The San Diego View
THE MISSION OF SDCOS IS TO SERVE THE PUBLIC AND ITS MEMBERS
THROUGH EXCELLENCE IN COMMUNITY SERVICE, EDUCATION, AND LEADERSHIP.
Happenings of the Society
We are San Diego Strong!
This month the California Optometric Association will be holding its annual House of Delegates in San Francisco. San Diego will be sending 14 delegates to represent our society.
The COA’s current priorities are the following:
- Scope of practice expansion
- Increasing Medi-Cal reimbursement rates
- PIA reform with OD choice outside of the PIA for Medi-Cal eyeglasses
- Waive licensing fees for all active-duty ODs.
As a legislated profession, we must stay alert and informed. Membership in the COA assures that we have people looking out for Optometry’s best interests. I’ll provide an update from the House of Delegates in next month’s newsletter.
I’m looking forward to seeing everyone at 2023’s first in-person CE on February 16th. Space is filling up quickly so be sure to register.
OD Relations Liaison
Please contact Dr. Melanie Langford, Society Optometrist Relations Liaison at firstname.lastname@example.org 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.
- Monarch School screening www.monarchschools.org
Looking for 1 OD to volunteer on March 2nd at the Monarch School from 8:45 am-2:15 pm
AMSA health fair
- Saturday 15 April 09:30 AM - 2:30 PM
Montgomery-Waller Park, National City
Welcome New Members
- Dr. Jay Mashouf
Meet a Member
Steven Giang, O.D.
What optometry school did you attend? Midwestern in AZ
When did you graduate/how many years have you been in practice?
2019, practicing for 3.5 years
What is your specialty?
Specialty contact lenses
What do you like to do for fun?
I love deep-sea fishing and joining Muay Thai
Favorite thing to do in SD:
deep -sea fishing
What is something people don't know about you:
My favorite food is Uni
Pearls of Wisdom from an OD
Stephen Chinn, O.D.
To my new San Diego County Optometric Society Colleagues,
Continue to educate yourself in all aspects of our profession. As eye care providers, it is crucial we stay on top of new clinical research, utilize new technology and tools to help us diagnose, treat and manage our patients. You have all the best knowledge now, but the worlds of technology, science and healthcare will continue to grow around you as you establish yourself in your career. Don't ever forget that being an eye care provider is about being a life-long learner, and it's for the sake of your patients.
Where do you work?
NVision Eye Centers-Alvarado Eye/NVision, One to One LASIK/NVision, San Diego Eye & Laser/NVision, NVision La Jolla, Coronado Eye/ NVision
How many years have you been in the industry?
I have been in ophthalmology for 25+ years in refractive, cataract and retina
What are your favorite activities?
Outside of ophthalmology, I enjoy being a real estate agent (top 10% of premier agents on Zillow & Trulia)
Gardening, cooking, traveling, spending time with family & friends
What is your favorite quote?
Don't worry, be happy!
and Corinthians 13:4-8
The State of Refractive Surgery in 2023
By Mihir Parikh MD (NVision La Jolla)
I say this every year: I love being a refractive surgeon because it just keeps on getting better and better. Refractive surgery yields the best outcomes when you can access all technologies available in the market with an experienced surgical team. In 1999 after I completed my anterior segment/refractive surgery fellowship, the surgical toolbox consisted of PRK, LASIK, INTACS, and a few monofocal intraocular lens implants. Accommodative lens implants and posterior chamber implantable collamer lenses (ICLs) were only available outside the United States.
Twenty-four years later, we have an amazing array of surgical options now available to customize patient outcomes. Topography guided LASIK or PRK (off label FDA) easily produces the most consistent outcomes on corneas with an optimized ocular surface. Precise, reproducible mapping plus skilled refraction with careful surgical execution are the necessary ingredients to deliver repetitively outstanding results. According to 2022 Q2 Market Scope US Refractive Survey Report, only 2% of excimer laser surgeries performed are topography guided, which is a testament to the level of difficulty to consistently use this technique. High volume locations are unable to efficiently allocate the staff resources and time commitment. Lower volume locations only have the most basic equipment to perform the surgery otherwise the business model would not remain financially viable. At NVision, 85% of our LASIK cases are Topography Guided using the Phorcides software and the enhancement rate in this surgical population is just under 2%.
