I can’t believe I’ve been  at the Hampton VAMC in Southeast Virginia for 2 months already.   I have been learning and doing so many things that the time feels like it just flies by.  One of the big highlights in the past month has been my first exposure to Grand Rounds at the VA.  And not only did I have to attend it, but I was the star!  As part of the educational portion of my disease/low vision residency I actually teach continuing education to local optometrists that have been out in practice for 20+ years!! Talk about intimidating to someone who hasn’t even gotten a copy of her diploma in the mail yet!   To make things a little more complicated, I had to find actual patients who were willing to come in, be dilated and sit as guinea pigs for grand rounds.  Luckily, one of my routine exams during my third week was a patient already diagnosed with Retinitis Pigmentosa.   I had never seen anyone with RP before so I was looking forward to him coming in.  He had the typical RP symptoms, but his fundus didn’t look quite like the bone spicules I’d been taught about at school. 

I decided to learn more about RP and use this patient as my grand rounds presentation.  I was also able to recruit one of our low vision patients with more typical RP to sit as a patient as well to show the diversity of the disease.  I worked hard to deliver a presentation that would be interesting, educational, and most importantly not bore these experienced ODs!  I am happy to say that the presentation went really well and I’m very proud of all the hard work and effort I put into it.  I now know more about RP than I knew I could, and I can say that not only am I a doctor, but also a continuing educator!

has been wonderful! These 6 weeks have been super busy, but really exciting! I’m living on Mud Island and am enjoying the beautiful summer scenery along the Mississippi River! As a 2010 graduate of the UAB School of Optometry, making the transition from student to doctor has been fun! The only exception would be obtaning a Tennessee license. My advice to new grads – apply for your state license asap. The process is not difficult, but sorting through the required paperwork can be time consuming.

I wanted to wait to blog until I could tell you all about a “typical day” in the life of an SCO Pediatric Resident. That being said, I still haven’t had a “typical” day! During this summer semester, I spend most days involved in direct patient care (ie – doing comprehensive eye exams). I’m learning quickly that I love this job! I often get the privilege of being my patients’ first optometrist. So many young patients are apprehensive about eye exams because they think I’m going to give them a shot – little do they know, I’d be the first one to pass out in that scenario! When I’m not in the resident’s suite, I’m usually downstairs in the Vision Therapy Clinic. I have a lot to learn about VT, but the staff docs, student interns, and patients have all been extremely welcoming and helpful! I’ve really enjoyed my time there!

Today, I had the opportunity to travel to a local charter school and perform eye exams… in a motorhome! It was the coolest thing! There were two compact exam “lanes,” each complete with a phoropter, acuity chart, slit lamp, BIO, etc. Patients got to leave class and climb aboard our traveling eye center. For patients who needed glasses, VSP provided a complete pair of eyewear at no charge. The kids had so much fun mingling through the optical area and trying on glasses for each other. For many of them, it was their first eye exam. I know we made a huge impact in the lives of two previously uncorrected high myopes. I look forward to participating in a similar local program (SAVE – School Advocates for Vision and Education) once a week during the fall semester.

I’ve also been busy traveling the world with my fellow residents. We were able to travel to Jacksonville, FL for Vistakon’s TVCI, which is always impressive. We learned a lot about bandage contact lenses, new options in daily disposable lenses, and incorporating contact lenses into pediatrics. Last weekend, we were invited to attend the GPLI (Gas Permeable Lens Institute) Residents Conference. I honestly think I doubled my RGP knowledge in just a few days! Next up in the world of optometric travel – Puerto Rico in October for COVD, where I’ll be presenting a poster about the effects of ocular dominance on sports. (Did I mention – I love this job?!) I’m looking forward to many more not-so-typical days at SCO!

I’ve been meaning to post about an interesting case that I had this week. The problem is that I’ve had several interesting cases and I couldn’t decide which one to share with you all. FINALLY, after much debate, I decided to share with you the tale of the man with a painful right lower lid.

