Pearls in Ophthalmology

Volume 5, Issue 1

2010-02-20T16:21:00.000-08:00

Doheny Eye Institute & Jules Stein Eye Institute 5th Annual Comprehensive Ophthalmology Review Course - March 11-14, 2010

OKAP and Ophthalmology Boards

* 10 Pearls to Prepare for Success on the OKAP Exam by Purnima S. Patel, MD

* Golden Pearls for the OKAP Exam by Ashley N. San Filippo, MD and Vinay A. Shah, MD

* How to Approach the OKAP Exam as a First Year Resident by Brad Feldman, MD

* OKAP Preparation Pearls by Sami Kamjoo, MD

* Studying for the OKAP Exam and Written Boards: Follow your personal style of learning by Arlene Bagga, MD

* OKAP/Boards Review Books by Vipul Shah, MD

* What courses are available for OKAP and Board preparation? by Molly Ritsema, MD

Practice & Clinical Pearls

* “Dry” Age Related Macular Degeneration Pearls by Rahul Khurana, MD

* Premium Intraocular Lenses and Astigmatism Management (Podcast) by Rob Melendez, MD, MBA

* Corneal Surgery and H1N1 Flu by David A. Goldman MD and Jonathan Etter MD

Pitfalls in Ophthalmology

* Risk Factors for Retained Nuclear Fragment by Anonymous

Technology Pearls

* Include the EMR in Your Evaluation of A Practice by Craig Wilkerson, MD

* Smartphones in Ophthalmology: Potential Uses of the Smartphone in Your Practice by Vinay A. Shah, MD, Ron K. Lord, MD, and Ashley N. San Filippo, MD

* What's the Buzz About Social Networks? by Andrew Doan, MD, PhD

* Compendium of Useful Ophthalmology Resources on the Web

Business and Management Pearls

* The 411 for 2010 by Lyn Walsh

* Avoid First-job pitfalls: Eight questions to ask a potential employer by Lance J. Kugler, MD

International Ophthalmology

* Foreign Medical Graduates & Ophthalmology Residency Success Stories by Vinay A. Shah, MD

* Entering a Residency in Ophthalmology: My Experience by Florin Grigorian, MD

Ethics Pearls

* How and when do you share with a patient they had a complication during surgery? by Damien Luviano, MD

* Waking Up Blind - Lawsuits Over Eye Surgery - New Book by Tom Harbin, MD

Health and Wellness

* Why Endurance Sports Come Naturally to Ophthalmologists by M. Kelly Green, MD

History of Ophthalmology

* Leonard Apt, MD

Announcement

* Winner of Vol 4 Issue 4 Photo Quiz

Feb 2010 Photo Quiz

What's the diagnosis? - click on image for enlarged view -

Submit your answer and subscribe to Pearls in Ophthalmology. Correct answers will be included in a drawing for a $100 Amazon.com Gift Card. Please include PIO Photo Quiz Feb 2010 in the subject line of your email to webmaster@medrounds.org. Include your name, e-mail, and your current position. By submitting your answer, you agree to the PIO Quiz Official Rules and Regulations.

Do you have a story, interesting article, or eye case? Submit your article to the editor. Contact us to become a Sponsor of Pearls in Ophthalmology or Post Your Job Opening. Pearls in Ophthalmology is published quarterly and is read by thousands of ophthalmology residents, fellows, and ophthalmologists starting their practice. In 2009, Pearls in Ophthalmology received over 73,000 page views.

Winner of Vol 4 Issue 4 Photo Quiz

2010-02-20T15:14:00.000-08:00

We congratulate Vinay A. Shah, MD! Dr. Shah answered morpheaform basal cell carcinoma and wins the $100 Amazon.com Gift Card.

Morpheaform basal cell carcinoma consists of dark blue cells arranged in thin strands and cords. The tumor is locally invasive, and clear surgical margins are difficult to achieve.

Compendium of Useful Ophthalmology Resources on the Web

2010-02-20T15:11:00.000-08:00

Bookmark This Page For Easy Reference

*This page will be updated with new links to resources. Last update 2/20/2010.

Ophthalmology Board Certification

Written Qualifying Examination http://www.abop.org/become/wexam/index..asp

Oral Examination http://www.abop.org/become/oexam/index.asp

News

AAO's YO Info™ Newsletter for Young Ophthalmologists http://www.aao.org/yo/yo_info.cfm

Pearls in Ophthalmology http://www.medrounds.org/ophthalmology-pearls/

AAO's ONE Network with news and educational resources for all ophthalmologists http://www.aao.org/one_passthru.cfm?link=1

AAO's EyeNet with articles and news for ophthalmologists http://www.aao.org/publications/eyenet/

Clinical Resources

Red Atlas (Recognizing Eye Disease) - online ophthalmology atlas http://www.redatlas.org/

Dr. Oetting's Cataract Videos on Facebook http://www.facebook.com/cataract.surgery

Dr. Oetting's Cataract Surgery for Guide for Young Surgeons http://www.medrounds.org/cataract-surgery-greenhorns/2005/09/title-page.html

Dr. Alward's Online Gonioscopy Atlas & Videos http://gonioscopy.org/

Dr. Glasgow's Eye Pathology Review http://www.missionforvisionusa.org/anatomy/2005/10/table-of-contents-for-eye-pathology.html

Dr. Cogan's Online Ophthalmic Pathology & Clinical Atlas http://cogancollection.nei.nih.gov/index.jsp

University of Iowa EyeRounds.org with cases, atlas, and tutorials http://webeye.ophth.uiowa.edu/eyeforum/

University of Michigan's The Eyes Have It with tutorials about eye care http://www.kellogg.umich.edu/theeyeshaveit/

Root Atlas with online videos and tutorials about eye diseases http://www.rootatlas.com/

Ophthobook is an online ophthalmology textbook for medical students and optometry students http://www.ophthobook.com/

Pearls in Ophthalmology YouTube Video Archive http://www.youtube.com/user/Eyepodvideo

Clinical Assessment Questions from the AAO's ONE (listed as "Self Assessments" under Educational Content) http://one.aao.org/CE/Default.aspx

Online Will's Manual for AAO Members (listed under Educational Content) http://one.aao.org/CE/Default.aspx

Dr. Young's Ophthalmology Podcasts http://asseenfromhere.com/

Ophthalmology Review Questions http://www.medrounds.org/ophthalmology-board-review/exam/

ASCRS' IOL Calculator for Post-Refractive/PRK/LASIK Eyes http://iol.ascrs.org/

Essential Optics Review for the Boards (1st Edition Only) http://www.medrounds.org/optics-review/

Macular Degeneration Reference for Patients http://www.medrounds.org/protect-your-sight/

Glaucoma Reference for Patients http://www.medrounds.org/glaucoma-guide/2006/02/table-of-contents-patients-guide-to.html

Online Refraction Tutorial for students, new residents, and clinic technicians http://www.medrounds.org/refract/menu.htm

If you have an internet resource suggestion to be considered for this list, then please e-mail us at webmaster@medrounds.org

Leonard Apt, MD

2010-02-20T15:09:00.001-08:00

Who invented the Apt Test?

The test was developed by Leonard Apt, MD, an American pediatric ophthalmologist.

Who is Leonard Apt?

Dr. Apt is recognized as the founder of academic pediatric ophthalmology. He is the first physician to be board-certified in both pediatrics and ophthalmology. At UCLA, he established the first full-time division of pediatric ophthalmology at a medical school in the United States.

What is the Apt test used for?

The test was originally used to identify the source of bloody stools in newborn babies. It has since been modified to distinguish fetal from maternal hemoglobin in blood samples from any source.

How does the Apt test work?

The Apt test exploits the differences in maternal and fetal hemoglobin. Fetal hemoglobin is resistant to alkali denaturation, whereas adult hemoglobin is denatured under basic conditions. Exposing blood to sodium hydroxide will yield distinct color differences based on hemoglobin viability (adult = yellow, fetal = pink).

*Photo Courtesy of Jules Stein Eye Institute Medical Photography

Why Endurance Sports Come Naturally to Ophthalmologists

2010-02-20T15:07:00.000-08:00

By M. Kelly Green, MD

This is my own personal theory. I have always believed that physicians and surgeons in particular, are drawn to challenging, almost impossible-seeming, feats at work, as well as outside of work. I was a swim team member and chemistry major at Trinity University. I noted that it was often the other math/science/engineering students who swam the mile-long race or did the 200 meter butterfly— both particularly grueling events. And as I continue to participate in such events as the half-Ironman race, or the 25 km trail run through the wilderness, I continue to find myself surrounded by those who enjoy a significant and extraordinary challenge. As a member of a large training group in Austin, TX, I have been joined by physicians from many specialties: neurosurgery, internal medicine, PM&R, and others. I believe that it is our determination, along with our ability to delay gratification almost indefinitely, which suits us for these longer races.

In order to perform well in the half-Ironman race, I began training more than three months ahead of time. I trained 1.5-4.5 hours per day, depending on the day of the week. Usually, there were only 1-2 days per week during which I was not exercising in some form. I also balanced the workouts with the demands of operating; I did not want to enter the O.R. with extremely sore legs, arms, or shoulders which could impede my ability to operate. I was exhausted and had to head to bed quite early to maintain my performance at work the day after a long workout.

