Knock Knock Eye: Consulting Ophthalmology: A Survival Guide
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That's aka.ms slash knock, knock, hi. Knock, knock, hi. Hello, everybody. Welcome to Knock, Knock, I. With me, your host, Dr. Glockenflecken, your one-stop shop for all things eyeballs.

In addition to your one-stop shop for ophthalmologists who sit in a bedroom with a skeleton in the background, licking at them during the podcast recording. That's what you can see over on YouTube at Glockenfleckens. I got our skeleton, Gerald. He was named by one of my children.

I think it really fits him. Sometimes I think today he's wearing some of those disposable glasses you get when you go to the eye doctor. Get your eyes dilated. You get the dark little things, little glasses. I brought one home and stuck it on the skeleton. So there you go. There's Gerald. But thank you so much for joining me today. I hope you're having a good day.

Uh, today is a clinic day for me. It's a bit of a slog. I just came back from a few days off and it's, it's just, it's hard to get back into it. You know, I don't, I don't know the best way to do it. Actually. I think I do know the best way to do it. Uh, about a week ago, I went to work, but I did something that I don't normally do. I exercised before work and man, like I hated it in the moment, just the making the decision to get up early.

at like 5.30 in the morning and go and increase your heart rate and use your muscles. It's a hard thing to decide how to do to do it, but I did it one day. And I did honestly feel better that morning. Like I was more awake and alert and I paid for it by the evening. I wanted to go to bed early, which is not a bad thing.

I just don't think I'm the type of person that can sustain that. I'm more of the type of person who will sit on my porch with a cup of coffee and just kind of glare at the people who are running at six o'clock in the morning. That's more my speed. But I don't know. I wish, I honestly, I wish I was the type of person that could exercise like that early in the morning. I just can't. I can't do it. I can't develop energy.

The habit, uh, I have too much, too much of my life is, is geared around, uh, uh, not wanting to go to bed because that means the morning comes sooner. I think there's, I think there's like a, uh, a disorder associated with that where like, you're, you're just like your brain, your night brain is telling you, you know, don't go to bed. Cause then like next thing you open your eyes, it's going to be morning. You have to do work.

And so just stay up late, just stay up later, just creep scrolling on your phone, just watch a movie. That's, that's terrible. And it just makes my life harder. Anyway, I'm sure there's other people that agree with me. So what we're going to do today is I go through a few, I've got a few great comments that came through on the YouTube channel, uh, about recent episodes about, uh, eyeball topics. So we've got a couple of good ones. So first we're just going to jump right into some of these comments.

The first one is about an episode that came out a couple weeks ago about a patient I have with acute retinal necrosis caused by a shingles infection.

caused by a herpes virus that's causing an inflammation of the retina of both eyes just a really terrible situation and so the question came in from at mary kirschman 6625 says great episode i'm a retired nurse so i love the deep medical dives into patients as to your patient with the acute retinal necrosis when she recovers will you address the cataract surgery

or cataract issue, or is removal of them contraindicated due to the risk of causing another episode of pan-UVitis? This is actually a fantastic question. So just to recap that patient, she came in with a decrease in vision. She had a lot of inflammation inside both eyes, which is very unusual for someone to have that at that age. Well, often we'll see what's called pan-UVitis, inflammation throughout the entirety of the eye, the front and the back,

Often we'll see that earlier in life. We don't usually see that when people get into like their eighth decade of life. But she had that. And also she had pretty dense cataracts. And my, the plan, obviously what you want to do when someone has uveitis is typically you want them to be free of inflammation for at least three months before you go and do a surgery on them for that exact reason that Mary mentioned that if someone has

recent active inflammation, well, you'll just kick up more inflammation and it could be really bad and you could maybe not have a great outcome after surgery because of the prolonged inflammation that could occur inside the eye. The eye does not like having inflammation, you guys. It's a very, lots of delicate structures in there that don't do well with white blood cells, especially a lot of them.

So we really try very hard to decrease the amount of inflammation inside the eye. So someone that has uveitis who needs cataract surgery, we'll make sure that they don't have any flare up, any inflammation for three months. So for this patient, obviously I sent her to see my retina specialist. We've been co-managing this patient together. He's doing the bulk of the work so far, just getting the retina and everything in the back of the eye under control. The problem is

that in order to see the retina and see how things are going and monitor for things like retinal detachments, which can very easily happen when you have something like acute retinal necrosis or just a significant amount of inflammation, rip-roaring inflammation in the back of the eye, you can get a retinal detachment. He has to monitor for that pretty frequently.

