In Contact - April 2008
The fact that last month?s column had nothing to do with contact lenses apparently didn't go unnoticed.
I received a firm reprimand from an expat Kiwi colleague [who tries to pass himself off as a Queenslander!]. He asked where the hell the contact lens content had gone. Had I jumped on the doctometry bandwagon, forsaken contact lenses and embarked on some compliant, PC-journey into optometric oblivion, he wondered?
Fear not my friend, there's still some fire and passion in this columnist?s belly as far as contact lenses go.
As I sit down to write this I come off a hell week chock-full of some of the most complex cases one can wish to see in a lifetime. Never mind a two-day session of non-stop consecutive cases that absorbed my breaks and had me straining at my limits of good natured behaviour. In addition It's the usual crazy March where it seems all and sundry think It's time to pack every day full of launches, meetings with reps as well as nights and weekends of CPD.
Hey guys, It's still summer! Why not move all this stuff into June, a nasty month that's too cold for pleasantries and not yet cold enough for skiing. As far as I'm concerned you?re likely to get a far better commitment if you at least let me enjoy the best of our short, infrequent summers.
Of course those of us that run a business also have to contend with stock taking and the related financial year-end compliance issues. A computer crash didn't add to my pleasure.
Case (Over)Load.
A Thursday in mid-March started with a severe myopic astigmat;
R -13.50/-3.00 x 10 6/12
L -14.00/-3.50 x 172 6/12
She had forsaken RGPs for high Dk disposables in the form of Oasys 8.4/ -12.00D sphere?s with which she remarkably achieves better than 6/12. Although we discussed sphero-cyl over specs she declined as she's happy with the comfort versus acuity balance. The limited Dk of currently available soft torics did not excite either of us. She's on my list for trials when we eventually get hold of the O2 Optix custom torics, rumoured to become reality in late ?08.
Before the chair had cooled I had a +6.00D hyperopic six year old take her place. His hyperopic, monovision wearing grandfather had asked me a few weeks prior if I would see his grandson and look into the possibility of contact lenses. When the time comes, we?ll almost certainly look at a one day modality.
Without much pause for reflection I had a middle aged lady fresh off the plane from the UK take his place. Now did she have some history! In a nutshell she's a former -19.00D myope with congenital cataracts and bilateral pseudophakia. The right has an anterior chamber IOL after her conventional posterior chamber lens popped posteriorly through a perforated capsule after a sneezing fit. It's still bouncing around on her inferior retina. That eye also has IOP around 30mmHg and trabeculectomy. The left has a conventional IOL and some cryotherapy following retinal detachment [RD]. On top off all this she successfully wears multifocal RGPs. She attains 6/7.5 binocularly with legal driving VA or better in both eyes. As expected she had severe peripapillary atrophy, an atrophic hole, pigment changes and signs of her former RD.
On top of this she had symptoms of amaurosis fugax.
I referred her promptly for the additional specialist care she needed.
Take a Breather, Bro.
Before I was allowed a breather, never mind a cup of peppermint tea, I was examining and trial fitting a severe tilted-graft referral that had driven up from Napier. A fifty-something keratoconic with bilateral penetrating keratoplasties performed in the mid 1970s was the basic history. The left had undergone a larger diameter re-graft in the late ?80s. Unfortunately it resulted in a tilted graft with around 15D curvature gradient, within the graft zone. To add to the challenge there was some lipid keratopathy and nasal neovascularisation to the graft-host junction. The referring optometrist had kindly and professionally sent me a report detailing a long list of previous attempts at refits, in a myriad of designs and diameters. These included intra-limbal designs from the USA, Rose K post graft, PGAs and Bi-Syms.
It's a point worth remembering: A decent letter can save the patient a lot of time and pain, never mind test the patience of the practitioner. Forewarned is forearmed. Such a detailed referral helps avoid covering old ground or reinventing the wheel and allows a more effective outcome, especially so for out of town patients.
A Rose K2 IC appeared to give a decent result. A remarkable four line improvement in VA to 6/7.5 seems on the cards, with less insult/bearing in the vascularised area. We are currently evaluating a refit - with some ACT ?tuck? - similar in nature to our well established NZ Bi-Sym CLC designs.
I?ll be sharing a case report in the next edition of a Rose K2 IC refit for a post-LASIK ectasia. It provided improvements in comfort and vision over a previous post corneal surgery [PCS] design.
Before I could have a break I still had to urgently see one of my regulars.
?No peace for the wicked? as my Welsh grandmother used to say.
The patient in question was heading off to meetings for three days in Whangarei. She's an RGP wearing high-hyperope with a frequent need for epilation of her aberrant and errant distichiatic lashes, aggravated by irregular lid margins, history of meibomian gland disease and chalazia. A few days prior she?d seen an out of town GP for treatment of a severe marginal chalazion. Some attention was needed before she left town. A quick email to her co-managing oculoplastic ophthalmologist with attached images and clinical notes had him on the phone to her mobile, en-route to Whangarei, with advice and updated meds.
The benefits of telemedicine, good communication and collegial relationships cannot be underestimated.
Eventually, at 3.00PM, I managed to wolf down some food - my first of the day - sign-off and despatch some urgent reports and referrals, answer a few emails and calls and head straight into a meeting with my accountants to wrap up some of the usual year end issues.
What a day.
Little did I realise the next day would be no easier. After reviewing an EW CL for a kite surfer heading off to compete in Europe, my second case on Friday was my all time record flattest and most plus cornea plana; A case I've detailed in my column before. A 9.72BC lenticulated 120Dk +33.00D lens is no common garden variety lens. To follow that I saw another record breaker with bilateral grafts, a prosthetic leg, with piggyback left and toric RGP right.
I doubt there?d be many practitioners who?d top these extremes in a dozen odd consecutive cases.
If you?re out there, flick me an email with details and I?ll let our readers know.
As Murphy would have it of course, a laptop crash earlier that week - caused by uninstalling a malfunctioning version of Google desktop - trashed my hard drive, lost 33GB of data, a few apps and around 1.2GB of email. Google is not in my good books and I have removed many of their apps. I'd suggest a full backup or disk ?image? before you uninstall Google desktop [and other] software.
Be careful out there.
Fortunately our systems, backups and Outlook exchange allowed me to recover most of my data. It's taken a few long days and nights to 1:00AM to get it all back the way I need it. The aforementioned telemedicine case is a good example of why fully functional IT systems are mission critical as far as my mode of practise is concerned.
It didn't help my stress levels, I can tell you.
Beware the ides of March?
You ain't kidding!
For more information or any comments email Alan at incontact@optom.co.nz.