Having a perfect (or near-perfect) endurance race is a lot like having the perfect surgery, or the well-run office. As eye physicians, we prepare for each “race” by studying intently for many years, by learning constantly, and staying current with the very latest in technological advances in order to benefit our patients. An endurance athlete calculates her caloric needs and expenditures precisely so that she may replace these calories perfectly. Doing this will help her avoid feeling weak and thus making her unable to finish the race. Similarly, the ophthalmologist makes precise calculations which will determine the plan for a patient’s vision. I believe that each and every day at the office or in the O.R. is like a race for which we have trained tirelessly, and for which we will continue to train, so that we can offer our patients the best in care.

So, if you haven’t tried an endurance sport, and you would like to see just how well-suited you really are to this activity, then get your running shoes on and take off! You will surely find as much or more satisfaction and challenge out there on the trail, pavement, on the bike, or in the pool as you do at work!

Waking Up Blind - Lawsuits Over Eye Surgery

2010-02-20T15:06:00.000-08:00

By Tom Harbin, MD

In the early 1980’s, professors at a highly-respected academic medical center began to notice problems with their gifted chairman, a powerful figure on campus. His patients complained of long delays and rushed exams. His bills to Medicare and insurance companies were suspect. Too often, the tissue that he removed from patient’s eyes showed no sign of the disease that he had diagnosed.

The professors and finally the Dean urged this chairman to mend his ways. He did not. His hurried care of patients was reaping profits for the medical center and his academic pursuits were increasing the center’s prestige. He seemed to know that he’d be protected by the medical center’s top leaders. He was right.

Finally, on a typically rushed day, he operated on the wrong eye of a patient, who eventually went blind from an easily detected and treatable problem. A departmental committee investigation found improper billing, examples of patients’ eyes harmed by neglect, and multiple other problems.

Once again, the university’s leaders paid little heed, approving a committee recommendation that did nothing more than ask its own chairman to slow down. Lawsuits and continued complaints from two faculty whistleblowers prompted a university ethics investigation. The result: exoneration for the chairman and a reprimand for a whistleblower.

Only after a national specialty society ethics investigation and even more lawsuits was the chairman forced to resign. What little was known of the story made headlines at the time, but now the full story is told, backed by court documents, official transcripts, letters and personal interviews.

How and when do you share with a patient they had a complication during surgery?

2010-02-20T14:55:00.000-08:00

By Damien Luviano, MD

http://luviano.com/22143.html

A 59-year old woman with a history of diabetes complains of failing her vision exam during her driving license renewal. She currently only wears glasses to read, but only with minimal improvement. Upon examination, her uncorrected distance vision is 20/100 in both eyes. Her vision corrects to 20/30 with +3.75 sphere in both eyes. Her brightness acuity testing (BAT) is 20/60. Her exam is unremarkable except for +2 nuclear sclerotic cataracts. The conversation between doctor and patient is as follows:

Patient: I have cataracts?

Doctor: Yes.

Patient: Are they going to get worse?

Doctor: Yes.

Patient: Is that why I don’t see well?

Doctor: Yes.

Patient: How can you help me?

Doctor: I can remove the cataract with ultrasound in about five minutes.

Patient: Wow! Do you think I will be able to see better?

Doctor: Yes. In fact, you will probably have 20/20 vision without glasses.

Patient: Really?

Doctor: Yes, but only for driving. If you want to have 20/20 for reading, you have to pay extra for premium lenses, which is about $4,000 for both eyes. In the long run it is cheaper to pay upfront than to buy glasses every year at $500 a pop. Think of the convenience of waking up in the morning and being able to see the time on the alarm clock, read a menu at a restaurant, and drive, all without glasses! It is a small price to pay for your eyes.

Patient: I really can’t afford that right now.

Doctor: Okay, then we will help you see 20/20 for distance.

Patient: When can I have surgery?

Doctor: Likely within the next two week. On the way out, my front desk will give you all the details you’ll need to prepare for surgery.

Patient: What are the risks involved with this surgery?

Doctor: Complications are rare and like any surgery, they include things like infections, retina detachments, etc. The risk is of losing vision is less than 10,000.

POST-OP WEEK ONE: Right Eye 20/25 uncorrected, 20/20 with correction

Patient: Doctor, you are amazing! I never had any pain and now I can see perfectly – already 20/25 without glasses. Just so you know, your lobby is packed with other patients you operated on last week and they are all talking about how good you are.

Doctor: Thank you! Do you think you’re ready to have surgery on the other eye?

Patient: Yes.

POST-OP DAY ONE: Left eye 20/40 uncorrected, 20/30 with correction

Patient: Doctor, why did the surgical center nurse mention that I was back too quick for a “broken capsule?” Is something broken?

Doctor: Nothing is broken, exactly. The bag that holds the plastic lens in the right eye is not intact because it opened during the removal of your cataract. Everything is fine. You see fine.

Patient: I know, I see perfect! My reading is better too, even with weaker readers.

Doctor: Your left eye is doing well too.

POST-OP WEEK SIX: OD 20/30 OS 20/20 uncorrected vision. OD 20/25 and OS 20/20 corrected vision

Patient: Doctor, the right eye is not as good as the left. Why is that?

Doctor: Well, your right eye will be able to see the same as left with a mild prescription of glasses.

Patient: So, what is my vision?

Doctor: Your distance vision without glasses is 20/30 in right eye and 20/20 left eye.

Patient: You promised I was going to be 20/20!

Doctor: I never promised. I said that I would try to help you see 20/20. Also, not all surgeries are perfect, and not all patients heal perfectly.

Patient: Why does my right eye seem so much blurrier if the difference is only two lines between the two eyes?

Doctor: Because the prescription is needed.

Patient: Why is the prescription needed? Because of the broken capsule?

Doctor: You are so smart! Yes, the lens I used could not be placed in the bag, so I placed it in the front of the bag, which changed the prescription.

Patient: I see.

POST-OP WEEK EIGHT: Best corrected OD 20/80. OS 20/20

Patient: I think the right eye is worse. Your office could not get me in last week. Do you think the diabetes is hurting my eyes?

Doctor: I think you are worrying too much about that prescription power. However, I will order a retina scan.

Patient: No, really the vision was clearer in the first weeks of surgery and now it’s definitely more blurry. Even straight lines look wavy now with the right eye.

Doctor: The optical coherence tomography of the retina reveals that you have cystoid macular edema and your best corrected vision is 20/80.

Patient: Both eyes?

Doctor: No, just the right eye.

Patient: The broken thing in the eye, huh?

Doctor: Yes, you are clever.

Patient: Do people with the same broken capsule condition get this macular edema?

Doctor: Some do.

Patient: Maybe we should have done the OCT thing weeks ago.

Doctor: I need to refer you to a retina surgeon.

Patient: For what purpose?

Doctor: Possible injections inside the eye.

Patient: I don’t like the way this is going.

Case Discussion:

Several issues arise in the case above, with all of them revolving around the issue of informed consent and indications of surgery. This case is fictional and includes many issues for educational ethics purposes.

Did the patient need cataract surgery?

Was proper consent obtained?

Is this patient a candidate for premium lenses?

Should this patient have been informed about the broken capsule?

Should this patient been informed that no new lens calculations were made and that an original lens was implanted in the sulcus?

Did the patient have second eye surgery too soon?

Did the surgical staff act inappropriately by mentioning to the patient that she is returning too soon for second eye surgery?

Was the patient promised 20/20 vision?

Did the doctor see the patient at appropriate intervals, given the patient’s history of a broken capsule, diabetes, and complaints of vision issues?

Should surgeons give patients the amount of time it takes to perform a specific surgery?

Did the surgeon use language that a fifth grade student could understand?

Please discuss these questions below.

Entering a Residency in Ophthalmology: My Experience

2010-02-20T14:50:00.000-08:00

By Florin Grigorian, MD

Second Year Ophthalmology Resident
University of Missouri - Kansas City

My journey began in my native country in Eastern Europe where I started a residency in ophthalmology. I realized then how extraordinary this field of medicine was to me. I discovered at the same time that I would like to practice ophthalmology at a higher level, one that would have been impossible with the training, technology, and health system available in my country. This is the reason why I decided to expand my training by pursuing a residency in the United States. There were many colleagues in my class that decided to further their education in the U.S. but none of them in the field of ophthalmology. My mentors in Romania were also very skeptical, even convinced that it was impossible to enter an ophthalmology residency when coming from Romania. Nonetheless, I was very determined to follow my goal and I began taking my first steps in completing this journey.

I realized that in order to succeed, I had to be close to perfection. The first bumps I had to meet were, of course, the USMLE exams. It was indeed very important to have good scores on these exams because my medical school, though prestigious in my country, did not mean anything in the U.S. My assumption was that a person evaluating my application paid more attention to my USMLE scores rather than the name of my medical school. These scores can open a gate: the FMG’s with excellent scores (95 or above) will find it easier to secure interviews. The foreign applicants with less than excellent scores will have a more difficult time in getting interviews, and will have to compensate for this perceived weakness in other areas to make their application stand out. Once I passed through this gate, I believe the weight of the USMLE scores diminished significantly. I was fortunate enough to have excellent scores, but I knew that this was not enough. My application needed more bells and whistles to draw more attention. I thought that my previous ophthalmology residency experience in Europe would be important, but in retrospect, I realize that this experience it is not as critical as I originally thought. Over the years, I met numerous people that graduated from ophthalmology residency programs abroad, but were unsuccessful in securing a residency position here. However, I did not meet a single person that completed a clinical fellowship in the United States that was not successful in securing a residency position afterwards.

