[00:00:00] Today’s episode is brought to you by Dax Co Pilot from Microsoft. Dax Co Pilot is your AI assistant, you know, like a little Jonathan in your pocket for automating clinical documentation and workflows that help you be more efficient and reduce the administrative burden that leads to feeling overwhelmed and just burned out, learn more about how Dax Co Pilot can help improve healthcare experiences for both you and your patients by visiting aka.

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Hello everybody. Welcome to Knock, knock. I with me, your host, Dr. Glock and Flecking. Uh, this is your one-stop shop, all things eyeballs. Just a [00:01:00] fresh off my surgery block ready to talk eyeballs with you guys some little ophthalmology. I’ve got some great topics It’s been an interesting last few clinic days.

I’ve had some some exciting Some terrifying things come into the clinic And I’m excited to share some of those things with you, including a pants patient, a pain that we’re going to, uh, you know, hearken back to the beginning days of knock, knock. I, when I was telling you all about all the different pants patients, well, I have a pants patients to tell you about today.

Uh, but first, before we get into the eyeball stuff, uh, I want to dedicate this episode to, um, a familiar foe for all of us. This episode is dedicated to UnitedHealthcare. They will not stop giving me content ideas. It’s, I, like, I appreciate it. I really do. I wish it didn’t come at the expense of, like, making people very angry.

And, uh, [00:02:00] and, and potentially like, uh, you know, having people die or become financially devastated because they can’t get the treatment that they need. I wish that wasn’t the case, but on a content side of things, I do appreciate that they keep just stepping in it and giving us lots of ways and things to, to make fun of them about, and the latest thing.

Is, um, is, uh, basically there’s a few articles have been, uh, been out there about this, they recently hired, well, actually before we tell you exactly what they did, let’s, let’s just, I want to set the state, like, how did we get to this moment? So UnitedHealthcare for years and years and years, decades, they’ve been operating in the shadows, right?

They don’t want people to know what they do because it is so harmful and so profit driven, they don’t want. All of us to know how much we hate United healthcare, like with, like, they don’t want us talking to each other. They don’t want [00:03:00] us to, to, to come to this grand conclusion of, for all of society, that United healthcare is terrible and that’s the way they’ve been operating.

They’ve been doing all these little things, you know, vertically integrating, you know, automated claim denial is using artificial intelligence to automatically deny claims. Uh, and, um, and, and, and just that being the default, like we’re not going to pay. For this care, uh, abusing the prior authorization system, uh, making us do peer to peer reviews with people that don’t have our level of expertise talking as a physician.

And surely UnitedHealthcare is not, is, is not alone in doing this. The other companies do various parts of these things as well, but UnitedHealthcare I think is the worst offender. And then, so they were chugging along doing their nefarious, you know, corporate malfeasance and, uh, and then their CEO was killed.

All of a sudden, [00:04:00] everybody’s paying attention. Everybody, I think. The, the reaction to the killing, which I’ve talked about on this podcast already a lot, uh, I really do think it caught UnitedHealthcare with their pants down. I don’t think they expected the reaction that they got, which was like pure, uh, vitriol and lack of sympathy for UnitedHealthcare.

For, for this company. I don’t think they were expecting it. I think they were, they were somewhat surprised. I don’t know how you could be surprised by that. Like, look at you, look at what you do, uh, that, that should not be surprising to anybody, but it was, I think, surprising to them. And. And so all of a sudden, because of the shooting, like everybody is talking about UnitedHealthcare pointing out all the, Oh, look what they did to my family.

Look what they did to the over here. All of a sudden everybody’s paying attention, which is not what a company like UnitedHealthcare wants. They [00:05:00] want to operate in the shadows. They want to generate enormous profits under the surface where we can’t really see or understand, really comprehend what it is they’re doing or why.

