The San Diego View

Inside this Issue:

• President’s Message
• Retina Corner
• Eye See
• CE Corner
• Classifieds
• Volunteer Corner
• SDCOS Announcements

President’s Message April 2022

By Simona Grosu

April has traditionally been that time of the year that we, as an organization, gather at the Capitol in Sacramento to discuss with our local lawmakers the bills we are working on for the year. And we are finally ready again to meet in person with our lawmakers, this time on June 27th! Previously thought it will be virtual once again, we are finally back in person. And we need your support more than ever as this is also an election year, and also, as I learned recently at the most recent Presidents’ council meeting, an unusual high number of influential lawmakers are leaving the Capitol this year, either because they are retiring, or running for higher office. Therefore, we need to be there in great numbers to put the face to our profession, and either strengthen or build new relationships with lawmakers. We don’t think often about this, but legislation has always been an important part of how we, as optometrists, are able to practice to the full scope of our training while increasing access to patients who benefit from our clinical expertise.

As with previous years, COA has put together an agenda outlining which bills it supports and how we, as primary eye care providers, can engage with our local legislators.

Here is a summary:

Scope of practice expansion (AB 2236) – For more than 20 years, patients in other states can go to their local optometrist to get the latest glaucoma treatment using lasers and remove small non-cancerous lesions from around the eye. COA is seeking legislation to allow optometrists to perform these procedures in California. We have a shortage of physicians that is getting worse because of the pandemic. A report from the Association of American Medical Colleges (AAMC) projects that the United States will face a shortage of between 54,100 and 139,000 physicians by 2033. At the same time, a higher percentage of people are over the age 65 and will need more eye care. We are extensively trained and can help elevate the doctor shortage if state law restrictions were removed.

Medi-Cal reimbursement rate increase – Medi-Cal reimbursement rates for optometric services have not been increased in over 20 years. In addition to the impact of inflation, optometrists have experienced increased costs because of the pandemic. As much as they want to, many optometrists can’t continue to accept Medi-Cal patients when reimbursement is far below the cost of providing care. Even though we live in a state with some of the highest overhead costs, California has the third worst Medicaid reimbursement rate for eye exams in the nation. The Medi-Cal reimbursement for a new patient exam and refraction is $47 where the national Medicaid average is $105. The average cost of an eye exam for a new patient with no insurance in California today is about $200. That is a significant difference that can’t be made up in volume.

PIA Eyeglasses (SB 1089) – The Prison Industry Authority (PIA) which fabricates eyeglasses for Medi-Cal recipients has had pandemic related closures at its prison facilities. As a result, an already significant turn-around wait time of 4-6 weeks has been more than doubled in some areas. The requirement to use the PIA to obtain eyeglasses is causing optometrists to stop accepting Medi-Cal because of the hassle involved. Poor children deserve timely, quality eyeglasses that are consistent with community durability standards. This new legislation would give patients an option to get their eyeglasses outside the PIA system.

Waiver of licensure fees for military personnel (SB 1237) – SB 1588 (Atkins) was signed into law in 2012 to require state licensure boards to waive the renewal fees, continuing education requirements, and other renewal requirements of any licensee who is called to active duty as a member of the US Armed Forces. The fee waiver has been interpreted by the Department of Consumer Affairs (DCA) to apply only if the licensee has had a “temporary” change in assignment to a remote location. DCA has ruled that “military personnel that have orders to serve in a permanent, career position at a base are not ‘called to active duty’ within the meaning of the exemption in AB 1588.” The COA is sponsoring SB 1237 (Newman) to waive the license renewal fee for any active-duty military licensee who is stationed outside of California, not just someone who was “called to active duty.” It’s unfair to require someone in the military to pay for a license that they must maintain, but can’t currently use. While fees are waived, no private practice of any type would be permitted. This bill would save optometry service members that are permanently stationed outside of California $425 every two years in renewal fees. We need to make sure our optometry military service members are not paying for a license they can’t use!