Let’s take the example of Pediatric Ophthalmology Fellowship: my wife and I are both former fellows and now we are residents. The fellows that preceded us and those that followed us also got residency positions. The same happened with many other former pediatric ophthalmology-trained people that I met over the years at different meetings. There are no guarantees that one will enter a residency after a pediatric ophthalmology fellowship, but based on my limited experience, the odds are extremely high that one will be successful.

Next, I found myself ready to complete my first application, and I needed something more than my passion for ophthalmology, my previous residency experience, and my USMLE scores. So, I completed a six-week observership at the Wills Eye Hospital that provided me with some U.S. experience and more importantly, a letter of recommendation. Even though the letters of support that I received from Wills Eye were very laudatory and extremely helpful, they still were not enough, as I spent such a short time there. In order to secure a strong letter a recommendation, my advice is to spend enough time in a given place, while also involving yourself hands-on clinical activities. In this regard, a clinical fellowship is an ideal venue.

To summarize the strong points of my first application: USMLE scores, a completed ophthalmology residency, a letter of support from well-regarded U.S. ophthalmologist, and a short U.S. experience at a prestigious institution. Those were enough to grant me 4 interviews but not a position.

What are the reasons for the first failure? Some issues that I mentioned before, namely a lack of significant experience in the U.S. medical system, and also mild letters of support. Another important part of the application process that I believe I missed was participating in volunteer activities. While these are certainly not critical, I do believe they can be very useful. Regardless of my initial failure, I realized you must be willing to improve. Even if there are things of minor importance, continue to strive for the best, as the competition to enter this field of work is intense.

After the first mismatch, I had three options. First was to do an internship and be ready to jump on board in one of the vacancy positions. That was what I did and it gave me the advantage of having a more consistent U.S. experience, another letter of recommendation, some financial security, and an opportunity to exercise my English language.

Second, my option was to enter a clinical fellowship if qualified (ECFMG certificate and completed or near-completed residency overseas) in order to have an even more valuable letter of recommendation, support from more visible people, and more valuable U.S. experience. In other words, this provides a place and opportunity where you can prove yourself as a qualified ophthalmologist, and gain recognition and reward through strong recommendations. The disadvantage lies in that you cannot participate in the selection process for immediate vacancy positions. Ideally, you should combine the first two situations that involve mainly clinical work with a good research background, which can lead to some publications. Research, and especially publications, is a tremendous asset to your application.

Finally, the third solution was to start a research activity and that can take different forms: earn a doctorate, or obtain a basic research position or pre-residency fellowship (pathology fellowship, or other types of research or combined clinical-research fellowship). I considered the research position the best solution and I pursued this in two interviews. The first position was a pathology fellowship at a noted ophthalmology institution. I was very excited about this possibility, but unfortunately I was not successful. The second position was a basic research position, associated with another famous university, where I would receive training in the various techniques of molecular genetics but I chose to pass up this opportunity because I felt it would remove me from the clinic. I instead decided to pursue an internship possibility. I was not able to secure an internship position before the match and I did not want to risk and wait for an after match vacancy. As such, I did participate in the NRMP and I was selected for a categorical internal medicine position instead. That complicated my path quite a bit as I ended with this 3-year commitment.

While I was in my internship, I participated in the SF match process again and I had only one interview. I also applied for vacancies but I was not offered an interview. Both these facts showed me that although I envisioned myself a better candidate with significant progress in my English, more medical knowledge, and a better understanding of the system, I was not considered a good candidate for the selection committees around the country. My work situation, as I mentioned, as well as my family situation was also complicated. I decided to slow down a little bit without renouncing my dream of becoming a resident in ophthalmology in the United States. My wife entered a pediatric ophthalmology fellowship, had numerous interviews, and matched. She came to do the internship in the program where I was a second year resident.

During my second year in America, I faithfully applied for the SF match and for vacancy positions. I had two interviews in the match, but I was unsuccessful again. That showed that my strategy was not good enough and I needed to change it. So, after discussing with my mentors in the internal medicine program, I decided to pursue my ophthalmology dream instead of continuing in internal medicine. I then started applying for fellowship and research positions. My efforts were successful this time and I was invited for an interview for Pediatric Ophthalmology Fellowship and then offered the position that I gratefully accepted. Interestingly enough, a few days after I was offered this position, an e-mail came with an offer for an interview at another fellowship position in a program where I had applied for a residency position but did not get an interview. To me, this proved two things. First, that it is relatively easy to secure a fellowship position if you are reasonably qualified. The fellowship positions in some subspecialties are not as competitive as residency positions, and program directors are looking for suitable candidates outside of graduates from American residencies. Secondly, it shows that people pay attention to your application even if you are a FMG. Someone should have noticed that I completed a residency in Europe, that I had an ECFMG certificate, and that I did not match in ophthalmology.

While in my fellowship, I continued to apply in the match and for vacant positions. With my new CV and with my mentors help, I was able to secure multiple invitations for interviews. But once again, I did not match. I began wondering why this was so. I called and e-mailed members of the selection committees to find out what was holding me back and how I could improve. The unanimous answer was that my English needed improvement. I started English lessons and I was lucky to have a good teacher. I strongly recommend that you consider English lessons if you have even minimal difficulties in pronunciation or accent.

With the help of my mentors, with my improved English, with my significant experience in ophthalmology (fellowship in USA and residency in Romania), with my USMLE scores, and with a lot of luck I was invited to participate in an interview for a vacant position. I was successful this time and now I am in the second year of my residency in ophthalmology. It took a lot of effort, but it all paid off.

Foreign Medical Graduates & Ophthalmology Residency – Success Stories

2010-02-20T14:48:00.000-08:00

How they did it, what they learned from the process and how they would alter the path if they had to go through this process again.

By Vinay A. Shah, MD

Kresge Eye Institute, Detroit MI.

In the US, ophthalmologists are among the most professionally satisfied physicians. The broad scope of ophthalmic practice including the medical and surgical aspect, treatment of pediatric and adult patients, and provision of primary care as well as highly specialized treatment makes ophthalmology a desirable specialty. Ophthalmology is one of the most competitive specialties in the US and thus acquiring a residency in ophthalmology is very hard for a foreign medical graduate.

In the international ophthalmology section of Pearls in Ophthalmology we have decided to start a series of articles on individuals who have been successful in acquiring an ophthalmology residency in the USA. Personally, I believe that by reading these stories the medical students/residents in the international community will get an idea on possible pathways to procure a residency, how much it took for that particular individual to get there and may give them ideas for their future. There is a perception that it is impossible to get into an ophthalmology residency in the US, which is not true. We believe with determination, patience, focus, luck and intelligence it is possible. We also want the American graduates to know what all it takes for an individual from another country to make it into ophthalmology in the US.

Disclaimer: The presented articles will all be from either present/past or future ophthalmology residents who are foreign medical graduates. These are article provided by the individuals where we will only perform copy editing but will try not to change the content. This is not legal or professional advice. We do not take any responsibility for accuracy of information provided. Please use this information at your own risk.

What courses are available for OKAP and Board preparation?

2010-02-20T14:43:00.000-08:00

By Molly Ritsema, MD

Review courses are a great way to get a quick, broad overview of ophthalmology prior to the OKAPs or written boards. The OKAPs, held this year on April 17th, can sneak up on you. If you’re a resident who doesn’t have quite as much time to study as intended, a review course will help fill in the gaps. If you’re a fellow or a newly practicing ophthalmologist preparing for the written boards, you may be in a similar situation and could benefit from a review course.

Also, don’t forget that there are tools for studying other than the BCSC series and review manuals:

- Review courses are available on DVD
- Take advantage of practice questions on the web:
o http://www.medrounds.org/ophthalmology-board-review/exam/

- If you’re an audio learner, Dr. Rob Melendez has compiled an excellent audio review for the boards, Ophthalmology Buzzwords,
o http://www.medrounds.org/ophthalmology-pearls/2007/03/study-with-ophthalmology-buzzwords.html

If you decide to take an ophthalmology review course, below is a list of courses with contact information. It is not meant to be comprehensive, but it should start you on the right track:

The Jules Stein Fifth Annual Comprehensive Ophthalmology Review Course
March 11 - March 14, 2010
UCLA, The Jules Stein Eye Institute
Los Angeles, CA

http://www.medrounds.org/ophthalmology-pearls/2010/02/5th-annual-comprehensive-ophthalmology.html

Illinois Eye Review Course
March 13 - March 19, 2010
University of Illinois at Chicago Medical Center campus
http://uic.edu/com/eye/IllinoisEyeReview/index.shtml

New York Eye & Ear Infirmary 2010 BOARD & OKAP Review CourseJanuary 5 - March 4, 2010
Review Courses run from 6:30 PM to 9:30 PM on Tuesdays with a few exceptions
http://www.nyee.edu/okap-and-board-review---lecture-schedule.html

The Osler Institute Ophthalmology Written Review
February 17 - February 22, 2010
San Diego, CA
http://www.osler.org/main/OPH.html

San Antonio Ophthalmology Course
March 8 - March 12, 2010
http://ophthalmologycourse.com/index.php

Wills Eye Institute 35th Annual Ophthalmology Review Course

February 27 - March 3, 2010
Philadelphia, PA
http://www.willseye.org/physicians/cme/Ad_Rev__10_color.pdf

Avoid First-job pitfalls: Eight questions to ask a potential employer

2010-02-20T14:38:00.000-08:00

By Lance J. Kugler, MD

When evaluating an employment opportunity after training, one typically focuses on the obvious issues: salary, practice style, call schedule, geography, etc. However the nuances of how a new physician will fit into the dynamic of an existing group practice are often overlooked. If it is not clear why a practice is hiring, or how a new associate will fit into the current practice model, it may lead to misunderstandings after employment begins. Here is a list of questions to ask a potential employer during the evaluation process in an attempt to avoid these problems:

1. Why are you hiring another doctor?
If the employer cannot give a clear, rational reason for hiring another doctor, then it may indicate that they either have not considered the question or they are not being forthcoming.

