Transcript

Will: [00:00:00] Knock, knock,

knock, knock. Hi.

Hey everybody. Welcome to Knock, knock. I with me, your host, Dr. Glaucomflecken Ffl, and this of course is your one-stop shop. For all things eyeball related, and we do have some fun eyeball stuff and some not so fun eyeball stuff to talk about. Uh, I have a pickleball injury to discuss and, uh, uh, a frustrating, uh, patient interaction, uh, that we, we need to talk about before we get to that.

Um, I am, uh, I, I feel like myself again because I am full of testosterone you guys. This is, I, this is the day after I got my testopel injections. I am, I am raring to go. I am ready, man. [00:01:00] You know what? It, it’s the, the whole, my, my testosterone journey has been interesting and just for people who have no idea why I’m talking about testosterone or why as a reasonably young person, I am just about to turn 40 I am on testosterone is because I don’t have any testicles, you guys.

And I, and I’m not meaning that like figuratively, like literally I don’t have testicles. Like they were both removed, uh, due to just a slight issue with cancer. And since then I have been on all different kinds of testosterone replacement. Finally got on something that works. It’s called Test Appelle.

It’s these little pellets and it requires me to go into the office and have my urologist every three months like inject me. I actually haven’t seen it done because I’m like, face down, ass up. And, but the uh, uh, there’s some kind of incision that’s made and then she just like puts them into my butt cheek.

It is like I, I, [00:02:00] I get the max because it’s pretty unusual for someone like me, uh, who doesn’t have any endogenous testosterone production, and it’s hard to get a young man. To physiologic levels in that way. But so I’m, I’m maxed out. I am maxed out on my test pill, but I can feel it when I’m getting low.

You guys, man, hormones are crazy. Hormones are just wild. I, I can feel, I’m like, I just am lethargic. I have no motivation. I stop making. Like video content. I stopped making videos, I stopped writing skits ’cause I just don’t have the motivation or I’m just tired. All I have, all I have the energy to do is my day job as an ophthalmologist.

And so obviously that’s gonna take priority. I’m gonna do that. Not that you all are not important, but you know, you know what I’m saying? Like, I gotta do this, I gotta gotta pay the bills, gotta do the, the cataract surgeries. Um, and so finally though, I got my appointment and uh, I was about. [00:03:00] Three or four weeks overdue.

’cause my doctor had to like reschedule, which is, which was devastating. But, but I got in and now, now we’re good. Now we’re good everybody. All right. Lemme know if you have any questions about test to Pill. I could tell you all about it. And as well as the difficulty with insurance getting to, uh, them to cover it.

How many times do I have to tell somebody, look, I don’t make my own testosterone. I could, I don’t have testicles. They don’t exist anymore. They’re in a jar somewhere. Now, probably I’ll be incinerated, but I don’t have them. I need this testosterone. I need it. Give it to me. So frustrating. Uh, but you know, I, I’ve talked plenty enough about, uh, about health insurance companies and I’m sure there’ll be plenty to more, more to go in the future.

But anyway, so I’m good. I’m ready to go. Um, but, uh, first I do wanna talk about something that’s very frustrating to happen in clinic today. So, uh, one of the big things that I treat, I deal [00:04:00] with, um, as an ophthalmologist is dry eye. Dry eye is kind of, it, it’s, I would say. Almost every patient over the age of 50 has some degree of dry eye, and there’s a lot of reasons for this.

I do think our, uh, screen addiction as a society is to blame a little bit. That’s one factor that goes into dry eye because we’ve seen, we have studies that show that whenever you’re looking at a screen. It holds your attention so well that we don’t blink as much as we should. Our blink rate goes down and blinking is what helps redistribute your tear Film it blinking helps push mebo oil out of your meibomian glands onto the surface of the eye, which, which insulates your tears and keeps your tears on your eye.

So if we’re not blinking, then your [00:05:00] tears will evaporate. ’cause they don’t have the oil, the oil glands get thick and plugged up. You’re gonna get dry spots on your cornea and your, your vision’s gonna get blurred. I even remember this as a kid, like I would, you know, stay up all night playing video games at my friend’s house and it’d be like, you know, three o’clock in the morning and like, you finally look away from the screen and you blink for the first time in like two hours it feels like.

And it’s just like sandpaper in your eyes. That that is, that’s what it’s like for people. And so, uh, I’m constantly talking about dry eye. It, it, it takes up probably, probably half, half of the day is talking about dry eye, which does get a bit repetitive, but it’s, and it’s not my favorite thing, you know, but, uh, it is important and it really does affect people’s quality of life.

