Monday
Nov112013

Proud to be...Eyemed Free.

Our practice is no longer participating with Eyemed vision plans.  Eyemed is owned by eyecare giant Luxottica, who also is a frame manufacturer as well as owning retail outlets such as Lenscrafters, Pearle Vision, Sears Optical, Target Optical, etc.  

As of October 1st, Eyemed changed their business model to disallow local practices to use their own in house lab to fabricate patient prescriptions, instead having to use Eyemed's lab and frame lines.  This increases patient wait time, decreases quality, and takes revenue streams away from local optical companies.  

They also changed some of the language in their new contract that would affect how I participate with medical insurance panels.  I believe the language to not only violate regulations set forth by the State Board that governs our profession, but also to violate contractual agreements with the medical panels themselves.  

Eyemed has seen a downward trend in quality and subscriber satisfaction for many years now as they are trying to make their business model relevant to parent company, Luxottica.  

In the event you are an Eyemed subscriber, we can help you file your claim with them for reimbursement for your examination.  All that is needed is an out of network claim form and an itemized exam receipt (both of which we can provide). As always, our patients are our top priority, and you are welcome to call with any questions.  

60 minutes did have an interesting expose on Luxottica's business practices recently.  It is about a 13 minute video, but very enlightening.

http://www.youtube.com/watch?v=voUiWOGv8ec

Friday
Nov092012

self driving car applications

Google's new, tech enabled self driving car is getting plenty of attention.  Watch this "sight related" video about the technology that guides the vehicle.  

 

Wednesday
Nov162011

Contact Lens Recall

Do you wear CooperVision Avaira brand contact lenses?  If so, you can go here and enter the lot numbers from your boxes to see if you are affected.  

The company is claiming that a small # of patients wearing the Avaira Toric or Avaira Sphere brand contact lenses will be affected.  

According to CooperVision, the Avaira toric and sphere are the company's only contact lenses manufactured using silicone oil, and residue contamination of some lenses has caused temporary adverse changes in vision, in some cases leading to severe eye pain or eye injuries requiring medical treatment.   

I personally rarely fit this lens, but it has gained some marketshare recently.  If you are wearing this lens or know someone that is, please look into this issue and contact your eyecare provider if you fall into the affected lot numbers.

For further information, you can contact CooperVision directly.

From their website:

Still Have Questions? Please consult our Customer Care Center by calling 1-855-5-COOPER
(1-855-526-6737). or emailing consumercare@coopervision.com. (Consumer Care hours of operation are 9:00AM - 5:00PM ET Mon-Fri).

Saturday
Jul022011

cone dystrophy

Due to her concerns never being met, this particular patient had been bouncing around from doc to doc, with generalized vision complaints, i.e. not seeing well, etc.  She was in her mid to late fifties when symptoms began.  

As can be common with cone dystrophy, dilated fundus evaluation tends to look perfectly normal.  Upon my examination of her, there were enough other "scapegoats" to blame slightly decreased and fluctuating vision on.  The patient had extremely dry eyes and had a surgical history for radial keratotomy.  Fundus evaluations always looked great.  We tried several refractive solutions, rigid gas permeable contact lenses for example, that would work for awhile, and then not.

In spite of me never truly having an answer for her chief complaint, this patient stuck with me over several visits.  Ultimately, due to her own research, we decided to send her on for further testing with a retinologist.  The diagnosis was again missed, due to all findings appearing "normal."  She then went to another retinologist in another state where the diagnosis was eventually confirmed.  

What's interesting here is that I did receive a spectral domain OCT in office during this time.  And when I did get a chance to examine her again, not long after her 2nd retinologist visit, I decided to run a macular grid scan.  The results were astounding.

As a control, below are 2 scans of a normal patient that was actually referenced in an earlier blog entry as a "normal patient" video.