Uh, But now they weren’t able to do that. Right. And this has been going on now. It’s been what, three months, something like that. Uh, well, the latest thing, which brings me into why I’m even bringing this up now is because they hired. A, a, a high powered law firm that deals with like defamation lawsuits with the expressed, you know, reason being to go after people on social media who are quote, like lying about United healthcare.

And one of the things that kicked this off was that there’s a physician on social media who talked about, you know, being pulled out of the operating room to be told that the patient she was operating on, [00:06:00] uh, was not going to have her post op hospitalization approved by insurance, you know, healthcare, she, she talked about this on, she made videos about it, you know, healthcare sent a letter Say basically cease and desist, like don’t tell lies, like this is not appropriate, but it’s kind of threatening legal action is really despicable letter that was also shared on social media.

Thank goodness. And, uh, and then, and then this is how United healthcare has, has, has dealt with that. It’s like, okay, fine. We’re going to start coming after all you people just for the record. They have not come after me yet. If they ever do, if United Healthcare ever comes after me, which I don’t think they will, because if I was just like saying things like I am now into a camera, uh, and, and talking about United Healthcare, and that was like the main thing that, that people knew me for, like, maybe I’d be a little bit higher [00:07:00] risk, although that’s kind of what I’m doing now, but everything I’m saying is true.

Um, but because I do it in comedy form and satire form. Uh, I have some level of legal protection from, for freedom of speech. Um, at least that’s what I tell myself. So they haven’t, nobody’s come after me yet. I’ve done some pretty, like I’ve gone hard on all the insurance companies, but mostly United healthcare.

So am I a little surprised that they haven’t said, sent me anything? Yeah. Am I a little bit disappointed? I mean, kind of, it’s like, what am I not, maybe I just need to go harder. Maybe I will. Um, so no, I have never been approached, uh, with the, like any kind of cease and desist from it, from a health insurance company, despite what I do on social media.

Um, but it’s stuff like this that you die healthcare is doing, like hiring this legal firm to, to threaten people and to like, not talking shit about United healthcare, like, come [00:08:00] on, like you just, you’re making it worse for yourself. Like, obviously public image is very important to this company. Like they don’t want people, they don’t want their company being synonymous with like hurting the public, but that’s what’s happening.

And then doing stuff like this. It’s just making it so much worse. Um, if they ever did come after me, you better believe I would start, uh, Oh man, I would, I would make, I would make so much ruckus on social media about it, like you would not hear the end of it. Uh, and, um, maybe that, that, that factors into their decision on not sending me anything.

I don’t want to give myself too much credit, but, uh, I do have a large audience and so maybe that’s part of it, but, um, I will tell you. One thing that happened really, and not even know they didn’t, the insurance company didn’t send me anything. This was Aetna. Uh, one thing that Aetna did back in 2022 [00:09:00] was they decided to institute this policy where they required every single cataract surgery to get a prior authorization.

So prior authorization required for all of their customers. Who needed cataract surgery and let’s see how much you’ve learned on knock knock eyes so far, folks who gets cataract surgery, everybody, everybody gets cataract surgery. If you’re over 60, you have cataracts and eventually you will get cataract surgery if you live long enough and guess what people are living longer.

Everybody gets cataract surgery. 4 million cataract surgeries performed every year in the U S. most common surgery out there. And so you can imagine this was, there’s a huge deal in the world of ophthalmology, big regulatory burden, especially in practices that had a lot of Aetna patients. Um, and so I, of course I made a video about it.

And during that video, I, I, I put up a piece of paper. On [00:10:00] my wall, because I like to make little posters and show them in videos sometimes. And this one, it was about the, what the Aetna mission statement was. And it just, I used Aetna’s logo on this poster and underneath it, it just said, be evil period. So I put that out there a couple of weeks later, I get a message from somebody, one of my followers on social media, who’s well connected and a new people in the C suite at Aetna.

And what they said was, uh, what this, uh, this message said was the company CMO, the chief, in this case, it was the chief marketing officer, but someone in the C suite, the company CMO saw the Glockenflecken video on Pryor Roth and held a huge internal meeting about it. The CMO was angry about how the company was portrayed and one of the video taken down.

