Done!!

After eleven weeks of work, I finally completed my last day at my last summer job. I didn't get around to posting last night, but yesterday we had an interesting new patient who was sent from an insurance company that deals with people who were in car accidents. One young lady had horrible visual field test results, and had such poor vision she struggled to even read the consent forms she had to sign. But the internal exams revealed nothing unusual, so the doctor had to conclude that the problems were likely neurological. The woman was so distressed and upset. It just reminded me that there will be times that optometrists will have to be the ones to give really bad news.

The last patients yesterday were also a family of three, who claimed that they were 'personal friends' of the doctor. Over lunch, he gave us a wry look and refused to confirm this, but he assured me that all of the problems I will face in the future will be due to 'friends and family'. And indeed the husband of that family was just a royal treat, with all his humming and hah-ing and attitude and impatience. That's just great.

Today was terribly busy. They definitely made me work for that last paycheck. The doctor was over half an hour behind. Patients were piling up, waiting for screening tests, fundus pictures, and help picking glasses. There was a patient with asymmetrical optic discs, and a small visual field defect in the eye with the more cupped disc - a prime suspect for a classic case of glaucoma. Another patient must have had some sort of binocular vision problem, so I did a first-time dispense for glasses with prism. The mother of one patient tried on half of the frames in the dispensary and didn't end up buying anything, which was just as well because her and her son's chart actually got lost in the midst of all the confusion and commotion. But at twenty past two, my coworker and I were outta there, and I walked out the door for the last time as an employee.

It's important not to say goodbye too quickly though. I still have to go back next week to pick up my things.

Days until school starts: 16

Days that make you glad to be leaving.

The day wasn't all bad. I saw a few interesting people: a woman who was diagnosed with glaucoma in her 30s; a patient with diabetes who refused the doctor's advice to see a physician; and a man who woke up blind in his right eye one morning and waited 10 days to see a doctor. For the man, the diagnosis was central serous retinopathy - a self-limiting buildup of fluid around the macula that resulted in count-finger acuity. The condition is often attributed to stress, which fits in this case since the guy's wife left him about three weeks ago. However, he was accompanied today by a rather affectionate young female. Intrigue...

It was just really busy today. One lady came in to replace a temple on her frame. I couldn't get the screw out for the life of me, so I had to pass the buck on to my more experienced coworker. I hate feeling so useless. Bested by spring-loaded temples once again.

I had to deal with one lady on the phone who was not impressed with the price she got on the sunglasses she ordered yesterday. All of us at the office have no idea where she would be able to find the same Coach frame for less then what she paid, but I wasn't about to challenge her. In the end, all I could do was assure her we gave her the best value we could. She was pretty nice about it, but I was just at a loss for words. More frustration.

The cherry on the top of the day came when another patient asked to make sure I know how to use a fax machine, because the prescription I was trying to send her was not getting through. I had to call her twice to let her know that the machine was not picking up, at which point she asked if I "normally send faxes" and requested that I "reset the system and try again". After I hung up, I did the exact same thing and sent the fax to the same number - and the stupid thing actually did go through. I'm sure that woman must have felt even more smug and certain that it was a mistake on my end. A similar thing has happened in the past, but the woman today was more accusing/mocking than the one from last time.
Gotta love these people.

Work days left: 2 !!!!

What's that smell?

Thanks be to God, who always leads us in triumphal procession in Christ and through us spreads everywhere the fragrance of the knowledge of him. For we are to God the aroma of Christ among those who are being saved and those who are perishing. To the one we are the smell of death; to the other, the fragrance of life. And who is equal to such a task? Unlike so many, we do not peddle the word of God for profit. On the contrary, in Christ we speak before God with sincerity, like men sent from God.

A couple of weeks ago my friend Monica and I went downtown for lunch. We went to Salad King, visited my friend at work, got some bubble tea, and decided to head back to the Eaton Centre just to hang out and shop around before we had to go on our ways home. We wandered around aimlessly, just chatting and perusing random merchandise. Since both of us went to Hong Kong this summer and have not fully readjusted to North American prices, we had no desire to actually buy anything. Instead, we made it our goal to trek the entirety of the mall just for fun (which led to, among other things, my discovery of a bathroom on the third floor of which I was not previously aware).
The last leg of our journey was to the lower Concourse level. There really isn't much down there - a small food court, a Mind Games Store, and an Athletes World? But in the spirit of why not, we headed down the escalator to visit the land down under. And as we descended, our conversation was suddenly interrupted - by a subtle, thoroughly delectable scent. It smelled like... chocolate? Pastries? We didn't know, but it was amazing.
The frantic foodies that we are, we immediately got really excited and looked all around to find the source of the aroma. But there was nothing in sight and no stores nearby that would identify it. What exactly it was, we will never know... but it was there, wafting into our noses so intensely that although we couldn't find where it came from, we knew it was real.

That experience helped me later to appreciate the above passage, 2 Corinthians 2:14-17. I've heard before that olfaction, the sense of smell, is the most primitive of the five senses. Babies learn to recognize the scent of their mother early on in infancy. Smell is strongly linked to the sense of taste, so something that smells bad is also considered to be unappetizing, and as well as to memory. For example, the scent of gingerbread reminds us of Christmas, the smell of mothballs reminds me of grandmother's closet, and the smell of oranges reminds me of three people in my life who I know really like oranges.
Now stop for a minute and think that Christians are the aroma of Christ. That we waft into people's lives, and they sense God living in us and loving through us. They may not know the source of the scent right away, but they are making up their minds about it: "to the one we are the smell of death; to the other, the fragrance of life" (v.16). This verse makes me think of the Lush store that is at the Eaton Centre, right near the Dundas subway station entrance. Every time I walk by to get to the subway, it makes me want to gag. But I can only assume there are people out there who really like that smell (even though it smells like a fistful of potpourri and a bar of soap shoved down your throat at the same time).
In the end, for those that find the scent appealing and keep searching, they will eventually find the source, and "taste and see that the Lord is good" (Ps. 34:8). But as Children of God, we are the aroma, the first sense that many people get of Christ. An important job, but then again, not really a job at all: it's just what we are. People inviting other people to taste and see - and feel and hear - the Living God.