The EVO Implantable Collamer Lens (ICL) was FDA approved in April 2022. High myopia with or without astigmatism can now be corrected bilaterally in less than 20 minutes without laser iridotomies and minimal risk of developing cataracts and glaucoma. Patients return to work in 48 hours (about 2 days) with clear vision. It's amazing how a simple “hole in the lens” can transform a company (STAAR Surgical) and provide previously difficult to treat patients access to refractive surgery. Expect a strong media blitz by STAAR Surgical in 2023 and thus patients inquiring about the technology in your exam lanes. The extended depth of focus (EDOF) presbyopia correcting ICL also made by STAAR Surgical is now available in Europe and means the ICL buzz is just beginning. Market Scope 2023 is predicting ICL surgery to be one of the biggest refractive surgery market expanders in the next 5 years.
For hyperopes or patients with dysfunctional lenses and cataracts at any stage, there is a robust set of lens options. Trifocals and EDOF intraocular lens implants are growing in popularity but still only represent 6% of the total implants used. “Super monofocals” are monofocal lenses without add on charge to the patient but offer distance and mid-range vision spectacle free and are surging in use. For the patient who wants the best quality of vision and reasonable range without correction, the light adjustable lens implant by Rx Sight allows detailed customization and the highest overall patient satisfaction. So if a patient wants to lose their dependence on glasses for social activities and most work activities, the technology is certainly available and just requires careful conversations to choose the best lens for each situation.
In a survey published in Q2 2022 Market Scope, the top two reasons patients opt for refractive surgery are because they have an active lifestyle and dislike the way they look in spectacles. Cost and fear will always be limiting factors but as the past 2 years of data shows, patients are casting these issues aside and moving forward. Covid has changed the world and today's patients are looking to seize the day...without their glasses. Refractive surgery delivers on this goal now better than ever and will continue to evolve.
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 email@example.com (02/23).
Build Ownership in a Growing Optometry Practice, Even as a New Grad. Growing Practice at the Heart of San Diego with a 25+ Year Veteran of the Optometry Profession, with a successful history of growing multiple practices, is seeking a motivated, self-starter, entrepreneurial optometrist to join a growing optometry practice in City Heights. Practice is in a custom modern office setting, with great visibility, and with a proven track record of success for medical practices. Working knowledge of Spanish is preferred. Opportunity to get involved (even as a New Grad) in a growing eye care practice from the ground up, earning equity toward part or full ownership. Please email your resume to firstname.lastname@example.org (02/23).
Topcon Maestro OCT-1 Pre-owned. VERY gently (as in barely) used with Image 6 software. Was at a satellite clinic and is in perfect condition! $29,000 obo. Please contact email@example.com or (858)208-3816. (03/23).
Private Practice is seeking a friendly Associate Optometrist for a full-time opportunity! We offer competitive pay, bonus opportunities, and benefits. Work alongside a friendly, knowledgeable support team utilizing the latest digital technology. The ideal candidate will demonstrate leadership, communication, and compassion for patient care. Send resume to MichelleKingOD@gmail.com (03/23)
Fill-in Optometrist needed: looking for casual fill-in weekday coverage at a sublease in National City. $550 per Diem. 10:15 am 6:00 pm with one hour lunch. Modern office with digital refraction, EHR, optos, and pretesters. Please contact Dena at 651-808-0247 or firstname.lastname@example.org (02/23).
Looking to hire an associate optometrist to work 2-4 days a week in a moderately busy Target Optical. The doctor will have tech support for pretesting and checking out patients. Competitive base pay with bonus incentives. Please email Alizadeh.email@example.com if interested (02/23).
Grand Vision Optometry (independent family private practice in North County San Diego) with 2 locations in San Marcos is looking for a Part-Time Associate OD for Fridays (8:30 am – 5:00 pm) and Saturdays (8:00 am – 3:00 pm). $500-$525/day base pay with a production bonus of up to $625/day. Exam appts are booked every 30 minutes, an optical technician will pre-test and pre-chart for the doctor. Please email firstname.lastname@example.org with your resume to apply. (02/23).
