision with as little impact on patients’ lives as possible.
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
email@example.com (personal email)
firstname.lastname@example.org (RCSD email)
By: Angela B. Nahl, MD
Cross-linking: Linking the Past and the Present
When the U.S. Food and Drug Administration (FDA) approved Avedro’s corneal cross-linking system in 2016, it provided an alternative treatment for patient’s 14 years and up diagnosed with progressive keratoconus and post-refractive ectasia. In the past, the only alternatives were rigid contact lenses, intra-corneal ring segments or corneal transplantation – none of which stopped the progression of the disease.
Corneal collagen cross-linking is a medical procedure that combines the use of ultra-violet (UVA) light and riboflavin (vitamin B2 Drops. The absorption of UVA by riboflavin generates radical riboflavin and singlet oxygen to form cross-links. It also results in a shortening and thickening of the collagen fibrils that leads to the stiffening of the cornea.
Although new in the U.S., corneal cross-linking has been performed outside the U.S. for over 15 years, and has demonstrated the ability to stabilize the progression of keratoconus, and in some cases improve corneal shape over the long term. Cross-linking was first studied in Europe at the University of Dresden in the late 1990’s by Eberhard Spoerl, PhD and Theo Seiler, MD, PhD. Their article, “Increased rigidity of the cornea caused by intrastromal cross-linking” was published in the German journal Der Ophthalmologe.
In 2015, the Department of Ophthalmology, St Thomas’ Hospital, London and the School of Optometry, University of Cardiff, Cardiff published a paper, Corneal Cross-linking to Halt the Progression of Keratoconus and Corneal Ectasia: Seven-Year Follow-up. Thirty-six patients were evaluated who underwent CXL 6-8 years prior to the study. The main measures were refractive error, visual acuity, corneal topographic keratometry, ultrasonic pachymetry, and topography-derived corneal wavefront. The results revealed an improvement in topographic and wavefront parameters evident at 1 year and were seen to continue to improve at 5 years and were maintained at 7 years.
Candidates for cross-linking are patients who are identified with an early diagnosis of keratoconus and are monitored for progression of keratoconus. Progression over 12-24 months is classified as: a. Increase >/= 1 Diopter steepest K, b. Increase >/= 1 Diopter astigmatism, or c. Myopic shift >/= 0.5 Diopters. Patient who show a central or inferior steepening with steepest manual K at least 47 and pachymetry at least 300-400 microns at the thinnest point.
The procedure starts with a 9mm corneal debridement of the cornea like PRK. Riboflavin (Vitamin B2) in 20% Dextran (Photrexa Viscous) applied to the cornea one drop every two minutes for 30 minutes. Corneal thickness is measured intraoperatively. If the pachymetry is <400, Photrexa is instilled every 10-15 seconds with repeat pachymetry every 1-2 minutes. The ultraviolet light is then applied to the cornea for 30 minutes with continued Photrexa Viscous every 2 minutes. A bandage contact lens is placed over the cornea and follow up care is similar to PRK.
There are no contraindications for the treatment, however CXL should not be performed on pregnant and lactating women.
Adverse reactions are few, but the most common are corneal opacity, punctate keratitis, corneal striae, corneal epithelial defect, eye pain, reduced visual acuity and blurred vision.
More insurance companies are authorizing cross-linking procedures than three years ago, however, many still do not. For uninsured patients, the cost is very reasonable.
Dr. Angela Nahl is one of a few ophthalmologists in San Diego to use the FDA-Approved Avedro’s KXL system and riboflavin solutions from Avedro, Photrexa Viscous and Photrexa. She works closely with referring optometrists to provide an alternative treatment for their patients with progressive keratoconus.
Thank you. Please feel free to contact me if you have any questions.
Angela B. Nahl, MD
La Jolla LASIK Institute
written by Dr. Byron Y. Newman
EMBARRASSING SYMPTOMS, ANSWERS AND PROCEDURES
There doesn’t seem to be very many embarrassing symptoms in optometry, but don’t let that fool you into thinking there are none.
In my own practice of 60 years, I had two female patients who refused the ophthalmoscope inspection of their fundus because it was embarrassing to have someone look inside their eyes.
I had one male patient who had tried wearing contact lenses several times and then quit. He explained after hemming and hawing about it and turning red that he was embarrassed to have someone look at him without his glasses in place. He felt exposed.
But whether you’ve had patients who were embarrassed to discuss their symptoms or not, the “Take Time to Talk Advisory Council” took a poll on the question: “What is the most embarrassing medical condition?” They determined from the answers, the top ten medical conditions that are too embarrassing to discuss with their physicians as reported some years ago in American Family Physician.
And, here is the list in reverse order of ranking:
9. Birth control and sex (especially teenage patients.)
8. Alcohol or drug abuse
7. Eating disorders
6. Emotional problems, such as depression
5. Incontinence of the bladder or bowels
4. Prostate problems
3. Physical and sexual abuse
2. Sexually transmitted diseases
No. 1. Impotence
We may hear of some of these—most likely STDs, the second most embarrassing, which occasionally affects the eyes.