Well, the problem is you have to be able to see through a cataract to see the retina. Cataracts can get so bad that it makes it to where it's really hard to do a retina exam because you got to look through someone's pupil. And by doing that, you're looking right through their lens. And so if they have a cataract, you have to look through that cataract. Now, it does take pretty dense lenses.

to get to the point where you can't see into the back of the eye unfortunately inflammation is one of those things that can rapidly progress a cataract so my retina colleague came to me and he said hey i'm having a little bit of a difficulty you know doing a thorough examination of this patient you think you could go ahead and get the cataracts out earlier um

Obviously, I wasn't planning on doing cataract surgery until this was totally under control for several months. I don't think that's going to be the case, though. I don't think it's going to be possible. And so I am looking at the probability that I'll be taking out this patient's cataracts while there's still inflammation inside the eye. It's not ideal.

But in this case, you kind of have to do it because he needs to be able to examine the retina. And, uh, and sometimes the only way to do that is just by getting the cataracts done. The eyes already inflamed.

It's already kind of a guarded prognosis. You know, we're not totally sure how much vision is going to be, you know, is going to come back. But so that's probably going to happen pretty soon. I haven't, you know, and I've done cataract surgeries like this before. It's essentially the same. We don't do a lot different. Might use much more frequent topical anti-inflammatory drops.

steroid drops after the surgery, maybe even do a steroid injection if it's safe to do that with the retinal necrosis situation going on. So anyway, it's all, it's kind of up in the air now, but yeah, that's a great point. Do you wait or do you go ahead and do the cataract surgery? Well, the answer, like most things in medicine,

It depends. But, you know, this patient is, I think, in great care and just a wonderful, wonderful lady. And it's hard to see someone, you know, go through something like this. But, you know, that's being a doctor, being a physician. And it's just kind of what we do. So a lot of you had good comments about

about this acute retinal necrosis subject that I discussed. People wanting to get their shingles vaccine. Yet another reason to get two-dose Shingrix vaccine series when turning 50 to prevent shingles. I couldn't agree more. Don Barchett, 8026. Yes, please get your shingles vaccine because man, not only is shingles painful, but very rarely, again, this is a rare complication, but

that virus can get into places you don't want it getting to, including the eyeballs. All right. So please do. If you qualify for the shingles vaccine, your doctor's like, yeah, you can get it. Oh, yeah. Go get it. Christmas morning. Go get your vaccine. No, you can't. Probably won't be able to do that. It's things are.

Things are not open. Speaking of vaccines, my wife, Kristen, Lady Glockenpluckin, she got her tetanus update because she got a severe burn on her hand pulling an ATV off of our daughter.

If you want to hear that story, well, it's coming up in a future episode. I think because I record these knock-knock eyes, they come out quicker than the knock-knock eyes. But just a quick two-sentence summary of this story. We have a little bit of land that we have a smaller-sized four-wheeler.

Fortunately, the kid was wearing a helmet. That's a rule. Absolutely have to wear protective gear, mainly just a helmet, but, um, turned it over, landed on top of her. She's fine. By the way, the kid's fine. She's great on this thing. It was like the first time she's ever fallen off of it. Um, but Kristen was obviously very concerned and she, her, her mom adrenaline kicked in and she yanked the thing off of our kid.

But, uh, but it was turned upside down. And so she grabbed something. I don't know where she grabbed it. Maybe the muffler. It was like a thousand degrees and it immediately burned her palm. We actually went into the emergency department and, uh, she was due for a tetanus. So, you know, she was like, you know what? I had to come in anyway. I had to see my doctor to get a tetanus update. So this is great. Meanwhile, she's sitting there like writhing in pain with a

with a, with a severe burn. So not the greatest way to have to like double up on, on, on getting like a vaccine and medical care, but, uh, it worked, it worked and she's doing great now, by the way. So she had like a couple of days of pretty bad pain, but she's, she's recovering her hands going to be just fine. Um, but man, that was, um, that was, uh, uh, it was so funny because, uh,

People at the emergency department, they kept saying, oh, I'm so sorry this happened. And Kristen's response is like, I've been through worse.

because the last time we were at that hospital was whenever I came in with my cardiac arrest. So she has, I mean, it happened to me, but she, it was very, just as hard for her, um, uh, doing those chest compressions. And, uh, so yeah, she had experienced worse. It really puts things into perspective when you go through something like that. And then you have something that hurts, but you can manage it because you know how bad things

could be. So anyway, a little perspective helps at times. But yeah, she's doing great. Let's take a break. We'll come back with a couple more eyeball topics. Hey, Kristen. Yeah.

