How to Qualify For CE Credit | Frequently Asked CE Questions

✅ (1) Listen to each CE episode (0.50hr) - podcasts are available on all major podcast providers for free

✅ (2) Take the quiz afterward by clicking on the respective link for the episode you listened to (Require 70% Passing)

✅ (3) Earn 0.5 hr of Asynchronous COPE-accredited CE per episode listened to & quiz taken!
 
✅ (4) Your 📄 CE Certificate  and CE QR Code will be given instantly if you pass at least 70%. 
 
✅ (5) For instant credit (Required OE Mobile App), please scan QR Code via OE TRACKER Mobile App (FREE or $25 Annual, NOT YOUR CAMERA)
 
✅ (6) Otherwise, please self-submit CE Certificate to your OE Tracker Mobile Tracker and keep certificate for your personal records 
 
⚠️ To see the Max Hours Allowed for Online/Asynchronous for your State-specific requirements, please visit CE State Requirement

⚠️  Passing grade of 70% needed for CE Approval, Unlimited Retakes. Please note that your information will be submitted to ARBO for audit control/record-keeping. 

Asynchronous or distance learning.  To see the Max Hours Allowed for Online/Asynchronous for your State-specific requirements, please visit CE State Requirement

70% is required for passing. As long as you take the quiz by clicking on the respective link for the episode you listened, majority of people will pass. 

⚠️   Unlimited Retakes. Please note that your information will be submitted to ARBO for audit control/record-keeping. 

Nope, as with all other education we provide, it is 100% free!

For majority of the episodes, there are sponsors that offer commercial support, allowing us to do this for free to all doctors! 

Your 📄 CE Certificate  and CE QR Code will be given instantly if you pass at least 70%. 

For instant credit (Required OE Mobile App), please scan QR Code via OE TRACKER Mobile App (FREE or $25 Annual, NOT YOUR CAMERA)

70% Passing Grade Copy

MIGS Complications

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Dr. Jessica Schiffbauer discusses the management of complications associated with minimally invasive glaucoma surgery (MiGs). MiGs, which include procedures like SLT, iStent, and the Zen gel stent, are minimally invasive, have a high safety profile, and require less follow-up compared to more invasive glaucoma surgeries. Complications such as inflammation, IOP fluctuations, and blood reflux are common, especially in patients with a history of uveitis or chronic inflammation. Management involves using antibiotics, NSAIDs, and steroids, and in some cases, pilocarpine or digital pressure. Effective communication with glaucoma specialists is crucial for successful outcomes.

Learning Objectives

  • Better understand MIGS procedures and the management of complications.
  • Highlight the importance of gonioscopy.
  • Discuss open communication with the surgeon performing MIGS procedures, including sending notes and receiving updates on the patient's status.
  • Illustrate postoperative care, especially for signs of inflammation, IOP fluctuations, and hyphema or reflux bleeding.
  • Understand the use of pilocarpine in patients at higher risk of peripheral anterior synechiae.
  • Learn how to better manage IOP fluctuations and hyphema/reflux bleeding.
  • Be aware of serious complications like wound leaks, hypotony, and bleb fibrosis.

Outline

Overview of MiGs and Its Importance

  • Jessica emphasizes the importance of managing complications associated with MiGs.
  • MiGs (minimally invasive or micro invasive glaucoma surgery) involves minimal trauma to the eye, has a modest effectiveness at lowering eye pressure, and a high safety profile.
  • MiGs procedures are typically done in ASCs or office-based surgical suites, requiring less operating room time and being gentler to the eye.
  • Different types of MiGs are classified by their site of drainage, device implanted, and whether they are standalone or combined with cataract surgery or corneal procedures.

Types of MiGs and Their Applications

  • Trabecular meshwork MiGs are reserved for mild to moderate open-angle glaucoma or ocular hypertension, targeting a modest IOP target.
  • Subconjunctival filtration MiGs are for more advanced or severe disease, targeting lower IOP targets and those intolerant to medications.
  • Implantable devices like the iStent, iStent Infinity, iStent inject, Hydrus, and Zen have been available since 2012, targeting different outflow pathways.

Candidate Selection and Patient Communication

  • Good candidates for MiGs include those with ocular hypertension, mild to moderate primary open-angle glaucoma, and those close to needing cataract surgery.
  • Patients with a history of non-compliance, uncontrolled IOP, multiple medication intolerances, or poor response to SLT are also suitable candidates.
  • Emphasize the importance of starting the conversation early with patients about potential glaucoma treatment options, including surgery.
  • Effective communication with glaucoma specialists or surgeons performing MiGs is crucial for managing complications and improving patient care.

Managing Complications Post-Surgery

  • Most MiGs patients are seen a week and a month after surgery, with follow-ups every 5 to 6 weeks to 3 months, typically on antibiotics, NSAIDs, and steroids.
  • Inflammation and IOP fluctuations are common post-surgery, and patients may need to be on drops for longer if inflammation persists.
  • Highlight the importance of identifying different things on gonioscopy, such as peripheral anterior synechiae (PAS) and blood reflux, to manage complications effectively.
  • The use of pilocarpine to manage PAS and the importance of patient education on post-operative care, including avoiding strenuous activities, are highlighted.

Specific Complications and Management Strategies

  • Hyphema and blood reflux are common complications, often seen early post-operatively, and can lead to decreased vision.
  • Educate patients on managing blood reflux, including avoiding strenuous activities and keeping their head elevated.
  • The importance of performing gonioscopy at follow-up visits to identify blood reflux and other complications is emphasized.
  • For severe cases, an anterior chamber washout may be necessary,

Subconjunctival MiGs and Their Complications

  • The Zen gel stent, a commonly used stent, creates a subconjunctival bleb and is effective in managing IOP in advanced glaucoma.
  • Complications of Zen procedures include conjunctival wound leak, scarring, scleral exposure, high hyphema, and choroidal effusions.
  • Discuss the importance of assessing for wound leaks and managing them with antibiotics, aqueous suppressants, and potentially vancomycin contact lenses.
  • Hypotony and choroidal detachments are also common complications, and patients should be monitored closely for these issues.

Fibrosis and Digital Pressure Techniques

  • Fibrosis of the blood in the subconjunctival space can be difficult to identify but can lead to increased IOP.
  • Digital pressure can be performed to promote aqueous outflow and decrease IOP, and patients can be taught to perform this technique.
  • If IOP remains uncontrolled, further management may include blood needling, revision, or anti-fibrolytic injections.

Conclusion and Recommendations

  • Emphasize the importance of developing strong relationships with MiGs surgeons and maintaining open communication to manage complications effectively.
  • The prevalence of glaucoma and the use of MiGs procedures are increasing, and it is essential to be prepared to handle both positive outcomes and complications.
  • Maintain continued vigilance in identifying and managing complications to ensure the best possible outcomes for patients.
70% Passing Grade Copy

IPL and LLLT

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Dr. Sarah Terlesky, an optometrist in Virginia, discusses the implementation and benefits of intense pulse light (IPL) and low-level light therapy (LLLT) in optometry. IPL, which targets chromophores in the skin, has shown significant success for many patients. IPL is effective for dry eye relief, particularly for skin types 1-4, while LLLT, which uses specific wavelengths for photobiomodulation, is safe for all skin types. Photobiomodulation has shown promising results for dry eye, rosacea, and AMD, with personalized treatment plans and careful patient selection being crucial for success.

