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Dr. Lloyd's blog has now been retired. We appreciate all the wisdom and support Dr. Lloyd has brought to the WebMD community throughout the years.

Thursday, November 30, 2006

Hey, Doc, Wake Up!

Years spent as an intern, resident, or fellow are euphemistically labeled Graduate Medical Education. During GME a young physician must cram as much knowledge and experience as possible during this training opportunity. Oh, before I forget, GME physicians are a very inexpensive labor force. Large hospitals could not function without these housestaff members.

Here’s an example: an ophthalmologist specializing in corneal surgery completes a one-year internship, a three-year residency, plus another year as a fellow.

Every hour asleep is an hour of missed training. At least that’s how sage medical educators used to think. We used to love to tell stories about we were forced to work 40-48 hours or longer without a break. It was a savage system. Well-documented studies have demonstrated how this draconian approach led to a marked increase in serious medical mistakes as well as a rise in personal health risks to these young doctors.

Here’s how it works. The Accreditation Council for Graduate Medical Education (ACGME) introduced work-hour limits for all first-year residents training in U.S. hospitals. Under these standards, interns are limited to a maximum of 30 consecutive work hours (known as the 30-hour rule), which includes time used for sign-out, teaching, and continuity of care. Interns also are prohibited from working more than 80 hours per week (the 80-hour rule), averaged over 4 weeks, and must be free of all duties for 1 day in 7 (the 7-day rule). In the year following implementation of the standards, mandatory reports submitted to the ACGME by residency programs concluded that only 5 percent of residency programs did not comply, and that only 3 percent of residents reported any violations of the 80-hour rule.

Interns and residents who pull an “all-nighter” are not supposed to be working the following day. They need to go home and rest. In our hospital we hired more residents to accommodate these welcome changes.

Hospitals who disregard the ACGME rules could jeopardize the accreditation of their training programs. That would be a disaster for the trainees as well as the institution. If you encounter a young physician who appears exceedingly drowsy – or – who admits to having been on duty for over 24 hours, report the incident to the clinic supervisor or hospital administrator.

Wake-up and smell the coffee! It is a proven fact that well-rested physicians provide more efficient, more compassionate, and far more safe care to their patients.

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Posted by: Bill Lloyd MD at 6:12 am

Monday, November 27, 2006

Eyestrain Reality Check

children in classroomIt’s always an anxious time when children complain about the way they feel. Parents become even more concerned when symptoms relate to the eyes.

‘My child has eyestrain. What could be wrong?!?’

Most of the time nothing is wrong but it should never be assumed. Parents are the child’s ultimate advocates. No matter what anyone else thinks, the parents have to trust their children and do right by them – even if a comprehensive eye exam is perfectly normal.

Now there is new research about children and eyestrain complaints that has been published in The American Journal of Ophthalmology. 1,448 children were enrolled (the parents consented on behalf of their underage children).

220 children in this prospective study were complaining of eyestrain or headache and 82% were found to have a normal eye exam. Here’s what they found in the remaining children (exceeds 100% because some children had more than one finding):

  • 15.0% had an uncorrected refractive error
  • 3.6% had some amount of lazy eye (amblyopia)
  • 7.3% had strabismus (misalignment)

Compare those numbers with the 1,228 children who did not complain of eyestrain or headache.

  • 9.9% had an uncorrected refractive error
  • 1.4% has some amount of lazy eye
  • 1.8% had strabismus

Now, here’s an interesting twist. Looking at the entire group of children as a whole:

  • 78.7% of all children with refractive errors never complained of eyestrain or headache.
  • 68.0% of all children with amblyopia never complained of eyestrain or headache.
  • 58.0% of all children with strabismus never complained of eyestrain or headache.

So, what does this study teach parents? It teaches them that ‘You never know!’ Fortunately, the odds are good that a child complaining of eyestrain either has no eye problem or a very fixable eye problem. It is also a powerful reminder that parents and families cannot predict whether or not a child’s complaints are genuine. Remember, parents, you are the child’s ultimate advocates.

REFERENCE: Ip JM, Robaei D, Rochtchina E, Mitchell P. Prevalence of eye disorders in young children with eyestrain complaints. Am J Ophthalmol 2006;142(3):495-7.

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Posted by: Bill Lloyd MD at 11:45 am

Tuesday, November 21, 2006

This Telescope Goes INSIDE the Eye

These are exciting times for folks worried about Age Related Macular Degeneration. New medications can now halt, reverse, or prevent the progression of their disease.