Wednesdays are great at the Salem VA eye clinic. The morning is spent in rotations, journal club, lectures, or- as the case was today- administration time. I had a nice chunk of time to catch up on some much needed work like looking over part of the lecture I have to give with Dr. Tara next week, reading up on my case that I’m putting together for the Academy meeting in November, and reviewing all the carotid ultrasounds that I have ordered. We all see patients in the afternoons on Wednesday; my schedule was not overbooked, which was a nice relief! Glancing ahead at what was to come, I noticed that I had two full eye exams, one dilation, one pressure check, and a walk-in for a “painful lower lid”. I hit the jackpot! One full exam and the one pressure check thought that they didn’t need their eyes checked, so they decided not to show up for their appointments. The other full exam was quite easy. The dilation was no big deal. It was the hordeolum that threw me off my game this afternoon.

Don’t get me wrong, I can handle a painful nodule with no problem, it was his history of glaucoma and his pressures of 19 and 47, right eye/left eye, that had my brain turning. My attending, Dr. Musick, walked in my exam room just as I was beginning to take his pressure reading on his left eye. My slow head turn, big eyes, and scrunched up eyebrows tipped her off that something was definitely not normal. I check the pressure twice after that… same thing. Obviously I requested that she quadruple check my readings. She measured a 48, big difference, I know.

Cue grand exit from the exam room to find glaucoma drops. Iopidine at 1432 (military time–> 2:32pm), timolol at 1441, dorzolamide at 1458, Travatan Z at 1508. Rechecked his pressure at 1532: 47. My thought: “you’ve got to be kidding me.”

Luckily, the Salem VA has an exceptional glaucoma specialist as the chief of ophthalmology, Dr. Li, who consulted with Dr. Musick and me and the best way to approach the patient’s care. In my head I was thinking we should give him some oral acetazolamide (2-250mg tablets), and that’s what Dr. Li suggested. At this point I’m also thinking, “how late are we going to have to keep this guy if his pressures don’t go down?” Oh yeah, and, “did I put the right order in for Keflex for his stye?”

Two acetazolamide tablets and a trip to the pharmacy to pick up his Keflex later his pressure was 37, so a reduction of 10mmHg 30 minutes after his dose.

Pressure lowered, go us. The tale is not over (it never is with me, is it?). The type of glaucoma that this patient was diagnosed with was pseudoexfoliative glaucoma… pseudoexfoliation seems to be following me lately. The patient had previously been on maximal medical therapy for glaucoma, then had a combination cataract surgery/endoscopic cyclophotocoagulation (ECP) in 2008 to reduced his aqueous production to HOPEFULLY keep his IOP low. Sometime around this time period he had 360 degrees of ALT to try to increase the drainage of the aqueous to HOPEFULLY keep his IOP low. Obviously neither of these procedures worked very well.

Differentials for unilateral increased IOP? Dr. Musick was thinking something inflammatory was going on, like a trabeculitis. I was thinking something more pseudoexfoliative-related, like pseudoexfoliative material in the angle. Gonioscopy showed some material on the inferior peripheral edges of the iris, but the angle was wide open and not overtly clogged up. Mr. Patient was definitely mister patient because he sat there with a gonioscopy lens on his eyeball for about 4 minutes while I messed around with my camera to get a picture of his angle and the white material hanging out on his iris. I did get a picture, but it’s on my camera, not uploaded yet, and it’s a bit blurry. But I was on 25 magnification and was using my digital camera, don’t knock my attempt. :) I might post it if I can enhance it a little. I know you are just dying to see it.

Anyway, we (Dr. Li, Dr. Musick, and me) sent him on his merry way with a prescription for acetazolamide (2-250mg po, because the VA does not have 1-500mg po on its formulary). He is to come back within two weeks to return to the care of his usual ophthalmologist, Dr. Eliason, who is absolutely phenomenal in his patient care. Not that I was bad or anything…

So my hordeolum patient left 2 hours later, still happy as could be. Except for the painful bump that was the reason he came in the first place, but we’re working on that.

-Dr. Meg

Today Dr. Davis and I were assigned to the SAVE mobile unit.  Vision Service Plan (VSP) had cooperated with the local Memphis Non-Profit to allow the Vision Care office on Wheels to travel to the Soulsville Charter School here in Memphis.  The Soulsville Charter School is adjacent to the STAX record company museum and has a goal of helping inner city students get the best education possible.  The youngest patients we saw were sixth graders up to grade twelve for the older patients.  Students were evaluated for refractive errors and ocular disease.  If eyeglass prescriptions were needed optical staff were on hand to assist them in choosing frames and placing their order.  CBS affiliate Memphis Channel 3 was there to cover the event.  Working with the students who were so grateful to be seen was really rewarding.  I was proud to be a part of something  bigger.  I felt like I was making a contribution to Memphis in a neighborhood that was really in need.