FDT and VFs.

I decided I should finally look into what FDT actually is, since the perimeter at work is different from the typical Humphrey Visual Field Analyzer I've seen before. Traditionally perimetry is done by presenting lights in the patient's periphery while they are fixated on a central target to see whether their retinal sensitivity is good enough to detect it or not. The FDT Perimeter uses a vertical sine wave grating as a stimulus:

It flickers at 25 Hz, with variable target size and contrast. And at a high temporal frequency, the spatial frequency appears to be doubled - thus, Frequency Doubling Technology, or FDT.

Points of interest:
1.

The large low spatial frequency targets are not significantly affected by refractive errors up to 6D, so optimal near correction is not needed

2. FDT perimetry is based on this phenomenon:

when an achromatic sinusoidal grating of low spatial frequency undergoes counterphased flickering at a high temporal frequency, the apparent spatial frequency of the grating appears to be doubled.

3.

FDT offers many advantages in that it is easy to administer and interpret, liked by most patients, not greatly affected by refractive error and cataract, has high test-retest reliability, offers rapid screening tests, and has different full threshold programs.

OC's and Δ

Today I spent like 20 minutes trying to fix a screw in a pair of glasses -- way too long. But on the plus side I finally got to learn about the nut and bolt assembly instead of using a temple screw, and I played around with some of the tools for that (ie. hexnut screwdriver, crimpers, file). I guess I should really look into finally purchasing that set of adjustment tools...
Oh also there's this adhesive called LocTite that can be used to keep temple screws tight over time. And apparently acetone can be used to remove paint from lenses without damaging the coatings.

I also received another lesson in anisometropia too. If a patient is +1.50 OD and -1.50 OS, and they look away 1 cm away from the optical centres, what do they get? Apparently... diplopia. And 3 prism dioptres of strain on the EOM. Oh this all sounds ever so vaguely familiar.


Work days left: 10

Hot potato.

Today I learned that co-management with ophthalmologists is like "a game of hot potato".. you don't wanna be the one stuck holding it! So: refer, refer, refer.
I'm also picking up a lot of tips on how to handle patients and meet their needs. Sometimes they won't give you the whole story, or say one thing when the issue is really something else, so you just need to take the time and effort to inquire a bit further.

Work days left: 11

DR and unhappy Px's

It was the Tuesday that felt like a Monday. I guess since yesterday wasn't that busy, today decided to make up for it.
Today I learned that it's important to communicate your expectations. A patient called and said that he was unhappy with the service that he received at his appointment in June, and wanted to switch healthcare providers. In the end, it turned out that there was just a miscommunication about what the doctor thought was important, and what the patient wanted at the time. Tiffs like this can also be easily cleared up by swallowing your pride and apologizing, and doing what it takes to right the wrong.
I also got to do direct ophthalmoscopy on one patient with diabetes who presented with a vitreous hemorrhage OD, just to get an idea of what the view looks like through a cloudy vitreous -- really shoddy.

Today's homework: pre-retinal and vitreous hemorrhages, prognosis, treatments; diabetic retinopathy

Work days left: 13

CLTs and BCs

For a Monday, today was not all that busy. The morning was a blur of answering phones and checking in patients, and nothing too out of the ordinary (except for one elderly lady who kept me on the phone for an extraordinarily long time). In the afternoon I did my first ever frame adjustment for a patient on my own, since my manager was busy with a contact lens teach. I also attempted a screw replacement for a spring-loaded temple, but it was unsuccessful...

I also need to get a lens clock. Apparently base curves are pretty important. If a person gets a new pair of glasses that have a front curvature that is different from what they're accustomed to wearing, it leads to perceptual problems that can be very difficult to adapt to.

Tomorrow I switched my shift with my friend so I have to open. Which means no sleeping in :(

Work days left: 14

OCT and ERM

Since summer's almost over and the countdown to my last day of work has begun, I decided that it might help the days go by faster and more memorably if I start documenting the things I see and learn at work.



Today I got to see the elusive OCT (optical coherence tomography) machine, which provides high-resolution cross-sectional images of the retina using light waves that are reflected in varying amounts by the different retinal layers. (See sample above.) Two-dimensional data sets taken in two meridians can be further used to create a three-dimensional representation of the patient's retina around the macula. This test is not part of a normal oculo-visual assessment; it incurs a separate cost ($85 where I work). It takes about 15-20 minutes for a compliant patient, and is recommended for those with macular pathology - for example, patients with diabetic retinopathy, which was the case today.

Hard deposits around the macula were evident in the patient's fundus photos. With the OCT images, you could see the edematous elevations around the macula. Focal hemorrhages were noted, as well as an epiretinal membrane OS. Epiretinal membranes (ERMs) are commonly associated with retinal vascular disorders. Cells liberated through a retinal break proliferate on the retina, resulting in tractional forces that can cause visual distortion, macular holes, and cystoid macular edema. Approximately 90% of ERMs stabilize or regress, otherwise they can be peeled away surgically.

I also learned a bit about Barter Networks, which allow people to acquire services by trading their time and services using a point system.

And there is also supposedly a new drug that 'reverses glaucoma'!

Workdays left: 16