Not how the internet works, everyone, just in case you didn’t know. The PR folks told the CMO that they couldn’t take the [00:11:00] video down. The company decided to review their policies, though, no one internally seems to believe there will be significant change. Uh, the point is that these videos are having a big impact and are more likely to bring about change, um, in healthcare.

I, that would, that, that, getting that message blew me away because that taught me. These companies, like they pay attention to social media and it matters to them. You guys, it matters. They care that people are complaining about their company. And it’s not just like one or two people. It’s like widespread.

Like public opinion matters to these for profit companies. And so it may seem like we can’t do anything to fight back against these billion dollar corporations, but it matters all the stories, all the anecdotes, all the comments on, on all the videos. Uh, talking about United healthcare, like that stuff matters.

It, you don’t have to have a [00:12:00] big audience. You don’t have to dress up in costume and record yourself as different characters in medicine. It helps. You don’t have to, uh, but just, just putting yourself out there and talking about these things. It really does. It adds up, it adds up in the company. If, if nothing else.

What that message to me showed is that at least I’m making them angry. And I think we need to be making them angry. All right. Because that means we’re, we’re eating away at them. And, and then we can use that momentum to help actually create real change and scaling back PBMs and, and prior authorizations and, and.

Just the cost of healthcare. I don’t know. So it’s, uh, anyway, I just, I shook my head when I heard about united healthcare hiring this company, because it’s like, what are you trying to, are you trying to make it worse for yourself? Cause I think that’s what they’re doing. Uh, because nothing people are saying is false.

Like, like these things that were these outrageous things that I’m putting in my [00:13:00] videos. Yeah. The interaction between the characters are fictional, but like, it’s all real, like these, these things are happening like to real people go to ProPublica, Google ProPublica, United healthcare or health insurance and just read all the, the, the in depth reporting that they’ve done over the past two years.

About all the insurance companies, but mostly UnitedHealthcare. That’s how we know about EvaCore, the hilariously named company external to UnitedHealthcare called EvaCore, E V I C O R E, which is a company that UnitedHealthcare, they, they. They, um, export their claim denials to this company and not their claims, their claims to another company in order for them to deny them.

So like, it’s like a way to deny claims more efficiently is hiring this external company called Eva core. [00:14:00] So anyway, all right. That’s the end of my rant. All right. We’re good to ophthalmology stuff. Let’s take a break. Hey, Kristen. Yeah. I’ve got some friends. I’d like you to meet. I see that you seem a little too friendly with them.

I have to say, aren’t they cute? Sure. But the little beady eyes and their little, little hands, the hands, the claws, I don’t know. Appendages. Okay. How about that? Yeah, it works. But anyway, they just like, well, they’d like to say hi. Okay. Like, okay, wonderful. They’re not, they, Oh, look, the one sticking around.

Sure is right on my mic. These little guys are a demodex and they live on your eyelashes. And they can cause flaky, red, irritated eyelids. See, that’s not cool. That’s a party foul. You just kind of want to like rub them. You’re not welcome here if you’re going to do that. And it’s caused sometimes by these little guys.

Yep. That’s rude. Uh, demodex blepharitis. [00:15:00] But you shouldn’t get grossed out by this. Okay. All right. You got to get checked out. Yes. Get checked out. To find out more, go to eyelidcheck. com. Again, that’s E U I E. L I D check dot com for more information about these little guys and demodex blepharitis.

All right, now I’m fired up. You guys, I’m, I’m ready to go with ophthalmology. All right. I got to tell you, I got a couple of main things that I want to talk about. The first is this. I told you about that. I had a little, little pants patient incident. Um, and this also goes back to one of my videos. One of my personal favorites, uh, which was the doctor getting a phone call from somebody, another doctor and says, Hey, you remember that patient you saw last week, I had one of those moments.