So, and some, sometimes I’ll have patients that I’ve been working to get them on a regimen. Uh, for, for, for months, sometimes years, trying [00:06:00] to figure out, tinker with different things. Do we start Restasis, which is a medication that has kinda anti-inflammatory properties that can help promote healthy tear production.

Do we start Restasis, uh, do we do punctal plugs, which is putting a plug, literally a physical plug in the tear drainage tube. Decrease the amount of the tears that drain, thereby increasing the amount of tears on the surface of the eye. Do we do that? Uh, do we change up the type of artificial tears this patient is on?

Do we do something that’s a little bit thicker? Like refresh is just a regular artificial tear. Do we do something like Celluvisc, which I love, I love Celluvisc. No financial interest in any product I might mention about dry eye, by the way. I just like ’em. I just know what works or what doesn’t work for people.

Celluvisc is a little bit thicker, preservative free, so it stays on the eye a little bit longer. Uh, do we do [00:07:00] ointment at night? That’s another treatment for dry eye. Uh, how about, um, how about Omega-3 fatty acid supplements? That you take by mouth. There’s conflicting studies. Some studies suggest it really helps.

Some studies not so much. You kind of get that a lot with like, like actual studies that have been done about supplements, but it’s generally pretty safe. It’s a little bit of a blood thinner, the fish oil. But um, most people can tolerate that just fine as long as you don’t mind like. Fishy burps, which can prevent people, those people actually tell to take flaxseed oil.

Flaxseed oil supplements are also, uh, there’s some, some data that shows that it can help with dry eye as well. Uh, what else is there? There are in-office treatments that people will do. There’s, um, things that, like a machine that will massage your eyelids and heat them up. With the goal of pushing that oil out of those meibomian glands, meibomian [00:08:00] glands that I’m talking about, those are very expensive treatments.

If people don’t want to pay for that, then we could just, I just talked to ’em about hot compresses. That’s another thing you can do. There’s also steroid treatments for people with really severe dry eye that need a, that are, are, have really like a high degree of inflammation on the surface of the eye. We will give you something in the short term that has a little bit of steroid to help quiet down that inflammation.

And I’m gonna get to a point here in a second. I. And also we have for very, very, very severe cases. I, I kind of as severe as it gets. One of our last line treatments is what’s called serum tears. So we’ve actually take a sample of your blood, send it to the lab, and they centrifuge it down to serum. They collect the serum and turn that into an eye drop that you can put on your eye.

It has all your, all your natural. Immune complexes and, and growth factors, and I don’t [00:09:00] know, I don’t know whatever the hell is in these things, but it works really well. The downside why most people don’t do it is because it is insanely expensive and insurance doesn’t cover it. So, uh, but that’s, that’s something that can be effective, uh, for, for people with very, very severe dry eye.

As you can tell from this conversation over the last few minutes, there are an enormous number of treatments. Some have better evidence than others. Most of them have been used for a long time. There’s even a lot of treatments that we tried out and didn’t really pan out. Like there was a, this is my favorite, this is my favorite dried treatment of all time, um, is a nasal stimulator.

It had like two prongs on it. That you would kinda like an electric outlet thing and you’d stick it in your nose and it would, it would electrocute you a, a small amount of electricity. And the goal, [00:10:00] the whole idea is that, you know, just like pulling, if you, if you pull a, a nose hair, it’s gonna make your eyes water.

That’s all they’re trying to do. Like stimulating that reflex by electrocuting your, your, your nose. To produ to produce tears. Um, surprisingly didn’t really catch on. No, I, you know, it’s, uh, I remember seeing booths for this at, at like eye conferences and thinking, wow, that’s crazy. I can’t imagine trying to convince my patient to do that.

But you know what it, I mean, it worked in terms of making someone tear up, but my God, is it not a fun thing to do? So. So many different treat. Dozens, dozens of different treatments. So we have, I have all of this at my disposal, right? To, to, to offer to, to patients. And it, it, it takes trial and error. It’s like you, you try, you, you, I try not to add too many things at [00:11:00] once.

So we might try one or two new things, have the patient come back in a two or three months, see how they’re doing. If something’s not working, then we stop that. Maybe we stop Restasis, we try a different medication, try different treatment, uh, a procedure, whatever it is, come back every two or three, so it takes time.

That’s the point. So I have. I had one of these patients that had been working for quite a while, finally got to like a good steady state, right? This, it’s a, an an elderly woman in her eighties and she is finally at a point where like things are going okay, and by the way, by the time you’re in your eighties, 100% of people have dry eye.

You just kind of dry up as you get older folks. And, um, but, but she was good. Well, she comes back after like, I think I’d seen her maybe a year, year and a half ago. She comes back and her dry eye is worse, and she didn’t have any of her eyedrops that we she’d been on. [00:12:00] She and, and, and what I do when I walk in on the counter, I see this like amber bottle and I, I know immediately what this is.

