Shock and horror!A couple of months ago, when I could not find one of the two mitomycin soaked 8x8mm instrument wipe sponges I had placed in the sub-tenon’s space, the first time this has happened in an estimated 2,000 surgical cases over 16 years, I thought…well, this won’t ever happen again. When it happened again a couple of weeks ago; I knew that it was time to change my technique of mitomcyin application.

I posted a message on our American Glaucoma Society listserv and was overwhelmed with responses from others this had happened to as well and also with the reassurance that nobody seemed to have any untoward complication as a result of the retained sponges; likely because Mitomycin is actually derived from an antibiotic. One interesting suggestion was to pass a suture through each sponge and pull it out when done. A few weeks later there was a whole new posting by another member who realized the potential medico-legal implications of a retained foreign body. By this point I had already tried the suture technique and then this mini neuropatty method that came about by Juanita and Celia in the operating room realizing they might be the ideal solution. In the latest flurry of AGS listserv postings, others mentioned just using very long pieces of sponges that hang out to the limbus so they can’t be lost. 

The advantage of this technique using the mini neuropatties is that this allows for posterior application of the mitomycin; in keeping with the current preferred technique. With such a posterior application over a very large area, we can achieve very low and diffuse blebs instead of the small, high blebs that overhand the corneal-scleral limbus and cause pain and risk infection.

Now that medico-legally there may be fears of retained foreign bodies by using cut pieces of sponges, this technique is worth considering and has been working quite well for me the past few weeks. 

Humiliation http://bit.ly/98hgdbA recent teaching encounter took me back in time to the ‘old-boy’ school of medical education by humiliation. This really hit home because, basically, it really hit home - it involved one of my children and their teacher in K-12. I will be discussing this with the school principal after I sort my thoughts out therapeutically in this article. I did discuss this with a friend of mine who is a principal at another school and she assured me that this is not the norm.

The teacher spoke slowly and in measured steps with a glimmer in her eyes and a smile that widened as she explained how proud she was of herself for thinking this up and what a great approach she thought this was in helping our child succeed. I listened in disbelief; was I really hearing this? Did teachers still do things like this or are they more enlightened? In front of the entire class, she explained, I told your son that if he did really well on his next spelling test, she would reward the class with 2 bonus stars. “Pressure, lots of pressure,” my son responded. And, the teacher then added, still in front of the whole class and directed solely at my son, if you don’t do well, I will take two stars away from the whole class. “Pressure, even more pressure,” my son responded. The teacher was positively beaming as she recounted this story and how she has found the way to motivate my child to do well; how this will give him a sense of pride and accomplishment that will allow him to succeed.

This archaic form of teaching by public humiliation I thought ended sometime after my medical education. In those dark ages of the early 80s and 90s, it was common for my teachers to put me on the spot in front of my colleagues and patients by making sure they could find things that we did not know about any given condition in order to encourage us to learn more after being publicly humiliated. I never expected this form of teaching to still be alive in K-12 or medical education and do not think it is an accepted behaviour in our school systems. 

Surely there are better ways to instil a sense of pride and self-worth that can allow children to succeed. I learned a bit about K-12 teaching during my Masters in Education, even though I focused on Adult Education. There are certainly some differences in how to help children to learn vs adults. Some of this actually comes down to children needing to learn some basic facts and making the assumption that there is no prior knowledge. In adults, we recognize that each learner has a lifetime of experiences they bring with them to assimilate with new things to learn. That being said, humiliation is not a great way to help an adult learn any better or at least feel motivated to learn for the right reasons and I can’t imagine it being a great motivator for children either.

Please don’t set teaching back 20 years by humiliating your students regardless their age. Cherish each student and what they have to offer. We can all learn so much from each other. We should teach respect by modelling it ourselves. 

