Wednesday, April 16, 2014

"Too Conservative" in Medicine

THIS ARTICLE hit the twitterverse today. It's the California Optometric Association's recommendations for dealing with the itchy, watery eyes from seasonal allergic conjunctivitis: "Use “preservative free” lubricating eye drops: while antihistamines can help with typical symptoms like runny noses and sneezing, doctors of optometry warn those medications can make ocular symptoms worse by reducing tear quality and quantity. The COA recommends using “preservative free” eye drops, or if you wear contact lenses, rewetting drops. Apply a cold compress: using a cold compress on the eyes will provide quick, temporary relieve from itching and redness by constricting the blood vessels that are releasing histamine in the eyes. Take contact lenses out each night: removing contact lenses and cleaning them every night can keep them free of pollen. Wear large sunglasses: Protecting your eyes when you are outside can keep pollen from getting into your eyes and irritating them. Wash your face and hair each night: If you wake up each morning with eye allergy symptoms, try washing your hair and face (especially around the eyes) each night to rinse out pollen and allergens. Take fish oil supplements: omega-3 fish oil also has anti-inflammatory properties that can help reduce redness and irritation. Maintain a healthy diet: foods rich in anti-oxidants including, spinach, kale, broccoli carrots and red peppers, help to improve the immune system and combat the symptoms of eye allergies." This stuff drives me insane. So for ocular itching, redness and watering from seasonal allergies, the C.O.A. recommends artifical tears, cold compresses, washing your face, omega-3 fish oils and "big sunglasses". Um, no topical antihistamines? I mean there are some topical antihistamines that have been available over the counter now since like 2007 (ketotifen fumarate, available as the brand names "Alaway", "Zaditor" and others) that absolutely work AWESOME for this. INSTANTLY stops itching and watering and associated redness from airborne in less than 30 seconds, with a 12 hour duration of action. No mention of this in the article. I distinctly remember having an argument about this exact scenario with a supervising doc I had at SUNY. We had this lady who was MISERABLE from obvious ocular allergy. I wanted to Rx Patanol (the leading Rx antihistamine at the time). He said "no". He was actually quite appalled that I wanted to "leap" so quickly to a medication when this problem clearly should be treated initially with artificial tears in his opinion. REALLY? Really. He was serious. Well let me tell you: artifical tears don't do SQUAT for ocular allergy. "Palliative" care at best. Come on, man! We know what the problem is! Gosh why are we making this so hard? Just Rx the dang antihistamine. THAT'S WHAT IT'S FOR! It's not like it's dangerous or something! I ended up going behind his back (oops) and giving her samples of it anyway instead of his worthless artifical tear idea (#rebelOD). I feel like a lot of my optometry collegues do whatever they can to be as conservative as possible, and I don't understand why. This problem (seasonal allergic conjunctivitis) has an OVER-THE-COUNTER solution! Why are we messing around with telling them to wash their face and wear big sunglasses? Is this a joke? I mean it's embarassing to the profession. Or at least *I* am embarassed by this article. They came to you with a problem that is (on paper) easy to solve. We know what the problem is and we have a cheap, OTC fix for it. Why avoid topical antihistamines? The article mentions that oral antihistamines can "reduce tear quality". WHO CARES? I mean it sounds to me like they're probably more worried with the itching, watering and redness, no? Fix the problem. Stop beating around the bush. "Maintain a healthy diet", the article says. Um...I'm sorry but that is holistic nonsense. Eating foods "rich in antioxidants" is NOT NOT NOT going to solve your itchy, red, watery eyes. Not in the short term and not in the long term, either. Who comes up with this stuff? This is not (in my opinion) medically sound advice. This also makes it sound like it's somehow the patient's fault that that they are allergic to pollen. If they would have only eaten healthier this wouldn't have happened, right? It's just a lack of kale and broccoli in their diet, right? No. It's allergy. Treat it with antihistamines. I mean how is this not painfully obvious? Well, it is to me. Sorry, C.O.A. (and my supervising SUNY doc circa 1999). To quote Donald Trump: "YOU'RE FIRED!".