Unfortunately, it is too late for these innovative treatments to help many of those already afflicted.

People suffering with advanced ARMD have lost much of their central vision – the eyesight needed for driving and reading. Bleeding and scarring destroys the delicate retinal tissues inside the central (macular) portion of the retina. Now there is hope for these folks, too.

Imagine an optical system that enlarge the image so that it extends beyond the damaged macula. That is what a telescope does. For decades hand- held telescopes have aided low vision patients to improve their reading and mobility. Telescopes, however, are not for everyone. They can be cumbersome and difficult to operate.

Now, what if a miniature telescope could be permanently implanted inside the eye – just like an intraocular lens implant after cataract surgery?

VisionCare Ophthalmic Technologies has created such an implantable telescope.

The prosthetic telescope, together with the cornea, acts as a telephoto system to enlarge images up to 3X magnification. The telephoto effect allows images in the central visual field to be focused outside the damage zone to other healthy areas of the central and peripheral retina. This generally helps reduce the ‘blind spot’ impairing vision in patients with ARMD, hopefully improving their ability to recognize images that were either difficult or impossible to see.

The prosthetic telescope is implanted by an ophthalmic surgeon in an outpatient surgical procedure. The device is implanted in one eye, which provides central vision as described above, while the non-implanted eye provides peripheral vision for mobility and navigation. After the surgical procedure, the patient participates in a structured vision rehabilitation program to maximize their ability to perform daily activities. Because it is situated inside the eye, the device allows patients to use natural eye movements to scan the environment and reading materials.

Results of a clinical study involving 217 volunteer patients who received this miniature intraocular telescope revealed a three-line visual improvement in two-thirds of study participants. The authors concluded that the implantable visual prosthesis can improve visual acuity and quality of life in patients with moderate-to-profound visual impairment caused by severe AMD.

Related Links: Macular Degeneration 101, Exercise Can Protect Eyesight

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REFERENCE: Hudson HL, Lane SS, Heier JS, et al. Implantable miniature telescope for the treatment of visual acuity loss resulting from end-stage age-related macular degeneration: One-year results. Ophthalmology 2006.

Posted by: Bill Lloyd MD at 11:23 am

Saturday, November 18, 2006

Genetic Discovery Creates Anxiety

This past week I have been attending a national conference of eye specialists. It’s a real hodge-podge of scientific presentations (new and rehashed material), technical displays, professional networking, and a few social gatherings.

At the end of such a meeting I usually depart enthused and energized – as if my ‘doctor batteries’ had just been recharged.

This year I went home worried.

Uveal melanoma is the most common malignant eye tumor. Roughly one-third of those affected die from their disease. Nobody has a clear answer on how best to treat this disease. There are many treatment options, and that typically means there is no single best way to cure the tumor.

Ruptured appendix? The recognized treatment is to remove the appendix. It works.
Uveal melanoma? There’s observation, surgery, radiation, laser, chemotherapy, thermal treatment, cryotherapy, and any combination of the above.

About the one-third who do not survive, we now know who they are. Gene researchers have discovered the signaling protein that causes the tumor to spread. Tumor survivors do not have the gene and do not produce the signaling protein.

Now, who wants to know? The debate has started.

Should doctors inform patients that the gene test will soon be available? Other than estate planning I’m not sure what good would come from burdening the hopeful patient with such tragic news. Certainly, patients have the right to decide the course of their treatment and that includes the application genetic prognostic markers. I get it. Nevertheless, it is such a brutal death sentence. I think physicians and families should approach such disclosures with the most thoughtful sensitivity to the patient’s true preferences.

What do you think? Would you want to know? Drop me a line here or at our WebMD Vision & Eye Disorders Message Board.

Related Topics: Intraocular (Eye) Melanoma, What You Need to Know About Melanoma

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Posted by: Bill Lloyd MD at 12:49 pm

Wednesday, November 15, 2006

Insurance Divides the Risk

A recent headline caught my eye and then poked it!

Most Americans believe that our current system of health insurance needs fixing and many would be willing to pay more to accomplish the task.

What health insurance system are they talking about?

As far as I know there is privately-funded health insurance paid by employers and families; Medicare for seniors; Medicaid for the economically underserved; and free emergency health care for the millions who have no coverage whatsoever.