I had one of those moments. One of my partners who was on call for our practice sent me a message. Uh, saying that, [00:16:00] uh, a patient that I, you know, had, had done surgery on, uh, about a month ago, all of a sudden had an eye pressure of 70, but it was in the non operative eye. So the, I did not do surgery on and my stomach just dropped.

I was like, Oh no, this, uh, that’s, that’s awful. I, you know, what are we going to do? Turns out it was angle closure glaucoma. So this patient ended up being seen at the university. Um, Before we even got wind of what was going on, they were, they already showed up to the emergency department and, um, with angle closure glaucoma.

Just to give you a quick recap, so the eye is constantly making fluid and draining fluid. Think of the eye as like a bathtub. You got two bathtubs in your face and the eye, you know, the faucet’s turned on and the drain is open. So you have this steady state of fluid inside the eye. Well, if the drain closes.

And there’s lots of different reasons you can get a drain to close [00:17:00] the, uh, the, the eye drainage system, which is right at the edge of where the cornea touches the, the, the iris. So right on the edge of the white part of your eye, right where you start to get to iris, that’s where you’re. Your, your trabecular mesh work is that’s where your, your drainage system is inside the eye.

So sometimes it gets plugged up because, or it gets closed. It closes off because, um, you have, you know, uh, scar tissue that’s closing the angle, or you have abnormal vessels, what we call neovascularization of the iris that causes. the angle to close. We see that sometimes with patients with severe diabetic retinopathy or they’ve had a retinal vein occlusion and started to develop neovascularization because the eye is so ischemic it’s making all these really fragile little blood vessels to try to increase the vascularization of the eye.

Sometimes the eye is just [00:18:00] small and as the lens in the eye As it gets larger when you develop a cataract, well that lens in the eye is taking up more amount of space in the eye. So as that lens fattens up, gets bigger, it starts to push. Everything forward and narrows that angle, narrows that trabecular meshwork, and it can narrow it enough to where it just closes off.

All of a sudden the drain is closed, but the faucet still works on your bathtub eyeballs. And then the body just fills with, with fluid. You get this really high pressure. We know from like monkey studies, like decades ago, that if you increase the pressure enough in the eye, uh, it’ll decrease the blood flow.

And then if you decrease the blood flow to the eye long enough, then the optic nerve dies out. And so you’re, it’s kind of a race against the [00:19:00] clock. That’s why. Angle closure glaucoma is one of the true pants patients in ophthalmology, like really that eye pressures, you got to do everything you can to get that eye pressure down as, as, uh, as efficiently, as quickly as you can.

So one way, so that’s what this patient came in with. She already had a small eye. So there’s about 21 millimeter eye, I’d say normal size is like 23 to 24 millimeters. Um, and so a smaller eye, everything’s a little bit more crowded. She had a cataract. I was planning on doing the cataract surgery coming up pretty soon, pretty quickly.

Um, unfortunately, she went into angle closure glaucoma. So the, the, the drainage system closed off, the fluid was building up in the eye. And in the acute setting, there’s two ways to try to fix this. Patient comes in the emergency room, pressure 70, acute angle closure glaucoma. What are you going to do?[00:20:00] 

Well, one option, the conservative option would be just to pound that patient with eyedrops. So we have lots of different classes of pressure lowering eyedrops that sometimes they try to open up the drainage system. You can’t really do that with angle closure because it’s closed, it’s not opening up. So the other way to do it is to close, to turn off the faucet.

And so we have numerous medications, Temelol, Dorzolamide, carbonic anhydrase inhibitors that the way they work is turning that faucet off inside the eye. So the eye stops making fluid and it can be very effective. We also have oral. Carbonic anhydrous inhibitors, acetazolamide that works really well. It’s, it’s like one of the strongest things we have to try to decrease the production of aqueous inside the eye.