Because I’ve seen other patients that come in with this. It’s like a big bottle. It’s like a, like probably a 50 milliliter bottle. And by just reference that, uh, like a normal eye drop bottle is like, uh, five milliliters. This is, it’s a massive eye drop bottle full of this liquid in this brown container that has one label on it or 1, 1, 1 word on this, on the label.

And that’s all it has. It says, I bright. This is an homeopathic medication homeopathic, and I just take it like a deep, a, a big deep breath because like, it’s so, it’s frustrating because basically what happened was this patient had a family member that told them, Hey you, I see you’re on like three or four different [00:13:00] medications for your dry eye.

Uh, let’s, uh, I think you should go to a homeopath. Go see my homeopath. Uh, and they’ll, they’ll help you out. They’ll do, they’ll, they’ll really, they’ll treat the root cause. They’ll really get down to business on treating your dry eye. And so the pa and I, I, I put no fault on the patient, none whatsoever.

But what the homeopath did, because the patient just doesn’t, she just like, oh, is a family member. It’s like, oh, they, they have my best interests at heart. Of course. So they went to the homeopath, homeopath told him, stop everything you’re doing. Disregard the, the, the years of expertise of, of your, your board certified ophthalmologist, who you’ve been working with for, for several years.

Disregard what he said and start this thing called I Bright. It’s gonna come in an amber bottle [00:14:00] with no information about what’s in it.

No, no information on it that it’s just, it’s like, it looks honestly like a medication you would see in like professor Snap’s closet at Hogwarts. It’s just like this old Amber bottle like that could have been from 500 years ago that says I bride on it. So I had to do research to try to figure out what’s in it.

Like med, these medications that you’re using, they should have what’s in it on the thing. This did not. It could have come from anywhere. And that’s the thing with homeopathic medications, everybody, it, it, they’re, they’re unregulated. There are these supplements, they’re herbs. They’re for the, for the most part it’s, it’s, it’s tap water with a little bit of stuff in it.

These herb, uh, extracts and so I did figure it out. What it is, it’s this flower like extract of a flower called [00:15:00] euphrasia. Which I guess has been used for centuries, uh, for, you know, various ailments. Uh, and, um, and now it’s like a tincture, tink tincture. Tincture that homeopaths give out. And, um, obviously no data whatsoever to suggest this is helpful.

Uh, we don’t know where it comes. I don’t know. Is it sterile? Is it, uh, does it have, uh, harmful other harmful chemicals in it? We have no idea because it, there’s nothing on the label. I don’t know where this thing came from, didn’t come from a pharmacy. I’m sure it just came from this homeopaths closets. Um, so anyway, and the way I deal with these types of situations, I don’t get mad.

I don’t get angry. I just, I say, I just, I’m truthful, right? I’m like, listen. You know, we, I don’t know what’s in this and I cannot tell you that this is safe. Uh, we have no information, there’s no [00:16:00] studies that have done, been done on this. It’s not regulated by any kind of regulatory body to make sure that this is safe for human consumption.

Um, and so I cannot recommend that you take this. I do recommend that we put you back on what we know has worked in the past. So I got it all sorted out. This is a wonderful patient, and just, it was like apologetic, but it’s like, it doesn’t need to be like, I, this is not your fault. Like it’s, it’s so hard to navigate the healthcare system and I just, I wish.

People just had more trust in like the, the evidence-based medicine that we use. And, and I know that’s under assault and, you know, I’m not saying everything doctors say is, is, is, um, is accurate or truthful, but, but the relationship that I have with this patient should have been a clue. And the fact that this patient was doing well.

But that’s not enough for some people. So, um, so anyway, it’s, it was frustrating, but [00:17:00] we dealt with it and, uh, and patient’s gonna be just fine. And I just, the, the homeopathic stuff just irritates because it’s all over the field. It’s every field, but it’s all over ophthalmology. All right, let’s take a break.

Kristin: Hey will. Hey, what’s up? I’ve been thinking the US healthcare system. It needs some improvement. 

Will: Yeah, it’s, it’s, there’s room for improvement 

Kristin: for sure. Yeah. It’s a confusing, scary place for everybody involved. 

Will: Absolutely. 

Kristin: Physicians, families, patients, everybody. 

Will: Everybody. And I’ve experienced it from both sides, right.

I’m a physician, I’ve also been a patient, so I wanted to use my platform to give people practical education. Really the only way that I know how. By making jokes. So, Dr. Glaucomflecken really fun and super uplifting. Guide to American Healthcare is Out and it’s a free resource that includes all my videos from the 30 Days of Healthcare Series, alongside deeper explanations, also reliable facts.