On August 13, 2010 the Gas Perm Lens Institute sponsored the National Resident’s Meeting here in Memphis.  As a pediatric resident I was unsure of how gas perm lenses would fit into my area of interest.  I was suprised about all the products and options that are now available.  I was intrigued by the possibility of myopia control with corneal reshaping lenses for the pediatric population.  Most of the visiting residents from out of town were focusing on the cornea and contact lens.  It was a great opportunity to meet other doctors with similar ideas and goals.  My favorite part of the symposium was the breakout session that allowed us to fit presbyopes that had never been fit with gas perm lenses.  The patient my group worked with was able to leave wearing the gas perm lenses with 20/20 distance vision, 20/20 near vision and a confidence that these lenses were fitting well.  This seemed as easy (maybe easier) than fitting soft multifocals from an inventory set.  Several manufacturers had been able to take the patient’s refraction and keratometry readings and design a lens for us to use for fitting that day.  I was amazed that there were several lenses that would have been a great beginning place for her.  Dr. Bennett, Dr. Quinn, Dr. Ames, Dr. Norman and Dr. Byrnes provided lectures to lay down the framework of what we would see in the hands on workshops.  All of these doctors were very knowledgable about different stategies and products for fitting success.  The group had dinner at the Rum Boogie Cafe on Beale street.  There was an Elvis sighting later that night.  Saturday the group went to B.B. King’s Itta Bena resturant where there was a sighting of football legend Terry Bradshaw.  Later that evening a small group stole away to Graceland to pay tribute to the king of rock and roll and to buy tacky souveniers.  It was a successful weekend.  I came away with updated knowledge about gas perm lenses and many good ideas to use in the future with my pediatric and adult patients.

Vistakon held a meeting in Jacksonville, Florida for the residents.  Continuing education covered topics on new products, pediatrics and contact lenses, the residents role in making the transition from student to teacher and grand rounds.  Working with optometric heroes Walt West and Lou Catania was exciting and challenging.  The patients they had brought in for us were to encourage “out of the box” thinking for bandage contact lenses.  My favorite take home pearl was, sometimes we get too focused on visual acuity  and we miss pain management and quality of life issues that patients are struggling with.  I will be a more compassionate doctor after attending this seminar.

My expectations for Memphis in July at the new residency were met with only a few surprises.  Memphis is hot.  Parents want their children’s eyes examined and new eye wear ordered before the beginning of school.  Opportunity to do well visits and encounter challenges in developmental problems has presented time and time again.

A typical day starts at 8:30 for patient care.  My patients are scheduled on the hour and progress amazingly well through the machine that is SCO’s primary care clinic.  Second year students interact with the pediatric patients by obtaining blood pressure, autorefractor and non-contact tonometry.  I am checking for refractive, eye health and learning related visual problems.  I am able to make in house referrals for visual training evaluation and developmental testing.  I have full access to technology and electrodiagnostic testing if it is needed.

My background is in primary care.  There are many willing faculty members on hand to assist in the duties in the Vision Therapy department.  There have been stroke victims, traumatic brain injuries and many vision developmental cases.  I know I will have a lot of experience with learning issues and strabismus after working with patients and students in this clinic.  I immediately rolled up my sleeves and got down to business in the Vision Therapy clinic.  An autistic child that was really excited about his therapy accidentally poked me in the eye.  Antibiotics, a bandage contact lens and several days later I had recovered from my corneal abrasion.  I learned the valuable lesson about personal space and have navigated the challenges successfully without any more injuries.

I am enjoying the professional camaraderie with the other residents.  It is great to discuss cases and different approaches that can be taken to solve problems.  My decision to take a year off from my primary care practice and focus on expanding my skills with children has proved to be worthwhile so far.  I am excited about starting school screenings next month.  My poster on Fetal Alcohol Syndrome was accepted for COVD.  I will be forced to present it in Puerto Rico in October.  I am also counting calories and exercising in preparation for my SCO twenty year class reunion.  Does anybody have a PORSCHE I can borrow?  I never would have dreamed I would be back at SCO doing residency at this milestone.  I am counting it as both a reward and a blessing.

You know, I figured potential applicants might want to know what my experience is like in the Roanoke valley.  This blog post has nothing directly related to eyeballs, but, no worries, I’ll have a new eyeball-centric blog next Monday most likely.