The BC-wide EHR initiative to date is failing interoperability, costs are beyond original planned federal matching funds, no strategic plan started until 4 yrs & $150 million spent, and doctors were only consulted this past year. The government is finally ready to assess physician adoption but are at least three years away from having an interoperable system in place. Perhaps this helps explain why still only about 5% of physicians have actually fully adopted an Electronic Medical Record system. Yet, in my private little world, my current EMR solution achieves what I need it do on a daily basis. (Please see the two articles from the Vancouver Sun written by Vaughn Palmer that are linked in this article and also appear in the references below.)

Interoperability in EHR http://www.ilink-systems.comDo we still think Electronic Medical Records (EMR) or Electronic Health Records (EHR) are the way of the future? Interoperability is the missing link that would make every physician jump on board but there is really no sign of this happening anytime soon. In the 16 years since I worked with David Pang, Luanna Bartholomew & David Campbell at Dartmouth Hitchcock Medical Center putting together our own EMR for ophthalmology, we have yet to crack the 5% mark of physicians who have fully embraced an electronic medical record. Of course the technology is there but politics, personal preferences for usability and other factors have continued to keep the dream of a world in which a patient can walk into any health facility and whomever they see can easily access health information to help care for them unattainable. When will we have interoperability and what is holding us back? Physicians are failing to buy stand alone EMR systems, even if they meet their current needs because they know the negative impact they will face in their transition and don’t want to have to later change to a system to make sure it will be interoperable.

The goal was visionary and noble when the BC government proposed a province-wide electronic health record system. The federal government was to provide $110 million to match the provincial commitment with milestones along the way to receive the fed money. Well, great idea but they ended up spending $150 million dollars before even developing a strategic plan until the auditor general called them on their major oversight. Last year a handful of EMR systems were approved by the government for physicians based on a minimal set of standards. Unfortunately, none of these solutions are of any use to specialist physicians such as myself as there was no consultation with us in the approval process so they had no idea that there are certain features that we need that family doctors might not. For example, we need to be able to generate consult reports based on the history and physical findings back to the doctors who referred the patient to us. This is not something a family doctor needs to do and is not a feature of any of the approved EMR systems. The approach to interoperability adopted by the government - make sure none of the data is stored at the physicians office but rather on remote servers. Not one centralized server but just any server NOT located in the physician’s office. This was supposed to be more secure and allow access to the information from other locations such as hospitals, walk-in clinics, family doctors and specialist offices alike? How? By magic? None of the approved EMR systems talk to each other.

Not In A Million Years http://bit.ly/ckasNJSo here we are, more than $150 million dollars spent, agreement for federal matching funds of up to $110 million total toward a proposed $220 million cost and probably three more years until we see results. The matching funds program will run out and we will likely see at least another several hundred million in provincial money poured into this. At some point we will have approved stand-alone EMR systems but will these ever be talking with each other? The stand alone systems are very powerful. I am able to generate the consult letters that I want and even able to look up what medications my patients are getting from the provincial-wide database. The computer code is actually in place to allow e-Prescribing but the government won’t turn that part of the system on for privacy reasons so I print out a prescription at the end of a patient encounter that is otherwise completely paperless. Lab results automatically get imported to my patient’s chart but only if I requested those tests or another doctors requested that I get a copy. If they had a test elsewhere and I need the result to help care for the patient…no such luck. Like I said, the technology has existed for probably the past decade or more but too many different groups are involved to ever make this work. I don’t think even 3 more years is realistic; in my lifetime would even surprise me. Oh, what great forward thinking by our government. This must be keeping some people gainfully employed for decades to come.

I also experimented with a program called KeynoteTweet when presenting this discussion. It allows the presenter to embed tweets in the presenter notes of a Keynote talk between [twitter] and [/twitter] markers and when that slide is reached, the words between those two marks get posted from your twitter account. I have removed these from the posted version of the talk so nobody accidentally resends these tweets! There is probably a future for this sort of technology to help broadcast information while it is being presented to a wider audience.

POTENTIAL CONFLICT OF INTEREST:

It should be pointed out that we have been using the HRT since 1994 and the FSM value for glaucoma detection, the Topographic Change Analysis for progression and the Glaucoma Probability Score for mathematical modelling/classification were developed by Drs Mikelberg, Swindale and Chauhan respectively (two current faculty and one former fellow.) Therefore, there is likely some bias toward speaking highly about this technology.