Learning Objectives

  • [ ] Educate patients on the benefits of IPL and LLLT for dry eye and other ocular conditions.
  • [ ] Implement IPL and LLLT treatments in the practice and follow the recommended treatment protocols.
  • [ ] Utilize before-and-after patient images to help with patient education and treatment conversions.
  • [ ] Discuss light therapy options with both symptomatic and asymptomatic dry eye patients to maximize opportunities.
  • [ ] Ensure that the practice has a designated staff member who is comfortable discussing the pricing and benefits of the light therapy treatments with patients.

Outline

Introduction to Light Therapies in Optometry

  • Sarah discusses the transition from basic dry eye treatments like artificial tears to implementing IPL and low-level light therapy in her practice.
  • The initial concern was getting patients to sign up for treatments, but the response was positive with 20 patients signing up in the first month.
  • Sarah explains the mechanism of action for IPL, targeting chromophores in the skin to reduce inflammation and improve dry eye symptoms.

Mechanism and Adjustments of IPL

  • IPL uses polychromatic, incoherent light pulses at high intensities, typically between 400 to 1200 nanometers.
  • The treatment works by targeting chromophores like hemoglobin and melanin, causing thrombosis and photocoagulation.
  • Adjustments can be made by the amount of pulses, intensity of light, and wavelength filter used, with a three-pulse mechanism and a 590-nanometer filter being common for dry eye treatment.
  • Pulse duration and delay are crucial for preventing epidermal burning, especially for darker skin types.

Patient Selection and Contraindications for IPL

  • Sarah describes the typical IPL patient as a female between 50 to 70 years old, typically Caucasian, with dry eye.
  • The Fitzpatrick scale is used for skin typing, with skin types 1 to 4 being safe for IPL and 5 and 6 (darker skin types) being contraindicated.
  • Contraindications include pregnancy, breastfeeding, recent sun exposure, cancer, medications causing photosensitivity, active infections, and skin types 5 and 6.
  • Sarah emphasizes the importance of asking patients about the use of creams or lotions that may alter skin pigmentation.

Post-Treatment Instructions and Treatment Protocols

  • Patients may experience redness, swelling, and hyperpigmentation after treatment, with hypopigmentation or blistering being rare.
  • Treatment protocol for dry eye involves IPL to the skin beneath the eyes, with optional treatment of the upper eyelids.
  • Sarah recommends overlapping treatment zones by 10 to 20% and applying appropriate pressure to ensure effective treatment.
  • Treatments should be repeated monthly for the first four months, with maintenance treatments varying from three to twelve months.

Introduction to Low-Level Light Therapy (LLLT)

  • LLLT is an emerging treatment option that requires no consumables and no doctor time, making it suitable for technicians to administer.
  • LLLT uses specific wavelengths for a constant period of time at lower intensity, with the irradiance playing a significant role in treatment time.
  • The mechanism of action is photobiomodulation, targeting cytochrome-c oxidase within the mitochondria to activate ATP production and reduce oxidative stress.
  • Wavelengths used include red, infrared, blue, yellow, and green, with red and infrared being particularly effective for healing and neuro regenerative impacts.

Patient Selection and Contraindications for LLLT

  • LLLT is inclusive and safe for all skin types, with fewer contraindications compared to IPL.
  • Contraindications include photosensitive medications, lupus, suspicious lesions or cancer, epilepsy, extreme photosensitivity, claustrophobia, and active infections.
  • Patient selection is similar to IPL, with LLLT being a suitable option for those with recent facial surgery, early to intermediate AMD, and pediatric patients.
  • Sarah shares a case study of a patient with blepharoplasty who used LLLT to speed up healing and improve scar appearance.

Treatment Protocols for LLLT

  • For MGD, patients are advised to come once weekly for four weeks, with a follow-up evaluation within one month of completion.
  • For gland atrophy, treatments are more aggressive, with patients advised to come as frequently as every other day until improvement is seen.
  • For chalazions, treatments are recommended every other day until resolution, with express after each session if necessary.
  • LLLT has been studied and approved for treatment of early to intermediate AMD, with promising results showing disease regression.

Combining IPL and LLLT

  • Sarah explains the differences between IPL and LLLT, describing IPL as the cleanup device and LLLT as the healer.
  • Both treatments serve their purpose, and combining them can lead to faster and longer-lasting results.
  • If cost and contraindications are not a concern, Sarah recommends both treatments for optimal results.
  • For patients with rosacea and MGD, starting with IPL can get them to a better baseline faster, while LLLT can be more suitable for pediatric patients or those with low pain tolerance.

Marketing and Selling Light Therapies

  • Sarah emphasizes the importance of educating patients about light therapies while they are in the exam chair.
  • Evaluating the patient's face for signs of dry eye, rosacea, and age spots can help motivate the conversation about treatment options.
  • Using before and after images of other patients can be a powerful tool to help sell treatments.
  • Sarah advises not to limit light therapies to just symptomatic patients and to use a dry eye rack card to explain treatment options clearly.

Final Tips and Advice

  • Sarah advises not to use light therapies as a last resort and to talk to as many patients as possible about them.
  • Being genuine and not pushy in recommending treatments is crucial for patient acceptance.
70% Passing Grade Copy

Light Adjustable Lenses, Pt. 1: Introduction

Dr. Jeff Banas and Dr. Nick Bruns discuss the Light Adjustable Lens (LAL) technology in a three-part series. The LAL, FDA-approved in 2017 and commercially available in 2019, offers precise refractive adjustments post-cataract surgery. It addresses issues like refractive surprise and dissatisfaction rates of up to 5% with premium IOLs. The LAL can correct up to +/- 2 diopters with 2 diopters of cylinder. Adjustments are typically done bilaterally sequentially, with an average of four visits over six to eight weeks. The technology allows for more customized vision outcomes, reducing patient dependence on glasses.

Learning Objectives

  • [ ] Discuss in-depth the preoperative and postoperative management of the LAL.
  • [ ] Discuss the nuances and art of managing the LAL to maximize its capabilities.

Outline

Introduction to the Light Adjustable Lens (LAL) Technology

  • Jeff introduces the three-part series on the LAL technology, focusing on preoperative, postoperative management, and patient awareness.
  • Jeff and Nick, both optometrists in southeastern Wisconsin, discuss their backgrounds and areas of expertise.
  • Nick shares his experience with the LAL, mentioning its impact on his practice since early 2020.
  • Jeff highlights Nick's extensive experience with the LAL, noting he has performed more treatments than anyone in the country.

History and Evolution of Adjustable Lens Technology

  • Nick explains the LAL's history, noting it was FDA approved in 2017 and commercially available in 2019.
  • The concept of adjustable lenses dates back to the mid-1990s, with early attempts like the fluid inflatable lens.
  • Nick and Jeff discuss the evolution of adjustable lens technology, including the pioneering work by Schwartz and Grubbs in 1996.
  • The first actual implant of a lens was in 1946, highlighting the relatively recent development of modern lens implants.

Challenges and Benefits of Traditional IOLs

  • Nick discusses the limitations of traditional monofocal and toric lenses, noting a success rate of 60-70% for hitting within a half diopter.
  • Jeff and Nick emphasize the dissatisfaction rate among patients with premium IOLs, often due to aberrations and poor visual quality.
  • The LAL addresses these issues by providing more precise and customized refractions, reducing patient dissatisfaction.
  • Nick mentions that unhappy patients with multifocal and toric IOLs are a common topic at major ophthalmology meetings.

