In Contact - August 2008

Hyped up Hyperopes

Colleagues often ask if I get stressed out managing the multitudes of keratoconics and grafts that I see. It would seem many practitioners do. I've asked surgeons similar questions. I sweat more than they do just watching them. It's really just a matter of what you?re familiar with.
I must admit though that after a dozen complex cases in a day or three, I may get a little anxious.
On the whole I enjoy good rapport with these patients and in general we achieve great results from both mine and the patient?s point of view.
Stressful? Challenging and stimulating would be a better way to describe it.
Without providing a service, nor challenge or reward, what would be the point?
There are of course other cases which I find rather more than challenging. Frustrating would be one way of describing them. Exasperating another.
Most long-term practitioners have certain patients whose mere name conjures up ominous feelings of foreboding.
There will always be people and cases that are both less enjoyable and more frustrating, but no less important. In addition to related ocular complications some may also manifest other associated psycho, neurological or systemic conditions. These may be masked or develop in time.
I've dealt with such cases in past editions.
I'm fortunate to have had the benefit of great mentors and acquired the necessary skills that make managing the majority of such complex cases almost second nature. There are of course many skills I don't have and some I'm no doubt yet to develop. I refer to optometric, ophthalmological and other medical specialists where necessary and do not try and exceed my abilities. I have an interest in many aspects of eye care and have practised many facets, to varying degrees. My main focus has always been contact lenses but general, behavioural and functional optometry, as well as VT and child vision have also held my interest. Many KC, PKP, extreme myopes, hyperopes & aphakes would often be classed as ?low vision? and the corrective contact lenses as low vision aids. Pharmacology, path and physiology are obviously an integral part of all of this.

A Curve Ball

Some of the cases I view with greater trepidation include refractive surgery complications. By far the worst of these are radial keratotomy [RK] cases that all too frequently end up with irregular, fluctuating hyperopic-astigmatism. The ?table-top? corneal topography they are left with also makes them really hard to fit.
Post PRK/LASIK complications and ectasias are similarly problematic.
Previously highly myopic and now very ectatic corneas pose a major challenge. Decentred, irregular, aberrated, small optic-zone ablations pose many physical and optical challenges. Thank goodness not too many of these are being created these days. At least not in NZ, but we are seeing a rise in these grief cases with the advent of low-cost refractive surgery and so called ?black box? second-hand LASERS used in some other parts of the world. At least one of these failures, recently seen by a colleague, needed a graft.
There are some pretty weird topographies out there.
One of the biggest problems with refractive surgery failures is that these people were already tired of contact lenses, often comfortable disposables. They had surgery to rid themselves of the perceived hassle of contact lenses and spectacles. They were sold on the (sometimes) attractive, refractive surgery marketing that promised permanent correction and the dream of ?throwing away their glasses?. Their minds were set on never wearing ?contacts? or ?specs? again. Ever!
When the wheels fall off - or presbyopia kicks in - they are not happy campers.
Their motivation to wear the now optically necessary RGP or complex soft lens is low and they are not always exactly enthusiastic or cooperative patients. They are also not very keen on the often necessary and sometimes additional reading glasses or progs.
Notwithstanding these significant hurdles we usually largely resolve the problems. Many of the more extreme RKs end up with grafts ? Descemet?s level lamellar keratoplasty [DLLK] or penetrating versions, with improved results.
In the hands of a fine surgeon one sees some pretty remarkable results. I sit in awe watching a fine surgeon do their thing.
Full Credit!
Great grafts make patients? and practitioners? lives so much easier.
We are all very pleased if these graft recipients end up with a relatively regular, low sphero-cyl refraction that can easily be handled with spectacles. Progressive versions are often necessary as by this stage many of them are also presbyopic.
I reckon of all the non surgical ?run of the mill? ametropias, hyperopia has to take the cake. Hyperopes have got to be the most challenging. For them there are not as many advantages to contact lenses or refractive surgery. The lower magnification, albeit more ?natural?, can rob them of a line or two of vision at both distance and near. They also cannot see their contact lenses very well on removal, without correction. Their now untrained eye, so to speak, suffers spectacle induced perceptual distortion and they can over or under-reach, resulting in lost or damaged lenses. Many, as a consequence of childhood accommodative esotropia and amblyopia, are further restricted by limited stereoscopic vision. This also rules out the option of monovision. Occasionally however an alternating esotrope with good vision in either eye can be a great monovision success.
Hyperopes, and in particular the presbyopic variant, also seem to suffer from some unusual aberrations that make refractive solutions rather tricky. Other aberrations can make them rather picky too.
I always remember the middle-aged, slightly overweight, high power executive who nearly bit my head off one day because I dared insinuate she was ?presbywhatever?. They get even more uptight when they find out what presbyopia means. Hormonal imbalances and oodles of stress do not make the poor optometrist?s life any easier on days like this.
It's even worse when the moon is full?

Full Credit.

The Tri Nations got off to a great start with some serious rugby having gone down. The ABs managed to regain and hold IRB number one slot for one week but then the Boks came back with an epic counter. Eighty years with never a win at the house of pain, a decade losing in NZ and the ABs thirty game unbeaten run at home all came to an end.
Just like in the World Cup Schalk made his mark. For a guy who was almost out for ever with a neck injury, he now plays with some bionic bits fitted in his neck. He seems invincible.
Ali can attest to that.

Yeehah

A hundred odd ski freaks [CPD freaks?] will be mixing see and ski at Snowvision in Queenstown this August. I reckon a few miles will be skied, pupils dilated, pool played and tequila consumed.
If you missed this one or want more then I suggest you join us in the Italian Dolomites at Val Gardena in January 2009. I?ll be presenting a few talks, hopefully for some J?germeister or Grappa to keep the blood from freezing. I'm looking forward to my first visit to some of my favourite ski places after a two decade absence. Our daughter was conceived during our last visit to these parts, hence why It's taken so long to get back.
This time she?ll be joining us and no doubt will be focussed on beating me to the bottom. Like the ABs at the hands of the Boks, she?ll also find out there's still something left in her cantankerous old man.
Logon to www.skiconf.com for more. Register soon before It's too late.
After Queenstown I'm off to Bangkok to present a few lectures and on to Hobart to speak at the OAAs Tasmanian Lifestyle Conference. I'm looking forward to claiming my double TPA CPD points for my therapeutically slanted keratoconus talk...
Going Blind? They reckon you should check out this movie before you do.
Seriously.

 

For more information or any comments email Alan at incontact@optom.co.nz.