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Okay, I have a great comment that came in. Again, this is on our YouTube channel, at Glockenfleckens. This is a great comment from a med student, at Ryan Preddy. Had an episode suggestion, and this is a great suggestion. So he said, I feel as if our med school curriculum was severely lacking in the eye department. Tell me about it, Ryan. It's awful. It's the reason why I didn't even know

That ophthalmology was something I was maybe interested in until I got to the very beginning of my fourth year of med school.

I just, there's like nothing. You get like two lectures on it and they're from, they're not even from an ophthalmologist usually. It's like from an anatomist because you have the anatomy lecture and then you have like probably a neurologist who, I mean, it's the eye is basically like an extension of the brain. So that does make sense. But often you don't have like an actual ophthalmologist that comes in and gives those talks. Sometimes you do, but often you don't.

Um, they're too busy doing cataract surgery, just hours and hours of cataract surgery. Uh, so I'm, I'm with you. I'm with you. Med school curriculum is still severely. It was lacking whenever I was going through med school. When I went through my third year, my first two years of med school, I should say in 2008, 2009, 2010, that range. And it's still severely lacking.

Ryan says, I would be interested to hear your input on eye exams in the clinic slash ER setting, basically outside the ophthalmology, outside the world of ophthalmology and considerations around opthal consults.

Maybe I should simply ask for how to not anger the ophthalmologist at 10 PM. That's a great question. That's a great question. Any input, anecdotes, unnecessary consults, pertinent positive negatives, all those things greatly appreciated. That is a fantastic suggestion, Ryan. And I'm going to spend probably the rest of this episode addressing this because it's a really important topic. And it's, you know, one of those things that in medicine that really, again,

Gets to the heart of all the conflicts that make up my videos, or at least a lot of them is just all these attendings and different specialties, not understanding each other.

get, you know, getting mad at each other, uh, pet peeves, you know, misunderstandings, all this stuff. Um, that that's like the conflicts in my videos are just, this is what it's made of. And so an ophthalmology is no different because, and in fact, it's even worse than ophthalmology because we are such an isolated specialty.

People, as we've already addressed, people outside of ophthalmology, they don't get any ophthalmology education. So it's like we're asking people to consult ophthalmologists with really, you kind of have to learn it on the job. You're getting an up-to-date, which by the way, is also terrible for ophthalmology.

And so you're just Googling things about the eye world and there's not great. There are some good resources out there. I wiki.com, which is put out by the American Academy of Ophthalmology. That's a really good resource. Um, but it's a bit, a bit patchy. It doesn't have everything. So then you're going for like textbooks. Well, who the hell keeps textbooks around anymore? Especially ones about eyeballs. If you're not an eyeball doctor, I could go on and on. The point is,

There's a big, giant disconnect between what I do as an ophthalmologist and what everybody understands outside of ophthalmology about eyeballs. And that's different from something like cardiology, where you don't have to be a cardiologist to know a lot about cardiology because that is a huge part of our education.

We had months of cardiology education. I learned at some point how to read an EKG. I have since clearly forgotten how to do that, but I still learned it and I could still like pick out ST elevations and, you know, really bad stuff. You know, no one's, no one's like, you know, no one is able to read an ERG, an electroretinogram. So, so other specialties, they, they have more

broad education to people outside their fields. Ophthalmology really doesn't have that. And there's a few specialties I feel like that are like probably in the same boat to a certain extent. I mean, EMT is probably, is also pretty specialized. Dermatology maybe to a lesser extent. I do remember having a lot more dermatology stuff, but you know, we are very, we're very siloed

in medicine in general. And it's just getting worse and worse as people become way more subspecialized and just focused on like, oh, I'm going to be a cone photoreceptor ophthalmologist and I'm not going to learn anything about the rest of the eye. Like that's an exaggeration, but it's kind of how things are moving in medicine. So I love an opportunity to try to just educate people a little bit