Emphasis on [00:18:00] reliable. Yes. All right, uh, uh, figures, uh, numbers, insights into how each of us can fight for a more. Humane, better healthcare system. Also, it has jokes. Did you mention the jokes? I did. I jokes. Okay. Yes, definitely jokes. Well, 

Kristin: this guide is great for anyone looking to learn more about US healthcare, but especially if you are experiencing it from the clinician side for the first time.

That’s right. We really hope you’ll check it out. 

Will: Get the free guide sent straight to your inbox by signing up for our mailing list. Glaucomflecken flicking.com/healthcare. Enjoy. Kristen, I gotta tell you about a new podcast that every clinician should know about. 

Kristin: Good. Tell me. 

Will: This is the sepsis spectrum.

Okay. It’s by the Sepsis Alliance and Critical care educator, Nicole Kic. This is really important. Each episode is about confronting blind spots and sepsis and antimicrobial resistance education. A lot of this stuff usually doesn’t make it into textbooks or compliance training. 

Kristin: That’s weird because it’s super important.

Will: [00:19:00] Yeah. Everybody needs to know about this stuff. You can listen to the sepsis spectrum wherever you get your podcast, or watch it on the Sepsis Alliance’s YouTube channel. To learn about how you can earn free nursing CE credits just by listening. Visit sepsis podcast.org.

I am tired of the misinformation. You guys, I’m tired of it. It’s, and like I can deal with it when it’s on social media, like the whatever. I do that all the time. You know, ev every so often there’s someone that claims that wearing glasses makes your vision worse. And so I gotta go and make my little silly little TikTok and, and tell people, no, actually it’s just physics.

It’s just light. You have a lens, you have a cornea, it bends light, but sometimes it doesn’t bend light enough and you’re near and you’re farsighted or it bends light too much and you’re nearsighted and you gotta have glass. We have this wonderful invention, the [00:20:00] greatest, one of the greatest disability accommodations in human history glasses that will make you see perfect again.

How would you not wanna wear them? It doesn’t make your vision worse, so I gotta do all, I gotta do this every so often. It’s, it’s exhausting. I’m so tired of it. I do it because if I don’t do it, then, then the, the people that are trying to sell you a course on how to fix your vision without glasses are, are, are going to be unopposed.

Someone’s gotta be out there, someone with actual knowledge. That’s what I tell that to whenever I go talk to physicians, healthcare professionals, they’re like, listen, I know it sucks. You might not like social media. I, there’s a lot of times I don’t like social media, but we can’t ignore it because then the homeopaths ones that give out amber bottles from Hogwarts, [00:21:00] the ones that sell courses for dubious reasons.

Health related, uh, they give bad advice. They’re gonna go unchecked, and they’ll just proliferate and they’ll make their money. Off of the misfortune of, of the general public who believe their lies. And the thing is, man in misinformation, oh, it spreads so much faster than accurate information. Like the, the claim that you don’t need that glasses make your vision worse, will spread across the internet so much faster than me telling everybody in the funniest way I possibly can.

That you, that, that glasses actually do help your vision and they won’t make your vision worse. It’s, it’s the, it’s the wild claim that that goes against conventional thought. Now, occasionally wild claims turn out to be true, like, like [00:22:00] the guy who discovered h pylori by that causes, um, gastric ulcers by actually infecting himself with h pylori and giving himself an ulcer.

But there’s data behind that, right? I’m talking about the people that just have zero evidence behind to back up anything. And then here’s what happens. Whenever I try to debunk a claim and I, I’ll just keep using this example of, of, or here’s another one that, that you have to do. I exercises if your vision is bad, if you’re, if you’re nearsighted, just do more eye exercises.

That’s gonna help. No. Because then you can’t divide the laws of physics. Everyone, okay? It’s, it’s optics, it’s physics, but that’s another claim. Like I Exercises can help your vision. When someone claims that, that I exercises will help your vision and then I respond with my actual truthful information.[00:23:00] 

One of the reactions that I get from that person sometimes is like, um, uh, well, can you prove that? Show me the proof. That glasses help your vision. And it’s, it’s this, this, this like circular way of, of thinking. And it’s, it’s, right. It doesn’t, that doesn’t, that’s not scientific because it is not on me to, to refute your wrong information.

It’s on you as the person claiming this crazy thing to prove that the crazy thing is correct. It’s not on other people. To disprove your crazy claim that that’s what drives me absolutely batty. It’s like, what are you doing? You can’t just claim the sky is purple. Prove to me. Oh, you say the sky is not purple, it’s blue.