Refractive Surprise and Effective Lens Position

  • Jeff and Nick discuss the concept of "refractive surprise," where post-operative outcomes differ from pre-operative expectations.
  • Nick explains the importance of effective lens position, noting even a small deviation can significantly affect the lens power.
  • The LAL allows for adjustments to compensate for these deviations, improving post-operative outcomes.
  • Jeff highlights the benefits of the LAL for post-LASIK and post-corneal refractive surgery patients, who often have irregular corneas.

Basics of the Light Adjustable Lens (LAL)

  • Jeff describes the LAL as a three-piece silicone lens with excellent optics and a large range of adjustability.
  • Nick explains the adjustment process, noting the LAL can correct up to two diopters of cylinder, eliminating the need for traditional toric lenses.
  • The LAL allows for bilateral sequential surgery, making the process more convenient and time-saving for patients.
  • Jeff and Nick discuss the financial implications of bilateral sequential surgery, noting it is more cost-effective for patients.

Adjustment Process and Patient Management

  • Nick outlines the adjustment process, typically involving four visits over six to eight weeks.
  • Jeff and Nick discuss the importance of patient feedback and test driving the LAL in different environments.
  • The LAL allows for multiple adjustments, ensuring patients achieve their desired visual outcomes.
  • Jeff emphasizes the importance of post-operative management, including addressing issues like posterior capsular opacification before adjustments.

Patient Experience and Outcomes

  • Jeff and Nick share their experiences with patients, noting the positive feedback and improved quality of life.
  • The LAL allows for more precise and customized refractions, reducing the need for glasses and improving overall vision.
  • Jeff and Nick discuss the importance of patient involvement in the adjustment process, ensuring they achieve their visual goals.
  • The LAL provides a more flexible and tailored approach to cataract surgery, improving patient satisfaction and outcomes.

Future Discussions and Conclusion

  • Jeff and Nick preview the next episode, focusing on the art of managing the LAL preoperatively and postoperatively.
  • They emphasize the importance of understanding the nuances of the LAL to maximize its capabilities.
  • Jeff thanks the audience for joining the discussion and looks forward to continuing the conversation in the next episode.
  • The session concludes with a commitment to providing valuable insights and practical advice for managing the LAL.
70% Passing Grade Copy

Glaucoma and Retina Billing and Coding

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Dr. Chris Lopez discusses the complexities of billing and coding for glaucoma and retina conditions in optometry. He highlights that only 28% of optometrists bill for visual fields, 28% for OCT of the nerve, 27% for OCT of the retina, 33% for fundus photos, 6% for pachymetry, and less than 5% for gonioscopy. Ophthalmologists bill for these tests at higher rates. Lopez emphasizes the importance of medical necessity and provides detailed reimbursement rates for various tests. He also notes the growing demand for medical eye care due to an aging population and the need for optometrists to expand their roles.

Learning Objectives

  • [ ] Familiarize ODs with guidelines on testing frequency.
  • [ ] Consider increasing use of gonioscopy 
  • [ ] Must document medical necessity.
  • [ ] Be aware of reimbursement for CPT codes.

Outline

Glaucoma and Retina Billing and Coding Overview

  • Dr Chris Lopez introduces glaucoma and retina billing and coding, emphasizing its educational purpose and the use of professional resources.
  • The purpose of the lecture is to clarify confusion and discrepancies in billing and coding for glaucoma and retina, aiming to provide a solid foundation for optometrists.
  • The lecture will focus on glaucoma, retina, and proper billing and coding for posterior segment conditions, excluding ophthalmologic codes, EM codes, S-codes, modifiers, and insurance-related topics.

Billing and Coding Statistics for Optometrists

  • Dr Chris Lopez presents billing statistics for optometrists, highlighting that 28% of optometrists bill for visual fields, 28% for OCT of the nerve, 27% for OCT of the retina, 33% for fundus photos, 6% for pachymetry, and less than 5% for gonioscopy.
  • Ophthalmologists bill for these tests at a higher percentage, with 2/3 billing for visual fields, OCT of the retina, and OCT of the nerve, and 80% billing for OCT of the retina.
  • The increasing number of optometrists and the stagnant number of ophthalmologists indicate a growing demand for medical eye care, which optometrists will need to address.
  • The lecture covers ICD-10 codes, CPT codes, frequency of testing, reimbursement information, and preferred practice patterns for glaucoma and retina.

Glaucoma Codes and Classification

  • Glaucoma codes include open angle with borderline findings, categorized by low risk or high risk, and primary open angle glaucoma (POAG).
  • Low-risk glaucoma suspects have two or fewer risk factors, while high-risk suspects have three or more risk factors.
  • CPT codes for glaucoma include visual field (92083), OCT of the nerve (92133), pachymetry (76514), gonioscopy (92020), fundus photos (92250), and extended ophthalmoscopy (92202).
  • Reimbursement rates for these tests are briefly highlighted

Preferred Practice Patterns and Testing Frequency

  • Preferred practice patterns from organizations like the AAO provide guidelines for testing frequency based on disease stages.
  • The importance of medical necessity and justifying tests for diagnosis or treatment is emphasized, with criteria for Medicare coverage.
  • The lecture covers the importance of documenting medical necessity, patient cooperation, and reliability, and comparing test results to previous ones.
  • The need for optometrists to step up in medical eye care due to the stagnant number of ophthalmologists and the increasing demand for medical eye care is highlighted.

Detailed Discussion on Specific Codes and Reimbursement

  • Visual field (92083) is discussed, with over 2800 CPT codes that may be reimbursed, but the focus is on whether the test is reasonable and necessary.
  • OCT of the nerve (92133) is medically necessary for glaucoma, glaucoma suspects, or optic neuropathy, with no more than two tests per year recommended.
  • Pachymetry (76514) should be performed with handheld units, and the alternative code (92499) may be more appropriate for optical pachymetry.
  • Gonioscopy (92020) is easy to remember, and fundus photography (92250) is typically not covered for routine screening but for monitoring disease progression or guiding treatment.

Additional Codes and Reimbursement Details

  • Serial tonometry (92100) is not commonly used, with most carriers requiring three tests over a six-hour span.
  • Corneal hysteresis (92145) is not covered by Medicare due to the low quality of evidence, despite its potential as a risk assessment tool.
  • Extended color vision (92283) is gaining steam in glaucoma management, as many glaucoma patients have color vision defects.
  • Extended ophthalmoscopy (92202) is highly audited and requires a detailed drawing, with reimbursement rates being poor.

ERG and SLT Codes and Reimbursement

  • Electroretinography (ERG) is not covered for primary open angle glaucoma but may be covered for other diagnoses like retinal diseases.
  • Selective laser trabeculoplasty (SLT) is covered for various glaucoma types and conditions, and has a global period of 10 days.
  • The safety of optometric laser surgery is highlighted, with a complication rate of 0.001% based on a study.
  • The introduction of direct SLT, a non-contact, automated procedure, is expected to increase the number of SLT procedures performed by optometrists.

Retina Codes and Reimbursement

  • OCT of the retina (92134) should not be performed more than one test per couple of months for non-active treatment patients and no more than one test per year for hydroxychloroquine users.
  • Extended ophthalmoscopy of the retina (92201) requires a detailed drawing and is not medically necessary if the condition is unchanged.
  • The lecture concludes with a reminder of the importance of medical necessity and the need for optometrists to step up in medical eye care due to the increasing demand and the stagnant number of ophthalmologists.
70% Passing Grade Copy

Plaquenil Overview

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Hosted by Dr. Chris Lopez and Dr. Sam Valley, this episode discusses hydroxychloroquine, its uses, side effects, and role in eye care. Introduced in 1955, hydroxychloroquine is used for malaria treatment, prophylaxis, and autoimmune diseases like lupus and rheumatoid arthritis. Key dosing guidelines are 400 mg weekly for malaria prophylaxis, 800 mg initially followed by 400 mg at intervals for malaria treatment, and 200-400 mg daily for autoimmune diseases. Monitoring for toxicity involves visual field testing, OCT retina, and other assessments. Risk factors include dose, duration, age, renal function, and genetics. Effective communication with rheumatologists is crucial for patient care.