Here’s a problem that goes against the common mis-perception about practicing medicine in Canada. While we often hear false allegations from mostly Republicans in the United States that there is inadequate access to medical care in Canada, I have found out recently that many of my patients are over-doctoring. Yes, they are seeing more than one ophthalmologist for their glaucoma, having the same tests repeated, and burdening our healthcare system because of this. Not only is this wasteful of our resources but it also creates confusion to patients and their doctors regarding their care.

It is understandable that many patients are concerned about their medical care. Does our system of universal coverage result in patients abusing the healthcare system by making unnecessary visits to doctors for insignificant things and to seek out second and third opinions? Is it just a small subset of our population that is doing this or is this rampant and an inherent fault in our system? Bear in mind, although we have universal coverage through a single payor (the provincial government and transfer funds from the federal government,) this is not a FREE system. Our tax dollars as well as medicare premiums pay for our healthcare. There are even people who do not have medicare as they do not pay their premiums however this percentage is much smaller than in the United States.

I fear that when patients over-doctor, they run the risk of having each one offer slightly different advice, oftentimes not aware of what recommendations have already been made. Sometimes it is only when the patient is not on the same meds as prescribed when I last saw them or are on several medications with the same active ingredients (there are several glaucoma drops that are combination agents that all contain timolol - a beta blocker) that the patient reveals that they have seen one or two other doctors since last seeing me. Not only does this muddle the treatment, it can lead to dangerous consequences. The glaucoma medications, although they are eyedrops, they do get absorbed into the rest of the body. Double of triple the proper dose of a topical beta-blocker can slow down the heart or drop the blood pressure enough to lead to a cardiac arrest or catastrophic fall from a drop in blood pressure in this patient population.

When medical resources are already scarce, it is a shame that some patients over-doctor yet others never seek the care that they need. There must be a better way. Any thoughts? 

I was sure I would not tweet any consults from this day as I still had many cases that I wanted to write about in greater detail here on my blog, but I couldn’t resist tweeting and now talking more about this particular patient presenting with rather high intraocular pressure but no other risk factors for glaucoma.

robschertzer 59 yo WM #glaucoma #consult w/ IOP 28 OD, 39 OS, normal cornea thickness and VF, slight disc asymmetry; anyone just observe?

This patient was referred by their Optometrist with asymmetrical eye pressure readings of 14-18 in the right eye and 23-25 in the left eye in the presence of slightly thin corneal thickness measurements of 531um and 516um.IOPs and CCT from referring Optom

Visual fields were also performed by the referring eye care professional and are below. These were not repeated at my office as they appeared to be reliable.

Faxed VF OS (click to enlarge)Faxed VF OD (click to enlarge)

On history, there was no family history of anyone with glaucoma and the patient was not on any medical therapy for any conditions. He is a smoker.

On examination, visual acuity was 6/6 OD and 6/9 OS with his current spectacle correction of plano -1.50 x 105 OD and -0.50 -1.00 x 090 OS. IOP readings were 28 mmHg OD and 39 mmHg OS at 0922hrs with corneal thickness reading of 567 +/- 2.2 ums OD and 563 +/- 2.6 ums OS. Pupils were brisk with no afferent pupillary defect. Early cataracts were present in both eyes. Angles were wide open with some extra iris processes and pigmentation in the left eye compared with the right and there was a slight asymmetry in the optic nerve shape, with generalized increased ‘cupping’ in the left eye compared to the right but still within the realm of normal.

His HRT nerve scan was performed for future comparison. As discussed in prior postings, this test is used to look for progression on follow-up visits. As a baseline test it just confirms what is seen clinically. In this case, essentially normal looking optic nerves.

HRT OU report (click to enlarge)Does this patient have glaucoma? If not, what is their risk of converting from ocular hypertension to glaucoma? Should they be treated? If you are seeing the patient, what would your plan be and how would you rationalize this?