2. How will you help me build my patient volume?
In residency programs there is no shortage of patients and residents often feel overwhelmed. Once you begin practice, however, the schedule can look barren. If an employer has not considered the source of your patients, then it may mean they are not prepared to take on a new associate. In contrast, an employer that is prepared to hire a new associate may have a marketing strategy to get your practice up and running.

3. Am I expected to generate my own patients and referrals, or are there already patients within the practice that require my skills?
The practice may be hiring someone new as a way to bring in new patient volume. If that is the case, then they likely are expecting you to generate your own patients and referrals. In contrast, a practice that is hiring because they lack sufficient physician coverage to handle the existing patient volume may have adequate patient load to keep a new physician busy from the start.

4. Do the current physicians have the same skills that I have, and if so, will they be upset if their patient volume is diluted in order to fill my schedule?
It may be a source of tension within a practice if a new associate is receiving referrals from outside the group or from within the group that previously went to the other associates. If there are physicians with the same skill set, it is advisable to discuss beforehand precisely how such referrals will be handled.

5. Will I be allowed to attend the business meetings and if so will I have any input into the decisions?
Depending on the structure of the particular employer, the current physicians or partners may be involved in the management. It is wise to know beforehand what role, if any, you will have in that process.

6. Do I have any input into the hiring of new staff, particularly the staff members with whom I will be working directly?
Your job satisfaction is only as good as the quality of the staff with whom you work. If you do not have control over the hiring or firing of the staff with whom you are directly involved then it may lead to problems.

7. Do the current physicians have an amicable relationship and work well together, or are there rifts or factions?
There is no such thing as a practice without any interpersonal relationship issues, however some situations are worse than others. Although you may get along well with all of the current physicians in the potential practice, they may not get along well with each other. If that is the case then you may find yourself trapped between factions or caught in a political game. To the extent possible, find out how well the group works together.

8. Have any physicians left the practice, and if so, why?
Turnover in new associates may indicate a problem with the way they are treated by the physicians in the group. If possible, contact doctors who left the practice and learn more about their experience.

The 411 for 2010

2010-02-20T14:35:00.001-08:00

By Lyn Walsh

Ms. Walsh supports customers in South Carolina, North Carolina, southwest Virginia, northeast Tennessee, and east Georgia.

“Hope for the best, plan for the worst, and prepare to be surprised!” Unknown

There is no doubt that 2009 was an interesting and challenging year for everyone, especially in health care. Changes in reimbursement for clinical services, programs from the federal government regarding new technology, and other possible legislation (local and national) have dominated conversations with our physicians. Now that 2010 is here, where do these issues stand and how will they affect our physicians?

MEDICARE REIMBURSEMENT

Medicare, the federal government’s health care plan for Americans aged 65 and older, is a very important payer for ophthalmologists, covering about 42 million beneficiaries. In an average practice, Medicare can represent 40% to 60% of revenue. Medicare fee schedules are also used as a standard of reimbursement for other payers, and any changes in Medicare can have a large ripple effect. It’s easy to see why Medicare reimbursement rates are always a hot topic for physicians. Medicare reimbursement amounts are determined in part by a conversion factor. This number is multiplied by the value for each CPT code (called the relative value unit, or RVU). Because of legislation passed in July 2008 that reduced the conversion rate, physicians were facing a possible reduction of 21% in reimbursement. On December 20, 2009, Congress passed a bill that freezes the conversion rate at the 2009 rate until February 28, 2010. This is only a temporary fix, and we hope a fair and more long-term solution is in place before the February deadline.

ELECTRONIC PRESCRIBING (eRX)

For 2010, the Center for Medicare & Medicaid Services (CMS) simplified the requirements for the eRX bonus payment. This year, physicians need to report only when they create a prescription using their eRX system. To do this, they attach a specific code (G8553) to the appropriate claim. If physicians report at least 25 times during the calendar year, they have met the requirement for the bonus. In 2010, physicians can earn a bonus of 2% of their total 2010 Medicare Part B charges.

PHYSICIANS QUALITY REPORTING INDEX (PQRI)

PQRI was created in 2006 to reward physicians who successfully reported on specific quality measures for covered medical services provided to Medicare beneficiaries. In 2010, physicians can choose to report for the entire calendar year of 2010, or choose to report only for July – December 2010. Physicians who meet the requirements for PQRI measures are eligible for a bonus of up to 2% of their total Medicare Part B charges for their reporting period.

ELECTRONIC MEDICAL RECORDS (EMR)

EMR continues to be a hot topic, as the first year for bonus for successful use of a qualified EMR system begins in 2011. The challenge is that CMS has not yet defined what “successful use” and “qualified system” mean. Our advice for physicians considering adopting an EMR system is to make their decisions for the right reasons: Is the practice ready? Is the system right for the practice? Making the EMR choice based solely on a possible bonus could be disastrous and expensive. We encourage physicians to do their homework and take their time to make the right decision.

Challenges and Opportunities

Undoubtedly, 2010 will bring many more challenges and opportunities for everyone in eye care. Contact your Eye Care Business Advisor to learn more about the many Allergan Access® tools and resources that are designed to help you assist your practices in areas related to the “business” of eye care.

What's the Buzz About Social Networks?

2010-02-20T14:32:00.000-08:00

By Andrew Doan, MD, PhD

Do you want to connect with old friends? Would you like to collaborate on business, academic or personal opportunities with like-minded individuals? Then I encourage you to explore Internet social networking.

An internet social network uses software to build online social networks for communities of people who share similar interests and activities. Social networking on the Internet is primarily web-based and provides a collection of various ways for users to interact, such as text chat, messaging, email, video, voice chat, file sharing, and discussion groups. Social networking has revolutionized the way individuals communicate and share information with one another. Various social networking websites are being used by hundreds of millions of people every day on a regular basis, and it now seems that social networking is a part of everyday life.

The most common foundation for internet social networking services is providing modalities to combine individuals into common categories and then providing ways for introducing trusted people to others within a network. For instance, if a friend is looking for a practice opportunity in Southern California, I can introduce my friend to an ophthalmologist in San Diego that I know well. Before the Internet, I would introduce my friend at the annual AAO meeting, with a phone call, or by arranging a lunch meeting. With an internet social network, I can introduce a friend with a click of the mouse and let the social network facilitate the introduction and meeting. Social networks are convenient, save time, and are effective methods for meeting others and conducting business.

Popular websites for social networks include MySpace, Facebook, LinkedIn, The Student Doctor Network, and most recently, our American Academy of Ophthalmology. What’s the buzz about these social networking websites?

MySpace (www.myspace.com)

MySpace is a popular social networking website offering an interactive, user-submitted network of friends, personal profiles, blogs, groups, photos, music and videos for teenagers and adults internationally. The 100 millionth account was created on August 6, 2006 in the Netherlands and a news story claimed 106 million accounts on September 8, 2006. The site reportedly attracts 230,000 new registrations per day. There are approximately 200 million users on the website. Users create personalized homepages that display their pictures, writing, music, videos, and everything of interest. Individuals invite “friends” to be added on their MySpace homepages. As the network grows, there is an increased opportunity for people with similar interests to find each other. While fun and popular amongst young people, MySpace is drawing interests from business and organizations as a way to market their services and products.

Facebook (www.facebook.com)

Facebook is a social networking website launched on February 4, 2004. Users join networks organized by city, workplace, school, and region to connect and interact with other people. People add friends and send them messages, and update their personal profile to notify friends about themselves. The website's name refers to the paper facebooks depicting members of a campus community that some American colleges and preparatory schools give to incoming students, faculty, and staff as a way to get to know other people on campus. More than 400 million people are using Facebook.

LinkedIn (www.linkedin.com)

LinkedIn is a business-oriented social networking site founded in December 2002 and launched in May 2003 mainly used for professional networking. As of December 2007, its site traffic was 3.2 million visitors per month, growing at an annual growth rate of about 485%. As of May 2008, it had more than 20 million registered users, spanning 150 industries. LinkedIn is an effective way to find employment, business and professional opportunities. The success of LinkedIn is based on the premise that an e-mail request is more likely to be answered if introduced by a trusted source. LinkedIn also facilitates the grouping of individuals belonging to a specific company or professional organization. As users publish their curriculum vitae on LinkedIn, others can search for individuals with similar professional, business, and personal interests.