The Salem VA is a fantastic residency program, inside and out.  The people are all great, and they really do push us to go beyond our comfort level and speed because Dr. Tara and I have to get better and faster.  If we don’t, we end up eternally behind and somebody might go blind because we missed something subtle.  So, yeah, the program is amazing.

What makes my program better than some of the other incredible sites SCO has to offer?  Roanoke is so much fun!  I think there might be something for everyone in this town… cliché? Maybe, but I sincerely believe it.  Where to start?

I live in an apartment that is 5 minutes from everything I need: a Panera for some awesome soup and sandwiches, a Barnes & Noble for some fluff reading/hot tea, 5 different RedBox locations, 3 different Krogers, a gym, a mexican restaurant, a Subway, etc, etc.  It’s amazing!  I lived on Mud Island in Memphis and I always got frustrated for having to drive 15 minutes to a Walmart or 10 minutes to a McDonald’s.  Now, everything is at my fingertips.  I love it.

What have I been doing with my time away from the VA hospital?  I joined Gold’s Gym and have been taking Zumba and BodyCombat classes.  Anyone who knows me really well is probably tired of listening to me rant and rave about how much fun my exercise classes are, but I never get tired expressing my excitement.  Zumba is totally fun!  Go to Zumba By Sara for a little taste of the fun I’ve been having.  BodyCombat is a mix of kickboxing and Tae Kwon Do set to current hits.  Think lots of squats, lots of kicking, and (for Sunnie Ewing in the SCO Student Services department) if you like the Pirates of the Caribbean there is one section where you do sword play set to the theme music.  Really exhausting, let me tell ya, but in a good way!

I’ve also joined a church in the area (or am in the process of joining, rather).  No matter your religious affiliation it seems that just about everyone is represented here in Roanoke.  I’m Methodist, so I found a great new church home at Cave Spring United Methodist Church.  I’ve been asked to join the choir (haha, fat chance), and I’ve been asked to work with the youth group (I might do that), but so far I’ve given blood at their Red Cross blood drive.  It’s a start, right?

Another thing about me that lots of people know is that I love to socialize.  Roanoke is a fairly progressive town.  Downtown has lots of unique shops and incredible restaurants.  If you like to dance then there are several great DJs turning the tables at night.  If you like fresh produce then you should check out the fully stocked farmers market; I haven’t been yet, but Dr. Tara has as well as senior intern Carli and they just raved about it.  Actually, Dr. Tara and I have a couple of things on our to-do list: a) go to the gigantic Roanoke Star, b) go to a couple of museums downtown, and c) go to a Salem Red Sox baseball game.  I’m not a Red Sox fan, but I love minor league baseball so I’m not opposed to supporting my least favorite franchise.

Did I mention how great the people are here in Roanoke?  The attendings in the eye clinic at the Salem VAMC truly make for an incredible experience.  These staff optometrists really go out of their way to make you feel at home and comfortable, like you are a part of their family.  Dr. Eckermann goes the extra mile to make sure you are 100% in charge of and involved with your patient’s care– ordering carotids, reading MRIs, coordinating outside-VA referrals with an inpatient’s attending doctor, or trying to get an acute NAION patient a waiver for his copayment because a resident didn’t think to take a picture on the day the patient presented from the ER (I don’t recall which resident’s patient that was, but it might have been mine, maybe, possibly).  Dr. Musick is all about the tips and tricks of CPRS (the electronic health record program for the VA) and helping ease your patient load when every patient shows up and you’re running behind.  Dr. Slagle will spend 20 minutes working with you in trying to see an asymptomatic shallow retinal detachment in the superior periphery that you missed (again, I’m not sure whose patient this was, but it might have been mine again).

I’m finished gushing about how much I love the Salem VA and Roanoke; I’ve written a novel again.  And no blog is complete without a picture, so I leave you with a picture of my dining room wall.  The pictures shows my optometric past, maybe you can have a wall like this sometime soon and maybe your optometric future could include a residency also.  Consider Salem.  I’m 97.6% sure you won’t regret it.

-Dr. Meg

PS- Dr. Tara and I survived last week’s one-attending-fully-loaded-schedule extravaganza with no problem.  And I was on-call again this weekend.  I did not get a single page Friday-Sunday, but I did get one from the ER this afternoon.