The patient and I discussed the findings as well as the potential risks and benefits of different treatment options along with the alternative of not treating at this time. With treatment consisting of either a single glaucoma medication or Selective Laser Trabeculoplasty, there is an excellent chance that five years down the road we would see no progressive damage to the optic nerve as measured by HRT nerve scan or Visual Field testing. Of course, there is also an 88% chance that this patient will no show progression from his current ocular hypertension status to glaucoma over the next 6 years based on the Ocular Hypertension Treatment Study (OHTS) even if they were to receive no treatment. 

In the probability graph from one of the OHTS papers, regardless of whether you use the IOP and CCT data from my office or that from the referring optometrist, the risk of developing glaucoma for patients in that study with these IOP and CCT readings were 12-13%. As long as this patient is followed on a regular basis, with repeated optic nerve form (HRT) and function (VF) testing, it is safe to just observe for now. 

OHTS IOP vs CCT and risk progression over 6yr median f/u (click to enlarge) http://www.blackwelleyesight.com/wp-content/uploads/2008/05/ohts-2.jpgThere are many factors to consider in the decision to treat a patient or observe for now. This was my rationale for this particular patient who lacked other risk factors, seemed to understand the treatment options that he was actively involved in deciding, and is available for ongoing longterm follow-up. At any point in the future, we can always start treatment. This takes extra work perhaps than just opting to treat the patient just because the eye pressure was high but it reduces the risks of treatment that may turn out to not ever be necessary.

Don’t worry; just my eyeOnce in awhile, patients of mine e-mail me an extreme close-up photo of their eye seeking my opinion. Is this a good way to practice medicine? I should clarify that it is not anonymous patients who find me on the internet and feel compelled to send me an eye photo in search of an internet-based consultation. It is always patients of mine, usually ones who I’ve performed glaucoma surgery on, who are doing this. Now is this good medicine?

Could it be that I’m too linked to technology and, if so, is this a good thing or a bad thing? My office is completely electronic medical record (EMR) based, my patients always see me on one or more computers, carrying around an iPhone when they come to see me, and watch animated videos explaining eye conditions and their treatments on a widescreen TV in the waiting room or tablet in the examining rooms. The technicians in our team are similarly wired, performing ancillary tests linked to their electronic records and all our correspondence to referring docs goes out within a few minutes of seeing the patient…any many of the patients know this. I’m quite wrapped up in technology and immediate connection including my website, this blog, twitter, buzz, facebook pages (mine, my office, glaucoma patient group,) LinkedIn and more. Hopefully my patients also understand that I need to see them if they are having a problem following surgery since it is impossible to make a diagnosis over the phone. It is probably a good thing that they are using technology available to them to give me a better idea of what is going on with their eye than they could achieve with a phone call. Sometimes though all this technology can interfere with doctor-patient interactions but hopefully we are using the technology to help.

Ahmed GV showing scleral patch graft (click to enlarge)Once I receive the photo from a patient, there are a few possible outcomes that do indeed improve patient care. Most commonly, I am able to re-assure the patient. They often just notice something that has actually been present since the surgery. For example, when performing an Ahmed Glaucoma Valve implantation, there is a small patch of donor sclera that is placed underneath the conjunctiva (the outer layer of the eye) covered by the upper lid that helps protect the conjunctiva from the underlying tube. Some patients suddenly notice this during their post-operative period and are concerned that it is something abnormal. By seeing a photo of their eye, I am able to reassure them that this is normal and can also get an idea if there is anything of concern such as signs of the wound opening or the tube wearing through that I might not otherwise know about if I just talk to them on the phone.

Is direct patient to doctor telemedicine good for our patients? Are we able to provide them with a better quality of care than we could otherwise achieve? I think so but I’m sure that not everybody agrees for various reasons. I would appreciate feedback from both doctors and patients on this topic. Please post your comments below.