And so that’s whenever I’ve seen patients in the emergency room with ankylosure glaucoma, that’s the first thing I started doing [00:21:00] like immediately, as soon as I know that that pressure is high and what we’re dealing with, I’m just blasting that patient. With eye drops, like every 10 minutes, every 30 minutes, I’m putting in another round of these pressure.

We got to get that faucet turned off, but that’s only a temporizing measure because we can’t obviously keep a patient on that amount of eye drops like forever, right? So we got to do something else and for angle closure glaucoma for. For an acute episode like this, one thing we’ll try to do is create a separate pathway for fluid to drain.

And so one part of the problem is that fluid that’s being produced by the ciliary body inside the eye, it doesn’t have a way to around the iris and reach the angle of the eye where the drainage tubes are. And so what we can do is create a small hole, a small opening in the iris. Please take a [00:22:00] laser like asteroids.

We just shoot that hole through the iris. And all of a sudden you have a new path for fluid that’s trapped back there behind the iris. You have a way for that fluid to now come forward and reach the angle. And it’s super cool when this works because you do the laser. And, and then you, you create that opening and all of a sudden, like there, the, I, the, the, the Iris, which is, uh, it’s in something called Iris Bombay.

It’s just, it’s like being pushed forward because of all the pressure behind it. All of a sudden it just relaxes and the pressure goes down and it’s just, it’s a beautiful thing when it works that well. In an ideal world, unfortunately, this patient, my patient, uh, and I didn’t do this laser. This was probably done by one of the residents over at the university.

Um, this patient, uh, uh, whenever the eye pressure has been high for too long, the cornea starts [00:23:00] to get cloudy. It starts to get swollen and you need a clear cornea to see what you’re doing with a laser for the laser to even get to where it needs to go on the iris. So there was a valiant effort done by the resident to get the pressure to do the, what we call laser peripheral iridotomy.

It, uh, it wasn’t enough. There was not a good enough view to the iris to get that done. So it was aborted trying to do the laser. And so what are you left with? Well, just pounding with drops, just keep doing the drops. And it worked. The pressure got down, it got down to under 20, which is fantastic. But then what do you do?

Well, you got to figure out a way to just for the longterm release, open up that drainage system. And one of the best ways to do that for someone who has a big cataract is cataract surgery. So that’s what I did [00:24:00] today. Uh, I found out about this patient yesterday morning and I worked with her, their schedulers to get the patient to come in today during my surgery block.

Did the cataract surgery. It went great. Pressure is going to be fine. It’s almost impossible to get it. angle closure glaucoma from that thick lens like we’re talking about after you’ve had cataract surgery because the thin, the artificial lens we put in the eye is so much thinner. So we’ve basically eliminated that patient’s risk for angle closure glaucoma, assuming nothing else happens in the eye, knock on wood.

So I think she’s going to be okay. We’ll have to see if there’s any permanent vision loss during the time when she had that 70 pressure. Good chance that there’s going to be some peripheral vision loss, but I’m hoping that, um, it doesn’t affect the center of her vision. Fortunately, her other eye went great.

2020. So, [00:25:00] um, kind of remains to be seen, you know, what effect that’s going to have, um, on her vision going forward. But, uh, I, I feel good about the care that she received. There’s good communication between the emergency department, the resident who saw that, who contacted our doctor, who was on call, who got in touch with me right away.

And then we got her in for the surgery that she needed. So, uh, sometimes when the, when the medical system works the way it’s supposed to. It’s a beautiful thing. So, uh, um, I, I just, I really appreciate all my. All my partners, because it’s a scary thing. It’s scary for the patient. It’s scary for us because, uh, you know, that’s, this is one of the, the, the nightmare scenarios sometimes is this high pressure, this angle closure glaucoma.

You don’t see it often, but when it happens, it’s, um, it’s a big deal. Um, try to give updates late down the road. All right, let’s take one more break. I have some comments to address and then a segment I’m calling difficult conversations.[00:26:00] 

All right, we are back. So a few quick comments on the YouTube channel. So, um, uh, these are on our YouTube channel at Glocken Fleckens. All the podcast episodes are there. Uh, it’s where I get all of these comments. So if you watch. Leave a comment, you know, question, thoughts, jokes. I don’t care what it is.