Monday, March 31, 2014

Absolutes in Medicine

I recently got in a "twitter war" with some UK keratoconus support groups over some false things they were tweeting. I probably shouldn't have bothered and nobody wins those things, but I have a problem with "fear-mongering". These people fevently believe, and repeatedly tweet to their hundreds of followers, that "eye rubbing" CAUSES keratoconus. It doesn't. Keratoconus is a poorly understood GENETIC/inherited corneal degenrative condition. People who have keratoconus can make their condition worse and progress faster by rubbing their eyes, but they did not initially acquire keratoconus solely by rubbing their eyes. That is false, no matter how many times those 2 support groups tweet it. You have to have a "susceptible cornea", AKA already have a weakened cornea from inheriting the gene for keratoconus, in order for "eye rubbing" to be a factor. So blasting out to everyone worldwide that "EYE RUBBING CAUSES KERATOCONUS! DO NOT EVER RUB YOUR EYE! ALL EYE RUBBING IS BAD!" is just irresponsible, even if you fervently believe it to be true (it's not). I call this "fear mogering". Someone somewhere will read that and get all scared that one time they saw their 4 year old rub their eyes when they were sleepy and NOW THEIR SON WILL DEVELOP KERATOCONUS! This stuff really happens. I get patients like this all the time. "DOCTOR! LAST NIGHT I SLEPT IN MY CONTACTS AND MY LAST EYE DOCTOR TOLD ME TO NEVER EVER EVER SLEEP IN THEM! SO I AM HERE BEFORE YOUR OFFICE OPENS JUST TO CHECK AND SEE IF EVERYTHING IS OKAY!" Well, yes. You're probably okay. Use some common sense here. As I tweeted to these people: "most of the time for most people, 'eye rubbing' does not cause anything, certainly not keratoconus". Well the piling-on began and I got multiple tweets with lay-person's definitions of what keratoconus is. Uh, yes thanks I fully understand keratoconus. I just disagree with fear-mongering EVERYONE EVERYWHERE with the false statement that if they EVER rub their eye they will get it, which is what these support groups repeatedly tweeted. Of course when I chime in to correct them I was attacked. I was even called "rude" for arguing the point, because if all health care providers worldwide don't agree with the 1100 followers of those 2 support groups, they must of course be rude people. When I jokingly asked the moderator/tweeter/blogger if they felt remorse for "causing" their own keratoconus by "eye rubbing", (since they argue that eye rubbing causes keratoconus and it is also NOT genetic/inherited) they responded with "it's not about whose fault it is! I don't know why I got keratoconus because neither of my parents had it!!!". Well unfortunatley that is a statement from a person who does not understand genetics. There is a lot of bad info out there on the internet: GPC is misdiagnosed as "dry eye", myopia progression is OFTEN blamed on "too much reading/computer use", and eye rubbing "causes" keratoconus...those are just a few examples of wrong/incorrect statements about eye care on the net. There is even a group out there who I have mentioned before that claims optometrists are literally "to blame" for worldwide myopia. Just because someone out there tweets/blogs something about health care does not make it true. Heck even health care professionals disagree, as I've blogged about before. In short: use common sense. Does common sense say that sleeping in your contacts ONE TIME will cause a corneal ulcer? Does common sense say that reading too much causes you to need glasses? And does common sense say that rubbing your eyes, in and of itself in the absense of any genetic predisposition, CAUSES keratoconus? Be careful about thinking in "absolutes".

Tuesday, February 18, 2014

The M.D.'s Guide to Eye Conditions

Poking a little fun at medical doctors here

Sunday, January 26, 2014

Private Labeling of Contact Lenses

So here's something everyone in the optometry field knows but few patients do: some vision places have "private label" contact lenses. It's kind of portrayed as an "exclusive house brand" available only from your eye doctor. Only it's not. They're the exact same...THE EXACT SAME (or super, uber similar) contact lenses that are available everywhere else, repackaged and renamed. Why do this? Why do you think? Money. The optometrists who do this don't want you to be able to buy contacts online or really anywhere else but from them. They portray it as a "safety" issue (because they won't sell you 16 boxes at once, etc) but of course it's really a money issue. As you can probably tell from my tone in this post, I am not a fan. Patients HATE being told where they have to buy their contacts, and rightly so. Does the doctor who prescribes your blood pressure meds sell you those meds? No. Does he/she tell you where to buy them? No. Do they repackage/rename the contacts to FORCE you to buy from them? No. So why do we do it? I don't know. It's stupid. Let me tell you something about contact lenses in 2014: there's not much money in it. When you buy a box of contacts from us, we generally make between $4-$10. The markup is so low thanks mostly to WalMart and 1800-CONTACTS that it's barely worth our time. It's really *NOT* worth our time at all once you factor in our overhead. So why even sell contacts at all? Mostly convenience. Seriously. Back in the 80's optometrists were making big bucks on contact lens sales, but not now. They're a commodity. It's just convenient to sell them so we still do. So why be so controlling and force patients to buy private label lenses? I honestly don't know why docs still do this. Patients hate it, there's no money in it, and the chairtime of explaining the idea to skeptical patients cannot be worth it. We don't do it at our office. When I write a contact lens Rx I tell the patient straight up: "you have the right to buy these anywhere lenses are sold". Sometimes I "lose" the sale because of this. So what? It has to be better than risking having the patient think you're "up to something" by prescribing them some brand they've never heard if. Which, technically the patient is right: you ARE up to something. The big culprit in this scheme is the contact lens manufacturer Coopervision. They repackage and rename their best sellers and make them available as "house brands" at WalMart ("Ultraflex" which is the old Biomedics line and "Equate" which will likely be an entire line of lenses from Biofinity down to Coopervision dailies) and "premier" brands like "Clearsoft" (again, old Biomedics) and AquaClear (Avaira and Biofinity) sold only at Vision Source practices. If it sounds shady, it is IMO. This is one of the reasons I don't fit a lot of Coopervision products anymore...that and I honestly think they do not have a superior product in any of the contact lens modalities (dailies, monthlies, biweeklies, torics, multifocals, etc) right now. Someone has them beat in every category at this moment IMO. I just think the whole thing is shady and too much work/explanation to horde the $4/box contact lens profit for. If you need the money that badly, go up on your fees instead of trying to stick the patient with your "house brand" because you get the sale and will make an extra $28/year or whatever. I had a discussion about this with a friend of mine who is not a patient. His doc (Vision Source) fit him in their private label lens even after he requested a different brand name. When he asked why, the doc apparently couldn't give a great answer. He eventually got the lens he asked for (so it probably wasn't a safety/health or fitting problem), but only after an uncomfortable and awkward exchange with the doc. Here's my thought on this: all of that for the possibility of making an extra $30 a year? Man I don't get it. Just give them what they want (within reason) and don't try to saddle them with your repackaged Cooper private label lens just because it gives you control over where they buy it and how much they buy it for. Optometry and Coopervision: stop the private label game. But I doubt they will stop. It's about the money...for Coopervision.