When I was looking over my printed schedule two weeks ago and saw “implant came loose” as the reason one patient was coming in, my first thought was, “the front desk must have messed up, that can’t be right”. My first tip to all you readers out there is: never think badly about the front desk clerks before actually seeing the patient come through the door.

When the man came in on his motorized chair saying he couldn’t see anything except a “big black bubble floating around” I thought, “shenanigans”. My second tip to all of you: “don’t discount the patient before actually looking into his eyeball”.

In all seriousness, I doubted the possibility that his intraocular lens implant dislocated and was actually floating in his vitreous because it is such a rare occurrence (no, I don’t have incidence or prevalence data to back up that statement). I checked the man’s VAs and he was 20/400 at 2 feet. Then I use the slit lamp to take a look at the IOLs to find that his right eye pupil had dense fibrosis arcing through it. This fibrosis moved, too! Not normal!

So, I grab my attending and tell him that I think the IOL is dislocated completely and suggested we run a b-scan to visualize the location of the implant. Dr. Gary Nadolsky was a resident at the Mountain Home VA while I was doing a rotation there, and I was basically mimicking what he did when he had a patient like mine– I can’t take credit for wanting to do a b-scan all on my own. Anyway, my attending took a look at the lens and agreed that it could be free floating.

My first b-scan was not pretty, and I did not necessarily follow protocol on beginning scans in a certain orientation first, but I got the job done- and I have since read up on the proper way to perform a b-scan. I wish I had a video that showed the IOL floating in the anterior vitreous then moving posteriorly to appear to be resting on the retina, but all I have to offer you is two pictures showing different locations and orientations of the same lens, which is attached to the bottom of this post.

Because of what my attending and I saw on the b-scan, we felt it was best to dilate the patient since the implant seemed to be bumping around on the retina. With dilation I was able to see the man’s IOL floating and tumbling (not fully, but pretty darn close to fully tumbling). My attending also noticed the presence of pseudoexfoliative material around the implant, which got us, namely my attending, making the connection between it and his zonular dehiscence and his dislocation. Kanski actually mentions that patients with pseudoexfoliation syndrome are more at risk for complications during cataract surgery and for “spontaneous decentration or dislocation of the IOL”. My third and final tip to you readers out there in cyberspace: Kanski knows all.

I referred my patient to our area specialists for a consult for a possible lens exchange using an anterior chamber implant. A letter came back and the ophthalmologist agreed with our assessment- the patient is scheduled for an a-scan and lens exchange within the month.

Funny note, the patient reported that his vision got better at times when it floated into position along his visual axis, but it was mostly just a big black bubble that he could draw out since he’s been looking at it so often recently.

Oh, and let me make a quick note about our Wednesday rotation in the retina clinic two weeks. The other resident and I got to try our hands at performing fluoresceins. There was only one patient who needed a fluorescein that morning and he pretended to pass out on me after I performed his IV injection for his fluorescein angiography. Haha, so thanks to that 63 year old veteran for making my heart stop for a half second last Wednesday. All in a day’s work!

My next post will be about surviving my first week with a fully loaded schedule and only one attending for two residents and two interns. Actually, I haven’t decided what I will post next, but just know I will try to make it more entertaining than this week’s installment. And click on that share link below this post to get the word out on all of these resident blogs! Oh, and “Dr. Tara” promises she is going to post very soon!

-Dr. Meg

We are already a month into the new year’s program and things are going great. Both the pediatric and vision rehabilitation residents and vision thearpy and rehabilitation resident are picking things up at lightning speed. They are all been working with the staff doctors in vision therapy and have jumped in without looking back!
Ragna (VTR) has been out to the Star Center several times and is learning the ropes from Dr. Schlesselman. Star Center is the multi-disciplanary rehab site located in Jackson, TN at which we provide low vision care several times per month. She has already requested several new pieces of equipment to assist in the care process. In August, she will take over responsibilites of patient care at the Clovernook Rehab facility in downtown Memphis.
Kelley and Angela in the fall are getting prepared to shadow a pediatric ophthalmologist both in surgey and in the office. Kelley has promised that she won’t pass out but we will have a chair close by just in case.
All three residents have recently gotten word that there posters have been accpeted to COVD and are starting preparations for the ardous trip to Puerto Rico. They, along with Michael, the primary care resident have signed up for applied concepts courses. These are two day intensive courses taught by some of the most respected VTODs in the world.