A common late complication of trabeculectomy (glaucoma filtration surgery) is wound leak occurring many years after the surgery, especially when an antimetabolite such as Mitomycin-C was used at the time of the original surgery. This video shows my surgical technique for excising the non-viable leaky conjunctival tissue and advancing fresh tissue from the surrounding area.

I had a patient recently left out of the loop as a colleague and I debated her fate and care! A large proportion of my patients live hundreds of kilometres away who are referred for surgery. I am often left with the challenge of co-managing them with the referring eye care professional without getting to examine them myself. Unfortunately for this patient, the referring ophthalmologist and I spent so much time talking amongst ourselves that we hadn't realized that the patient was not being kept informed of our thought processes.

This patient had previously been referred to me for uncontrolled glaucoma that I treated with an Ahmed Glaucoma Valve. Although this is successful in 90% of patients at 2 years and decreases the need for glaucoma drops from on average 3.4 meds prior surgery to 1.1 meds afterwards, there are still some patients in whom the glaucoma remains inadequately controlled. This was the case for this patient as despite adding glaucoma medications and several 'needlings' to help break scar tissue over the implant was still not enough.

http://fotosa.ru/stock_photoThe referring ophthalmologist and I exchanged several emails, faxes, and phone calls regarding the best next step in this patient's care. I had made the erroneous assumption that as this patient lived far away that the referring doctor was conveying the information to the patient after we talked amongst ourselves each time. We each actually spent quite a bit of time discussing how best to care for this patient and settled on the idea of augmenting her prior surgery with a small amount of diode laser cycloablation therapy. Little did I know that the patient was never made aware of any of our conversations and was just sitting at home, worrying about why nobody was helping her get her glaucoma under better control.

My office arranged for the patient to come back to Vancouver in order to undergo the cycloablation by calling her. It was a complete surprise to her as nobody had explained anything to her as I later found out. The patient had many questions but was told by my office staff something along the lines of "Dr Schertzer is really very busy and won't be able to talk to you when you come for your procedure," or at least that is how it was remembered by the patient.

Fortunately, a few days before the patient was to come to see me for the cycloablation, she called me on my cellphone. I clarified what my office staff meant in that I was squeezing in her procedure after my morning surgery in the operating room and before my afternoon patients, which was not meant to sound like I have no time for her. Over the phone I was able to explain to her that her referring eye doc and I had thoroughly discussed various options including a repeat round of 'needling,' an additional drainage tube, and supplemental cycloablation and the rationale for why the latter would be best for her.

Communication lines need to always remain open between doctor and patient so they are actively involved in the treatment decisions. I usually strive for this in the patients I see on a regular basis but in this case I should have picked up the phone to call the patient and am grateful that she tracked me down so we could speak. She and I have since joked about the whole thing.

I had a bit of an ah-ha moment about many of my patients in the middle of the night. My eyes were dry last night so I put in some artificial tear drops before going to bed and kept the bottle by my bedside. At one point during the night I awoke; with eyes feeling dry, I reached for the drops, lined them up, and proceeded to put one drop on each eyelid before getting each one in my eye. It's no wonder that some of my patients go through their glaucoma drops in just 2 or 3 weeks instead of the full 6 weeks that they should last. (At least these patients are taking their drops!)

How do my patients with limited vision get any of their drops into their eyes? I was aware of some of the other issues. Many patients are on more than one glaucoma medication, some of which are once every morning, others twice daily, and still others at bedtime. At least with these it is usually possible to pick drops that have bottle with different shapes to them. That is provided they receive the brand name drugs and not the genetics that are all in similarly shaped bottles. Also, if any patient is also on an artificial tear drop or steroid or dilating drop, then they're in trouble as these all have the same shape.

We need better ways to help patients get their eyedrops in their eyes when they have limited vision. There used to be an eyecup that screws onto the top of the bottle made by Merck and Pfizer used to make the Xal-ease that only fit their Xalatan bottle. Both of these could be rested over the eye to properly position the bottle. I'm not sure if these are still available. Also, if there are better ways to help patients identify the bottles that people know about I would be interested in knowing them.