San Diego County Optometric Society
The San Diego View
Inside this Issue:
- President’s Message
- Retina Corner
- Eye See
- CE Corner
- Volunteer Corner
- SDCOS Announcements
By Alexandra Scovill
I hope everyone had a wonderful and safe holiday season, even if you couldn’t be with your loved ones. Let’s look forward to a brighter 2021! I am honored to serve as your president in 2021 as we continue to work through all the changes COVID-19 has brought.
Let’s thank the amazing Dr. Wendy Gross for all of her hard work navigating us through 2020, making many tough decisions, and keeping SDCOS continuing education meetings running even when we could not meet in person. 2020 was a challenging year to be president, with lots of changes, but she made the transition seamlessly! Also, I would like to acknowledge the efforts of Dr. Jason Tu as COA President for 2020. Not only did he assist SDCOS, but he also led the way for all optometrists in California, keeping us up to date with the ever-changing practice recommendations from the CDC and the Governor. His title of “Optometrist of the Year” is well deserved! Thank you, also, to the entire board of 2020 for their hard work and service during the past year. Many extra hours were put in to make the year run smoothly, so we appreciate your time and dedication!
This pandemic has brought many changes, but one thing that I will make sure does not change is our legacy as one of the best societies in the country! In years past we have been known for hosting numerous continuing education opportunities as well and many volunteer outreach programs such as the Lions Optometric Vision Clinic, Veterans Stand Down, and Monarch School Screenings. With continuing education becoming much more easily accessible online and in-person screenings not meeting social distancing requirements, we are coming up with new ways to support our members as well as serve our community. I don’t see these changes as a burden, rather as an opportunity to better our society. I am thrilled to be a part of this exciting time for our society, and profession as a whole. Please do not hesitate to contact me with any questions, comments, concerns, or ideas you have for keeping our society thriving. Together we can make it through this pandemic better than ever!
Visual Function in Patients with Diabetic Retinopathy
By Nikolas J.S. London, MD FACS
President and Director of Research, Retina Consultants San Diego
Chief of Ophthalmology, Scripps Memorial Hospital La Jolla
Hey everyone – I hope that you are all doing well, staying healthy and safe. Last year is in the rearview mirror, and 2021 is sure to be better.
Over the past few weeks, I have been working as an expert on a Department of Justice case involving an accident between a bus and a parked tractor trailer on a small rural highway. My task was to evaluate the bus driver’s visual function and potential contribution to the accident. It has been a fascinating exercise, and fun to serve as a bit of an ophthalmic detective. For this month’s article I would like to review some of the things I have learned.
Like most things, the incident is more complicated than it appears. If you watched the video you would see a bus traveling in the right lane of a small highway, just before dawn with the sky illuminated but everything below the horizon shrouded in black. About eight seconds into the video, you would just start to see a truck parked in the same lane (no lights on), and two seconds later, the bus running into the truck. There is footage of the driver, and you can see her start to turn the bus approximately one second prior to impact. At first glance, it seems clear that the truck is at fault with no warning lights on, but of course there is more to the story. In reviewing the records and deposition, the driver had a 20-year history of very poorly-controlled diabetes, with HbA1c levels consistently in the 10-14 range. Moreover, the driver had her low beams on, and she was wearing her reading glasses. Her closest eye exam was three weeks prior to the accident, revealing an uncorrected VA of 20/50 OD and 20/70 OS, a BCVA of 30/30- OU, as well as moderate diabetic retinopathy OU. So, the question is did the driver’s diabetes, diabetic retinopathy, use of low beams, and use of reading glasses play a role in her ability to see and react to the truck? In short, I believe that they clearly did. It was interesting to research and learn how diabetes affects visual function outside of what we would normally consider visually-significant diabetic eye disease, and I would like to share what I learned.
Changes in visual function among diabetic subjects occur before structural abnormalities can be detected on exam. Multiple measures of visual function exhibit impairment related to diabetic retinopathy, including contrast sensitivity, dark adaptation, and low luminance visual acuity. These visual impairments correspond with abnormalities reported on the National Eye Institute’s Visual Function Questionnaire (VFQ). Of note, the VFQ deficits in patients with diabetes commonly include poor night vision. Moreover, the deficits measured on the VFQ are at least partially reversible when the diabetic retinopathy is treated with anti-VEGF injections, providing further evidence for a causal relationship between the diabetic retinopathy and VFQ deficits, and further rationale for early use of anti-VEGF therapy.
