Month: January 2021

Optometry in Focus: Dry Eye

Happy Saturday… Monday…Tuesday, y’all!
So, full disclaimer – I wrote this post on Saturday, only to be too tired to post it after a long day of traveling. When I finally looked at my blog on Sunday (since some of the content of my post felt familiar), I realized that I had already posted something dry eye related several months ago, in the form of a discussion on Computer Vision Syndrome.
Oops!
But, who wants to let an hour or so of blogging go to waste?
Certainly not I!
Besides, considering the prevalence of dry eye in society, what harm will another post do?
Okay… now back to the post!
Today’s blogging challenge?
Coming up with a topic that I don’t need wifi to complete.  #inflightprobs
Thinking of flying though, I guess there’s no better time than now to discuss a common flight (and winter) problem:  dry eye.
So, before we can really jump into what dry eye is, let’s go over a quick ocular anatomy review!
Anatomy
 
First things first: the cornea.
    The cornea is the clear, front surface of the eye, that is responsible for a significant portion of your vision.  If this surface becomes hazy, clouded, swollen, or irregularly patterned, it causes significant distortions to vision.
    Around the cornea is the limbus – a special transition zone, where the cells responsible for corneal formation reside.
    After the limbus, we arrive at the conjunctiva.  The conjunctiva (or conj for short) is actually another thin, clear layer, that covers the rest of the front surface of the eye (the bulbar conj) and the inside of the eyelids (the palpebral conj).
    All of these anterior (or front) surfaces are bathed by tears to remain healthy and clear.
Great, we’re done now, right?
Not so fast.
Let’s take a little bit of a deeper look at the tears themselves.
Tears are, believe it or not, comprised of three layers – the mucin, or protein layer that allows the tears to remain on the front surface of the eye, the aqueous, or watery part of the tears that, well, helps them maintain the proper moisture content of the front surface of the eye, and finally, the outer lipid, or fatty layer.
These three layers work together to protect and nourish the front surface of the eye, by providing oxygen and nutrients, carrying vital immune cells, and washing away debris.
Okay, now onto dry eye!
 
Dry Eye
 

So, first things first, dry eye is an inflammatory condition affecting the anterior (front) surface of the eye. 

Dry eye, as everything else in life and optometry, comes in a couple of different forms:

  • Aqueous deficient – not enough (quality) tears are produced 
  • Evaporative – there’s not enough lipid, or fatty, component in the tears, causing them to evaporate more quickly, leaving the anterior segment dry and irritated.
These two types of dry eye, naturally, have different causes.
Aqueous deficient dry eye, as a problem with production, may be associated with age to corneal nerves, dysfunction of the lacrimal (or tear producing gland), or simply a natural age associated decrease.

Evaporative dry eye, on the other hand, is caused by improper lipid formation.  This is often due to a disease called Meibomian Gland Dysfunction, or MGD for short.

Who Has Dry Eye?
If I’m honest, literally anyone can suffer from dry eye.
Dry eye, as I’ve mentioned before, can be significantly exacerbated by external forces, such as a dry environment (ie an airplane or the desert), fans, heat, or air conditioning.
Additionally, dry eye may be worsened by excessive screen time, as screen time is proven to significantly decrease blink rate, and therefore tear distributions, as well as contact lens overwear.
Finally, dry eye has also been shown to worsen with age, disproportionately impacting post-menopausal women.

Signs and symptoms
While dry eye may affect anyone and everyone, the signs are typically similar in all age ranges of patients.
Generally, patients present with complaints of red, irritated, watery eyes, that often feel like something is in them.
 
They additionally also report variable vision, that seems to improve for a couple of seconds after blinking.
 