Temporary License Expansion (SB 509) – SB 509 (Wilk) was an urgency bill that was signed into law in 2021 to create a “temporary license” that allows an optometry school graduate to practice under the supervision of an optometrist or ophthalmologist if the graduate is unable to immediately take the required examination for licensure due to COVID-19. This new legislation would expand SB 509 to other declared state of emergencies beyond the COVID-19 pandemic. The intent is to allow a pathway to licensure in case of a future disasters that could cause the closure of the only testing site in Charlotte, North Carolina. SB 509 had no opposition and passed without any “no” votes.

Please consider joining us for Legislative Day, even if it is your first time! Every doctor makes us stronger! COA will walk you through all critical legislation beforehand. We will cover your travel costs for this day trip to the capitol. If you feel intimidated by the idea of discussing legislation with your local lawmakers in person, you can help via email. COA has on their website letters for each bill, ready to be personalized and sent out. Just log in to www.coavision.org, and follow the links under Government Affairs > Contact Your Legislator.

Ready to win one for optometry? Feel free to contact me at dr.simona@yahoo.com to learn how, and become a key to COA’s ongoing legislative success!

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Retina Corner Interesting Macular Lesion in a Healthy Young Man

By Nikolas J.S. London, MD FACS
President and Director of Research, Retina Consultants San Diego
Chief of Ophthalmology, Scripps Memorial Hospital La Jolla

Dear SDCOS Readers – I hope that everyone is well and enjoying Spring!

Every now and then you see an interesting case that makes you pause and marvel at the beauty of our field. Retinal pathology can be truly fascinating, and our deductive tools to uncover the nature of that pathology are extremely powerful. Take for example a case recently sent to me by Dr. Elaine Limpiado: A 29 year-old healthy man who works in law enforcement, who presented to Dr. Limpiado with a 1-year history of abnormal central vision OS. According to the patient, he was participating in a training exercise which involved bright lights, and noted altered color vision in his left eye shortly thereafter.

On our exam, he was 20/20 OU with normal IOP and no pupillary defect. His medical history included only seasonal allergies, for which he used daily flonase. He denied any use of recreational drugs. His anterior segment exam was entirely unremarkable. His fundus exam was unremarkable OD, and was significant for a 2×2 disc area of flat hypopigmentation involving the left macula (figure). Optical Coherence Tomography revealed subtle RPE elevation in the area of the lesion, with an atypically uniform sub-RPE hyper-reflective appearance throughout most of the lesion, with a central hypo-reflective space (figure, C). Fluorescein angiography revealed late staining of the lesion with no evidence of leakage (figure, B).

The differential diagnosis in this case is broad, but the vast majority of similar cases would most likely be resolved Central Serous Chorioretinopathy – the patient fits the demographics perfectly, and the fundus appearance of mild hypopigmentation is what one would expect. On the other hand, however the RPE does not appear atrophic on OCT, and the RPE elevation would be atypical. In fact, it was this subtle elevation that suggested to me that this was not an atrophic lesion, but a mass.

Time for a question: Based on this presentation and initial findings, what would the most useful next test be?

1. Fundus autofluorescence
2. Electroretinography
3. Genetic testing
4. B-scan ultrasonography

All of the above are good options, and likely to be informative. FAF is routinely used in our practice, and primarily reveals the health of the RPE and/or lipofuscin accumulation. In this case FAF would be important to rule out RPE atrophy as a cause of the lesion and would also help to rule out metabolically-active lesion, such as choroidal melanoma. For our patient, however, FAF revealed neither of these. ERG and genetic testing might be helpful to look for hereditary macular dystrophy, but would be less useful for our patient given the other findings making a dystrophy less likely. In this case the answer is D, which is not shown, but revealed a flat, highly-reflective suggestive of calcification, and a diagnosis of choroidal osteoma.

Choroidal osteoma is a rare benign choroidal tumor described by Don Gass in 1978. As the tumor develops, choroidal tissue is replaced by mature, cancellous bone. The typical patient is a young healthy woman in her teens or twenties, and the lesions are unilateral in 70% to 80% of patients. Symptoms can be vague, minimal, or entirely absent, and 80% of patients present with 20/30 or better visual acuity. The lesions are often noted on routine examination, with observation of a yellow, white, or orange peripapillary and/or macular lesion. Varigated coloration may be present in cases with partial decalcification. About half of all lesions will enlarge at a rate of 0.37 mm/year. Tumors may also undergo spontaneous decalcification at about 10% every 2 to 5 years until complete due to osteoclast activity and phagocytosis by inflammatory cells. Decalcificaiton halts tumor growth in that area, but is associated with overlying photoreceptor damage and vision loss. Vision loss is also seen in cases complicated by CNVM formation.