Check out Dr. Newman’s website, www.thehumorfactory.com!!!
We are committed to helping you fulfill your CE requirements through our local meeting with the support of our sponsors!
Featured Annual Sponsors
September 12, 2019, 2-HOUR CE
All 2019 CE meetings are located at the Handlery Hotel, 950 Hotel Circle North, San Diego, 92108.
2 Hour CE
- SDCOS Members: Free if reserved 4 days in advance*
- COA/AOA Members: $35
- Non-members: $130
- Registration 6:00 pm, lecture at 7 pm. Dinner included.
5 Hour CE
- SDCOS Members: $90 if reserved 4 days in advance*
- COA/AOA Members: $90*
- Non-members: $325
- Registration 7:00 am, lecture at 8 am. Breakfast included.
*Late registration and no-shows will result in an additional fee of $35 to cover the cost of food.*
Members need to make sure they sign out at the end of all CE meetings. Even though they receive a letter of Validation and COA is notified, if audited, the sign in and out sheet is the document that will be considered.
Practice for sale: North County Carlsbad “Upscale” Practice established in 1982. Great opportunity to buy a practice in a well-desired location with great visibility and walk-in traffic. Only two miles to the ocean! The owner is interested in an immediate sale or will consider a buy-in or possibly merge with another practice. I am looking to retire but will consider a part-time position to make the transition easier. Center is well-established with Vons market and Movie theatres as anchors. Don’t miss this opportunity to own your dream practice! Email: email@example.com or call 760-310-8492 (09/19)
Optometry Practice for sale in an upscale shopping center in Escondido, San Diego County. California. Solo Private Practice established since 1996. Please email firstname.lastname@example.org details/questions. Has a large patient base. Equipment is in excellent condition. A full scope Optometry Practice. Complete Sale or buy out option. If interested please email or call at (858) 487- 8075 (09/19)
Optometrist looking for full-time, part-time, or fill-in position in San Diego. Available to work on Tuesday, Wednesday, Thursday, Friday, and Saturday after Sept 25. I have been practicing in NYC for the past 4 years in both full scope medically-oriented private practice as well as high-end boutique practice. Please email email@example.com or call 626-677-6995 for my resume or to learn more about me! (09/19)
Full-Time Optometrist – East County La Mesa Full-time position to start immediately, Some Saturday mornings and early evenings. A competitive salary, commensurate with experience with a full benefits package and potential productivity bonuses. This position requires the ability to perform routine eye exams, implement new technology- medical software, complete contact lens, and specialty lens exams and frame fitting. Please send CV to firstname.lastname@example.org (10/19)
Optometric Practice for Sale East County in the city of El Cajon 40+ years Optometry Practice for sale By Dr. Robert L. Evans and Dr. Marilyn A. Carter. Many long-time, loyal patients and excellent staff. Please call Dr. Evans at 619-444-9012 (El Cajon) Or 619-422-5361 (Chula Vista) Or 619-479-5070 (Home) (10/19)
Dr. John Fitzpatrick, the Society Optometrist Relations Liaison, offers a unique service to the San Diego Optometric community. Several lists are kept on file for doctors seeking the following, or any combination: • full-time work • part-time work • fill-in work • purchase a practice • sell a practice • partner in a practice. There is no charge for this service. To put your name on the list, please contact Dr. John Fitzpatrick at email@example.com
Monarch School Screening
- Monarch School Screening, Monday September 30, 2019, 8:00am-3:00pm
- Monarch School Exams, Tuesday October 15 and Wed. October 16, 2019, 8:00am-3:00pm
Lion’s Optometric Vision Clinic
ALL DOCTORS WILL RECEIVE A FREE 5 HOUR CE FOR EVERY SHIFT FOR WHICH THEY VOLUNTEER
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 the society office at 619-663-8439 or email firstname.lastname@example.org
Volunteers Needed for Free Medical Outreach
Where: Mountain Empire High School
3305 Buckman Springs Rd. Pine Valley, Ca. 91962
When: October 20, 2019
Time: 8:30 am to 3:00 pm
We are looking for volunteers for upcoming Medical Outreach. This is the fifth year we are bringing this to Mountain Empire. We are in need of non-professional volunteers (No previous experience Necessary) and Professional Medical volunteers (Dentists, Optometrists, and Nurses). The event is being put on by the Tzu Chi Foundation and is free to all. If you can help out contact Mark Ostrander for details at email@example.com or (201) 890-3344. We will offer a free training for all non-professional volunteers.
- Click here for most recent SDCOS Board Meeting Minutes
- Click here for the 2019 CE schedule!
- Click here for COA membership benefits!
Please update your information on www.eyehelp.org
Phone: 619 663 8439
Fax: 800 643 8301
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