You know, if, if it strikes my fancy, I’ll read it on these episodes. So we have a few one. The first one is at Vance underscore Tang said, wait, knock, knock. I and knock, knock high are two different series laughing face. Uh, I think, uh, hopefully you’re joking, but in case you’re not, I realized I should probably address this.

Yes, we have two different episodes. Once a week, we do an episode where me and Kristen, sometimes we’re just like talking to each other and, um, just like, like, uh, you know, married couple who works together does. [00:27:00] And we talk about things in society or just weird things that happen in our daily life.

Sometimes we have interviews with people. We just, uh, recently interviewed a, um. Uh, one of the, um, uh, like the biggest names in Canadian hockey. And if you’re a hockey fan, uh, go check it out. Uh, and then once a week I have one of these knock, knock. I, so it’s like one episode of eyeball stuff, one episode of just random things, uh, with me and Kristen lady glock and Flecken.

So yes, they’re both on the channel, by the way. So check it out. Uh, let’s see at Norn. IEA. This is a good one. Topic for conversation. Risk of NAION from using Ozempic. So this is a really good topic. I may have talked about this once before, but um, there’s, there has been a study. It was published. I probably didn’t talk about this because it was published in 2024.

It was in July, so [00:28:00] maybe I did address it, but, so there’s this disease called non arteritic ischemic optic neuropathy, N A I O N. Basically, you just lose a little bit of blood flow to the head of the optic nerve that causes you to have vision loss. And we have a, an observational study of, um, something like 16, uh, 16, 000 patients who are taking, uh, Ozempic, uh, and what this study showed is that there was a, a higher risk of NIO, NAION in patients prescribed semaglutide compared with patients prescribed non GLP receptor agonist medications for diabetes or obesity.

So yeah, it’s, it was, it was, it’s a little bit alarming. Um, now this is an observational study, right? It did show that there was a higher risk of NAION, but it’s not a prospective study. So you got to look at [00:29:00] the level of evidence here. And although it is, it’s certainly something that would benefit from a prospective trial, looking at this, So whenever, you know, any study their conclusions, like more studies are needed, absolutely more studies are needed to look at this because in IO and can be a pretty devastating disease.

Um, In our neck of the woods and, but you have to like, life’s all about risks and benefits, right? So like, yeah, they’re on Ozempic or whatever it is, Munjaro and, um, uh, their life, their health gets better because they’re losing weights. They’re, they’re, you know, decreasing their amount of insulin they have to use.

And just, there’s so many benefits that we’re seeing to this. Do those benefits outweigh what’s most likely a very, very small risk of developing an NAION. That’s a hard question That’s why informed consent is just so important with stuff like this. Like you, [00:30:00] I, you, you just, you talk about it with your patient.

And, um, I would say I haven’t gotten into the habit of bringing this up for patients who are taking, um, taking one of these, uh, GLP 1 agonists. Uh, maybe I should, I just, I haven’t done it yet. I’m just, I’m not sure what the data. How to, how to address it really with the, the amount of data we have this, this, this, uh, you know, observational study.

Um, and it does, I mean, this meant these medications are like life changing for people. And so I, you know, I don’t want to scare people and I don’t want to say, I don’t think it’s, it’s my, it’s my, I can tell people like, yeah, there’s this study that show there’s an increased risk of this ischemic optic neuropathy.

But then how do I accurately assess that risk for somebody? Uh, without just making them like nervous that they’re going to go blind, you know, because a lot of times [00:31:00] people just think in black and white, Oh my gosh, this is the, I might go blind from this medication. Well, it’s helping you in all these different ways.