Poway Costco seeking permanent part-time for Mondays and Saturdays. Hours are 10-6 pm on Mondays with 1 hr. lunch and 9:30-4:30 pm on Saturdays with 30 min lunch. Staff does all pretesting. 525 per Diem rate. If interested please email email@example.com (02/23).
Part-time OD wanted: Consistent Saturday coverage for a busy private practice. Easy, young patient demographic. Competitive pay plus bonus pay. Please email: firstname.lastname@example.org Contact: Dr. Steven Thurston (02/23).
Optometrist needed for Mondays, Thursdays, and Saturdays at the Mission Valley Costco. If interested please contact email@example.com or text 619.977.7703 (02/23).
Revenue $800,000. This opportunity includes two practices co-located in one location. Huge potential with more efficient operation under one owner. Recently relocated to terrific buildout in a new location next to the hospital; 4 lanes in 2200 square feet. Long-term employees include a bilingual optician. Photos available. Offered at only $295,000 plus sellable goods inventory estimated at $100,000. Seller financing may be available. Contact info@PracticeConsultants.com (04/23).
Goodbye, Thank you, and Retina Summary
By Nikolas J.S. London, MD FACS and Michael J Ammar, MD
Retina Consultants San Diego
Dear SDCOS Members,
We regret to inform you that after 10 years this will be the final Retina Corner for the SDCOS Newsletter. We have thoroughly enjoyed the collaboration and hope that our articles have, in some way or another, benefitted you and your patients. Retina is an interesting field where we take a very deep dive into a very small intellectual space. As retina specialists we are extremely lucky to have witnessed remarkable advances over the past few decades, with even more exciting discoveries on the horizon that we can’t wait to share with you. To be able to pass these advances on to our patients and fight alongside them to preserve, enhance, and even restore vision is a huge honor. Given that this is our final article here, we thought it might be best to wrap things up in a rapid-fire format. Despite the potential intellectual complexities of our field, in the end we often describe ourselves as just “simple retina specialists” and often boil down pathology and patient care concepts to the bare minimum. So here we go:
Dry AMD: Very common to see mild changes in our patients over 60 or so. Most do not require treatment other than recommending a healthy (Mediterranean) diet, active lifestyle, avoiding smoking, and routine home and MD/OD monitoring. Patients with Intermediate AMD have a higher risk of progression to advanced AMD (GA and/or nAMD), and should take an AREDS2 supplement with tighter adherence to all recommendations.
Geographic Atrophy: One of the advanced forms of AMD where the RPE becomes dysfunctional and eventually dies. More common in our older patients, 80-90+, and more common that you may realize. Circular areas of macular atrophy develop and grow at an average of 2mmsq per year. Visual function is greatly affected in all stages, and visual acuity significantly declines with foveal involvement. GA is best monitored with fundus autofluorescence and OCT. We are on the brink of our first treatment option to slow the growth of GA, something many patients are desperate for. Please look out for GA and consider a referral to your retina doc.
Wet AMD: Previously devastating to vision, and now extremely treatable with anti-VEGF injections as long as it is caught early before bleeding and fibrosis develops. Patients tend to do well with treatment every 1-3 months on average. Injections are extremely safe and should be essentially painless with proper technique. We have very exciting treatment options on the horizon in clinical trials (currently enrolling, feel free to ask), including long-acting injections that should control the disease for 6 months or longer, as well as gene therapy, which transforms the eye into an anti-VEGF manufacturing plan, potentially a cure for some patients.
Intravitreal Injections: Speaking of nAMD and intravitreal injection technique, this has evolved over the past 15 years. Initially docs applied betadine to the eye and surrounding skin, and always used a lid speculum. This was very uncomfortable with lingering pain for hours. Now, at least at RCSD, we use aggressive topical and subconjunctival anesthesia, only minimal betadine, and have access to chlorhexidine for very sensitive patients. We also often do not use a lid speculum, and prescribe topical anti-inflammatory drops for patients post-injection discomfort. Patients do quite well, and often comment on our technique.