Learning Objectives

  • Communicate with rheumatologists and other prescribers about hydroxychloroquine patients, including documenting therapy duration, dose, and risk factors.
  • Establish a good relationship with a local clinical pharmacist for guidance on hydroxychloroquine and other medications.
  • If signs of toxicity are detected, discuss them with the prescribing rheumatologist, as alternative medications may be available.

Outline

Introduction and Overview
The education focuses on hydroxychloroquine, its uses, side effects, and role in eye care. Dr. Valley highlights its importance in current practice and the need for communication with rheumatologists.

Historical Context and Uses of Hydroxychloroquine
Dr. Lopez provides a historical overview of hydroxychloroquine, its origins in malaria treatment, and development from quinacrine and chloroquine. The discussion covers its use in treating autoimmune conditions like lupus and rheumatoid arthritis. The evolution of hydroxychloroquine from a malaria treatment to a staple in rheumatology is highlighted. Its use during the COVID-19 pandemic and pharmacology, including its mechanism of action and classification as a DMARD, are briefly mentioned.

Pharmacology and Dosing of Hydroxychloroquine
Dr. Lopez explains the pharmacology of hydroxychloroquine, focusing on its mechanism of action in suppressing tumor necrosis factor alpha. The concept of a narrow therapeutic window is introduced, stressing the need for close monitoring. Dosing guidelines for malaria prophylaxis, treatment, and autoimmune diseases are detailed, including the importance of weight-based dosing. Clinical pearls on dosing discussions with patients and the significance of actual body weight are covered.

Potential Side Effects and Toxicity
Dr. Valley outlines common side effects of hydroxychloroquine, including gastrointestinal disturbances and skin reactions. Major toxicities, such as ocular toxicity (Plaquenil maculopathy) and cardiac toxicity (QT interval prolongation), are discussed. The concept of cumulative toxicity and the significance of reaching 1000 grams of hydroxychloroquine in seven years are explained. Risk factors, including dose, duration of use, age, renal function, and genetics, are detailed.

Monitoring and Testing for Hydroxychloroquine Toxicity
Dr. Lopez discusses the importance of monitoring Plaquenil patients and the role of visual field and OCT retina testing. CPT codes and reimbursement details for these tests are provided, along with typical visual field defects and OCT findings. Less common tests, such as multifocal ERG and fundus autofluorescence, are mentioned as potential tools for early detection. The importance of repeating tests before making medication adjustments and the role of microperimetry and adaptive optics in future testing is highlighted.

Guidelines and Best Practices for Managing Plaquenil Toxicity
Dr. Valley summarizes the AAO's guidelines for baseline and follow-up testing, emphasizing early detection. Higher-risk criteria for toxicity, such as high dosage, long-term use, and renal dysfunction, are discussed. The role of continued care with rheumatologists and the importance of intra-professional communication are stressed. The irreversibility of Plaquenil toxicity and the need for proper documentation and communication with prescribers are highlighted.

Case Study and Practical Insights
Dr. Valley shares a case study from a VA clinic, underscoring the importance of communication between prescribers and optometrists. Dr. Lopez discusses personal experiences with Plaquenil toxicity and the role of communication in managing these cases. The need to balance the risks and benefits of long-term hydroxychloroquine use is discussed, with a focus on early detection and communication with rheumatologists. The episode concludes with a summary of key points and a reminder of the importance of proper documentation and communication in patient care.

70% Passing Grade Copy

Opening a VT Practice Cold

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Dr. Mikey Lynn Zilnicki, co-owner of Twin Forks Optometry, shared insights on cold starting a vision therapy practice. Key decisions include whether to focus solely on vision therapy or offer full-scope services, accepting insurance, and whether to include an optical. Miki emphasized the importance of aligning practice goals with personal values and cautioned against over-investing in advanced technology initially. She detailed the costs of starting a practice, which was around $250,000 for her, and highlighted the benefits of virtual vision therapy during COVID-19. She also discussed the importance of precise documentation for workers' compensation and no-fault cases.

Learning Objectives

  • [ ] Determine the long-term vision and goals for the practice.
  • [ ] Decide whether to accept insurance and which insurances to accept.
  • [ ] Evaluate the need for an optical department within the practice.
  • [ ] Assess the essential equipment required to start a basic vision therapy practice.
  • [ ] Explore virtual vision therapy options and platforms, such as HTS and Eye-Hero, to accommodate patients who cannot attend in-person sessions.

Outline

Starting a Vision Therapy Practice: Initial Considerations

  • Miki introduces herself as the co-owner of Twin Forks Optometry, a vision therapy and rehabilitation practice.
  • Emphasizes the importance of deciding the long-term vision for the practice and reverse engineering goals to create the desired space.
  • Highlights that no two vision therapy practices are alike and stresses the importance of personal goals and values in shaping the practice.
  • Stresses that the job should fuel life, not be life itself, and outlines the first step in starting a vision therapy practice: defining goals and values.

Deciding on the Practice Scope and Insurance

  • Miki discusses the decision of whether to focus solely on vision therapy or to offer full-scope services, including primary care.
  • Explains the insurance debate in the vision therapy community, noting that many insurances do not cover vision therapy or do so at low rates.
  • Describes the challenges of being on insurance panels, including the risk of being busy but not profitable.
  • Shares their decision to accept three major insurances (Medicare, Blue Cross Blue Shield, and Aetna) and the limitations of Aetna's coverage for convergence insufficiency.

Handling Workers Compensation and No Fault Cases

  • Discusses the additional paperwork and systems required for workers compensation and no fault cases.
  • Emphasizes the importance of precise documentation and the potential risk of being subpoenaed for records or testimony.
  • Shares their experience of handling these cases and the benefits of being on insurance panels.
  • Highlights the importance of having systems in place to manage these complex cases effectively.

Deciding on an Optical and Building Relationships with Local Opticians

  • Miki and her partner decided not to have an optical in their practice, focusing instead on building a specialty care vision therapy practice.
  • Explains the decision based on local competition and the abundance of optical options in their area.
  • Describes their approach to building relationships with local opticians to ensure proper prescription fulfillment.
  • Highlights the benefits of these relationships in creating lifelong patients and maintaining high standards of care.

Equipment and Cost Considerations for Starting a Vision Therapy Practice

  • Miki references an article she wrote detailing the costs of opening a cold start vision therapy practice, which was around $250,000.
  • Emphasizes the importance of distinguishing between what is needed versus what is wanted in terms of equipment.
  • Lists essential equipment for a vision therapy practice, including an exam lane, auto refractor, lensometer, and possibly a fundus camera.
  • Recommends using a manual phoropter over a digital phoropter for better binocular assessments and flexibility in vision therapy exercises.

Advanced Vision Therapy Equipment and Technological Advancements

  • Discusses advanced vision therapy equipment such as the VTS four, Synaptec, and Vision Integrator.
  • Highlights the benefits of these technologies in providing comprehensive vision therapy and sports vision training.
  • Shares their decision to invest in the VTS four and gradually add other equipment as the practice became more profitable.
  • Emphasizes that while advanced equipment is nice to have, it is not necessary to start a vision therapy practice.

