Tired surgeon

What does it say of a society that prioritizes shortening of cataract waitlists, an elective procedure which certainly is of benefit, over glaucoma surgery - needed to prevent permanent visual loss? The government mandates that the different health regions meet certain benchmarks for wait times or be subject to large fines. Cataract and hip surgery are both part of this mandated benchmark approach but glaucoma surgery is not. There are many more patients who await cataract surgery so this can be seen as a move for popularity for a government if it can boast that these thens of thousands of patients can get their elective cataract surgery in a timely manner. However, delaying glaucoma surgery causes permanent damage but only hundreds of patients per year in our region need glaucoma surgery. Just because less people are in need of the surgery doesn’t mean it is less important. We have a self-imposed benchmark at the Vancouver Coastal Health/Vancouver General Hospital UBC Eye Care Centre of 6 weeks for 100% of glaucoma surgery to be performed. We are currently only getting about 50% of patients in within that benchmark. But, since there is no risk for financial penalty to Vancovuer Coastal Health, they have no financial incentive to re-allocate cataract time in favour of glaucoma surgery time or they risk being penalized for prolonging the cataract waitlist.

Several months ago I was getting tired of doing multiple after hour glaucoma emergency surgeries. I was told that my colleague, whose wait list was even longer than mine, would be glad to do the extra cases. Although he didn’t end up having to do those cases, I did give him a couple of my surgery days in order to help equalize the waits for all our patients. I brought up the issue again this past week and now discussions are about to begin on how to get more glaucoma surgery time to avoid watching our glaucoma patients go blind. I can’t keep adding emergency surgery cases at night and expect to stay alive; I won’t be around long enough to care for more glaucoma patients. They are looking at options such as opening up the operating room on Saturdays to deal with the backlog. G_d forbid they should actually take away operating room time from cataract surgeons in order to care for patients who risk permanent blindness. This reminds me of when McGill University made the decision to accept Jews into their medical school as long as it didn’t take away any positions from non-Jews so they enlarged their class to add a Jewish quota. Well, our operating room is already running at a loss so they can’t come up with new funds for a glaucoma quota. Sorry Vancouver Coastal Health and Eye Care Centre, you will need to take away time from qualified cataract patients to take care of those glaucoma patients who are being deprived of care in your failure of a healthcare system.

And, don’t even get me started as to how different hospitals work to falsify waitlist data such as removing patients from the list if they will exceed the wait or not even enter them on the list if the surgery is too far off. This province’s healthcare system is severely broken, corrupt, and is harming British Columbians.

This procedure has been described as being the glaucoma equivalent of angioplasty in cardiac surgery. Our standard glaucoma surgeries are more analogous to bypass surgery in that we bypass the obstructed trabecular meshwork with a partial thickness trap door (trabeculectomy), a surgical steel shunt (ExPress mini-shunt), or silicone tube attached to a plate (Ahmed or Baerveldt shunts.) Although technically more challenging than the other procedures, it is less invasive which should lead to fewer complications. To date, it appears that it is capable of achieving pressures that are just as low as the standard techniques which other co-called non-penetrating procedures have yet to achieve.

In this video, I present a Canaloplasty glaucoma surgical procedure that I performed in December 2011 at the University of British Columbia Eye Care Centre.

Blinded with prejudice

My current glaucoma surgery for semi-urgent cases is 8-10 weeks with a benchmark set as 100% of patients within 6 weeks - oops. My colleague’s wait is even longer. More urgent cases are supposed to get in either the same day or by the next day with an agreement to call in Anaesthesia from the main hospital to cover. Alas, we can never get Anaesthesia to come before the nurses have to leave for the day - oops.

I have a patient who showed up at the office this morning having partially extruded a glaucoma device that was implanted some 35 years ago. He now has an open pathway into his ONLY eye, which barely has hand motion vision and his fellow eye is totally without sight. This requires within 8 hours emergency surgery…before scurrying off to the Eye Care Centre operating room for an already full afternoon of 4 glaucoma surgeries, I personally completed all the paperwork to get this patient ready for the main operating room and my office staff was left to complete the fine details. I also had to abandon 5 patients who were booked to see me as this emergency kept me sidetracked to fight for his sight. Alas, there were no beds in the hospital so they were not officially able to start the clock on his within 8 hour emergency until after a bed became available at 5:30pm. 