Student Doctor Network (www.studentdoctor.net)

The Student Doctor Network (SDN) is a nonprofit web site that started as a grassroots Web community at the University of Kansas in the mid-1990s. Since then, SDN has emerged as one of the most comprehensive and most useful student-driven resources on the Internet. The Student Doctor Network is operated by the Coastal Research Group, a nonprofit 501(c)(3) tax-exempt charitable organization. As part of CRG’s mission, they provide the Student Doctor Network as a free and independent resource to the pre-health and health professional student community. SDN hosts discussion forums and is the largest premed and medical student community on the Web. The website has over 30,000 active members and a thriving forum of over 4 million posts willed with advice, information and support.

I have volunteered as the ophthalmology forum moderator since 2002 on SDN, and it is amazing to see that over half of the people applying for ophthalmology residency each year use the discussion forum to discuss politics, medical economics, admissions procedures, and topics about residency training.

American Academy of Ophthalmology (www.aao.org/community/)

The latest addition to the social network offering is from the American Academy of Ophthalmology. The social networking buzz is infectious, and the American Academy of Ophthalmology has implemented software solutions to facilitate online communication between members. The YO Committee has worked closely with the AAO's Social Networking Task Force and the Clinical Education Committee to implement a new professional networking solution and to add exciting functionality to the Academy’s website. I encourage you to explore professional networking on the Academy’s website: www.aao.org/community/. Currently, it's a three-way race between Drs. Melendez, Kitchens, and myself for the number one contributor on the AAO's online professional network.

Social networks on the internet are here to stay because they facilitate an enormous number of interpersonal interactions not possible in the physical world. The success of social networks is simple: people enjoy human interaction and internet tools that facilitate discussion, interaction, and sharing of common interests lure people in by the millions around the world.

Smartphones in Ophthalmology: Potential Uses of the Smartphone in Your Practice

2010-02-20T14:07:00.000-08:00

By Vinay A. Shah, MD, Ron K. Lord, MD and Ashley N. San Filippo, MD

Physicians appear to be embracing mobile technology at a faster rate than the general population, and ophthalmologists are no exception. Currently, smartphones are being utilized by 64% of U.S. physicians, and this number is projected to reach 81% in 2012. As ophthalmologists, we have the ability to use smartphones in countless areas of practice and education. We believe potential functions of smartphones in ophthalmology can be divided into the following broad categories:

1. Testing Tools
2. Patient Education Tools
3. Physician Reference Tools
4. Physician Education Tools
5. Calculators and Other Office-Based Tools

In the following article, we will discuss the potential for using your smartphone as a testing tool. Examining a patient for the first time in the emergency room or hospital setting can be a hassle, especially with the limited availability of ophthalmologic equipment in these settings. The smartphone has the potential to combine many commonly used clinical evaluation tools into one easy to use interface. No longer do you need to fumble through your overly-stuffed white coat pockets to find your bent, faded near vision card—it’s there at the touch of a button on your smartphone. Forgot your penlight in the emergency room? There’s no need to search the halls for a working flashlight—there’s a suitable alternative right in your pocket. While these tools may not replace office-based testing under ideal conditions, with appropriate standardization and acceptance of some testing variability, they can be especially valuable during inpatient consults and emergency room visits.

The following are some of the tools that are currently available, or have the potential to be used with your smartphone:

Near Vision Cards

This tool can be used as described above in situations where other tests of visual acuity are not readily available. In addition, they could potentially be used in the office as a substitute for your typical near vision card testing.

Color Vision Plates

Similarly to the near vision cards, these could be used in emergency or inpatient settings. Since it is unlikely that most ophthalmologists carry color plates with them in these situations, this tool may add value to your clinical evaluation. Also, since this tool is on your smartphone, it will not undergo the usual “aging” of color plates with faded colors and potentially inaccurate results.

Pupil Gauge and Measuring Ruler

These tools allow quick access to measuring devices and can be used in any exam setting.

Fluorescein Light & Pen light

These tools, again, will have most of their utility in non-ideal patient exam situations. They may be extremely valuable in the diagnosis of corneal surface disease when a slit lamp is unavailable, or when patients are unable to be examined at the slit lamp.

Pediatric Fixation Targets

These tools can also be accompanied by motion and sound to entertain pediatric patients while you examine them.

Worth 4 Dot & Accomodation Targets

Again, these can be used in office or non-office based testing situations.

Amsler Grids

These can be beneficial in quickly evaulating a patient with suspected macular disease.

Pediatric Optotypes

This tool, like the near vision cards, can be used in an emergency and inpatient settings, but can be used in pediatric patients and patients who are unable to read numbers or the English alphabet.

Red Desaturation Test

This tool allows for comparison of nasal and temporal fields in the same eye:

And for comparison of red desaturation between two eyes:

Several new testing tool applications for smartphones have and are being developed. Eye Test, Eye Chart, EyeChart RandomEyes, Eye2Phone, and Fast Acuity Life are just a few examples. Our new application for the iPhone is called the “Eye Handbook” (Available on iTunes – for free or at www.eyehandbook.com). This application is one of the most comprehensive ophthalmology applications available and provides most of the above-mentioned examination tools.

Smartphones have a number of useful applications for any medical professional, but ophthalmology uniquely requires several testing tools for a basic patient exam. In addition to being a power-packed communication device and having all of the features available in a PDA, smartphones with testing tools such as those mentioned above offer the ability of increased ease and efficiency in ophthalmology exams, especially those conducted under non-ideal testing circumstances. . Smartphone applications in ophthalmology have great functionality and have vast potential for future growth.

References

Eye Handbook: Free iPhone application for eye care professionals. http://www.eyehandbook.com/

http://www.manhattanresearch.com/newsroom/Press_Releases/physician-smartphones-2012.aspx

Gillingham W, Holt A, Gillies J. Hand-held computers in healthcare: what software programs are available. N Z Med J. 2002 Sep 27; 115(1162):U185

Low DK, Pittaway AP. The Iphone induction – a novel use for the iPhone. Pediatric Anaesth. 2008 Jun;18(6):573-4. Epub 2008 Feb 2

Disclaimer: Please note that all the testing tools are not standardized and should be used by the eye care professional in proper testing conditions, using their professional judgment.

Include the EMR in Your Evaluation of a Practice

2010-02-20T13:59:00.000-08:00

By Craig Wilkerson, MD

One of the most difficult challenges for a young ophthalmologist is to choose the right practice or partner with whom to start a career. Pearls In Ophthalmology has provided valuable insight into how to evaluate the potential partners, staff and practices. Much has also been written on how to incorporate an evaluation of practice styles and financials into making this decision. Increasingly, however, the presence and type of electronic medical record is becoming a consideration in deciding on a practice.

Electronic medical records (EMR) and practice management (PM) systems are becoming more common in medicine. Between 2001 and 2006 the use of EMR's rose by sixty percent to include nearly thirty percent of physician practices. CMS essentially is mandating the use of these systems by 2014. It is unlikely that the young ophthalmologist will be able to avoid using one of these systems during their career.

This article is not about choosing an EMR or PM system. I spent a great deal of time and effort research and using systems until I found one that had the ease of use, value and vendor support and longevity that I needed. As a solo practitioner, this decision was entirely mine. This article is for those who are joining a practice that has or is in the process of implementing an EMR or PM.

It’s probably safe to say most practices will give more consideration, time, and money to finding the right EMR than they will to finding the right partner. Most of the providers and staff will spend more time working with the EMR than they will with each other. It’s also likely that any one of them or you will leave the practice before the EMR does.

Given the amount of time you will spend working with the EMR and likelihood it’s there to stay, it becomes important to include it in your evaluation of the practice. Here are some brief observations that come from our implementation of an EMR and some tips on evaluating EMR’s in practices you may be considering.

-Is the EMR a sail or an anchor? Most EMR systems are not neutral. Either they help the practice or they hinder it. Determine if the providers and the staff feel as if it has helped them to improve efficiency and accuracy.

-Find out how long the system has been in place. Just because a practice is on the steep part of the learning curve doesn’t mean that the EMR won’t ultimately be a gem for the practice.

-Is the effect on the practice universal? Does everyone love it or are the technicians (or schedulers or receptionists) looking for new jobs because of it?

-Is it paying for itself or taking an increasingly bigger bite out of the profits? Most EMR’s will have maintenance fees, provider fees and hardware costs. Most also require IT support on an ongoing basis.

-How will it affect your interaction with the patient? Are you required to turn away and type or does it allow you to maintain your style of patient interaction?

-Can you take it with you? Most young ophthalmologists do not stay with their initial practice. If someone leaves what happens to the records? Most of the EMR databases are designed to work with their proprietary user interface. Unless you have the same system in your next practice, the data may have limited value to you.

-Is it integrated with other systems? What happens when you need to view lab results, radiology scans, visual fields, OCT’s, etc? It’s inefficient if you have to leave your workstation and travel to another part of the clinic to view this data or wait for a fax to arrive with lab results.

-What happens when it inevitably goes down? Does the clinic stop functioning or is there a backup procedure for continuing to see patients?

These are some of the more practical issues that we had to resolve as we implemented our system. I would advise that you ask the receptionists, technicians and providers if they would buy the same system again. Ask what the ideal or dream system would have that their system doesn’t. Find out what frustrates them about the system. Beware if there are no frustrations. Remember, it’s a computer system, so something will frustrate them. Finally, I would want to know how the patients like it. Do they feel it interferes with or enhances their care?