Prove to me it’s not purple. No, that’s not how it works. You [00:24:00] make the crazy claim, you prove to everybody that your crazy claim is correct. You infect yourself with h pylori to prove that h pylori causes gastric ulcers. That’s how it works. Okay. All right. That’s done. I’ve, I’ve now bled this, this diatribe into two different segments, so I apologize everyone, but man, the homeopaths just get me, they get me going.

Alright, I have a, um, oh, you know, let’s, let’s, let’s go and talk about a patient, another patient I saw, um, this was, uh, last week. And, um, and then we’re gonna get to a, a new story, uh, after the second break. And, uh, uh, a very, very fascinating news story that I think you’ll want to hear about. Um. Alright, so first let’s, let’s do a little bit more like ophthalmology stuff.

I know I talked a bit about dry eye, but this was a, uh, the, um, the dreaded pickleball accident. We’ve been seeing more of these. All right, pickleball came off the edge of the, what do you call ’em? [00:25:00] Paddles. Pickleball paddles. Not quite rackets. Paddles probably made that little ding sound and, uh, right up into the eyeball, blunt trauma directly to the eye.

Unfortunately, this patient was on blood thinners. And so you might be able to guess what he showed up with. He had light perception vision, first of all. So again, all he could see was a light shining right in front of his eyes. So the tech, I’m sitting down in the hallway documenting whatever, probably just a.

Start from the internet and, uh, the, the, the, the tech came to me and said, okay, uh, doc, can you come and take a look at this patient? Uh, their light perception? And so if a patient has light perception, that is like an immediate, oh, something bad’s happening, and so well, let’s get the doctor in there. Let’s try to figure out what’s going on.

So I, I immediately go, went in there and I took a look and there’s a 90% Hy fema. Hyphema is blood in the [00:26:00] anterior chamber. So this blunt trauma was severe enough that caused, it caused a shearing injury to the blood vessels. That are in, on the iris and in the angle of the eye, kind of on the inside of the eye where the cornea meets the iris.

That’s, you have some blood vessels in there. Uh, the, in the angle where the trabecular meshwork is, that’s where your, your eye fluid drains. And so, um, it caused a severe enough blunt trauma that it, that the, that the eye just filled up with blood and that the, it was hard to clot because the patient is on blood thinners.

So the most important thing when we see a hyphema that’s bad is what is the eye pressure? And fortunately, this patient had, uh, an eye pressure of only 28. Great. So we get really concerned when the eye pressure gets in. That situation gets above 40, all right? [00:27:00] That’s when you’re starting to get into danger territory, where if you don’t treat that pretty aggressively, then the patient could develop permanent vision loss.

That occurs because high eye pressure puts stress on the optic nerve, on the nerve fibers that make up the optic nerve. It causes damage to those nerve fibers. That’s what happens in glaucoma. So this patient’s pressure was a little bit above the normal range, which is like 11 to 20, but not in dangerous territory.

So I went ahead and started him on a, a pressure lowering eye drop. Coop, which is a combination drop. And for these patients, we, chances are there’s going to be some inflammation in the eye as well as blood, because that’s a big blunt trauma. So I start as steroid drop as well. And these are the patients that we see every day while there’s blood in the eye to make sure that it resolves.

Okay. Especially that first five days, because there’s [00:28:00] always a risk that a re-bleed could happen, say the patient. Despite our advice that they remain a couch potato for the next week, uh, they decide to go exercise or they feel like they’re, oh, they’re doing a little bit better. They’ll do some yard work, and then enough jostling activity occurs, and there’s another bleed that occurs inside the eye.

And the second bleed is always worse than the first bleed. And then there you have it, the patient. Really high pressure and they’re getting emergency surgery. So we’re trying to avoid that by telling ’em to be a kind of a couch potato. And, uh, the problem with this patient is that there was so much blood in the eye that I could not assess for any injuries in the back of the eye, which is always a concern.

Anytime you have a, an injury that’s severe, could there be a retinal tear or a retinal detachment? So. Set this patient up with our, uh, fortunately in the same, right in the same clinic, we have one of our wonderful [00:29:00] Glock, uh, one of our wonderful retina specialists who took a look, used an ultrasound. All you emergency folks, you’ll love to hear that.

IU we used an ultrasound. We did an o ocular ultrasound. This is one of those examples where an ophthalmologist use an ocular ultrasound in an emergent situation. Uh, and we assessed for the presence of any retinal tears. There were none. And so the patient was okay to go home. And, uh, would see that patient back every day and probably seeing him sometime this afternoon.

Uh, so anyway, that was exciting. Pickleball, I had no idea. I didn’t know pickle balls traveled fast enough. I’ve seen these types of injuries with baseballs, softballs, tennis balls. I think this is the first direct. Trauma pickleball to the eye that causes this severity of, of an injury. So be careful out there, folks.