Now there’s talk about calculating insurance premiums based on an individual’s health risks. Yes, charging more for smokers, more for overweight people, etc. At first glimpse it seems like an attractive, fair proposition but you soon realize that it is contrary to the entire concept of insurance – pooled risk.

I know, homeowners on flood plains pay extra for flood insurance. Lexus owners pay more for auto insurance than Honda owners. Even life insurance rates are linked to health risks like smoking and hang gliding. You can only apply that analogy so far.

If a smoker is targeted today what about the parents of a child with cystic fibrosis or a young adult driver severely injured in an auto collision? Insurance is pooled risk, and that means you cannot limit access to the pool or tell specific people to get out of the pool!

Rather than restrict coverage, insurance funds could be more wisely invested in proven programs that encourage smoking cessation, safe driving and other healthful behaviors.

If you want to discuss this topic further simply post your comments on my WebMD Vision & Eye Disorders Message Board.

Related Topics: Mental Health Insurance Pays

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Posted by: Bill Lloyd MD at 10:05 am

Monday, November 13, 2006

Multivitamins Delay Onset of Cataracts

A cataract is loss of transparency of the crystalline lens inside the eye. The most common type of cataract is called nuclear sclerosis – yellowing and hardening of the innermost portion of the lens (the nucleus).

Besides providing near focusing power (accommodation), the crystalline lens is also a vital filter that blocks hazardous infrared and ultraviolet light from damaging the sensitive retina. This protection occurs throughout life. How well would your car run if you never changed your oil filter? Well, after 60 or 70 years the lens is toast! It has accumulated so much chemical waste from filtering dangerous light rays (urochrome pigments) that the lens turns yellow-amber in color.

A new report in the peer-reviewed journal Ophthalmology now claims that daily multivitamins can delay the onset of cataracts. AREDS stands for the Age-Related Eye Disease Study – the folks who looked at vitamins and cataracts. 4,500 volunteers took a daily Centrum multivitamin for 6 years. When compared to the general population, this group developed cataracts later in life and cataract progression was significantly slower.

The researchers conclude that use of a daily multivitamin may delay the progression of lens opacities. A National Eye Institute–sponsored clinical trial scheduled for completion in 2007 will provide additional data on Centrum use and cataract development.

DISCLOSURE: Dr. Lloyd has no financial interest in any vitamin manufacturer. Dr. Lloyd eats lots of fresh fruit and vegetables.

Related Topics: Focus on DSAEK Eye Surgery Watch Video, Panel Questions Use of Multivitamins

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Posted by: Bill Lloyd MD at 10:21 am

Tuesday, November 7, 2006

Look What I Found

There are so many medical TV dramas that WebMD has launched an innovative new blog to provide expert insight regarding all of the arcane and obtuse health maladies that appear on the likes of E.R., Grey’s Anatomy, House and similar programs.

Click here to take a peek at WebMD’s TV Checkup.

After reviewing several recent posts I started thinking about what one thing infuriates me most about this TV genre. The irksome answer came quickly. It’s that egotistical surgeon on Dr 90210. Yeah, him, you know which one: the one who is not a board-certified plastic surgeon. (Ooops! You didn’t know that?)

Medical students ought to be FORCED to watch several of his past appearances as examples of how not to interact with elective surgery patients. This physician’s schtick is unprofessional and downright inappropriate at times. Need an example?

During one episode his O.R. did not stock the appropriately-sized implants for a breast augmentation patient. Rather than reschedule the operation he had the patient agree instead to have the available (bizarre) monster implants stuffed under her boobs. This show is all about boobs, however, not all of them are breasts!

It would not surprise me to learn that malpractice lawyers also record each broadcast for its intrinsic academic and entertainment value.

Related Topics: How to Choose a Plastic Surgeon, Is Extreme Plastic Surgery Safe?

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Posted by: Bill Lloyd MD at 12:44 pm

Monday, November 6, 2006

Second Life: Visual Metaverse

Computer technology and computer users are both maturing.

College students who played PONG thirty years ago have fully assimilated to the expanding role of digital reality in our everyday lives. Voicemail anyone? Anybody younger has lived with this evolutionary phenomenon since birth. Traditional pen-and-ink animated cartoons have been replaced by ultra-realistic 3D computer generated imagery.

Voicemail, cartoons… two single examples. What about the entire universe?