Navigating Virtual Vision Therapy and COVID-19 Impact

  • Miki initially resisted virtual vision therapy but was forced to adopt it during COVID-19.
  • Describes their approach to conducting virtual sessions, including setting up home vision therapy studios for patients.
  • Highlights the limitations of virtual therapy but acknowledges its benefits for patients who cannot attend in-office sessions.
  • Mentions other virtual vision therapy programs like HTS and Eye Hero, which are effective for certain patients and conditions.

Final Advice and Encouragement for Starting a Vision Therapy Practice

  • Miki encourages aspiring vision therapists to go for it, emphasizing the high demand for vision therapy services.
  • Reviews key questions to consider when starting a practice, including the long-term vision, insurance acceptance, and equipment needs.
  • Advises against analysis paralysis and stresses the importance of taking action to open the practice.
70% Passing Grade Copy

Hypertension & Cholesterol - An Ocular Look

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

The discussion focused on the interplay between hypertension, cholesterol, and cardiology, emphasizing their implications for ocular health. Key points included the ASCVD risk calculator, which evaluates factors like blood pressure and cholesterol levels. Hypertension treatments were detailed, highlighting thiazide diuretics (e.g., hydrochlorothiazide) and their side effects like dry eye. ACE inhibitors (e.g., Lisinopril) and ARBs (e.g., Losartan) were also discussed, noting their effects on blood pressure and potential side effects like dry cough. Calcium channel blockers and beta blockers were mentioned for their roles in hypertension and arrhythmia management. The conversation also covered statins for hyperlipidemia, their benefits and rare side effects like myopathies. Finally, the discussion touched on medications for congestive heart failure, including loop diuretics and potassium-sparing diuretics, and their potential ocular side effects.

Learning Objectives

  • [ ] Review the ASCVD risk calculator and understand how it can provide insight into a patient's risk of cardiovascular events.
  • [ ] Be aware of the potential ocular side effects of thiazide diuretics, such as photosensitivity, angle closure glaucoma, and dry eye, and be prepared to communicate with prescribers about medication changes if the side effects are severe.
  • [ ] Recognize ACE inhibitors and ARBs on a patient's medication list and understand that they are being treated for hypertension.
  • [ ] Be aware of the potential increased risk of glaucoma associated with calcium channel blockers, although more research is needed to establish a causal relationship.
  • [ ] Monitor patients taking amiodarone closely for the development of corneal deposits and optic neuropathy, and communicate any findings to the patient's cardiologist.
  • [ ] Be aware of the potential ocular side effects of other antiarrhythmic medications, such as dry eye and vision changes, and communicate these to prescribers.
  • [ ] Communicate with primary care and cardiology providers about patients taking medications that may have ocular or visual implications, even if the patient is not experiencing any adverse effects, to build stronger interprofessional relationships.

Outline

Hypertension, Cholesterol, and Cardiology Overview

  • Speaker 1 introduces the meeting's focus on hypertension, cholesterol, and cardiology, emphasizing their importance to eye care providers and patients.
  • The discussion will cover medications for these conditions, their implications for ocular and visual health, and clinical pearls for interprofessional communication.
  • Speaker 1 highlights the overlap in medications used for these conditions and the importance of concomitant use.
  • The ASCVD risk calculator is introduced as a tool for evaluating patient risk factors for cardiovascular complications.

Hypertension: Factors and Treatments

  • Speaker 1 explains the factors that determine a hypertensive patient's risk for ocular events, including disease severity, duration, and treatment status.
  • First-line therapies for hypertension are discussed, including thiazide diuretics, ACE inhibitors, and ARBs.
  • Thiazide diuretics, particularly hydrochlorothiazide (HCTZ), are explained in detail, including their mechanism and common side effects like photosensitivity, angle-closure glaucoma, and dry eye.
  • Clinical pearls for managing HCTZ-induced dry eye are provided, emphasizing the importance of medication changes if symptoms are severe.

ACE Inhibitors and ARBs

  • Speaker 1 discusses ACE inhibitors, explaining their mechanism of blocking the enzyme that converts angiotensin I to angiotensin II.
  • Common ACE inhibitors are listed, along with their side effects, including photosensitivity and a dry, lingering cough.
  • A case study is presented to illustrate the importance of interprofessional communication in identifying and managing side effects of ACE inhibitors.
  • ARBs are introduced, with a focus on their mechanism of blocking the angiotensin receptor and their lack of ocular or visual side effects.

Calcium Channel Blockers and Beta Blockers

  • Calcium channel blockers are discussed, including their classification into dihydropyridine and non-dihydropyridine subclasses.
  • The potential ocular side effects of calcium channel blockers, such as glaucoma, are mentioned, along with the need for more data to confirm causation.
  • Beta blockers are briefly covered, noting their use for rate and rhythm control of the heart and their lack of significant ocular or visual side effects.
  • The importance of checking for beta blockers and other anti-arrhythmia drugs when prescribing topical glaucoma medications is emphasized.

Hyperlipidemia and Statins

  • Speaker 1 transitions to discussing hyperlipidemia, emphasizing the importance of cholesterol levels in estimating cardiac risk.
  • The role of statins in treating hyperlipidemia is explained, with a focus on their mechanism of reducing low-density lipoproteins.
  • Common statins are listed, along with their most common adverse effect, ocular surface disease, and the rare but serious side effects of myopathies and rhabdomyolysis.
  • The importance of interprofessional communication in managing statin therapy and identifying severe adverse events is highlighted.

Cardiology: Anti-Arrhythmic Medications

  • Speaker 1 introduces the topic of cardiology, focusing on medications used for different types of heart disease and arrhythmias.
  • Class I anti-arrhythmics, also known as sodium channel blockers, are discussed, along with their common side effects of dry eye and vision changes.
  • Class II anti-arrhythmics, or beta blockers, are briefly covered, noting their use for both hypertension and arrhythmias.
  • Class III anti-arrhythmics, or potassium channel blockers, are discussed, with a focus on amiodarone and its side effects of corneal deposits and optic neuropathy.

Non-Dihydropyridine Calcium Channel Blockers and Other Medications

  • Class IV anti-arrhythmic medications, or non-dihydropyridine calcium channel blockers, are discussed, with a reminder of their potential to cause open-angle glaucoma.
  • Other medications used to treat arrhythmias, including adenosine and digoxin, are briefly covered, with a focus on their ocular side effects.
  • The importance of monitoring patients on digoxin for visual changes and ensuring timely discontinuation if adverse events occur is emphasized.
  • The discussion transitions to congestive heart failure, with a focus on the use of diuretics and their potential side effects.

Congestive Heart Failure and Diuretics

  • Speaker 1 explains congestive heart failure as a chronic condition leading to the heart's inability to pump blood effectively, resulting in fluid buildup in the body.
  • The role of diuretics in managing congestive heart failure is discussed, with a focus on loop diuretics (furosemide and bumetanide) and potassium-sparing diuretics (Spironolactone).
  • The potential side effects of loop diuretics, including elevated blood glucose levels, are mentioned, along with the importance of monitoring for vision changes.
  • The importance of interprofessional communication in managing patients on diuretics and identifying side effects is emphasized.