With the pickle balls, man, it’s, it’s getting more, it’s getting more popular. It’s growing popular. We’re gonna be seeing more of these. All right? We don’t want you to go blind. No one should go blind from [00:30:00] pickleball. No one should go blind from anything. Much less pickleball. Uh, so that was, um, that was a, a bit of excitement.

Now, next, uh, next week when I record this episode, I will have. Just about finished a week of call. I’m starting call on Wednesday this week, so I’m starting call tomorrow. And, um, and I, I always dread it even though it’s private practice, ophthalmology call, and I have no reason to complain. No reason at all.

It’s still kind of an annoying thing I gotta do. So, um, anyway, I’ll have maybe some tales to tell, uh, about my, uh, on-call shift. Uh, so shift my on-call week. It’s like a dozen shifts back to back. Um. All right. Let’s do, before we take one more break, uh, I’ll address a couple of questions that I got on our YouTube channel at Glaucomflecken Flecking.

This is on the episode that’s titled, should There Be a Loan Cap for Med School? Not a lot of you people, not a lot of you [00:31:00] listened to that episode, so I don’t think you found that discussion of the Big Beautiful Bill particularly interesting. Maybe it was just a little late on the information. But anyway, uh, some good comments at.

A LC 5 4, 4 0. Uh, said, surely this won’t have a massive impact on our current physician shortage. Um, sarcasm there. Unrelated side note, I had an optometrist appointment today and noticed that they hired a scribe since my last visit. I was very excited for them. That is very exciting. I love scribe scribes.

Do wonderful work. Um. Here is one. Uh, let’s see. I liked this one. Oh yeah. This is good at Jim Belter too. Jim, I think I’ve, I think you, you keep giving, uh, giving me comments. I appreciate that. I think I’ve done a couple of your comments before. All this talk about different eyeball procedures had me thinking back to the TV show house.

Love a love, a good comment about house. As you know, he loved his biopsies. He did. What’s interesting is when he does a biopsy on the eye, usually for vitreous fluid while performing the procedure, the [00:32:00] patient is sitting in the chair, retractor in the eyelids, and you see this huge needle heading straight for the center of the eye.

Yes. Which will go straight through the lens. And pupil, uh, I know this is TV dramatic, but how is the biopsy done? That’s a great question. Yes, we will never biopsy something directly through the center of your eye because that is what you need to see. That’s the vision that you’re the, that’s the center of your vision.

You don’t wanna put any needle in there. You don’t want to disrupt that part of the eye. Anytime we do a procedure. Um, for the most part, with a few exceptions, if we’re like trying to clear up the center of the cornea, but like cataract surgery, uh, vitrectomy, uh, like a retinal surgery, we’re going in through the side of the eye because we don’t wanna disrupt, we don’t wanna put any kind of incision or needle track right through the center of the cornea.

So, yeah, it’s all actually all the biopsies for the vitreous. [00:33:00] Which we’ll do a vitreous biopsy if we’re concerned about any kind of, uh, neoplastic process happening, like ocular lymphoma or, um, if we’re biopsying a lesion, which doesn’t happen very often, but it can occasionally, or, uh, or we’re worried about infection endophthalmitis, we’ll put a.

Usually like a 25 something gauge needle into the white part of the eye, into the, that, that will go through the white, the wall of the eye, the sclera into the vitreous cavity. And then we just pull a little bit of fluid out of it. It doesn’t take much. You suck. One time I sucked out too much in residency and the eye kind of deflated and we had to, we had to put a, put some back, but so that, that, uh, we, we gotta be careful.

It doesn’t take much. You’re just getting a little bit of that fluid. Send it off to the lab for, for gram stain and everything, but yeah, that’s how we do it. So we do it through the white part of the eye. This is Clara. Good question. All right, let’s take one more break and we’ll come back with a [00:34:00] news story.

Kristin: What should 

Will: what you do in there, buddy? I’m so glad you asked. Oh, I’m being a Dex. 

Kristin: Oh, are you? 

Will: Yeah, that’s what they sound like. Those 

Kristin: little mites, 

Will: Uhhuh, I, if you put a microphone in front of them, I’m sure they would probably most likely maybe sound like that. 

Kristin: You think so? 

Will: I don’t really know. 

Kristin: Oh, well, let’s see how much you do really know.

Will: Oh, you’re gonna quiz me? Yeah, let’s do it. 

Kristin: What are the only two main species of dex mites found in humans? 

Will: Uh, type one and type two. 