Vitreous Opacities: Lots of talk about symptomatic vitreous haze and floaters these days. There are few options for patients: observation, laser (yag) vitreolysis, vitrectomy, and recently a nutritional supplement. Of these most retina docs do not endorse laser or supplements due to cost and limited efficacy. Vitrectomy for select (preferably pseudophakic) patients is extremely safe and effective with very impressive results including improvement in contrast, color saturation, and clarity. These are our happiest patients, and the days of telling patients that they need to simply live with massive floaters are long gone.
Macular Hole: Another condition that once had no treatment options that is now repairable in 99% of cases. The key to diagnosis is OCT, looking for a full-thickness defect (all the way to the RPE). Not an emergency as repair is highly successful even months out, but I’d get them to your retina specialist soon to plan surgery. Vitrectomy is performed in most cases, with a gas bubble. Positioning after surgery is controversial, but there is convincing evidence that face down positioning is NOT necessary, and we at RCSD very seldom require it, much to the relief of our patients.
Epiretinal Membrane: An extremely common finding of a hyper-reflective layer on the inner macula on OCT and cellophane-like macular appearance on exam. Macular distortion and thickening correlates well with symptoms, and vitrectomy is indicated for symptomatic patients, particularly with a VA deficit. The surgery is not urgent, is again extremely safe and effective, and, to be honest, pretty fun to perform. Most patients do well after surgery, with a slow recovery in symptoms.
Diabetic Retinopathy: Over the course of many years, most patients with diabetes are bound to develop damage to the retinal vascular network, including pericyte loss, vascular leakage, microaneurysm formation, and, when these rupture, intraretinal hemorrhages. Some patients progress to closure of segments of the of vascular tree with secondary tissue ischemia. Consequences of this include macular edema and neovascularization. VEGF is a major driver of this process and fortunately anti-VEGF injections have a profound effect on regressing diabetic retinopathy and macular edema. This is also an exciting area of research, with long-acting medications and gene therapy being explored in clinical trials. Feel free to contact us for more information or possible candidates.
Retinal Tears and Detachment: Peripheral retinal pathology can be anxiety-provoking both for patients and eye doctors. Retinal tears typically develop secondary to vitreous separation in the far periphery. In older patients with a liquified vitreous these are fairly urgent situations with laser barricade indicated the same day in most cases, however many tears will not progress quickly and younger, asymptomatic patients can be treated on a less urgent basis. The risk of an untreated tear is progression to a retinal detachment, where liquid vitreous enters the subretinal space. RDs often require more than just laser, but we can nearly always repair them. Good options include in-office pneumatic retinopexy, as pioneered by our practice in the 1990s, vitrectomy, and scleral buckling. On the other hand, asymptomatic retinal holes in a patient without risk factors such as RD history in them or a family member, symptoms of traction, early subretinal fluid, or systemic disease associated with RD, can usually be observed.
Retinal Vein Occlusion: In many cases RVOs develop macular edema, which can nearly always be successfully treated with anti-VEGF injections. Unlike nAMD, patients eventually should be weaned off treatment.
Patient Communication: Retinal pathology can be extremely anxiety-provoking for patients, and it is very important that us retina docs to communicate clearly, kindly, and thoroughly with them. I love to use multimodal imaging on large monitors to review exactly what is going on with patients. I strongly believe that when they understand their pathology they can be a more active participant in the treatment plan. Patients and their caregivers appear to really appreciate these explanations as well. I think you guys probably do a better job of this than most OMDs, so keep up the good work and I’d encourage you to ask your patients if things are being communicated well to them by their retina docs – if not, please let us know!
With that, I wanted to thank you all for reading our little articles over the years. We will certainly miss contributing to the SDCOS, but definitely understand the decision. We are actually in the process of developing our own Retina newsletter with educational content, meeting summaries, and interesting cases. You may see an email from us regarding this soon, and feel free to let me know if you are interested in receiving it. We are also in the process of planning a Retina Update meeting for the late summer or fall. More details to come soon!
Thanks everyone – please all keep in touch and never hesitate to call or us at any time. My cell number is 415-341-5456 and Mike Ammar’s is 480-323-9196. We are always happy to help with any patient as best we can.
Nik and Mike