Closing Remarks and Clinical Pearls

  • Speaker 1 emphasizes the role of eye care providers in the patient's care team, highlighting their ability to advocate for patients and communicate with other healthcare providers.
  • The importance of sending notes to primary care and cardiology to keep them informed about patients' status and potential side effects is reiterated.
  • Speaker 1 concludes the meeting by thanking the listeners and expressing hope that they gained valuable clinical insights.
  • The meeting ends with applause, indicating the end of the discussion.
70% Passing Grade Copy

Diabetes Management

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Dr. Sam Valley, who holds both an OD and PharmD degree, discusses the role of eye care providers in diabetes management, emphasizing interprofessional communication and continuity of care. Key points included the common use of metformin for type 2 diabetes, its adverse effects like nausea, and strategies to improve patient adherence. Sulfonylureas, such as glipizide, glyburide, and glimepiride, were highlighted for their risk of hypoglycemia. GLP-1 agonists, like ozempic, were discussed for their effectiveness in controlling blood glucose and reducing cardiovascular risks, despite potential ocular side effects. The importance of monitoring patients on these medications was stressed, especially for those using them for weight loss.

Learning Objectives

  • [ ] Educate patients taking metformin to take it with food to reduce GI side effects.
  • [ ] Recommend glucose monitoring to providers prescribing GLP-1 agonists for weight loss due to risk of hypoglycemia.
  • [ ] Monitor patients closely if aggressively decreasing blood glucose leads to worsening of microvascular changes initially.

Outline

Diabetes Medications and Their Impact on Eye Health

  • Dr. Valley introduces the episode's focus on diabetes, including medications, their effects on the eyes, and the role of eye care providers.
  • Emphasis on interprofessional communication and the need for improved efficiency and continuity of care in the healthcare system.
  • Overview of the episode's structure: clinical overviews by disease state, with a focus on medications affecting the eyes.
  • Introduction to the first class of diabetic medications, biconids, specifically metformin, and its common use in type 2 diabetes.

Medication Reconciliation and Metformin Usage

  • Discussion on medication reconciliation, defined as reviewing the patient's medication list for accuracy and pairing each medication with a disease.
  • Common adverse effects of metformin, such as nausea, vomiting, and diarrhea, and strategies to improve patient adherence, including taking the medication with food.
  • Importance of documenting diabetes as a diagnosis if a patient is taking metformin, even if well-controlled.
  • Mention of off-label use of metformin for polycystic ovary syndrome (PCOS) and similar dosing recommendations.

Sulfonylureas and Their Clinical Pearls

  • Introduction to sulfonylureas, including glipizide, Glyburide, and glimepiride, and their use as second-line or combination therapies with metformin.
  • Clinical pearls: potential allergic reactions in patients with a sulfa allergy and the risk of hypoglycemia due to these medications.
  • Importance of recognizing sulfonylureas and their mechanism of action, which can lead to hypoglycemia.
  • Scenario of a diabetic patient presenting with sudden vision changes and the need to rule out hypoglycemia if using sulfonylureas.

DPP-4 and SGLT-2 Inhibitors

  • Overview of DPP-4 and SGLT-2 inhibitors, their use as third-line add-ons to diabetes therapy, and common medications in these classes.
  • Mention of specific medications like Januvia, Sitagliptin, and Invokana, and their lack of significant ocular implications.
  • Brief discussion on the importance of recognizing these medications and their relation to diabetes.
  • Transition to the next topic: injectable GLP-1 agonists, which are currently a hot topic in diabetes management.

GLP-1 Agonists and Their Clinical Significance

  • Introduction to GLP-1 agonists, including ozempic, trulicity, and semaglutide, and their effectiveness in controlling blood glucose for type 2 diabetic patients.
  • Discussion on the potential for worsening of microvascular diabetic complications, including diabetic retinopathy, due to aggressive blood glucose control.
  • Importance of staying the course with treatment and monitoring patients more frequently if worsening occurs.
  • Positive outcomes of GLP-1 agonists in reducing cardiovascular risks, as shown in recent studies.

Weight Loss and GLP-1 Agonists

  • Discussion on the use of GLP-1 agonists for weight loss and the need for close monitoring due to the lack of insurance coverage for glucose meters and continuous testing tools for non-diabetic patients.
  • Importance of interprofessional communication to educate providers about visual symptoms and recommend more regular glucose testing.
  • Studies showing the effectiveness of semaglutide in reducing body weight and returning patients to normal glycemia, with significant outcomes.
  • Emphasis on the importance of due diligence by prescribers and eye care providers in identifying and managing patients at risk for adverse events.

Insulins and Their Clinical Implications

  • Introduction to insulins, including mealtime and long-acting insulins, and the importance of documenting their use in diabetic patients.
  • Brief overview of different types of insulins, including rapid-acting, short-acting, intermediate-acting, long-acting, and ultra-long-acting insulins.
  • Importance of recognizing the use of insulin and documenting it in patient records.
  • Discussion on the risk of hypoglycemia and visual changes due to rapid decreases in blood glucose levels.

Monitoring and Managing Insulin-Dependent Patients

  • Importance of close monitoring by prescribers and interventions by eye care providers to ensure positive patient outcomes.
  • Recognition of insulin dependence in both type 1 and type 2 diabetic patients.
  • Brief list of common insulin names, including rapid-acting insulins like aspart and lispro, and long-acting insulins like insulin degludec and Glargine.
  • Emphasis on the need for interprofessional communication and collaboration in managing insulin-dependent patients.

Conclusion and Final Thoughts

  • Recap of the episode's focus on diabetes medications, their effects on the eyes, and the role of eye care providers.
  • Emphasis on the importance of interprofessional communication and continuous care in improving patient outcomes.
  • Final thoughts on the need for close monitoring and intervention by healthcare providers to ensure the best possible outcomes for diabetic patients.
  • Encouragement for continued education and collaboration among healthcare professionals to enhance patient care.
70% Passing Grade Copy

Norms & Expectations in PreOp Prep

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Josh Davidson, an optometrist at Williamson Eye Center, discussed norms and expectations in preoperative prep for cataract surgery. He highlighted that 60-80% of cataract patients have ocular surface disease (OSD), which affects post-surgery satisfaction. Davidson emphasized the importance of treating OSD before surgery to prevent vision and safety issues. He noted that routine preoperative lab tests are unnecessary, citing studies that found no benefit. Davidson recommended tear osmolarity, MMP-9 tests, and staining for preoperative workups. He also stressed the need for optometrists to educate patients about surgical options and preoperative hygiene.

Learning Objectives

  • [ ] Test all cataract patients for dry eye and treat any issues found before referring for surgery.
  • [ ] Discuss dry eye risks and treatment strategies with patients. Recommend pre-surgical hygiene kits if needed.
  • [ ] Consider delaying surgery if dry eye is present to optimize ocular surface first.

Outline

Introduction and Purpose of the Meeting

  • He outlines the course's objectives, including highlighting research on preoperative prep guidelines and patient behaviors.
  • Josh mentions the high number of cataract surgeries performed annually in the U.S. and the issue of patients not utilizing recommended diagnostic tests and treatments for ocular surface disease (OSD) before surgery.
  • He explains the risks patients face if OSD is not managed before surgery, including vision, comfort, and safety issues.

Incidence and Impact of Ocular Surface Disease

  • Josh discusses the incidence of OSD in cataract patients, estimating it to be between 60% and 80%.
  • He cites an ASRS survey showing that even mild to moderate dry eyes affect patient satisfaction after cataract and refractive surgery.
  • Josh emphasizes the importance of optometrists handling preoperative care for cataract patients, given the high prevalence of OSD.
  • He highlights the effectiveness and safety of cataract surgery, which is the most commonly performed operation in the Medicare population.