On OCT, the inner retinal layers are nearly always preserved with potential attenuation of outer retinal layers, particular in cases associated with decalcification. Shields and associates described intact photoreceptor layers overlying calcified lesions, with disruption overlying areas of decalcification. Subretinal fluid or a neurosensory retinal detachment may be present overlying the tumor. The lesions themselves are commonly highly reflective with dense shadowing except in areas of decalcification. Enhanced-depth imaging may reveal multiple intralesional layers, intralesional blood vessels, and/or a sponge-like appearance.

While our preliminary diagnosis is not definitive, we do believe this is an atypical case of choroidal osteoma in a young man. We will follow him to verify the diagnosis, as well as to watch for choroidal neovascular membrane formation and/or decalcification. If anything interesting develops, we will be sure to let you know.

Well, that’s our article for this month. Thanks so much for reading. Please don’t hesitate to contact me with any questions.

Best wishes, and until next time,
Nik

Nikolas London, MD, FACS
Retina Consultants San Diego
415-341-5456 (cell)
london@rcsd.com
www.rcsd.com

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Eye See written by Dr. Byron Y. Newman

The history of optometry as “Spec Peddlers” does not have the flair that the profession of dentistry in the middle ages has had in the role of “tooth pullers.”

A clever short history of dentistry was written by four historians of medicine and published a few years ago in the American Journal of Public Health.

The days when toothaches were treated with leeches and laxatives as well as prescriptions of lizard liver, green frog and urine gargle were reviewed from the middle ages through the early 19th century. In those days tooth pulling was often a performance art.

It seems that when refined sugar became widely available in the 17th century dental caries became more common. For different sufferers itinerant tooth pullers set up shop in market places and fairs. The ‘dentist’ and his assistants attracted a crowd by telling stories, singing and dancing, performing tricks and juggling. The ‘tooth puller’s’ assistant was usually dressed as a clown or a harlequin with a pointed hat on which was inscribed the insignia of St. Apollonia, the patron saint of toothache sufferers.

In elaborate cases the ‘tooth puller’ had a stage as well as two assistants. The music they provided attracted the crowd and also helped drown out the cries of the clients.  The tooth extraction was an essential part of the entertainment, and, as the article pointed out, the public setting provided considerable drama and let the gathering crowd judge the skill of the “dentist” If he was smooth enough and could extract teeth without causing too much pain, others might volunteer as patients.

Just as a reminder, the patron saint of eyesight is St. Lucy or Santa Lucia of which there are paintings and songs.

Check out Dr. Newman’s website, www.thehumorfactory.com!!!

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CE Corner We are committed to helping you fulfill your CE requirements through our local virtual meetings with the support of our sponsors!

Featured Annual Sponsors

2-hour CE Thursday, April 21, 2022

****IN-PERSON MEETING in a NEW LOCATION!!!!!*****

Hilton Mission Valley San Diego
901 Camino del Rio S
San Diego, CA 92108
bit.ly/HiltonMissionValley

Speaker: Dr. Melissa Barnett.

Topics:

Breaking News! Presbyopia Updates. This lecture will focus on the impact and burden of inadequately treated presbyopia, the role of corrective lenses and surgical procedures for the treatment of presbyopia, and the classification of presbyopia. Newly emerging presbyopia-correcting drops, their mechanisms of action, and clinical evidence will be emphasized.

The Art and Science of Dry Eye and Contact Lens Wear. Contact lens wear and ocular surface disease are often seen concomitantly. This course explores dry eye prevention, etiologies, diagnosis, clinical findings, and the latest management techniques for contact lens-induced dry eye. Novel management therapies and clinical examples will be illustrated. 