And the risk based on what we have, the data we have is very, very low, like less than a 0. 05 percent or something like that. So anyway, I, I don’t think it’s like a, this, like this bombshell. Type of thing. Like we, we can’t be prescribing this because we don’t have the data to back that decision. So anyway, I, I am, I am watching it and I am, I am appropriately concerned, um, while acknowledging that these medications are really good for a lot of different things.

Just might not be great for your optic nerves. So I don’t know, there needs to be seen. I I’m, I’m interested to see, uh, what’s going on about this. Um, you know, in the next year or two and see if more data comes out about it. Good question. [00:32:00] All right, let’s do a couple more. Uh, okay. Here’s one at S a Mary lists says when I heard about people cutting their eyelashes, that was the last episode I’d talked about that, that trend on Tik TOK, I immediately thought of that house episode.

Where the patient had to use toenail clippers to trim their nostril hairs and ended up getting some kind of foot fungus in their brain. I wouldn’t be worried about doing that kind of stuff near my eye. You’d have to have sanitized blades. Good. You know, anytime we can relate a dangerous thing on social media to house, I’m all for it.

Uh, I’ve got a, I have not that, that episode does not come to mind, but, uh, it’s, it’s, it’s an interesting thought. Yes. I don’t know. What are people trimming their eyelids? And that’s really close to your eye. That’s close to a mucous membrane and mucous membranes are prone to getting infections by from things because bacteria love moist, hot [00:33:00] environments.

Although your eyes aren’t as hot as other mucous membranes, this is kind of getting kind of a gross conversation, but a couple of the things about eyelashes that I think people are wondering about when you cut eyelashes, they grow back in like two weeks, so very quickly. As opposed to like. Plucking your eyelash, which don’t do, by the way, or eyelashes that just fall out at the follicle.

Those take like six to eight weeks to, to come back. So, um, even if you do for some reason, decide to try this trend where you, you trim your eyelashes, I mean, they’re, they’re gonna grow back in a couple weeks, but just like, why, you know, why keep them? Just keep them all right. And the last thing I want to talk about before we wrap up here.

Oh, difficult conversations. Okay. This is, uh, something that’s come up a little bit in my life recently is like, what are the, and I’ve been thinking about this, like, what are the most [00:34:00] uncomfortable, awkward conversations I, as an ophthalmologist have to have with patients. There’s two big categories for me.

One is talking about weight, a few circumstances where we have to do this. All right. So like telling patients like what, what’s going on is because they’ve gained weight or they’re overweight or obese. Um, and so one of them is with the disease, idiopathic intracranial hypertension. We’ve talked about it on this podcast before, um, basically increased pressure around the brain.

That’s, um, a big risk factor for it is being overweight. And so that’s always a kind of a. Can be a little tricky conversation to have with someone. Obviously you try to do it respectfully, but, uh, it’s, um, it’s a, uh, that can be, it can be tough, tough to hear, tough to bring up, um, to say that, you know, it’s your weight is a big part of, of what is, is happening here.

And so, [00:35:00] um, you know, Trying to work with them and, and, you know, their, their primary care doctor, whoever would be better at, at talking to someone about ways to lose weight, um, is, uh, that can be a challenging conversation that I’ve had to do a little bit. A couple of different times over the past month, I would say, uh, another one with weight is with Plaquenil.

Now this is actually the opposite. This it’s kind of a weird thing because hydroxychloroquine, one of the big risks of it, and it’s not even a big risk. It’s a small risk is that medication has a, carries a risk of, of permanent vision loss, which is why with the Plaquenil, the hydroxychloroquine craze with COVID, it was just like, like.

Just drive an ophthalmologist up the wall because it’s like this is not just a this medication is not benign It’s it has risks to it One of them being that [00:36:00] you could permanently lose some of your photoreceptors in the center of your retina And you have big blind spots in the middle of your vision.

Nobody wants that and so You know, a few times a week I’ll get patients that are on hydroxychloroquine and we have to do an evaluation to make sure they’re not showing any signs of, um, of maculopathy, what we call it. So, toxic maculopathy from Plaquenil is pretty rare. You have to be on the medication for years before you even have a Somewhat significant risk of developing it.