Historical Context and Evolution of Preoperative Testing

  • Josh recounts the 1993 guidelines from the Agency for Healthcare Policy and Research, which recommended comprehensive medical exams and laboratory testing for cataract surgery.
  • He explains that a survey from that time showed that many surgeons ordered preoperative tests out of institutional requirements or medico-legal concerns rather than clinical necessity.
  • Josh discusses the 1994 study initiated by the Agency for Healthcare Policy and Research, which found that routine medical tests with lab work before cataract surgery were unnecessary.
  • He mentions that subsequent Cochrane reviews and updates in 2009 and 2012 confirmed the findings, leading to the discontinuation of routine lab testing before cataract surgery.

Role of Optometrists in Preoperative Care

  • Josh emphasizes the importance of optometrists referring cataract patients to ophthalmologists and ensuring that patients with OSD are treated before surgery.
  • He shares his experience of seeing many patients with substantial OSD who have never been told about it by their previous eye doctors.
  • Josh stresses the importance of treating OSD before surgery to improve patient outcomes and satisfaction.
  • He explains that if dry eye is discussed before surgery, it is considered the patient's problem, but if it is discovered after surgery, it becomes the surgery center's issue.

Preoperative Workup and Testing Recommendations

  • Josh recommends a dry eye workup for all cataract patients, including tear osmolarity readings, MMP-9 tests, and staining with lissamine green and fluorescein strips.
  • He suggests using non-invasive tear breakup time measurements and other advanced diagnostic tools to assess the ocular surface.
  • Josh explains the importance of objective data in patient education and the potential for referral centers to send tough dry eye patients to optometrists for preoperative treatment.
  • He advises optometrists to delay surgery if abnormal readings or symptoms indicate OSD and to educate patients about the importance of a healthy ocular surface.

Treatment of Dry Eye and Its Impact on Cataract Surgery

  • Josh discusses the importance of treating OSD before cataract surgery to improve patient outcomes and reduce infection risks.
  • He mentions studies showing that untreated OSD can lead to dissatisfaction with cataract surgery and postoperative dry eye symptoms.
  • Josh recommends preoperative prophylactic treatments, such as artificial tears, warm compresses, and hypochlorous acid solution, to improve biometry results and surgical planning.
  • He highlights the need for optometrists to be aware of the diagnostic tools and guidelines available to manage OSD before surgery.

Patient Expectations and Misconceptions About Cataract Surgery

  • Josh references a 2022 study by Miss Amy Helm, which found that only 6.1% of patients expect perfect vision after cataract surgery and that many are afraid of surgery.
  • He explains that patients often delay seeking care for cataracts, leading to a more desperate state when they finally seek treatment.
  • Josh discusses the importance of addressing patient fears and educating them about the benefits and risks of different cataract surgery options.
  • He emphasizes the need for optometrists to be proactive in discussing OSD risks and treatment options with patients.

Preoperative Prep Kits and Patient Compliance

  • Josh mentions a study by Miss Amy Helm, which found that 87% of patients would use a preoperative prep kit if provided, and 83% would buy one if recommended.
  • He discusses the availability of preoperative prep kits and the importance of patient compliance in managing OSD before surgery.
  • Josh highlights the role of optometrists in providing patients with the necessary tools and information to prepare for cataract surgery.
  • He emphasizes the importance of optometrists being knowledgeable about the surgical options and the preoperative needs of their patients.

Final Recommendations and Conclusion

  • Josh provides recommendations for preoperative care, including discontinuing certain medications and ensuring patients are well-informed about the day of surgery requirements.
  • He emphasizes the importance of treating OSD before surgery to improve patient outcomes and satisfaction.
  • Josh encourages optometrists to be proactive in discussing OSD risks and treatment options with patients and to be knowledgeable about the surgical options available.
70% Passing Grade Copy

Identifying Bino Vision Disorders

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Dr. Miki Zilnicki, co-owner of Twin Forks Optometry, discusses handling complaints of double vision (diplopia). Key steps include determining onset, frequency, and direction of double vision, which can indicate serious conditions like space-occupying lesions. Imaging is recommended for new onset cases. Visual acuity, extraocular muscle testing, and cover tests are essential examinations. Prism and vision therapy are treatment options, with vision therapy being particularly effective for convergence insufficiency. Proper handling of double vision can enhance patient satisfaction and build practice reputation.

Learning Objectives

  • Address patient double vision complaints thoroughly through history and evaluation.
  • For new onset double vision, consider medical imaging to rule out underlying causes even if the exam suggests accommodative or vergence issue.
  • Consider combination treatment with prism and vision therapy if seeking immediate relief and long term treatment.

Outline

Handling the Chief Complaint of Double Vision

  • Emphasizes the importance of addressing double vision (diplopia) promptly to rule out serious conditions.
  • Stresses the need to understand the onset, frequency, and direction of double vision.
  • Shares a case where a patient with new onset double vision had a small growth in the cavernous sinus, highlighting the importance of imaging.

Key Initial Questions for Double Vision

  • Outlines the first three questions to ask about diplopia: (1) onset, (2) frequency, and (3) direction of double vision.
  • Onset is crucial to rule out serious conditions like space-occupying lesions or uncontrolled high blood pressure.
  • Frequency helps determine if it is intermittent or constant, and the time of day it occurs.
  • Direction can be horizontal, vertical, or diagonal, providing valuable information for the exam.

Detailed Examination and Case History

  • Miki discusses the importance of a thorough case history, including systemic diseases, medications, stress levels, and diet.
  • Visual acuity, extraocular muscle testing (EOM), and cover tests are essential parts of the examination.
  • Emphasizes the need to check for muscle restrictions and any increase in double vision in different gazes.
  • Non-competent cover tests indicate more serious conditions that may require further evaluation through MRI.

Cover Test and Its Importance

  • Miki explains the cover test, including unilateral and alternate cover tests.
  • The unilateral cover test looks for strabismus, while the alternate cover test assesses visual posture.
  • For intermittent double vision, a prolonged cover test is necessary to identify fatigue-related tropias.
  • Vertical deviations require careful observation, including head position and eyelash movement.

Von Graff Phoria and Binocular Ranges

  • Miki describes setting up the Von Graefe phoria test to quantify deviations.
  • Explains the importance of aligning the patient's eyes and understanding the setup for accurate results.
  • Binocular ranges help assess how well patients compensate for deviations, especially for new onset verticals.
  • The Park three-step method is mentioned for isolating muscle involvement in vertical deviations.

Treatment Options for Double Vision

  • Miki outlines treatment options: prism, vision therapy, or a combination of both.
  • Prism is effective for vertical and esophoric deviations, especially in distance vision.
  • Vision therapy is recommended for convergence insufficiency and intermittent exotropia, addressing the root cause of double vision.
  • Emphasizes the importance of presenting treatment options clearly to patients, explaining the benefits and limitations of each.

Final Advice and Practice Building

  • Miki advises optometrists not to ignore double vision complaints and to address them thoroughly.
  • Highlights the financial benefits of providing effective glasses and the potential for repeat business.
  • Encourages optometrists to refer patients for further medical evaluation when necessary.
70% Passing Grade Copy

Enhancing Patient Care with Anterior Segment Technology

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Dr. Chris Lopez discusses the advancements in posterior segment technology, focusing on four key areas: ERG (Electroretinography), extended color vision, virtual visual field testing, and lasers in optometry. ERG, now a handheld device, assesses retinal function objectively, with protocols like DRA for diabetic retinopathy. Extended color vision tests, quick and subjective, aid in retinal and optic nerve function assessment. Virtual visual fields, performed via headsets, offer convenience and are comparable to traditional tests. Lasers, including YAG capsulotomy, LPI, and SLT, are increasingly used by optometrists, especially in rural areas, despite low ROI, emphasizing comprehensive patient care. 