Wednesday, January 22, 2014

My Tumblr Account

Opened a Tumblr account. Pretty interesting. I might change over but for now I'm just playing with it. So far I like it better than this site. We'll see. My 1st post over there is an image I took with our new OCT (laser retinal thickness analyser) of a patient I saw a few weeks ago with Central Serous Retinopathy. Basically fluid under the macula of an otherwise healthy person, usually a young caucasian male, often with a high stress profession. Here's the image also posted over here:

Friday, January 17, 2014

Google Glucose-Monitoring Contact Lens

Google has announced that it is testing a prototype for a contact lens that would help people with diabetes manage their disease. In a press release distributed Thursday, the company said that the lens it is designing would measure glucose in tears continuously using a wireless chip and miniaturized glucose sensor. Google says that using the lenses would be a less invasive method of measuring glucose levels than finger-pricking. It also claims that the more frequent testing would consequently reduce the risks associated with infrequent glucose testing such as kidney failure and blindness. The contact lenses were developed during the past 18 months in the clandestine Google X lab that also came up with a driverless car, Google's Web-surfing eyeglasses and Project Loon, a network of large balloons designed to beam the Internet to unwired places. “We wondered if miniaturized electronics — think chips and sensors so small they look like bits of glitter, and an antenna thinner than a human hair — might be a way to crack the mystery of tear glucose and measure it with greater accuracy,” Google said in its press release. “We hope a tiny, super sensitive glucose sensor embedded in a contact lens could be the first step in showing how to measure glucose through tears, which in the past has only been theoretically possible.” The chip and sensor would be embedded between two layers of soft contact lens material, while a pinhole in the lens would allow fluid from the surface of the eye to seep into the sensor. Palo Alto Medical Foundation endocrinologist Dr. Larry Levin said it was remarkable and important that a tech firm like Google is getting into the medical field, and that he'd like to be able to offer his patients a pain-free alternative from either pricking their fingers or living with a thick needle embedded in their stomach for constant monitoring. "Google, they're innovative, they are up on new technologies, and also we have to be honest here, the driving force is money," he told The Associated Press. Worldwide, the glucose monitoring devices market is expected to be more than $16 billion by the end of this year, according to analysts at Renub Research. The Google team built the wireless chips in clean rooms, and used advanced engineering to get integrated circuits and a glucose sensor into such a small space. Researchers also had to build in a system to pull energy from incoming radio frequency waves to power the device enough to collect and transmit one glucose reading per second. The embedded electronics in the lens don't obscure vision because they lie outside the eye's pupil and iris. Google is now looking for partners with experience bringing similar products to market. Google officials declined to say how many people worked on the project, or how much the firm has invested in it. An early, outsourced clinical research study with real patients was encouraging, but there are many potential pitfalls yet to come, said University of North Carolina diabetes researcher Dr. John Buse, who was briefed by Google on the lens last week. "This has the potential to be a real game changer," he said, "but the devil is in the details." While excited about their prototype, Google warned that there is still a lot more work that needs to be done before it could be turned into a useable product. ---------------------- Here's my thoughts on this: probably a pretty good idea. Will be surprised if this is actually available on the market anytime soon (next 5 years). Also - now endocrinologists will be "prescribing" contact lenses? Great. There's already enough health care providers out there trying to Rx contacts who don't really know what they're doing, but sure let's add another. What could go wrong? I forsee these being PRICY as well. Finger sticks are *CHEAP*. Even after they're available on the market, I personally kind of doubt this tech will take off quickly. Just MO's