Kristin: Uh, close dex follicular, which are found in the eyelash follicles. Okay. And dex revis, which are found in the meibomian glands. Okay, 

Will: sure. Yeah. Okay. Next one. Next question.

Kristin: Okay. Why do people with Dex blepharitis often feel itchy eyelids first thing in the morning? 

Will: I know this. And, uh, because they avoid light and come out at night to mate. 

Kristin: Oh 

Will: yeah. There’s, they’re mating on your eyelids while you’re sleeping. 

Kristin: Super. 

Will: Is that, is that a, how does that make you feel? So gross. And so people wake up that [00:35:00] itchy, irritated feeling ’cause they’ve been moving around and the eyelash follicles all night.

Kristin: Mm-hmm. Yeah. Yeah. Great. 

Will: I’m surprised you even brought that up. 

Kristin: I know. I’m just trying to get used to these mites since Demodex blepharitis is such a common disease and we keep talking about them, it’s And 

Will: that’s a big step. That’s a big step. Thank you. There’s a prescription eye drop, though that’s available for Demodex Blepharitis.

Yes. To learn more about these mites and Demodex blepharitis, visit mites love lids.com for more info. Again, that’s M-I-T-E-S-L-O-V-E-L-I-D s.com To learn more. This ad is brought to you by Tarsus Pharmaceuticals.

All right. Here we go folks. Uh, some news, this is, this is sad. This is a, not a funny topic to discuss, but I think it’s an important one. It, it’s an interesting one. So, the, um, the news articles from Independent, which is in the UK, I believe, uh, says doctors playing music Bingo missed that their patient had stopped breathing during [00:36:00] routine cataract surgery.

Lawsuit says, so you might, some of you might have seen this, but this made the rounds in some of the Facebook groups that I’m a part of, and I got sent this a, a a few times from different followers. Uh, and so basically the story goes that in February of 2023, a patient was undergoing a routine cataract surgery when, um, uh, about.

10 minutes into the surgery, they noticed that the patient was not responsive, that they were turning blue and the vitals indicated that the patient wasn’t breathing and they tried to save the patient, but it was too late. And, uh, by the time the patient was sent over to the hospital, um, uh, the, the patient unfortunately had died.

And as it turns out, through the investigation that these doctors, the staff in the. In the operating room, we’re playing music. Bingo. [00:37:00] So they would play a song and, and they would, it just had a, basically a game that’s like, you know, could, what’s the name of the song? And you try to get bi NGO. Uh, it doesn’t matter.

It doesn’t matter. The fact they were playing a game that was distracting them from the surgery. Now obviously there’s a lawsuit involved here. It is extraordinarily rare. For a patient to die during routine cataract surgery? Uh, I don’t know the details as far as what kind of sedation was used. Um, typically, I’ll tell you what we do and what I’d say 99% of cataract surgeons do is give the patient.

And we don’t give it, by the way. Usually we have either an MD anesthesiologist or A-C-R-N-A, so a certified registered nurse anesthetist. Uh, give the patient like one to two milligrams of ed, which is an [00:38:00] anxiolytic, and then also usually like 50 to a hundred milligrams of ent. So I don’t know the details about what medications were given, um, but basically this story and the lawsuit hinges on the, the, on the, the idea that these doctors were distracted to the point where, um, they didn’t recognize that the patient wasn’t breathing.

So I’m gonna speak about this from the perspective of the surgeon, obviously. Um, and I, a lot of comments, a lot of people. Chime in on this, both in the medical community and outside the, the community. Uh, a lot of people are remarking, uh, because the, the news story, some of the statements from the doctors show that.

The surgeon was really putting a lot of blame on anesthesia. It’s kind of that tail, the, the age old, uh, uh, trope of surgeons blaming anesthesia when something goes wrong in this case. That’s, that’s [00:39:00] literally what’s happening is, is, is some of the statements show that, you know, you know, the surgeon is saying, okay, this is the anesthesia’s fault.

They, they, they’re, they should have been monitoring the patient and, um, I. It. It’s silly, I think for us to speculate like who’s at fault? ’cause we were, none of us were there. Alright. But I will just tell you what my experience is at someone who’s done thousands of cataract surgeries in that we do not have the ability to monitor a patient’s vital signs at all.

That is not possible. We have to have someone there doing that, whether it’s A-C-R-N-A or whenever I would do cataract surgeries at the VA in residency, it was a nurse, it was an rn, uh, RN, CRNA or an MD there monitoring the patient’s vital signs. Uh, someone has to do that. Someone has to be there doing that.

And the reason we can’t do that as the physician is because we’re [00:40:00] looking through a microscope. Now you do have monitors beeping, but I would say that’s not good. You have to have to be able to see the monitors. Right. And apparently when this lawsuit, some of the information is that, like some of the monitors, some of the alarms were turned off, which obviously is not a, I don’t know why that would be the case.