Lighting conditions at the time of the accident clearly played a role in the incident. While patients with even severe retinopathy, can retain excellent visual acuity under photopic conditions, it is well-established that acuity under scotopic conditions is significantly reduced. We call this difference between standard and low luminance visual acuity (LLVA) the low luminance deficit (LLD), and LLD is a frequently reported outcome measure in research of retinal function. In addition, other measures of scotopic visual function corroborate the effect of diabetic retinopathy. Dark adaptation is a quantifiable measure of an eye’s ability to adjust to scotopic conditions, and studies evaluating dark adaptation reveal progressive dysfunction with worsening diabetic retinopathy, with significant impairment even at mild stages of diabetic retinopathy. Other studies have demonstrated preferential dysfunction of rod photoreceptors with rod dysfunction evident even with mild retinopathy and normal photopic function.
Contrast sensitivity also likely played a role in the incident. Scotopic conditions in general greatly exacerbate the need for strong contrast sensitivity. Scotopic vision is primarily mediated by rod photoreceptors, which are 10x less effective at detecting contrast. Diabetes has a significant negative effect on contrast sensitivity. Even patients without retinopathy exhibit loss in contrast sensitivity. Reductions in contrast sensitivity also correlate with the severity of retinopathy, with patients with moderate diabetic retinopathy more affected than those with mild disease. Even eyes with normal visual acuity can demonstrate prominent reduction in contrast sensitivity. Moreover, HbA1c is a highly significant predictor of contrast sensitivity change among patients with diabetes. Per the most recent report, the bus driver appears to have had at least moderate diabetic retinopathy, and her two most recent HbA1c levels were highly elevated at 14.2 and 11.5.
On top of all of the above reasons for poor visual function, refractive error may play the most significant role in Ms. Aguilar’s inability to see and react the truck until it was too late. Wearing standard +2.00 reading glasses by someone who does not require distance correction would reduce distance visual acuity by approximately five lines on an eye chart under normal testing conditions, likely more so under low luminance conditions. Based on her closest eye exam, wearing reading glasses would have reduced the bus driver’s distance visual acuity to 20/200 or worse in each eye, meeting all common definitions of legal blindness. Again, this would likely be even worse under the low luminance conditions under which Ms. Aguilar was driving.
To summarize, my impression is of a driver with chronic, poorly controlled diabetes which is associated with multiple measures of visual dysfunction including poor low luminance visual acuity and poor contrast sensitivity, not only not wearing necessary distance correction, but wearing the wrong distance correction likely with the equivalent of 20/200 vision, driving in the dark with low beam illumination of the road. With low beam illumination of the road, the reflectors of the truck were visible approximately two seconds prior to impact. Use of high beam illumination would presumably have made the reflectors visible earlier. Given all of the above, I find it very likely that the driver’s visual function, compounded by the use of reading glasses and low beam illumination played a substantial role in the incident and believe this is reinforced by the apparent delay in her reaction time from when the truck was visible in the video to when she initiated an evasive maneuver.
Best wishes, and until next time,
Nikolas London, MD, FACS
Retina Consultants San Diego
written by Dr. Byron Y. Newman
Why Physicians don’t like being called “Providers”
Physicians say that the replacement of ”Physician” or “Doctor” with “Provider” is deliberate–promoted by the insurance industry to undermine the physician-patient relationship, minimize the physician’s role in health care and wrest more authority from them-and more concessions come contract time. “There’s something very commercial about “Provider”,” said Peter S. Liebert, MD, a pediatric surgeon and president of the Westchester County Medical Society in New York.
It’s all part of a plan that benefits insurer’s bottom lines, physicians say- a plan to wean the public from medical doctors and replace physicians with lower costing nurse practitioners and physician’s assistants, according to an article a few years ago in American Medical News.
“They keep using the word to camouflage what they’re really doing,” said Walter J. Khan, MD an ophthalmologist in Red Bank, N.J. “They say, ‘We’ll send you to a provider.’ “Well, who’s the provider? They’re trying to make everybody synonymous with the lowest common level. Providers are also people who sell medical appliances.”
The article was long on the complaint about the use of the term, but a director of a health plan is reported to say, “I think (Physicians’) arrogance and paranoia is the problem. It certainly is easy to point the finger at us and call us the evil empire. Think about this. We have gone from a system that years ago basically dealt with doctors and hospitals, and over the years, other professions—chiropractors, nutritionists, acupuncturists and now registered nurses—want to be paid directly from our coffers, It’s easier to say that people who provide services become providers”, he said.
Check out Dr. Newman’s website, www.thehumorfactory.com!!!
We are committed to helping you fulfill your CE requirements through our local virtual meetings with the support of our sponsors!