One in b & w, normal patient:

and one in color, normal patient:

 

These are 5 separate HD macular scans that image the entire macula from our patient with cone dystrophy.  These patient scans can be enlarged by clicking on the image, they will open in a new window.

scan 1:  (click image to enlarge)

 

scan 2:  (click image to enlarge)

 

scan 3:  (click image to enlarge)

 

scan 4:  (click image to enlarge)

 

scan 5:  (click image to enlarge)

Some commentary.  Note the scans are scanning sections of the macula.  The fovea, or most central part of the macula, is the middle scan or scan #3.  This is undeniably the most important anatomical point of the macula.  This contains the fovea, within the foveal pit, and has the most dense packing of cone cells.  This is where our 20/20 or better, visual acuity comes from.  

Scan 1:  You can see some disruption of the lower layers of the retina, but this is subtle, and could easily be missed by a technician, or attributed to a "low signal" scan.  

Scan 2:  Enlarge this scan by clicking on the picture above, and you will see more lower retinal layer "disruption,"  still somewhat subtle.

scan 3:  central macula.  At this point, one can plainly see something is amiss.  The lowest, hyper reflective layer in the scan is the RPE layer.  It is intact.  That is where normal anatomy ends.  In cone dystrophy, the outer nuclear layer of the cones can completely disappear.  

For this scan, one could say that the photoreceptor outer segment and RPE complex are gone in areas.  There are some areas where it is still there, but mottled or inconsistent.  There is an anatomical feature in the scan that runs directly above this portion that is called the inner segment/outer segment photoreceptor junction.  It has also been referred to in peer reviewed journals as the PIL, or photoreceptor integrity layer.  It is missing in some areas, and "beat up" in others.  There is also something called the PIL hump, where the cone cells are actually more highly developed and "longer" in the foveal area: this is normal and is a good sign.  Check the normal scan above to see this.  The hump is diminished, if not present at all, in this cone dystrophy scan.

scan 4:  extensive photoreceptor integrity loss, though less than that of scan 3.

scan 5:  looks like relatively normal retina.

Here's the graphical overlay map of her macular thickness.  It's colored blue due to the unit determining that her macular thickness is far below others her age, when compared to the normative database.

 Here is a look at the 3D manipulation tool the Cirrus offers, of this cone dystrophy patient:

 

 

 

 This scan is part of the advanced imaging tools.  Skip ahead to about the 38 second mark.  (The defect actually starts at the :57 second mark.)  You can actually see the cone outer segment defect as the scanning line passes through the area.  It is a remarkable view of the macula in a top down view.

Keep in mind all of the above data was achieved with a single scan that took around 3 seconds.

 

Just for kicks, have a look at how the older imagers used to look.  Many of these are still in use today, due to the large price tag of the newer units.

 

These older scans are no fun to view, due to the low rez, but do still have some clinical usefulness.

Cone dystrophy is difficult for general eyecare practitioners to diagnose, but HD or spectral domain OCT can sort it out rather quickly.  Ultimately, all retinologists would prefer to have an ERG as well as a fluorescein angiography to have a definitive diagnosis.  Although, I'm confident OCT imaging will have a much larger role in detection of this rare disorder.  

Family history, color vision testing, and genetic research (family history) can aid in this diagnosis as well.


Friday
May132011

epiretinal membrane with Cirrus imaging

This is a good example of an epiretinal membrane causing a patient some issues.  The ERM, or epiretinal membrane, is a sticky substance, made up of leukocytes, protein, inflammatory debris, that is "hyper-reflective."  It is in the top most part of the video that appears to be a bridge over the various valleys of the scan.  We use the term "hyper reflective" in regard to certain elements of OCT scans, since we are only using a non-invasive, near infrared light source.  This is in contrast to fluorescein angiography, which requires an injectable dye, intra-venous.  In regard to angiography, we use the term "hyper fluorescence," since the dye itself is what is illuminated in an angiography.  See if you can spot the ERM in the video.