Alright. The article doesn’t say, we don’t know. So, so the, the, A surgeon cannot, I, as, as you’re doing cataract surgery, you are looking, you have a very magnified view of the eye. You cannot see the patient’s skin, like if they were turning blue, you cannot see what their blood pressure is, what their oxygen saturation is.

I’d be able to hear it if alarm went off, but apparently those were turned off. So, um, so it’s. I, there’s, I think there’s a lot we don’t know about this because again, it’s light sedation typically. So maybe there’s a medication error that was, that was, that happened. Um, but uh, in the end [00:41:00] it’s brought up a lot of questions about what happens in operating rooms, especially during cataract surgery when the patients are awake.

Um, now we, we usually do have music playing. But it’s interesting, anytime I have a conversation with a member of the staff, um, sometimes we’ll, we’ll be like, okay, hey, you know what, what do you, how was that trip you went on? Or, you know, stuff like that. And that’s, that’s, you know, I would say that’s, that’s okay.

That’s okay to do that. Uh, what’s interesting and, and thinking back on it, I never have conversations with the person who’s monitoring the patient. Usually it’s with my, my, my scrub, uh, the scrub tech. Um, thinking back, I never do that. I never, and it’s not, I don’t purposefully ignore that person, but they’re kind of at the other end of the patient and I know that they’re monitoring, they’re, they have their own, they’re doing medications and so I don’t talk to, and I think [00:42:00] that’s probably, unless it’s directly about patient care.

I think that’s probably a good thing, but it does call into question, should we be having any kind of conversations with each other during the surgery that’s not directly related to patient care. And I’ll tell you, most operating rooms around the country, especially for like routine cataract surgery, we’re having conversations, we’re talking, we’re not, not saying anything untoward, you know, about the patient, obviously.

It’s just, it’s just chit chat. Um. And so you can make a, an argument like that, you shouldn’t even do that. Okay, I’ll, I would listen to that argument, but, uh, in the end, you, it’s, it’s just about like, are you doing a safe surgery for the patient? Are you doing everything that needs to be done to keep that patient safe?

And in this situation for this patient that wasn’t happening. Alarms were turned off. Um, there was distracting conversation. Uh, and I think the combination of all these [00:43:00] things. Is usually what sets you up for failure. So this is certainly left an impression on me hearing about this, this poor patient that died and um, uh, and made me more aware of like, okay, maybe we should be.

Making sure that everybody, that if, if there, that there really should not be any distraction with anybody that’s doing something directly with patient care and making sure our focus is on the patient. I typically don’t talk much anyway in the operating room, but man, this, um, these types of things really do make you think so.

Uh, you know, look up the story if you’d like. Um, it’s, you know, you could probably just Google it. Uh, doctor’s, uh, playing music. Bingo. Um, and a little bit too much, I think, uh, for, for a surgery. So, uh, uh, anyway, that’s all I have today for, uh, knock, knock eye. Thank you all for listening. Leave a comment on our YouTube channel at Glaucomflecken Flexin.

Oh, by the way, go and go and watch the, the Animated Show please. [00:44:00] Please go watch those episodes because the more people, even if you don’t really like animation, that’s okay. You like my characters, I think you like me. Go and go and watch the episode because uh, the more people that watch it and like it and comment on it saying this is great, then we can take that to like Netflix and Amazon or whoever might be interested in picking up this show.

Funding it for us so we could keep making it because we don’t have enough money to produce an animated series ourselves because it’s a crazy expensive and we’re not gonna use ai ’cause I’m not all about that. Uh, so, so, um, let’s, uh, let’s do this, let’s, uh. Let’s, let’s get the word out about, uh, Glaucomflecken fl in general and, um, uh, so check it out.

It’s on my main YouTube channel, uh, Dr. Glaucomflecken Flecking. And, um, yeah, we’ll see you next time. My, I’m your host, will Flanary, also knows Dr. Glaucomflecken Flecking. Thanks to my executive producers Aaron Cordy, Rob Goldman and Ashanti Brooke. Editor Engineers a Portr. Music is by Omer Ben-Zvi, who by the way did, also did the music for the animated show.

So [00:45:00] Emmy Award winner Omer Ben-Zvi, um, AKA is a human contemporary. We’ll see you next time. Everyone.

Knock, knock.

Thanks for watching the episode. You can find more on that playlist over there If you prefer to listen or you just had your eyes dilated, you can binge full episodes wherever you get your podcast or join the party over on Patreon where you get early access episodes. Hang out with us, get lots of exclusive bonus content, help you subscribe, leave a comment below, let us know what you think.