That's really what this whole podcast is about, by the way, is just trying to teach you all a thing or two about the eyeballs that you might not get otherwise. And maybe you don't need it in your day job. Maybe you do, but even if you don't, oh, then you could, you know, just learn a thing or two, you know, just have a story to, you know, be able to impress your friends at a dinner party with how much you know about the cornea. So, so anyway, um, let's, let's talk about this. So

Um, input on eyes. Let's just talk about consulting ophthalmologists. All right. First of all, and I, I'm sorry if some of this probably like a year ago, I think I did a similar episode about this, but it's been a while. So it's, it's time to time to re up and rehash some of this stuff. Um, never feel bad about calling an ophthalmologist for help. All right. And mainly for all the reasons I just mentioned.

I know your on-call ophthalmologist knows that people, you guys don't know anything for the most part. A little bit, you know, but we know that your education is limited in this area. And so when a doctor is on call, like we're on call to do a job. And so I've never understood getting mad at people for calling.

That's like you're immediately upset just because you're woken up at 2 a.m Well, guess what that person needs help. They don't know as much about this as you that's why you're on call idiot like What what what purpose why start a a conversation in an adversarial tone? Just because like they're doing what they're supposed to do and you're not wanting to do what you are supposed to do You see what I mean? It just drives me crazy now

There are some things for every specialist, but even for ophthalmologists, there are some things that would kind of frustrate us. If you do call us, it doesn't matter what time it is, middle of the night, middle of the day, if you just don't have this information. So let's talk about it. Let's start with history.

I'd say the most common things that people will come in for or will start to complain to you about, whether you're emergency medicine or family medicine or internal medicine, whatever. How about decreasing vision? So what do I, as the consulting ophthalmologist, want to know about decreased vision? I want to know how quickly it happened.

So did they lose vision suddenly, like the lights were turned out? Or was it gradually over the course of hours, of days, weeks? I want to know if there's any pain associated with this vision loss. In general, painful vision loss is a big deal. We're talking about really serious things like giant cell arteritis, like

Bad traumas, obviously, chemical injuries, angle closure, glaucoma, painful vision loss, especially severe vision loss that should grab your attention and basically tell you to call us to talk about it. Also, the the level of vision loss, not only how quickly it happened, but like, are we talking like the lights were turned out?

Do you, were you able to like, you know, drive and all of a sudden out of that eye, you can only see a hand moving in front of your face or you can barely count fingers. Like what's, what's, how bad was this vision loss? Those are the things I want to know about vision loss.

Um, how about flashes and floaters? That's a really common thing that people come into the emergency department for. Uh, so one thing I want to know about flashes and floaters is, uh, do they have a history of retinal tears or retinal detachments or a family history, or are they really nearsighted because people who are nearsighted have a much higher risk of retinal tears, retinal detachments.

And if you, if you don't, you can ask those things. I might ask you if you know those things, but you know, sometimes the patient doesn't know if they're nearsighted or they don't bring their glasses in with them or, you know, whatever. So, um, but, but it's always, it's a good thing to ask.

Eye pain, another thing. So we talk about vision loss. Eye pain is another common one. Kind of a similar stuff is the vision affected. And what's the quality of the pain? That's really important because depending on the type of pain, that really helps us hone in on a possible diagnosis. I can usually diagnose vision.

what the patient has based on their presenting symptom and then a few other questions about that symptom so for eye pain if the patient's having like burning itchy scratchy it's going to be either allergy or dry eye blepharitis basically like a non-emergency follow-up with us you know in the you know sometime over the next few days to a few weeks

If the pain is deep and unrelenting, like an ice pick, maybe causing nausea and vomiting, obviously that's a big deal. And that could be a high pressure in the eye. That could be endophthalmitis. So the quality of the pain is really helpful, obviously the severity of it. But whether or not the vision is affected is also really important for us to know.

All right. So that's that. And then two things, two questions to always get in the habit of asking when a patient comes in with an eye problem, no matter what the eye problem is. Did you have any recent eye surgery or any recent eye trauma within the past month? Very important questions. It takes two seconds to ask those questions. Just ask them. Recent eye surgery, recent eye trauma. Patient had eye surgery and now they're having pain.

