In Contact - March 2008

Latest Cure for AMD?

You will have recently received some ?Quit Cards? from the MoH. They apparently want us to hand these out to smokers and in particular those with a risk of developing age-related macula degeneration.
A recent study, mentioned in last month?s NZ Optics, [See NZ Optics February 2008, page 3], showed that AMD would, on average develop around age 74 for non smokers, age 72 for former smokers and around age 69 for smokers. The very day after reading this recent AMD research I noted that an increased suicide risk has been associated with one of the drugs supplied under the quit programme.
Champix [varenicline], marketed as Chantix in the USA has, according to various reports, been linked to various psychiatric disturbances, including suicide. It's regarded as a smoking cessation aid and blocks pleasure centres associated with nicotine. No wonder people feel blue.
One could of course surmise that such a drug certainly would prevent one from developing AMD: If someone commits suicide then one is certainly not going to live long enough to develop AMD!
Now I don't make that comment lightly as I have a family history of AMD and have significant drusen myself. that's one of the reasons I gave up smoking many years ago.
I discussed this issue with a vitreo-retinal specialist and some others. They all agree that death is certainly a cure or preventative strategy for numerous diseases and degenerative conditions.
As to smoking. Yes, It's dumb. Everyone should quit. However, as far as I'm concerned, forget patches, gum and other pharmaceutical and nicotine replacement options. It's simply a matter of will power. Make the decision and stop! Cold Turkey. After a day or two It's all over. Ask me, I've had enough experience over the years at quitting. The hard part is never having another drag after a nice dinner or a good red.
Now that smoking is so frowned upon and banned from most places, there's less exposure to it. For many that's a great help. Like any other addict.
I say harden up and take control of your life. Stop smoking.
We don't need nanny state hand-holding for everything do we?
we've come a long way from the days when Camel cigarettes were marketed with the slogan ?More Doctors smoke Camels than any other cigarette?.

Old Blue Eyes.

Consider this: Danish researchers reckon they can trace all blue eyed people to one common ancestor.
The world class Mission Bay Jazz and Blues festival was great and easily compares to some of the great European festivals. As far as quality, location, manageable crowds and easy access to music, food and drink It's hard to beat. Get there in 09.

Cool, Blue & Competent?

Speaking of AMD, I've found that the swing to Slit Lamp Indirect Ophthalmoscopy [SLIO] seemingly at the cost of direct ophthalmoscopy may in some ways delay the early detection/diagnosis of subtle maculopathies and other fine detail. Some years ago, while having BIO and SLIO performed on me during CPD workshops, I noted that few observers commented on my fine drusen.
My ubiquitous drusen were picked up decades ago by my old man with a non-halogen B&L direct ophthalmoscope. They can satisfactorily be imaged with a fundus camera or direct ophthalmoscope but are too fine for detection even by current high resolution OCT. Of course the OCT is marvellous when it comes to larger drusen. YouTube has some great OCT videos of larger drusen and other interesting stuff.
With the trend in optometric education and continuing education to promote BIO and SLIO, at the relative cost of direct ophthalmoscopy, a number of subtle maculopathies may go undetected. The direct ophthalmoscope may too often be left to gather dust?
I felt I was slipping into that trap too but a few recent cases got me back on track.
In one such case a very subtle macula change was barely detectable with retinal imaging or SLIO but was clearly and easily seen with my trusty Keeler specialist direct, as a discrete almost perfect ?red spot? or circle at the macula pit. Associated with a long standing peri-macular epiretinal membrane [ERM] it was an important change to note. The patient concerned was experiencing entopic phenomena, in her central field, when she got out of bed and again in the evening. She was certain they were ?different? to her more common visual migraines.
She was referred back to the co-managing retinal specialist and they are monitoring the change carefully. It would seem that there's been an increase in vitreomacular traction [VMTS] in this area and she is thus at greater risk of developing a macula hole or cystic macula oedema [CME].
Within 24 hours of seeing me I already had electronic versions of her OCT from the retinal specialist. Pretty impressive eh?
There were mild Amsler grid changes and a qualitative change in her 6/6 vision for that eye. With symptoms as a guide, the direct ophthalmoscope was the best detector of the subtle changes. The OCT allowed a better understanding and diagnosis.
As I've said so many times before: We should expand and enhance the profession but we shouldn?t throw out or ignore our tried and tested tools and skills.
Many practitioners like being removed from the close contact direct ophthalmoscopy demands. They may even enjoy more garlic and onion in their diet but that's hardly reason to avoid direct ophthalmoscopy?
don't get me wrong: There are excellent lenses designed specifically for macula work but the average optometrist often only has one slit lamp fundus lens, usually in the form of a 90D. Some also use wide angle or super field lenses with further sacrifice of magnification for field of view and are thus even less likely to detect such microscopic changes. Micro haemorrhages, small drusen, pigment, Roth?s spots and other fine pathologies may also require a more magnified, narrower field image.
For those with an interest in ERM and VMTS check out this detailed article at Review of Optometry. there's also an interesting interactive simulation and tutorial on SLIO here

The People?s Lens.

As we know the great Volkswagen brand derived its name from the German for ?People?s Car?.
While on the subject of slit lamp fundus lenses we have to mention the people's lens, the Volklens. Volk lenses are synonymous with slit lamp fundoscopy aka SLIO and many clinicians simply refer to the technique as ?Volk? as in ?I did Volk on her and found toxoplasmosis chorioretinopathy?
For some time I'd been hearing comments, reading reviews and seeing promotional information on the latest ?Digital? series of Volk lenses. Was it all hype?
I saw one on display at the Queenstown CCLS conference last March and asked for one to be sent on trial. I never sent it back.
I was so impressed with the optical clarity, ease of use and detail that I simply sent payment. It works very well undilated for many patients but of course It's even easier to use on dilated eyes.
Thus my favourite lens over the past year has been my shiny, new, blue Volk Digital Wide Field. [Black was getting sooo boring doll]. Now to decide whether I need the 1.0x or High Mag version next. I'd initially thought to get the 1.0x and rely on the Keeler direct for fine macula work. At the same time the binocular depth one obtains with SLIO - for detecting such things as NFL disturbances and serous changes ? may well sway me toward the High Mag. Of course I'd happily have one of each. We all would.
In our office that's an extra five or ten grand. If we didn't have to spend so many dollars to ?prove? our competence and stay registered via expensive CPD and compliance, we?d probably all have a whole lot more money to buy the tools we actually need to be more competent.
It's a ?Catch 22? eh?
One-eyed South Islanders can of course relax, save the money and spend it on Speights, as they hardly have a use for binocular instruments?
Cheers and Go Bulls.

 

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