Learning Objectives

  • [ ] Consider implementing ERG testing into the practice to objectively assess retinal and optic nerve function for conditions like diabetic retinopathy.
  • [ ] Evaluate extended color vision testing for tracking progress in patients with retinal conditions like macular degeneration and diabetic retinopathy. 
  • [ ] Assess virtual visual field devices for testing patients with limited mobility, like those in wheelchairs. They are convenient and less physically demanding than traditional devices. 
  • [ ] Obtain proper training before implementing laser procedures like YAG capsulotomy, LPI, and SLT. Have standard protocols and patient materials ready

Outline 

Enhancing Patient Care with Posterior Segment Technology 

  • Chris introduces the podcast episode titled "Enhancing Patient Care with Posterior Segment Technology," focusing on four topics: ERG, extended color vision, virtual visual field testing, and lasers in optometry. 
  • ERG (Electroretinography) is described as a modern, handheld device that assesses retinal and optic nerve function, providing quick, objective results with a small footprint. 
  • The benefits of modern ERG include its quickness, objectivity, ease of use, and detailed reports, which are crucial for managing retinal diseases like diabetic retinopathy. 
  • ERG protocols include the DRA (Diabetic Retinopathy Assessment), PHNR (Photopic Negative Response), and Flicker 16, each measuring different aspects of retinal function. 

Extended Color Vision Testing 

  • Extended color vision testing is introduced as a method to assess cone receptors, which are responsible for color vision, and can indicate cone damage associated with retinal disorders or optic neuropathies. 
  • The test is quick, subjective, and functional, providing easy-to-interpret reports similar to OCTs, with red, yellow, green indicators for severity. 
  • Applications for extended color vision testing include retinopathy, posterior segment disease, and glaucoma, where color deficiencies are common. 

Virtual Visual Field Testing 

  • Virtual visual field testing is highlighted as a rapidly advancing technology, with headset devices performing visual fields and other tests, such as extended color vision. 
  • The benefits of virtual visual fields include convenience for patients, especially those with physical limitations, and the ability to perform tests in various settings, including wheelchairs. 
  • The technology is also useful for hydroxychloroquine testing, ptosis, and driver's license testing, with applications expanding to include binocular vision tests. 
  • Virtual visual fields are quick, easy to use, and provide comparable results to traditional visual field tests, with a smaller footprint and patient appeal. 

Lasers in Optometry

  • Chris discusses the increasing role of lasers in optometry due to the aging population and the need for more surgeons, with optometrists taking on more laser procedures. 
  • The three main laser procedures are YAG capsulotomy, LPI (Laser Peripheral Iridotomy), and SLT (Selective Laser Trabeculoplasty), each with different settings and energy levels. 
  • Implementing lasers in a practice requires comfort in performing procedures, standard operating protocols, patient education, and trained staff. 
  • The footprint of laser devices is similar to a slit lamp
70% Passing Grade Copy

Enhancing Patient Care with Anterior Segment Technology

👉 Show Sponsor: ODs on Finance Merchant Services, get the lowest average 1.73% effective rate and free POS (up to $200). Click here to get today and save thousands annually. 

Dr. Chris Lopez discusses the integration of anterior segment technology in optometry to enhance patient care. Key technologies include low-level light therapy (LLLT), which has anti-inflammatory properties and improves dry eye symptoms, and intense pulse light (IPL), which reduces inflammatory mediators and improves meibomian gland function. Zest, a product by Zocular, uses okra polysaccharide technology to remove Demodex mites, providing immediate clinical improvement. Anterior segment cameras aid in disease management by improving patient compliance and buy-in for advanced treatments. These technologies offer significant ROI and are often used as cash-pay services. 

Action Items 

  • [ ] Consider implementing low level light therapy in your practice. 
  • [ ] Consider implementing IPL in your practice. 
  • [ ] Consider implementing zest in your practice to treat Demodex and blepharitis. ● [ ] Consider obtaining an anterior segment camera to improve patient buy-in and compliance.

Outline 

Introduction to Anterior Segment Technology in Eye Care 

  • Dr. Chris Lopez introduces the lecture on enhancing patient care with anterior segment technology. 
  • The lecture aims to explore technological advancements in eye care, focusing on anterior segment diseases. 
  • Objectives include understanding the benefits and challenges of incorporating technology into optometric practice. 
  • The focus is on anterior segment, particularly ocular surface disease. NPR Strategy for Technology Integration 
  • Dr. Lopez introduces the NPR strategy: N for nerd (clinical information), P for practical (implementation), and R for revenue (financial impact). 
  • Low Level Light Therapy (LLLT) is introduced as the first technology to be discussed. ● LLLT has been used in dermatology for anti-inflammatory and aesthetic purposes and is now used in eye care. 
  • The mechanism of action involves activating mitochondria to increase ATP, leading to anti-inflammatory effects. 

Benefits and Applications of Low Level Light Therapy 

  • LLLT has shown impressive results in dry eye disease management. 
  • It is non-invasive, painless, and safe, with a spa-like experience for patients. ● LLLT is repeatable, with sessions separated by a few days. 
  • The financial impact varies, but most offices use it as a cash pay offering with a good ROI. 

Intense Pulse Light (IPL) Technology 

  • IPL is the second technology discussed, commonly used in eye care and other medical fields. 
  • IPL works by absorbing light to destroy blood vessels, reducing inflammatory mediators. ● It has anti-inflammatory properties and may have antibacterial effects, reducing Demodex load. 
  • IPL is safe, repeatable, and effective for dry eye disease, blepharitis, and rosacea. Implementation and Financial Impact of IPL
  • IPL is usually performed by doctors but can be delegated to staff or technicians. ● The procedure involves pre and post-procedure steps, with treatments separated by three to four weeks. 
  • IPL devices are moderately sized and require some office space. 
  • Most offices use IPL as a cash pay offering, with a good ROI despite the high cost of devices. 

Demodex Management with Zest Technology 

  • Demodex is an underdiagnosed condition, now receiving more attention due to its impact on dry eye disease. 
  • Zest, a product by Zocular, uses patented okra polysaccharide technology to remove Demodex load. 
  • Zest provides immediate clinical improvement and is safe, repeatable, and non-invasive. ● It is effective for blepharitis, Demodex, dry eye disease, and acne. 

Implementation and Financial Aspects of Zest 

  • Zest is usually performed by doctors but can be delegated to staff. 
  • The procedure takes five to ten minutes and involves a pre-procedure prep. ● Zest kits are affordable and easy to use, with a minimal footprint. 
  • Most offices charge patients out of pocket, avoiding insurance claims and ensuring a good ROI. 

Anterior Segment Camera Technology 

  • Anterior segment cameras are basic but underutilized, with various offerings available. ● The cameras help in disease management by providing visual evidence to patients. ● They improve buy-in for advanced treatment options and enhance patient compliance. ● Anterior segment cameras are easy to use, with a minimal footprint and a CPT code for reimbursement. 

Conclusion and Final Thoughts 

● Dr. Lopez emphasizes the rapid advancement of technology in optometry. ● The lecture aims to highlight financially feasible technologies to improve patient care.