Maybe you’ve already heard about Second Life. If not you will soon. Move over, Borat, Second Life is the next big thing. Second Life is a virtual online community that can replicate nearly any activity in life, a three dimensional metaphysical universe – a metaverse. Registered participants can buy land, build structures, run businesses, earn real money, and involve themselves in whatever life enterprise interests them. There are already over one million inhabitants of the Second Life metaverse.

Academicians have discovered that Second Life can help medical students and physicians-in-training gain valuable clinical experiences in a virtual setting. A psychiatrist colleague of mine at UC Davis Medical Center, Dr. Peter Yellowlees, has pioneered the use of Second Life to demonstrate what bizarre things patients experience when they have affective disorders like schizophrenia. Click here to read a detailed article about a visit to Dr. Yellowlees’ Second Life island.

Can you imagine the unlimited possibilities for eye doctors and their patients? Developers would be able to vividly simulate what happens to the vision of glaucoma patients as well as those afflicted with cataract, macular degeneration, and retinal detachment. Young surgeons can safely practice simulated surgical procedures to flatten that real world ‘learning curve’.

Wait, there’s more! Customized eye trauma cases can be programmed to arrive in a virtual Second Life E.R. and trainees would have the opportunity to examine the injuries and workup all of the diagnostic possibilities by ordering tests and analyzing the results.

Many corporations have already invested in a Second Life presence because they do not want to miss the opportunity to participate in this new information platform. Hopefully the entire medical community (including ophthalmology) will enthusiastically embrace the powerful ways Second Life can facilitate knowledge transfer.

Unlike Borat, technology experts predict Second Life and its competitors will be around for many years to come. Maybe it is time for you to explore a new universe.

Related Topic: Virtual Solution for Fear of Public Speaking, Virtual Sex: Threat to Real Intimacy?, Spare Change: The CDC’s Second Life

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Posted by: Bill Lloyd MD at 10:01 am

Friday, November 3, 2006

Cancer Warriors

Over one million Americans are diagnosed with cancer every year. I mean real cancer, not superficial skin tumors like basal cell carcinoma.

Sadly, over half succumb to their disease but the numbers have been steadily improving. Survival data for breast and colon cancers are good examples. Lung cancer remains extremely difficult to cure.

My message today goes out to all active cancer warriors and their families. Regardless of whatever chemotherapy or radiatior treatment is being prescribed, make sure you receive ongoing comprehensive eye care during this critical period. Many of the drugs used to fight cancer can interfere with vision. Some drug metabolites accumulate in the cornea and retina. Specific chemo regimens can harm the optic nerve. Susceptibility varies from patient-to-patient.

There are always options. If one regimen causes too many problems the oncologist can adjust the treatment strategy. Beware, eye symptoms can be very subtle. Without knowing if chemo-complications have occurred permanent eye damage could develop. Routine eye checks can prevent such problems without jeopardizing the fight against the cancer. It’s a team approach and, for once in your life, everyone on the team is on your side.

Related Topics: Cancer: Treatment News and Options, 50 Years of Milestones in the Fight Against Cancer

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Posted by: Bill Lloyd MD at 1:24 pm

Thursday, November 2, 2006

Focusing on ‘Presold’ Cataract Patients

America’s population just hit the 300 Million mark, and every year 2.8 Million Americans have cataract surgery.

In earlier blog posts I’ve described different types of lens implants that replace the cloudy natural lens. These devices help folks see at distance after surgery. Most wear glasses for reading.

Until recently insurance covered the costs of the surgery plus the lens implant. Folks who want one of those innovative multifocal lens implants that provide clear focusing at all distances, near to very far away, must pay the difference out of pocket. That averages $3500 per eye. Ouch!

Doctors don’t want to become car salesmen so the implant manufacturers are spending plenty marketing these new implants to the lay community. The goal is to convince consumers of the value of these expensive lens implants before they visit the eye surgeon. These patients are PRESOLD.

The unresolved issue is full disclosure. Patients (consumers) should not make any healthcare decisions without full knowledge of the proposed benefits, alternatives and potential risk of complications. We’ve all experienced the TV commercials for Rx pills and those ridiculous disclaimers, “Don’t take Xxpill if you have liver problems. Xxpill can cause headache, painful urination, dizziness, and projectile vomiting. Blah, blah, blah.” That is no way to choose an intraocular lens implant.

Related Topics: Gap in Medicare Rx Coverage is Costly, Share in Every Medical Decision – Shared Decisions About Surgery

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Posted by: Bill Lloyd MD at 8:10 am


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