Our system has been in place for nearly three years. It is far from perfect, but has become a powerful tool in the practice. It has turned out to be a good match for us. Just as you will need to do when evaluating partners or practices, you will need to find the right match in an EMR.

Risk Factors for Retained Nuclear Fragment

2010-02-20T13:57:00.000-08:00

By Anonymous

One of my personal loves is looking at a cataract patient post-op day one and seeing a nice chunk of nucleus staring at you from the inferior anterior chamber. This happens on occasion to us all and we can usually point to the reason why it occurred. It is important to remember that nuclear fragments will not go away with steroids, so you need to go back to the OR and get it. ASAP. So back to why this happens. With this particular patient, the reasons were simple. To start, she had a lighter iris that can “camouflage” pieces of the lens that are sitting against it. She also had dense arcus senilus that can hide pieces of the lens behind it. You’d be amazed how big a piece of nucleus can hide behind arcus. I remember, during phaco, seeing a piece of nucleus go over to the side towards the angle while chopping. I finished chopping and phaco and didn’t see the piece in the area that I had previously. I thought to myself that it had likely flushed out and I had emulsified it. I swept through that area with the phaco on aspiration and no piece came to the tip. Then was rewarded the next day…

Always be meticulous about looking for pieces of lens that you’ve seen go into the angle. You can be surprised by the size of the lens material hiding there. If you are fairly certain that there is a piece, you can even lightly sweep with your second instrument. Risk factors include a lighter iris, dense arcus, and a poorly dilating iris. All can hide lens fragments. And if you do find a present in the anterior chamber on post-operative day one, don’t sweat it. Take the patient back to the OR immediately and things will be fine.

Corneal Surgery and H1N1 Flu

2010-02-20T13:47:00.000-08:00

By David A. Goldman, MD¹ and Jonathan Etter, MD²

1. Assistant Professor of Clinical Ophthalmology, Bascom Palmer Eye Institute
2. Lecturer, Bascom Palmer Eye Institute

Because concerns of H1N1 have become widespread across the U.S., many have rushed to obtain the H1N1 vaccine. While the adverse effects of this vaccine are relatively mild, they can have ophthalmic consequences. The following case demonstrates one such occurrence:

A 25-year old female with history of bilateral corneal transplants for keratoconus (OD in 2009, OS in 2004) received the live attenuated H1N1 vaccine intra-nasally. The following morning she awoke with bilateral corneal rejection OD more severe than OS. While the left eye has responded well to topical steroid drops, the right remains edematous despite both sub-tenon’s injection of triamcinolone and oral prednisone.

Corneal transplant rejection following vaccination has been described previously with the influenza vaccine [1-3]. However, in these cases the time from vaccination to rejection has ranged from two to eight weeks. The fast onset of corneal transplant rejection in this patient may likely be related to the close proximity of the inoculation site (nares) to the eye. However, this may also represent a more robust immune reaction to a relatively new and understood vaccine.

Where does this matter in refractive surgery? Increased immune response, and therefore inflammation, can be associated with regression, diffuse lamellar keratitis, transient light sensitivity, and, in severe cases, corneal melting.

As the H1N1 vaccine becomes more available, our patients will be more likely to obtain it, particularly without alerting their ophthalmologist. In discussing laser refractive surgery with our patients in these upcoming months, we must take care to warn our patients about receiving the H1N1 vaccine prior to refractive surgery. If the vaccine is administered to the patient around the time of refractive surgery, we may want to consider a more frequent and prolonged course of topical steroid therapy.

References

Wertheim MS, Keel M, Cook SD, Tole DM. Corneal transplant rejection following influenza vaccination. Br J Ophthalmol 2006; 90(7):925.

Solomon A, Fruct-Pery J. Bilateral simultaneous corneal graft rejections after influenza vaccination. Am J Ophthalmol 1996; 121: 708-9.

Steinemann TL, Koffler BH, Jennings CD. Am J Ophthalmol. 1988; 106(5):575-8.

Correspondence:
David Goldman, MD
Bascom Palmer Eye Institute
7101 Fairway Dr
Palm Beach Gardens, FL 33418
DGoldman@med.miami.edu

W: 561-515-1543
F: 561-355-8600

Premium Intraocular Lenses and Astigmatism Management (Podcast)

2010-02-20T13:41:00.001-08:00

By Rob Melendez, MD, MBA

You have a patient who is 67 years old pilot with the following findings:

Best Corrected Visual Acuity:
OD: 20/50 -3.50 +0.50 x 178
OS: 20/60 -2.00 +0.75 x 165

Slit lamp exam remarkable for:
OD: 3+ Nuclear Sclerosis
OS: 3+ Nuclear Sclerosis, trace Posterior Subcapsular Cataract

How should you manage this patient's cataracts?

Click here to play podcast.

“Dry” Age Related Macular Degeneration Pearls

2010-02-20T13:33:00.001-08:00

By Rahul Khurana, MD

Early Age-Related Macular Degeneration (AMD) (referred to as DRY) is a charged diagnosis that can bring much fear and anxiety to patients. Most patients know someone who became blind due to advanced AMD (referred to as WET), and are worried that the same will happen to them. Fortunately, with the revolutionary Anti-VEGF therapies, this is often not the case and they can be reassured. Furthermore, here are a few “pearls” in managing your early AMD patients.

Stop Smoking: After aging, smoking is the most significant risk factor for developing Advanced AMD. All patients with early AMD should be counseled on smoking cessation.

Anti-Oxidant Vitamins: The Age-Related Eye Disease Study (AREDS) was a randomized, placebo-controlled trial that showed that a combination of anti-oxidants and zincs (Oral Preservision) reduced the progression to advanced AMD by 25% in patients with intermediate AMD (defined as extensive (>6) intermediate drusen ( >64 µm in size) or with large drusen (>125 µm; width of a large vein at disc margin). Patients with early AMD had no benefit.

Some would argue that all patients with AMD should take it regardless, as there is little downside to the vitamins. However, many of these patients already take many medications and adding another with little to no benefit might be problematic with polypharmacy. In addition, it can be expensive. One of the high-dose antioxidants studied was beta-carotene which was found to increase the risk of lung cancer among smokers. Thus, smokers with intermediate AMD should take the AREDS vitamins without beta-carotene.

Home Amsler Grid Testing: It is essential that patients with early AMD test each of their eyes regularly. Advanced AMD can progress slowly and it can often be missed by patients. Therefore, it is imperative that early AMD patients have regular visits with their ophthalmologists and check each eye individually at home. It has been shown that diagnosing advanced AMD early often leads to better results with Anti-VEGF therapy.

Estimating RISK: Many AMD patients want to know their likelihood of developing Advanced AMD. A simplified severity scale was developed from the AREDS to estimate likelihood of progression after five years. The scoring system assigns to each eye one point for the presence of large drusen, one point for the presence of any pigment abnormality, and two points for advanced AMD. Risk factors are summed across both eyes, yielding a five point scale (0-4) on which the approximate five-year risk of developing advanced AMD in at least one eye increases:

0 Points, 0.5%
1 Point, 3%
2 Points, 12%
3 Points, 25%
4 Factors, 50%

I find this scale simple to calculate from a clinical exam and a quick way to convey risk of progression to patients.

These are some simple “pearls” that are helpful in managing early AMD patients. There are many new treatments on the horizon that should give us more options in the future.

OKAP/Boards Review Books

2010-02-20T13:27:00.001-08:00

By Vipul Shah, MD

The holiday season has come and gone, and the New Year is here. While many of us look ahead to the promise of the coming months, for those of us early in their careers, a black cloud looms once again: OKAPs and the written Board exams. I keep hoping for the day when these tests will be replaced with a statement that we have to sign: "I promise to look up stuff that I'm clueless about." I think it would improve our stress levels considerably.

Until that day, however, the tests need to be taken, and therefore need to be studied for. If you've been putting off getting started, now is a great time to start—not so early that you'll forget everything, but not so late that you'll run out of time (maybe).

Hopefully at this stage, most of us have some idea of which study method is most effective, but you'll probably be using some sort of review book (or two, or six). There are many available, and they usually fall into one of two categories: review or questions. Here's a snapshot of just some of the useful tools available for you:

Review Books

The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology (Friedman, Pineda, Kaiser): An excellent, quick reference book with a decent number of pictures. Suitable detail for test purposes, although may be difficult to read straight through.

Review of Ophthalmology (Friedman, Kaiser, Trattler): Excellent review book (and my review book of choice), with significant detail, as well as many high-yield pictures, tables, and charts.

Ophthalmology Review Manual (Chern, Zegans): Concise, high-yield outline that may be missing some minutiae that can show up on the tests. Some pictures, but few tables or charts.

Clinical Ophthalmology: A Systematic Approach (Kanski): World-famous, with beautiful photos and a great layout. Excellent as a refresher, but may not be quite detailed enough.

Last Minute Optics (Hunter, West) The only optics book you'll ever need for the OKAP, written, and oral boards—seriously. Work through this book a few days before the test (it only takes a few hours), and you'll rock Optics.

Question Books

Ophthalmology Board Review (Tamesis) Questions are in an open-ended format that is great for studying with a partner or quizzing yourself. Does not simulate written test questions, but helps with recall.

ProVision: Preferred Responses in Ophthalmology (Lane, Skuta): AAO-approved two-volume set of questions. The questions themselves are very similar to the actual tests (although perhaps a tad easier). Can be cumbersome to use, as the answers and discussion are in a separate volume from the questions.