So if you just started that medication, you’ve been on it for just a few years, like your chances are you don’t have it, but your risk goes up the more the higher the dose and the lower weight you are. It’s a weight based risk. So we like the way to mitigate this risk for plaque when L is to be on a medic, a dose that’s less than five milligrams per kilogram per day.[00:37:00] 

And so patients who are overweight. Uh, or obese, they’re much lower risk of developing toxicity, but it’s the opposite. If you’re very thin, we want, we don’t want you on a large dose if you’re thin because it’s, it’s a weight based risk. And so your, your milligrams per kilogram is much higher if you’re very thin.

And you’re taking what’s considered like a normal average dose of, of hydroxychloroquine. So that’s another situation where I have to talk about weight as an ophthalmologist. It doesn’t happen often and I’m, I’m not the best at it, um, just because it’s not a big part of my job. The other, a difficult conversation that I have to have from time to time is when patients come in with uveitis and I have to somehow tell them that we need to check for syphilis.

I still haven’t quite figured that one out. I, I don’t optimize, we don’t do a lot of sexual history taking. I still remember and somewhat mortified the, the [00:38:00] time in med school, the first sexual history I had to take on a patient in my internal medicine rotation. I had to ask someone if they’d been having anal sex.

I don’t remember the details, something about a UTI. I don’t know, but it, it, it traumatized me. Maybe part of the reason I became an ophthalmologist, but here I am still occasionally have to go and do it a little bit about the sexual history stuff. So having to tell it’s okay. You know, this is just one of the things we always have to check people with uveitis have inflammation in their eyes.

It could be syphilis. Uh, so we went to check for that. It, you know, who knows I’ve, I’ve learned to stop saying it’s probably going to be normal. Honestly, you, you never know. And, and I, I’ve been fooled in patients who ended up dead having, you know, like neuro syphilis. Um, but it’s, uh, I never feel. That’s how it’s hard for me.

It’s hard for me to do like the sexual history stuff. It’s just so far outside my Normal day to day [00:39:00] conversations with patients. So anyway, I think I’ll leave you guys with that

Let’s see, how about how about one more one more one more YouTube comment from at in the root I for one enjoy not having blood infections. I will keep my spleen unless it needs to be removed. Thank you. I love this, the, the, this, the spleen apologists. Um, you know, it’s great because some of these comments I get, cause I check them about a week after the, the episodes published, and usually it’s about two weeks after I record that episode when I read the comments, sometimes I like.

I learned from you guys. What are the things that I said in this, in, in the video, I forgot, like, I don’t remember going on a rant about the spleen, although I am, I am, you know, I do that from time to time. So it’s kind of funny. He’s like, Oh, I must. I guess I did talk about, about my hatred for the spleen.

It’s all in jest, right? Although I do think we would be a little bit better having two [00:40:00] livers, but you know, I can’t argue with evolution. I don’t know. I’m sure there’s a reason something to do with bloodborne infections. I don’t know. I’m an ophthalmologist anyway, you know, in route, keep your spleen. All right.

No, one’s going to take it out of you. All right. We’re not paying people for organs yet. Uh, so, um, um, I’m just saying it’s a thought experiment. What organs would be better if we had two? I mean, two eyes are great. Two kidneys. Awesome. Two spleens. Why two livers? That makes a lot more sense, doesn’t it?

Anyway, what other organs would you like having two of? Let me know in the comments. That’s it for knock, knock. I thank you for listening. I’m your host. We’ll plan. And we also know as Dr. Glock and Flecken. Thanks to my executive producers, Aaron Corny, Rob Goldman, and Sean T. Brooke, editor engineers, Jason Porteaser.

Music is by Omer Benz. V not knock high is a human content production. We’ll see you next time.[00:41:00] 

Bye.

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