Yeah. I mean, I, I'm very worried about infection. You need to get on the phone and call me. All right. And remember, don't feel bad about calling me. Chances are I'm, I'm, I'm either recording a tick tock or I'm watching Netflix either way. Feel free to interrupt me. Okay. It's fine. Like that's what I'm here. That's what I'm there for. Don't apologize. Don't be like, Hey, I'm really sorry to bother you. Dr. Glock and Fleck. And I'll be like, first of all, I forgive you. I forgive you my follower.

But also like, again, I'm, I don't know. I'm not done. I'm eating cookies. I don't know. I I'm, I'm doing, I'm, I'm swimming. I eat, who knows? I do nothing important, nothing that's more important than talking to you in that moment. All right. So let's talk about eye exam. So

Again, our expectation as consulting ophthalmologists is very low for non-ophthalmologists, especially when it comes to the eye exam. Oh, one thing I didn't talk about for presenting symptom, double vision. That's a huge one. And actually one that kind of scares me as an ophthalmologist because like there can be really serious things, but most of the time, the vast majority of the time, double vision is nothing to be concerned about.

It could be dry eye. It could be, you know, just anyway. So the one thing, one thing to, to know, to ask about double vision, this is really important. This will like really, this will impress your ophthalmologists and, and also be really helpful to us. Ask the patient who has double vision when they cover an eye, it could be either eye when they cover the, we'll say when they cover the right eye, does the double vision go away?

When they cover the left eye, does it go away? When it always goes away with one eye covered, that is true binocular double vision. That is the double vision that we get concerned about. That could be an aneurysm. That could be a brain tumor. Basically, something in the brain or in the orbit, I suppose, is

is causing a true misalignment of the eye. Something is affecting those cranial nerves, multiple sclerosis, any kind of other demyelinating diseases. There's a whole host of things. Increased intracranial pressure could do it. So any vascular disease can do it. So it's a big deal. Covering an eye, figuring out if it's binocular diplopia.

If the patient covers an eye and they're like, oh yeah, I still see it, or I still see two or three images, that is monocular diplopia. If they cover an eye and they still have double vision, all those images are coming out of one eye. So you know it's not going to be because of a misalignment because there's no misalignment if one eye is covered.

So it, that means it's a, it's what's called monocular double vision and 99 times out of a hundred. That's because of dry eye. And it's not true double vision. It's more like you can ask this and people will tell you, is it, is it really like, do you see two of me right now? Or when you look at the TV, are there two TVs or is it more of a shadowing or a ghosting of the image?

People who have monocular double vision from dry eye, usually it's more like a ghosting of the image or it kind of separates and they blink a little bit and it can get better and it separates again. So it's not like two completely separate things or they don't have one eye pointing in one direction, the other eye pointing in another direction. It's just a little bit of a ghosting of images. So monocular double vision versus binocular double vision.

All right. Let's take one more break and then we'll come back and talk eye exam. So, Will. Yeah. You're always teaching me things about demodex mites, little friends there. Let's switch things up a bit. Okay. How about I ask you a couple questions to see how much you really know? Go for it. Okay. Let's do it. What are the only two main species of demodex mites found in humans? Oh.

Type 1 and type 2? Hmm, got you on that one. Demodex follicularum, which are found in the eyelash follicles, and demodex brevis, which are found in the meibomian glands. Impressive. All right, next question. Why do people with demodex blepharitis often feel itchy eyelids first thing in the morning? I know this because I use it to gross you out. Demodex mites avoid light and they come out mostly at night to mate.

and move between your eyelash follicles. So many people will wake up with that itchy, irritated feeling along their eyelids. So gross.

I'm surprised you even brought that up. I know. 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 it. Well, that's a big step. And we know there's a prescription eye drop available to treat demodex blepharitis. To learn more about these mites and demodex blepharitis, visit miteslovelids.com for more information. Again, that's M-I-T-E-S-L-O-V-E-R-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. This podcast is brought to you by Carvana.

Okay, I exam...

For the non-ophthalmologists. All right. The first thing, and this is one of those things that like, I'm not going to get mad at you for, for calling me, but I will get, I might get frustrated if you don't do this and that's check vision.