Pricing:
SDCOS Members: FREE
Students: FREE
Sponsors: FREE
COA/AOA Members: $35
Non-Members: $130

• See 2022 CE schedule

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Classifieds

CLASSIFIED ADVERTISEMENTS

Multi-location private practice is hiring a full-time Optometrist. Highly trained staff provide full work-up, latest digital technology, friendly team culture, benefits, competitive pay. Send resume to MichelleKingOD@gmail.com (05/22).

OPTOMETRY PRACTICE FOR SALE: Coastal San Diego County This modern practice has been established for just over 5 years and is located in an affluent area of coastal San Diego County.  Situated on a busy main street in town in a mixed-use commercial/residential building on the ground level with high visibility, the practice is beautifully designed and truly turnkey. Purchase includes 2 exam rooms, pre-test area, spacious dispensary, lab, frame inventory, and EMR.  Revenue in 2021 was almost $400K on part-time doctor hours. Plenty of room for growth/expansion.  Seller is motivated and willing to assist in the transition.  Please contact Allison Robles at Practice Concepts at 714-797-1605 or email allison@practiceconcepts.com for more info. (ID#76720) (04/22).

Practice for sale: Long-time established practice for sale in La Mesa–seller wishes to retire–Seller has set a very low purchase price to facilitate an immediate sale—don’t miss out on this great opportunity to own your own practice.  Contact Dr. Levy at 619-743-1442 or email at drlevy@pacbell.net (04/22).

Equipment for sale: Nidek’ Autorefractor, Reichert 7 Auto Tonometer, Lombart VA monitor. All in good working condition. Make an offer for one or all. Please call 858 245 9143 leave a message. I will return the call. (05/22).

 

Please contact Dr. Dave Sherman, Society Optometrist Relations Liaison at odjobs@sdcos.org or 760-208-3456 to be put on an official list for the following:

• fill-in/part-time work
• full-time work
• purchase/partner in/sell a practice

This service is offered free of charge to SDCOS members.

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Volunteer Corner

Monarch School Screening

After a pandemic-influenced delay of over two years, SDCOS again partnered with VSP to bring eye exams and free eyewear to the Monarch School for students experiencing homelessness. After the vision screening in February identified 33 students needing further testing, the VSP Mobile Clinic drove south from Sacramento to provide the vehicle for exams on 15-16 March. It contains a complete eye lane as well as an autorefractor, fabrication equipment, and a selection of hundreds of frames for the students.

Dr. Bob Meisel, the program coordinator since 2013, was assisted by Drs. Simona Grosu and Joyce Medina and they were able to see 45 patients, as several new students had enrolled since the screening and a few were absent in February but were identified as needing an exam and new eyewear. Included in the students were two who had undiagnosed hyperopia of +8.00 and another with a +4.00 previously unidentified refractive error. Needless to say, they will be experiencing a different visual world once they receive their eyewear. Most of the Rxs were fabricated the same day as the exams, but higher prescriptions will be made at the VSP lab and sent to the school.

Dr. Byron Newman started the SDCOS involvement with Monarch in 2009, with semi-annual vision screenings for all students with several society volunteers. Each semester, SDCOS volunteers administer a one-day screening of all students and several weeks later, two days are allotted for eye exams at the school. The fall events will take place on Monday 3 October and on Tuesday 24 – Wednesday 25 October

YouTube: Students who are unhoused get a gleam of hope in their eyes

NBC 7 San Diego – Eyes of Hope: Nonprofit Has Outfitted Thousands of Kids With Free Glasses

Please contact Dr. Meisel at rmeisel47@gmail.com to volunteer and help make a difference in a student’s life!

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www.monarchschools.org

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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:

• 619.298.5273
• lionsvisionclinic@gmail.com

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

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DONATE GLASSES
Please contact the society office at 619-663-8439.

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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 sdcos@sdcos.org

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SDCOS Announcements

For updated information and resources regarding COVID in San Diego, please register using this link. This will sign you up to receive weekly emails from the San Diego Health and Human Services Agency, including weekly tele-briefings on everything COVID.

• Click here for most recent SDCOS Board Meeting Minutes
• Click here for the 2022 CE schedule!
• Click here for COA membership benefits!

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Please update your information on www.eyehelp.org