Testing
In addition to just physical signs and symptoms, your eye doctor may perform several tests to better understand your specific dry eye.
    Tear Break-Up Time (TBUT): In this, the doctor literally measures (in seconds) how long it takes for your tear layer to start dissipating or breaking up on the front surface of your time. This test is generally short – under 20 seconds total, 10 for each eye.  The lower your score is, the worse dry eye you generally have.
    Tear Meniscus Measurement: This test just involves looking at the amount of tears that lie on your lower eyelid while looking from behind the slit-lamp (big microscope). If it is too low, it is generally a sign that not enough tears are being produced.
    Schirmer’s Test:  Schirmer’s is another test of the amount of tears produced by the eye.  In this, a little piece of paper is put between the eye and the bottom eyelid for a (relatively) short amount of time, to quantitatively measure tear production.  This test has two varieties – one that involves numbing your eye first (decreasing reflex/automatic tearing), and one that… doesn’t.  **Not my favorite test**
    Phenol Red Thread Test: This test is very similar to Schirmer’s, however, instead of a smal piece of paper, a tiny red thread is place in between the eye and the bottom eyelid, to again quantitatively measure tear production.  This test is very quick (around 5 seconds/eye), and much less invasive than Schirmer’s – making it more enjoyable for patients and doctors alike!
    Corneal staining:  In this, a small amount of dye (generally fluorescein or lisasmine green) is placed in each eye, with the goal of highlighting inflammation on the front surface of the eye.  The staining pattern observed may help determine the cause of ocular dryness (exposure, etc).
    Meibomian gland expression: Meibomian gland expression is especially helpful when it comes to diagnosing MGD.  For this, the practitioner gently pushes on the meibomian glands (generally in the lower eyelid) to determine the expressivity and consistency of their lipid product (meibum).  Thicker meibum is generally indicative of MGD.
    Tearfilm osmolarity: Finally, or at least finally for now, some offices have the ability to test tearfilm osmolarity, typically using a device called Tearlab.  (How many of you remember back to Chemistry for what this means?  It’s something with number of particles/amount of water… right?). Higher values are more closely correlated with dry eye.
 
Phew. That was a lot.
 
Okay, so now that we know some of the ways dry eye can be diagnosed… what in the world do you do about it?
 
As a rule, there is a step-wise approach to dry eye treatment, that varies some depending on the original cause, however, I am out of time to write about them for today.  Catch y’all next time!
 
 
If you learned something from this post, please share it with a friend or family member!  If you liked it, please subscribe, or like my page on Facebook! And as always, if you have any questions or comments, please contact me – I’d love to hear from you!
 
If you’re interested in reading my first post, Computer Vision Syndrome: Addressing Dry Eye, click the link to check it out!
 
PS: My apologies for the formatting issues on this post.  I wrote it in Google docs (because, flying…) and then copied it over to blogger.  Lessons for next time…

Hannah Vollmer, OD: Life Update 2021

Happy 2021, y’all!
Wow. It’s been a really long time since I’ve posted in this blog – sorry about that!  It would seem that life has gotten a bit away from me.

With the new year, however, I figure it’s the perfect time to get back to publishing Hannah’s hot takes on all things optometry.  (This phraseology stolen from one of most faithful readers, and up-and-coming OD, JH.  Thank you!)

 
But first, let’s do a quick(ish) life update!
 
Okay, so, the last time I wrote anything about my actual life, I was living in Texas, had just finished residency, and was beginning the lovely process of job searching.
 
*News Flash*
 
I don’t live in Texas anymore!
 
At this point, I have moved back to the Midwest, to work as a mobile optometrist at long-term care facilities and nursing homes.
 
What does this look like?
 
My average day goes something like this:
 
  • I leave between 6:30a and 7:45a to travel to my facility for the day.  My longest drive days are ~2 hours, and my shortest drive days are 30-40 minutes
  • When I arrive, I unpack all of the equipment from my car, take a COVID screening test at the door, and then meet with my facility contact to assess the day’s patient list.
  • My contact takes me to my base for the day (usually a beauty salon, but sometimes just an empty bedroom), where I then unpack all my equipment.
    • Depending on the current facility lock-down status, I will either prepare my room to be a makeshift exam room, or I’ll load everything onto a cart to take around from room to room.
  • Once I’m set up, it’s time to see patients!
    • The optimal set up is when residents are brought to my room for their exams (normally about 20 minutes, including refraction and dilation), but bedside exam days mean lots more steps!
  • Currently, I typically see ~10 residents per day, all with varying levels of physical and cognitive abilities.
    • Exams can be comprehensive, problem-focused checkups, or simple glasses checks to make sure that what was ordered fits the resident’s needs.
  • Once I finish with all the scheduled exams (generally between 12p and 2p), I pack my equipment back up, give written orders for any necessary medications to the nursing staff, and head back home!
  • At home, I finish charting, review my following day’s patient list, and then enjoy the remainder of the day!

Perks of the job:

  • Flexible schedule:  There is no defined time that I have to be at a facility.  I typically aim to get there ~8:30a, that way I can meet with my contact before morning meetings (~9:00a).  Also, it allows me to see most of my patients before lunch (I’ve learned that some of them get very upset when you come between them and food… especially with a Tonopen or dilating drops), and before they fall asleep for an afternoon nap.
  • No defined patient count: I largely get to choose how many residents I see a day.  Most docs with the company see 10-14/day, with some seeing fewer, and others seeing up to 20.
  • Work/life balance:  My typical work day, including driving (sometimes 4 hours), working, and charting, is done by 4.  And, there is no overhead for me to worry about.  So, once my charts are submitted at the end of the day, I’m done. 
  • Incredible EHR:  The Electronic Health Records system that the company uses was designed entirely in house, and by doctors.  It is completely intuitive, allowing for fast, easy charting.  Additionally, any suggestions or complaints are submitted directly to the designers, who quickly implement necessary changes.
    • Oh yeah, and it’s all housed on a system with onboard internet, so wifi connectivity is never a problem.  
  • Fantastic support team: Despite being on my own at each facility, I have 24/7 access to my “provider support team” via email, phone, fax, or HIPAA secure text, that allows me to troubleshoot any problems while on the job. (Or anywhere else for that matter…)
  • Variety:  Since starting optometry school, I have always said that I didn’t think I could survive in a bread and butter optometry practice that primarily focuses on prescribing glasses and contacts. (Maybe this is because I find refraction – which is better 1, or 2 – to be one of the most boring procedures employed in our profession.  While shadowing docs, I have literally started nodding off during it.  Thankfully, I’ve yet to fall asleep while performing the task, but, you get the picture.)  With this job, every patient is a new challenge.  Between bedside exams, trying to get as much information as possible out of a completely non-verbal patient, learning to understand what my aphasic residents are telling me, and Macgyvering a pair of specs to hold until a new pair can come in, all while effectively diagnosing, managing, and treating ocular disease, there is literally never a dull moment.  And I love it.*

Downfalls of the job:

  • Referrals are difficult: In this lovely COVID era, getting residents to see the proper external practitioners has been difficult.  Many residents are in poor health to begin with, and thus, facilities are hesitant to risk their physical well-being for an external appointment.  Unfortunately, this means that I have seen patients who are seeing 20/400 due to mature cataracts that have been unable to be removed for over a year, or patients with retinal bleeding that have been unable to receive treatment for proliferative diabetic retinopathy, therein increasing their risk of significant, permanent vision loss.
  • No scribes or techs:  Admittedly, during optometry school, and even through residency, I dreamed of being in a practice where I had scribes to take care of all the charting, and techs to do most of the work-up.  And here I am with neither.  Thankfully, however, this gives me an opportunity to work on my own optimal exam efficiency.
  • COVID:  Obviously, nursing homes and long-term care facilities have been among the most hard hit by the effects of COVID.  Some days, nearly all of the patients on my schedule have had COVID, and many are still feeling the effects.  Additionally, there is significant concern of me bringing the virus into the facility, or taking it home to my loved ones at night.  As such, I wear enough PPE (personal protective equipment) to literally be sweating in a 60 degree room – which is hard to find in a nursing home.  You can only imagine how it is performing retinoscopy (figuring out a glasses prescription) over a heater in an already 80 degree room.  However, I’m happy to wear it all if it means that I, my patients, and my friends and family are safer! 
  • Long drives: As much as I like driving, some days the 6:30 leave time, hours of darkness, and travel through snowy areas is a lot.  Prayers for safety, alertness, and good conditions appreciated!

 Random tidbits:

  • COVID Vaccine: Being a doctor working with high risk populations, I was among the first to be eligible and subsequently receive the vaccine.  I have only received the first dose so far, but have had minimal side effects – some upper arm soreness, three days with a mild headache (though that may also be attributable to sinus pressure with changing weather conditions), and some mild fatigue (I was less ready to get up before 5 than normal for 1-2 days).  I’ll keep you posted as to how things progress after I receive the second dose!
  • COVID Testing:  Additionally, due to the patient population that I work with, I receive a COVID test a minimum of once per week.  (PS: The nasal swab is much better when you can perform it yourself, rather than having someone else try to swipe up to your brain!)  The biggest downfall with this is delay of results (especially around the holidays), which can become an issue on the first days of the week when my new results have yet to come in.  However, thankfully, many facilities have rapid-testing capabilities to allow me to test on-site before beginning patient care for the day!

 
Annnd I think that about covers it!

Regarding this blog, I’m currently hoping to begin a once a week pattern of posting.  The publishing day will probably be variable, depending on how my week pans out, but stay tuned for more exciting posts from your favorite young OD!
*Side note: I have genuinely been grateful for the additional training that I obtained during residency literally every day that I have been on the job.  I use tips and techniques that I gained during the past year on a daily basis, and could not imagine taking on this position without that experience.  So, if you’re a young OD-to-be on the fence about residency, or know someone who might be, this is my shameless plug for residency.  Just do it.  It may not feel like it at the moment, but residency is 100% worth it.
 
 
If you learned something from this post, please share it with a friend or family member!  If you liked it, please subscribe, or like my page on Facebook! And as always, if you have any questions or comments, please contact me – I’d love to hear from you!