If we had a real healtcare system, patients who needed urgent care would be able to get it. We don’t have that here. We need more glaucoma surgery resources to handle the load but we live in a system where the government cannot afford to pay for everyone’s healthcare and looks at ways to do less for patients in order to save money. This costs life, limbs, and blinds people. Get me out of here; I want to be able to help my patients.

Reddit.com provides a great service for anyone to post links to articles that they think others would like to read. A very successful use is http://reddit.com/r/technewstoday for the popular daily technology podcast Tech News Today. As this one now has over 3,000 participants, you can see how hopefully one day the reddit for talkingaboutglaucoma could look in terms of articles getting ranked by popularity and you will also see that many people have contributed links to articles.

Talking About Glaucoma sub-redditI have started by posting links to some recent on-line glaucoma journal abstracts and news stories about glaucoma. Usability is excellent for reddit.

Here is how you read, comment, rate and forward articles

• Click on the article title to jump to the article.
• Go back to return to the reddit page
• Click the up or down arrow in front of the article title to vote the article up or down
• Click on comment to add your thoughts about the story
• Use the Share button to email a link to someone

This is how you post glaucoma related articles to the talkingaboutglaucoma reddit if the site has a Share button

Share optionsEnter sub reddit

• Many websites have a Share button that opens a window with options
• Select Reddit
• In the subreddit field in the reddit window, type in talkingaboutglaucoma
• Confirm that you are human

If no Share button available

Submit a LinkIf you want to post a link to a site that does not have a Share button on it or does not have a share option that includes Reddit, the instructions are similar

• Copy the url from your browser address bar when viewing an article
• Go to reddit http://reddit.com/r/talkingaboutglaucoma (or really from any sub reddit site) and find the well hidden ‘submit a link’ button on the right side panel. 
• This will pop up the same sort of window as above but now you need to paste in the URL in the URL field, click on the option to have it suggest a title, then still type in talkingaboutglaucoma for the subreddit.

I look forward to readers of my blog getting involved in the Talking About Glaucoma sub-reddit. Please read, comment, vote up or down and submit other articles so that we can turn that into a useful learning environment for glaucoma. At some point, I plan to see what is popular on the Talking About Glaucoma reddit to use that for the basis of future Talking About Glaucoma podcast episodes.

This video shows me using a similar technique based on what I remembered from seeing that video once. Dr Gupta’s technique may have been different and I have only done this on the one patient shown in this video. However, this is such a promising idea that I know I will be doing this again. It is far easier to use a 10-0 mersiline double-ended suture to pull back a tube tip than to perform a major re-operation that would have involved opening the prior surgery site, cutting away extensive scar tissue, lifted up the donor sclera flap, reposition the tube entry site, then closed things up again.

This patient went from IOP into the 40s on medical therapy to the low teens or lower without medical therapy by having this suture technique to pull the tube back from the cornea.

I posted the following on 5Mar2011 in the Members’ Only Glaucoma Blog at the American Academy of Ophthalmology Community. I am sharing it here as well to open it up for discussion with a wider audience.

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I’m reporting live from the American Glaucoma Society 21st Annual Meeting in Dana Point, California. There were two talks today that warrant more discussion in terms of figuring out if we are using imaging devices appropriately in the care of our glaucoma patients. One talk was from Josh Stein on the changes in diagnostic evaluation of patients with open angle glaucoma from 2001-2009. The other talk by Mitra Sehi looking at topography and nerve fiber layer imaging as a predictor for visual field progression.

The good: temp-inf moorfields’ parameter as well as GDx-ECC inferior rim and TD-OCT inferior rim were the only 3 parameters of the dozens of values produced by these three devices that was shown to be a predictor of visual field progression. This helps to justify that these ancillary tests can help guide us in caring for our glaucoma patients.

The bad: more optic nerve imaging is now being done than visual field testing in patients with open angle glaucoma. Does this contravene the AAO Preferred Practice Pattern guidelines for the care of open angle glaucoma in which imaging is an ancillary test that may show increasing merit as the technology evolves but is not a replacement for visual field testing.

Is imaging being pushed by some eye care providers to patients as an integral part of a full eye exam thus making patients feel pressured to pay for imaging that may not be needed or in their best interests? Or, are our guidelines out of date and imaging is now more important than visual field testing?

Please discuss.