Featured Annual Sponsors
Speakers: Mile Brujic, OD, FAAO
Topic: Anterior Segment Potpourri and How to Treat Them
Date: January 28, 2021
Webinar ID: 817 6853 8402
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Turnkey practice available in Murrieta, California. It has modern equipment including a digital exam lane and Optos Daytona, 1 exam lane plus a tech workup room, and a bright and open optical. The practice currently sees about 150 patients per month during COVID with room to expand. Murrieta has some of the most affordable housing costs in Southern California with fantastic schools, local wineries, and is less than an hour to the beach and mountains. Email firstname.lastname@example.org for more information. (01/21)
Practice for Sale: North County “Carlsbad” upscale high-end practice. Owner at the same location over 30 years, boasts a strong net with easy hours. Great visibility location within high traffic Vons Center, theatres, library, great restaurants, great tenant mix. Office current remodeled with glass showcases, LED lighting, granite countertops, designer wallpaper, light wood floors. Updated equipment in the exam and pretest room with blue tooth transfer. Great opportunity to own a modern practice and be independent with much room for continued practice growth. Call Howard Levy, OD 760-310-8492 or email email@example.com PRICED TO SELL! (01/21)
UNUSUAL PRACTICE OPPORTUNITY My long-time friend and colleague, Dr. Bob Evans, has unfortunately recently passed away. His Chula Vista practice is available for IMMEDIATE TAKEOVER as a satellite practice with excellent potential to return to full-time. Tons of records from two offices that have provided years of vision care to patients in underserved nearby neighborhoods. If serious, or just curious, call me ASAP. Mid-January is our final turnover date. John G. Wells, O.D. (Retired) 619-435-1350 (02/21)
Monarch School Screening
Lion’s Optometric Vision Clinic
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.
The LOVC has Reopened!!
Please call or email the clinic if you are interested in volunteering:
Alterations to the schedule to accommodate social distancing are in place and PPE will be provided for all volunteers/staff/patients.
New flooring was installed with the donation from the SDCOS 2019 golf tournament and a special thanks to Dr. Phil Smith!
Please think of the LOVC for your end of year charitable giving, visit our website: lionsvisionclinic.org
Please 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
- Click here for most recent SDCOS Board Meeting Minutes
- Click here for the 2021 CE schedule!
- Click here for COA membership benefits!
Robert Lee Evans
September 3, 1937 – October 25, 2020
Bob had a very full 83 years, and had been convalescing from a procedure when he developed acute pneumonia. He passed away peacefully with his wife and daughter by his side. Known as Robert, Bob, Bobby, and Dr. Evans, he was a man of tremendous dedication and exceptional work ethic in service to others. Born in Carroll, Nebraska, the family then moved to Neligh where he worked on the family farm and grew up alongside his older brother Bill and cousin Dean. Known to many in his hometown as Bobby, he graduated high school at 16 years old and went to work for Contois Motor Company. At 22, he enlisted in the US Army and was stationed at Camp Roberts, CA. After the service, he attended Wayne State College in NE, CSU Long Beach, and then graduate school at the Los Angeles College of Optometry (class of 1967), where he met the love of his life, and only female co-ed in the 1966 graduating class, Marilyn Carter. They were married August 10, 1968, and the newlyweds settled in San Diego and made their permanent home in Bonita. Dr. Evans practiced optometry 53 years, and 47 years in the same location on Oxford Street in Chula Vista. Dr. Evans was an early provider of vision therapy and his practice was one of only a few in the county back in the 1970s offering this treatment. He and his wife Marilyn traded offices on Wednesdays so he also became a sought-after provider in El Cajon and East County as well. Together they cared for generations of families as patients, and many of the staff remaining have been with the practice 20, 30 and over 40 years to date. He was an active volunteer and a member of many community service and professional organizations including the Jaycees, the Optimist Club, the Bonita Sunrise Rotary, San Diego Optometric Society, Chula Vista Elks Club, and the Lions Vision Clinic. He and Marilyn have been members of the First United Methodist Church of Chula Vista since 1968.Bob and Marilyn were fortunate to travel to many international destinations, including Antarctica, Kenya, Machu Picchu, Russia, China and India. They loved domestic travel as well, and made dozens of visits to see family and friends in Nebraska, and favorite spots San Francisco and Estes Park were repeat destinations for many years. Robert is survived by his wife of 53 years, Marilyn Carter Evans, his daughter, Carole DeJonge, and grandsons Curren and Blake of Encinitas. He was preceded in death by his parents, Johanna and William Evans, his brother William Evans of Florida, and his only son, Robert Carter Evans. Since we cannot have the Celebration of Life that we would have normally had in a different year, we are postponing services at this time. In lieu of flowers, please consider a donation to Scripps Hospital http://donate.scripps.org/giving/scrippshealth or The Lions Club Optometric Institute http://lionsvisionclinic.org/donate/
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