Yet we have to have some kind of vision assessment. Often that is the only thing I'll ask you about the eye exam, because again, I can really get a lot of information just from the history when it comes to eyeball stuff.

But the vision is so, so important. All right. So 2020, can they see anything on the chart? Do they wear glasses? That's a good thing to know. All right. Well, the patient wears glasses, but they're not wearing them today. So their vision is pretty bad. Well, that's helpful. That's helpful information. Can they see, can they see the big E on the chart, which is like 2200, 2400.

And if the patient can't see the biggest letter on the chart, you don't stop there. There's a lot of useful vision beyond.

that, that point. So if the patient can't read anything in the chart, then what you do is you put your hand in front of their face and you wave your hand or you count fingers. Again, you're testing one eye at a time, right? Everybody, everybody, one eye at a time. It's useless to do two eye vision exams. All right, don't do that. One eye, then the other. Have them wear their glasses if, or contacts if they have them.

Um, and so, uh, you're checking each eye separately, waving your hand that's hand motion vision or count fingers vision, or you just get a bright light in the emergency part. You get that, get the brightest light you can.

So for someone who's not seeing anything out of their eye, that's what you do. You get a bright light, like a pin light. You hold it right in front of their eye. If the patient cannot see that light, first, make sure you're not accidentally examining a prosthetic eye and the patient's playing a joke on you. It's happened to me. It really does. It happens. And it's a good joke, by the way. It really is good.

And then you call me if it's true, no light perception vision. That means there's something very seriously wrong with that eye. There's only a few things that can cause that level of vision loss like giant cell arteritis, angle closure glaucoma, endophthalmitis. So please call your on-call ophthalmologist with massive amounts of vision loss like that. In general, you know, there's...

A pupil exam is probably second best thing you can teach yourself how to do. Learn what an afferent pupillary defect is. All right. That's just a swinging flashlight test. You swing it to the bad eye, the affected optic nerve eye, and the pupil will dilate instead of constrict because it doesn't sense as much light. That's a really helpful thing to be able to diagnose.

Beyond that, you know, big motility deficits, having the patient look in all the different directions, and that can be helpful in a double vision case. Position of the eyelids are really helpful. But that's pretty much it as far as my expectation for a non-ophthalmologist. Now, if you're an emergency physician, I might ask you if you checked eye pressure.

Emergency docs are the only ones I would ask that of. So if I'm being called by a family doc, an internist, or any other specialist, I'm probably not going to ask for eye pressure because you don't have the means to check it. Emergency departments all have a tonal pin typically, but you're not going to have that in your family practice clinic. If you do, I'd be very impressed, but I don't expect you to have that, and so I'm probably not going to ask you about eye pressure.

If you have the information, great. Otherwise, I'm not going to ask you. Same thing with a fundus exam, dilated, like a back of the eye exam. I'm not going to ask you for that because it took me two months as an ophthalmology resident doing 40 exams on dilated patients every day to get comfortable looking at the back of the eye consistently. How can I expect any of you that have not done that

to be able to see what's back there. If you're good at it because you've been practicing for 30 years and you've gotten the hang of a fundus exam, by all means, tell me about it, but I'm not going to ask you. That's not fair. And most of the time, like, am I going to trust it too? Like what you see, I don't know. Like that's nothing against you. That's just maybe my own neuroses. But if I think a patient needs a back of the eye exam,

I'm going to see that patient. I'm going to bring him in that day or the next day or within a few days and take a look myself. All right. So I'll wrap up here with that. That's like the basics. History is a big part of this. Okay. Just get a pretty good history about the eye. And then just the vision at the very least vision, please, please have some kind of vision assessment. We got to have something, something.

Even if the patient can only see count and can only count fingers, like that's great. That's helpful. Um, but that's it. That's it. I, we don't, we don't expect a lot. Now, uh, the one of the part of the question that, uh, that, that Ryan asked was about, uh, what are the, what are the frustrating or just flat out bad consults I've received? I'll tell you what my, the worst one was. And now it makes me laugh. I mean, in the moment it was very frustrating was basically I was consulted, uh,

as a resident, uh, for, uh, uh, basically to put someone's glasses on. So,

That's why you should always ask someone if they wear glasses, if you're doing something for the eyes. Because this patient, it turns out, all they needed were their glasses that were in their bag in the other room. But for some reason, they didn't come out with that information or let someone know. Maybe there's mental status issues. But basically what I did was I figured out that patient.