I was referred a patient as a glaucoma suspect due to high intraocular pressure readings when seen by his referring Optometrist. The eye pressures were fine on the day I saw the patient and I was ready to give him my standard explanation for ocular hypertension being a risk factor for glaucoma but that a high pressure reading does not = glaucoma. As he was about to leave, he pulled out a bottle of Tobradex that he had been prescribed to take whenever his eyes felt gritty! Let’s talk about this one.

The 66 y.o. patient had been referred with IOP readings of of 27 OD and 26 OS that changed to 26 and 34 upon dilation at the referring Optometrist’s office. Although his optic nerves appeared within normal limits in each eye, there was an asymmetry such that the temporal rim was a bit thinner in the left eye compared to the right. When the patient was seen in my office, the IOP readings were 20 and 17 at 1030hrs, visual acuity 6/9 in both eyes with moderately low degree of mixed astigmatism correction. Visual field findings were non-specific with some spots missed in the right eye compared to age-matched controls.

Tobradex dropsThe late to divulge information about having been prescribed Tobradex for when his eyes felt scratchy, itching or burning was neither expected nor appropriate. This patient had moderate prolapse of his lateral orbital fat pads in both eyes which were likely contributing to his already moderate dry eyes to cause irritation. Indiscriminate use of antibiotics can lead to resistance and the unnecessary steroid use, although it can comfort the inflamed eye, is known to carry with it a significant risk of raising the intraocular pressure which can lead to permanent glaucoma damage.

This patient needs follow-up to make sure he is not developing early glaucoma damage that may have been at least partially due to the inappropriate use of steroids for dry eyes. He will be followed every 6 months for now and has been started on artificial tear drops for his dry eyes. In the future, surgery to remove some of the prolapsed periorbital fat will be given if this gets worse.

This 50 y.o. patient underwent a trabeculectomy with mitomycin-C then developed progressive hypotony maculopathy as well as a cataract. After concluding the cataract portion of the surgery, I placed a suture through the conjunctiva and its underlying scleral flap supratemporally. This video shows this portion of the surgery.

This procedure has been described already in the literature and I do perform it albeit infrequently. You have to be cautious if the bleb is too thin as you can end up with a permanent leak. In the weeks following the surgery, the nylon suture gets buried UNDER the conjunctiva.

A week after the surgery, this patient was seen by her local optometrist, as the patient is several hours away from the nearest ophthalmologist and almost a full day away from me. The optometrist called in a bit of a panic to say the patient’s bleb had a crease in it! I was able to reassure him that this was the plan. Also, encouragingly, the eye pressure was now 23mmHg instead of its pre-op value of 4.

The accessibility options now available on iOS 4 for the iPhone helps people read their screen more easily. Probably more important than the higher resolution on the new iPhone 4 device are the accessibility options in the upgraded OS that can be used on prior iPhone/iPod touch models. (As always, click on any thumbnail in this article to enlarge.)

Accessibility options iOS 4As someone who needs reading glasses, it can be quite challenging seeing the information on my iPhone if I don’t have my reading glasses with me or just have contact lenses on because I’m working out. There are two important accessibility features along with a modification of a built-in and often used app found in iOS 4 for your iPhone or iPod touch that are very helpful.

Accessibility iOS 4 font sizesThe accessibility features allow you to adjust the font size globally for the built-in apps and a 3-fingered screen tap (called Zoom in accessibility settings) to enlarge everything on the screen. The simple change to 20pt font makes enough of a difference for me to avoid eye fatigue but you don’t have to stop there; if you need to you can make the font size much bigger. So, skiing with your contacts on, you can still read your address book entries to call your ski buddy after you took a wrong turn. The Zoom function of using your 3 fingers to tap on the screen is a bit awkward but really does a great job of zooming in everything on the screen similar to the option-scroll-up in Mac OS X.

The feature that can also be very helpful in a built-in app is the camera! This was possible before with third-party apps like GoMagnify but now with the camera, when you tap on the screen, not only can you control what object is being focused upon and light balanced as was introduced with 3.0 but control your zoom as well. So, that can be helpful if you are just trying to read a price-tag when shopping or your lock to open up your locker at the gym.

Settings—>General to find Accessibility iOS 4To find your accessibility options, tap on Settings—>General—>then scroll way down to Accessibility. The features from the prior versions of the iOS such as VoiceOver, White on Black, Mono Audio are still there and another new one to Speak Auto-text so that you can be verbally warned of typos. Play with the settings and be sure to post any feedback such as useful tricks or omissions in the comments section below.