Review Questions in Ophthalmology (Chern, Wright): One of the more popular question books, this book has loads of questions that are accurate to the test. A must-use.

The Mass. Eye and Ear Infirmary Review Manual for Ophthalmology (Jager, Lamkin): Although not in the approved format, with true/false and "Except," this book has loads of questions and is an excellent supplement for those looking to get more practice under their belt.

While everyone studies differently, the vast number of review books available to you should ensure that you will be able to find one that suits you and your study style. However, be sure to keep in mind that there is a vast amount of material to get through, and continued procrastination is off limits! Those corneal dystrophies aren't going to memorize themselves, and you need to be ready for the one case you'll see in your entire career 20 years from now.

Good luck!

Studying for the OKAP Exam and Written Boards

2010-02-20T09:26:00.000-08:00

Follow your personal style of learning

By Arlene Bagga, MD

By the time you are a first year Ophthalmology Resident, you are an expert in studying. You have tackled all types of written, oral, and practical exams, and have developed a personal style for how you process and integrate information.

Everyone who has successfully passed these exams will share with you their own strategy, each containing common elements that piece together an individualized plan.

In order to come up with your own plan, consider three items:

What type of test am I taking?
What are the resources available to me?
What type of learning works best for me?

The OKAP exam and written boards are written or computerized, multiple choice format tests that cover all subspecialties of Ophthalmology. They require you to memorize a great deal of information and recognize the correct information when you see it on the exam.

There are a number of resources available, so many, that it is now a matter of narrowing down what you will use because there is no time (and no need) to cover everything. Some helpful resources include: Basic and Clinical Science Course – Text and Questions, Residency Lecture Series, Board Review Books, Board Review Question Books, Review Courses and atlases.

Types of learning include reading text, reading outline form, attending lectures or review courses, listening to recorded information, completing questions, and viewing photographs/diagrams.

In order to maximize the impact of your studying during a busy residency, fellowship, or first year of practice, understand what your learning style is and stick with it. For example, if you learn by hearing things aloud, devote yourself to paying attention during lectures, make flash cards and quiz yourself out loud on the material, and attend a board review course. If instead you learn better in a question/answer format, don’t waste your time reading all of the BCSC books in great detail. Just start with the questions and review the material you did not score well on.

While it is important to heed advice from mentors regarding these exams, it is also important to realize that you are already an expert in studying. There is no one specific formula to help you pass these tests, but instead, there are many based on your own personal learning style.

OKAP Preparation Pearls

2010-02-20T09:22:00.000-08:00

By Sami Kamjoo, MD

The Ophthalmic Knowledge Assessment Program (OKAP) exam is an important test not only for Written Boards preparation, but also because it is reviewed by some Program Directors as you apply for Fellowship, which may influence how you match.

Preparation for the OKAP exam should not be thought of as a one week or one month cramming session, but rather a disciplined schedule starting your first year of residency. The Basic and Clinical Science Course (BCSC) should be your first study source during the year, and as you get closer to the exam in April, you can use other review and question books.
Everyone has a different studying style, and what works for your co-residents may not work for you. Try not to compare yourself to others, as this may discourage you. Instead, find what works best for YOU and stick to it.

Here are some tips that I have gathered through the years that seem to work for most people:

Try to read everyday – at least 30 min to one hour. Stick to a schedule early in the year and try to finish all of the BCSC books (or a least cover the main sections – Cornea, Retina, Peds, Neuro, Glaucoma, Path).
Do the questions in the back of all the BCSC books – these are very good and representative. Repeat these questions again in March or April.

Optics – Last Minute Optics is a good book to review a month or so before the exam.
Review books: Review of Ophthalmology (Friedman) is very good, and detailed. The Chern Review book is also excellent, although more outdated than the Friedman book. Ophthalmology Board Review (Tamesis) is also another good source, but may not be very comprehensive, and mainly covers highlights of most topics (and therefore not very detailed).

Questions books: The Chern & Wright Review Questions in Ophthalmology seem to be most representative of the OKAP exam, although the OKAP exam is probably a little more difficult than this book. The Massachusetts Eye and Ear Infirmary Question book is overwhelming and too detailed in my opinion; the questions are not very representative of the OKAP exam, and the style of questions (matching, etc.) does not correspond to OKAP questions. Another question source is the Provision Series from the AAO bookstore – these are decent questions, although I thought the difficulty level was easier compared to the OKAP exam.

Pathology Review – One week or so before the exam, flip through the BCSC pathology book and look at the pictures/slides, as well as the captions. Also review the Tables – these are usually where the tested material comes from. Another good source that people have recommended is Eye Pathology: Atlas and Basic Text (Eagle).

Start an “OKAP Quiz” session at your residency program. The Chief Resident or another resident can find 10-20 questions that all the residents can do together every week and discuss your answers (of course the quiz should not be graded so people are more comfortable).

Lastly, focus on your weaknesses: This is how you improve your score. Look at your performance on the question books and see what subject you need improvement in. If you have already taken the OKAP exam last year, then look at your breakdown for each subject and focus on the subjects that you did not do well on. Your previous year OKAP performance also comes with a section that gives you hints on the type of questions that you missed. Look at these and review them so that you do not miss these types of questions again this year.

As we go complete our training and jump through the hoops, all while taking test after test, remember that at the end, you are doing this for one thing: patient care. The knowledge that you are working hard to acquire in order to successfully complete these tests will ultimately be used to better treat your patients. Good luck.

How to Approach the OKAP Exam as a First Year Resident

2010-02-20T09:05:00.000-08:00

By Brad Feldman, MD

The Ophthalmic Knowledge Assessment Program (OKAP) will cause an undue amount of stress to most residents during their three years of ophthalmology training. In order to minimize your stress and maximize your success with the OKAP exam, you need a practical understanding of the true value of the exam and how to approach it strategically, starting with your first year.

The OKAP is an important examination. In most programs, the faculty members will have access to your scores. It will not be the primary instrument for them to evaluate you, but it is one of the only standardized, objective exams that will create a perception for them of your knowledge base. While you’ll hear that most fellowships don’t place an emphasis on OKAP scores during applicant selection, doing well can only help you, while scoring in the lower percentiles can only hurt you. Likewise, you are more likely to get a strong letter of recommendation from your program director or chair if you can stand out with a high OKAP score.

You’ll want to think of the OKAP scores that you receive over your three years as constructive feedback. The primary value of taking this examination three times during residency is to let you know where the holes are in your knowledge base as compared to other residents at your level. This allows you to either feel comfortable and confident that you are on track to learn what you ‘should’ know as an ophthalmologist, or be appropriately concerned that you need to put more time into reviewing ophthalmic knowledge. By the time you’ve taken your third OKAP exam, you’ll have an idea of how hard you’ll have to study for the more important and expensive examinations, as well as the written and oral boards. Walking into your boards with a history of success on the OKAP exam is really going to boost your confidence, and this is extremely important, especially during the stress-inducing experience of the oral boards.

The key to success on the OKAP exam is thoughtful preparation. The amount of time itself you spend studying will not necessarily correlate with your success. The more important factor will be creating a study strategy that works for you. Everyone should personalize their approach to studying, as no single strategy works well for everyone. Whatever strategy you create, starting in your first year of residency, you should incorporate the following components:

1. Set Attainable Goals

The first year is the most stressful year for the OKAP exam, but it’s also the year when your score is least important. However, your studying strategy now will lay the foundation for the next few years (if you do it right).

You will not be able to learn everything well, so don’t set unreasonable goals. Instead, try to learn the most common diseases well (Diabetes, POAG, AMD), and try to familiarize yourself with most diseases (White Dot Syndromes, Corneal Dystrophies, Phakomatoses). This means you’ll need to create a schedule to work through all the subjects once, either through a single review book (if you’re short on time), or through the BSCS (if you’re ambitious). The key subjects should then be revisited repeatedly throughout the year.

You will have the opportunity to learn some subjects in detail, especially when you are on rotations or preparing for presentations. I encourage you to go in-depth on these occasions – be comfortable when you sacrifice breadth for depth, and next year, be prepared to make up for anything that you’ve skipped.

It is a must to take the time to sit down, write a study schedule, and then try your best to stick to it. If you miss a day or a week of studying, double up on studying the next week.

2. Make Reviewing Easy

Be kind to yourself, and devise a study method that will make recalling the information easier when studying for future exams (written and oral board exams). If you are a visual learner, then take notes or make flashcards. If you are an aural learner, then record notes for yourself to listen to later. Be creative if you have to, but remember, you’re going to want to balance efficiency with quality in order to actually get through the material while creating something worthwhile to study with in the future.

3. Schedule in Time for Review and Questions

At the end of any section, test yourself with study questions. More importantly, leave a couple of weeks prior to the OKAP free in your schedule to review everything, rather than continue to focus narrowly on a single subject. This will be the most important part of your strategy, allowing you to review the details of topics that you’ve already studied but may have slipped into the recesses of your mind. This is the time to take out the review books and questions books, and to try to reinforce the knowledge that you have acquired.

Good luck with your studying!