I just needed glasses. I put them on the patient and the vision was miraculous. I healed that patient.

but I was a bit frustrated that I came in to do that. And, but you know, I, I kind of learned as a resident, like I didn't ask when I was on the phone with them, like, well, does the patient wear glasses? I didn't, I learned to do that now. So I now, I, I have also learned as a practicing physician, what questions to ask, what things could be. You just, you'll learn it as you go. Obviously you get more experience, but that was a kind of a frustrating consult. It

It could have been very easily avoided. Right. Uh, but you know, you don't get mad. You just, you educate. That's a good thing to do. Right. In a very calm way, because like, you know, people can learn from you because you have more expertise in this than anybody else. So, um, uh, teach, uh,

I frequently try to, if I see an interesting exam finding in the emergency department, as long as it's not like, like 3 a.m. and I'm just like dead to the world, I will grab one of the doctors and say, hey, come check this out. This is what an afferent pupillary defect is. Or look, look at this dendritic lesion on this patient with a herpes viral keratitis. You know, I think people appreciate that. They, people, um,

Because we all come from an educational background, right? We learned how to be doctors this way. And so I remember it always being fun whenever I was on a service and then we consulted somebody and you learn something in the moment about a patient directly from this person who knows more about this organ system than anybody else in the hospital. It's cool to learn in that situation.

And so I tried to, I tried to be that for others, um, especially in the emergency department. Uh, and so, uh, anyway, that's, um, let's see what else I got. If I come up with any, if I could think of any other like bad, interesting, you know, I will say whenever you're in a residency training environment, I think you get more bad consults whenever you're, whenever you are in, when, when people have access to residence, um,

in a residency program, you will get more bad consults. You will get more things that people could probably take care of themselves or figure out on their own. But because residents are there, it's like gives you an excuse to just like kind of like let someone else do that thing.

So I didn't know what I, what I was, what, what to expect when I got out into practice. I thought maybe it's going to be the same way, but it was completely different. Once I got out into the community, I realized people really up their game.

when it's just them out there, right? It's these, you know, you get these community hospitals staffed by these emergency physicians, what we would have called in our ivory tower of residency, outside hospital. You get this kind of, this jaded, distorted view of what medicine is like in community hospitals. You just get this feeling of this bias, right?

that's built up over your years of residency that it's bad care. And that honestly can't be further from the truth because I get the best consults from the people, the emergency physicians in my community

Because they're kind of put on an island to a certain extent. It's harder to get specialists to come in. Sometimes it's harder to reach them. And so you've got to be a little bit more self-sufficient. You don't have residents that will like,

are terrified of missing a page and will just will show up within minutes to see anything because they don't want to get in trouble for saying no to something. Right. So, so people out in the community, they're just a little bit more self-sufficient because they have to be. And also a lot of them, they've been in practice for a while. Right. So they've seen a thing or two. And so I was very pleasantly surprised whenever I got out into my job out in the community and I

I would hear the presentations from emergency physicians and they were giving me like every piece of information I asked. And it was pretty accurate and still can't do a dilated exam or a fundus exam. But that's OK. That's that's the last thing I actually need. And so and so it's just don't don't get it twisted, you guys. It's it's very different in an academic center.

versus when you get out into the community. And so anyway, those are my thoughts on consulting ophthalmology.

Thank you all for listening. I'm your host, Will Planner. He also knows Dr. Glockenflecken. By the way, if you have any comments or questions about consulting ophthalmology, if you've had an experience consulting an ophthalmologist, a story you want to tell me about, let me know. All right. Go to our YouTube channel at Glockenfleckens and in one of the Knock Knock Eye episodes, leave a comment.

All right, ask me your question. That's where I get all of these questions from, okay? I'm happy to help you out. Thanks to our executive producers, Aaron Corny, Rob Goldman, and Shanti Brook, editor and engineer Jason Portizzo. Our music is by Omer Binzvi. That's it for Knock Knock Eye. We'll see you next time, everyone. Bye! Knock knock, goodbye! You've been talked into.