Golden Pearls for the OKAP Exam

2010-02-20T06:36:00.000-08:00

By Ashley N. San Filippo, MD and Vinay A. Shah, MD

April signifies more than just warmer weather for most ophthalmology residents—this month represents the culmination of all of your studying and hours of preparation into one 250-question test. The Ophthalmic Knowledge Assessment Program (OKAP) examination is given annually across the United States and Canada by the American Academy of Ophthalmology to ophthalmology residents, each of whom vary in their methods and intensity of preparation. Residency programs vary in attitude toward this exam. Some may gear lectures toward popular OKAP topics, while others may provide little or no “official” preparation. No matter what type of program yours is, it’s important to remember that this test in no way tests your ability to be a great clinician or surgeon. However, it does give you three chances to practice for the “real” boards, which you will want to be prepared for. The following are some brief tips for achieving success in the OKAP exam.

Year-long preparation is the key: Read the Basic and Clinical Science Course (BCSC) books throughout the year (yes, all of them) if possible. This does require a good deal of discipline and time, and if you’ve done this, you’ll be very well-prepared. If you have been unable to keep up a rigorous reading schedule throughout the year, review books are an option for you. However, be sure to keep the BCSC books nearby as a reference if needed. If you are using a review book, use it early along with your BCSC books if possible and take notes in the margins. This will make for easier studying when it comes closer to exam time. Although there are several popular review books available, we particularly found Review of Ophthalmology by Friedman helpful. The content of this book closely mimics that in the BCSC.

To lessen the massive load, here are a few tips for abbreviating your BCSC reading (Note: These tips are based on the personal opinions of the authors. These methods are by no means a comprehensive guide to OKAP studying):

Skip the General Medicine book, especially if you’re a first year—most of these test questions will be easy to answer if you’re just coming off an internal medicine-based internship. Plus, this topic is not covered on the written board exam.

The optics book is HUGE, so use it as reference only. Most of what you need for the optics portion of the test can be covered by reading Last Minute Optics: A Concise Review of Optics, Refraction and Contact Lenses by Hunter and West and by doing a few review problems from a question book.

Lightly skim the refractive book. This topic is integrated into optics and the cornea sections so there will be only a few questions that may come from this book.

The Neuro-ophthalmology book is not the best-written book. You may decide to skip this book altogether in favor of a more concise book like Neuro-ophthalmology Review Manual by Kline and Bajandas.

Most of the contents of the Fundamentals book are contained in the other subject books. You can use this book to refer to if you need a refresher on a fundamental topic.

Don’t skip the questions at the end of each BCSC book—these tend to be very similar to those on the OKAP exam.

You know how to study: You haven’t reached this point in your life without knowing how to prepare for tests. What works for your co-residents may not work for you. If you learn best by discussion, find someone who works the same way and bounce topics off of each other. If you learn best by listening and can’t stand the thought of reading for hours, you may want to incorporate a review course into your strategy (If you attend the SAOC course in San Antonio, TX, you will be provided with lectures in MP3 format). If you are more of a passive learner, a great resource is Ophthalmology Buzzwords™. No matter what kind of study methods you prefer, try to keep the basic study principles that are specific to you in mind when you design your study plan. And speaking of study plans…

Have a study plan: Even the most disorganized resident can benefit from a rough outline of what to study and when. A study schedule is a great idea for your final months or weeks, and even days of studying. When creating a schedule, keep in mind your call schedule, vacations, and other occasions where you may not get much time for test prep. Having a plan also guarantees you’ll give equal time to all subject areas and not just the ones you enjoy more. If this is your second or third year taking the OKAP exam, you can use this schedule to put extra emphasis on your weaker areas.

Know the topics covered: The subject areas covered in the OKAP exam differ from the topics in the BCSC. They also differ from the subjects on the written board exam. There are 11 subject areas covered in the OKAP exam, each having equal emphasis: General Medicine; Fundamentals and Principles of Ophthalmology; Optics, Refraction, and Contact Lenses; Ophthalmic Pathology an Intraocular Tumors; Neuro-ophthalmology; Pediatric Ophthalmology and Strabismus; Oribit, Eyelids, and Lacrimal System; Cornea, Lens, and External Disease; Intraocular Inflammation and Uveitis; Glaucoma; Retina and Vitreous. Knowing what you’ll be tested on allows for better time management when studying.

Practice questions: This is important to start early. If you’ve done many questions, you’ll start to see patterns and popular topics. These often mimic testing patterns on the OKAP exam. Once you’ve begun to recognize these patterns, you’ll start to think of them in your reading. You’ll start to think to yourself, “I saw several question about this, I should pay close attention to this topic” or “how can this bit of information be formed into a question?” Once you’re thinking like the test-maker instead of the test-taker you’re well on your way to success. Some popular question sources include Review Questions in Ophthalmology by Chern and the Massachusetts Eye and Ear Infirmary Review Manual for Ophthalmology by Jager and Lamkin.
Know what things “look like: There are many photographic questions on the OKAP exam. Ask yourself when reading a description if you’ve actually seen this disease process before, either in person or in a photograph. If not, find a picture. A few good sources for this are Kanski’s Test Yourself Atlas in Ophthalmology, and http://www.redatlas.org/. Any atlas will do. If all else fails, you can always do a Google image search.

Be conservative: You’ll find that during the OKAP exam that there will be many management questions that will appear to have more than one correct answer. Don’t be surprised or panicked when you see this. A good approach is to choose the option that is the least aggressive, even if this is not the most definitive treatment. Observation and a cycloplegic drop will almost always be the answer over taking the patient to the operating room. Thus, when studying, pay close attention to initial, conservative management.

Last minute studying does help: Some topics deserve some last minute attention because they are high-yield and they are hard to keep in your memory for more than a week. These topics include the phacomatoses, optics formulas, chromosomes and inheritance patterns, embryology, and glaucoma medications (especially side effects). Study these topics in the last week before the test—you’ll be surprised how many of these will show up.

Relax the day before: It’s unlikely that any studying will significantly benefit you on this day, and it may actually harm and confuse you. Do something mindless and relaxing that evening so you’ll sleep well and be refreshed on test day.

10 Pearls to Prepare for Success on the OKAP Exam

2010-02-20T06:21:00.000-08:00

By Purnima S. Patel, MD

The Ophthalmic Knowledge Assessment Program (OKAP) examination causes much anxiety each year for ophthalmology residents. But, with proper preparation and planning, residents can significantly reduce stress and increase performance. Below, are 10 pearls for success on your OKAP exam:

1. Have a plan and stick to it.

Reduce anxiety with a well-constructed, attainable study plan. Create a schedule where topics that you understand better are covered first, and those that are more challenging are saved for closer to the OKAP exam date. For topics that are more of a challenge for you, designate and appropriate reasonable amounts of time to study these and grasp the concepts. Make every effort to stay on schedule, but make sure to include time to catch up.

2. Utilize review resources.

The Basic Clinical and Science Course (BCSC) is the foundation for OKAP studying; however, other review materials can help cover topics in a more concise manner. Review of Ophthalmology by Friedman et al. is a good resource. You can fill-in notes in the review book while you are studying from the BCSC or when you go to review sessions so you have a compact book to review as you approach the exam.

3. Complete lots of questions throughout your studying.

Questions are important in assessing your progress and comprehension while you are studying, but they also help build test taking skills. Do not wait until the end for all the questions. I recommend answering questions in Review Questions in Ophthalmology: A Question and Answer Book by Chern and Wright after you complete each subject. Save the BCSC questions for closer to the OKAP exam. Dedicate more time towards the test date to complete more questions. In addition, it is helpful to read the explanation to the answers, in order to learn why your answer is right or wrong.

4. Leave time in your schedule to cram 1-2 weeks before the OKAP exam.

No matter how prepared you are, you will always want to cram. Planned cramming will reduce the anxiety associated with the cramming. Save questions to complete, especially in more challenging areas. Look through pictures in the pathology book, and review any study sheets or tables you may have made, especially optics formulas.

5. Do not ignore optics.

Remember, your faculty will be much more lenient on your optics score compared to any other topic, so do not obsess over it, but do not ignore it either. Last Minute Optics: A Concise Review of Optics, Refraction and Contact Lenses by Hunter and West is a good, quick resource. Dr. Guyton’s review book is also helpful, but takes longer to get through. The BCSC optics book can be confusing and overwhelming. Save your optics studying for closer to the exam so you do not get overwhelmed early in your studying and so you remember the formulas.

6. Review pictures.

The OKAP exam has a lot of pictures, so incorporate reviewing pictures into your preparations. The pictures in the Pathology BCSC book are an absolute must in the cram schedule. The Red Atlas at www.redatlas.org is also an excellent resource to quickly review color photos.

7. Use your co-resident and upper levels for motivation and tips.

You can make efficient use of your time by arranging to meet with other residents before or after clinic, or during lunch for scheduled weekly quick reviews. Each resident can be assigned to a topic and lead a review or you could participate in a question and answer session. Ask your upper levels for studying advice and which topics are more high-yield.

8. Make the best of review sessions or review courses.

Most residency programs have some OKAP review sessions. These review sessions do not obviate the need for self-study. Study before-hand and have questions ready in order to get the most out of the reviews

9. Have a test-taking strategy.

Remember, the OKAP exam is not just about your ophthalmic knowledge but also about your test-taking abilities. Most people have plenty of time to finish as long as they pace themselves. I recommend writing down the optics formulas you can remember immediately after you open your booklet so you do not forget or confuse them. Save all the optics questions until the end so they do not slow you down.

10. Do not panic.

Stick to your plan and stay relaxed.

Good luck!