Knock Knock Eye: Is Oregon Leading the Fight Against Corporate Medicine?
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hi 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 eyeballs plus

The new subscription to Eyeballs, Eyeballs Plus. We don't just do eyeballs here. Sometimes I dabble in other parts of the human body. I try to dabble too far just because it makes me uncomfortable. But we got some healthcare stuff to talk about today, healthcare system things. If it looks like I just rolled up my sleeves,

rolled out of bed. It's because I did. I have an unexpected day off. I was traveling. Uh, uh, Kristen and I did our wife and death show in, um, uh, French lick, Indiana and great time. Wonderful. I love going to places that are a little bit off the beaten path.

a little bit further away. It was a great event, great people. I talked about farmers. Oh, here's a really cool thing. I realize sometimes I learn things talking to people that practice in just a very different

type of practice. So I'm, I'm in an urban environment, you know, I'm in the Portland area. Um, but when you get out into the rural communities, like basically where Texaco Mike would work and live, uh, you, um, uh, you just learn things that you never otherwise would know. Like I learned, uh, that there are different factions of the Amish community. Like I just assumed that

Like everybody in, we'll just use Indiana for an example because I was just there. Like everybody in Indiana, all the Amish community, they're all the same community. But no, that is not the case with the Amish. They have like lots of different smaller communities. Some of them are more prosperous than others, like just have more money. Some of them are more poor. Some of them are very regimented in their, how they, they,

you know, what they allow, I guess. I don't know what the right terminology is, but here's an example. So there's like one Amish, like small Amish community might be very traditional in their Amish ideals in terms of like a no, you know,

No closed roof buggies, like all the buggies have to be open, you know, following the rules in terms of no like electronic things and and, you know, a distrust of modern medicine, that kind of thing. But then there might be other things.

Amish communities that like will have a boom box in their buggy and allow that, or they may seek medical care more frequently. Uh, it's, it's fascinating, you know, hearing people talk about this. And so I would actually, I want to know more if so.

If you have insight into your local Amish community, let's hear it. Send me an email or just leave a comment on our YouTube channel at Glockenfleckens. But I had no idea. I just thought all Amish kind of do the same thing. But no. They're even like, they argue, they fight with each other. Not like...

there's not like battles, like Amish battles, but you know, they're, some of them are not happy with the other communities because they do things a little bit differently. I think it has to do with just who is the leader of that community. Like they, they're the ones that set the rules and how they do things. But hearing some of the, some of the physicians talk about taking care of the Amish, it's very challenging, right? Because

There's a distrust of modern medicine for a lot of people in the Amish community. There's just a general lack of basic knowledge about

Like a lot of the distrust is a ton of distrust around COVID obviously because, because COVID ripped through some Amish communities, right? So you had people that come in very sick and some of them ended up dying and, and, um, you got a lot of blame directed toward the physicians who were trying to save their life. Like they put a breathing tube in and, uh, the, the breathing tube went into the heart and caused a death, you know, that kind of,

Just not understanding the whole situation. And that's how that's really hard to deal with. And you do the best you can write as a physician to educate, like what's going on. But sometimes there's just a big knowledge gap to try to overcome and you just can't do it. So it is just hearing some of the stories as I was fascinated. I could honestly, I could listen to maybe there is a podcast out there just about the intersection between the Amish and

medicine. I would, I would listen. I would listen to like a 10 part podcast about that. If anybody wants to pursue that, um, or maybe we can do it. So if you think you could do that podcast, let me know. All right, let's talk. I want to help. So great time in Indiana. Um,

But real quick, before we go further into some medical stuff, because I do have... I'm going to do some Q&A. I've had some great questions come in about different parts of the eye, about different things with the eyeballs and optic chiasms and visual processing and stuff that I want to address. Man, I'm looking at myself right now in the camera. I look...

I look like I haven't slept for days. I'm a little tired, but man, I swear I'm doing okay, you guys. I am showering regularly. So don't worry about me. If you're watching me on YouTube right now, I'm okay. Everything's fine. Milo is sitting over there in the corner of the screen. You can't really see him, but he's passed out. We're doing just fine, everyone. So

Before our first break, I got to talk about a great thing I think that happened in Oregon over the last week. By the time this comes out, this is delayed by a couple weeks. So the governor signed a new law that is the corporate practice of medicine. Basically, it curtails the corporate practice of medicine. What it does is it prohibits

Private equity firms, private equity in general, from buying up the medical practices. So not hospitals. Hospitals were excluded, which I'm not real happy about. But medical practices cannot now be majority owned by private equity. That's what it is.

I'm not sure if there's like a grandfathered clause in there, like people, practices that are already owned by private equity. Can they stay owned or do they have to divest? I'm actually not sure about that point, but going forward, private equity will not be able to buy up and be majority owners in medical practices. So I posted about this on a couple of social media platforms. And every time it's so interesting when I talk about

United Healthcare. Like it's everybody agrees. Like everybody's like, yeah, death to United. Like the insurance companies suck. I, this is the only thing I can post where everybody agrees with me, which is very rare in social media, which I appreciate. Right. It's always fun when everybody agrees with you.

It's not quite that like the response when I talk about private equity is a bit more muted. It's because obviously I have a huge physician following and I think people are a little bit uncomfortable because a lot of people sell their practices to private equity or might want to sell to private equity. So it's actually a more complicated, you might think, oh yeah, private equity sucks. It's terrible. And that's how I feel.

But there's a lot of people that are not quite sure because, man, can I turn down a $10 million payout? And you know what? I get it. I totally understand. You take a physician who's built up a practice, who's working through constant decreases in reimbursement and red tape, prior authorizations, and all of a sudden they have some nameless, faceless patient

company comes out of nowhere is like, Hey, do you want $10 million? Like who among us that's so, that would be so hard to turn in when you're like, you're, you just finished paying off your student loans. You're, you're actually, you're kind of like, you're getting burned out. You're looking for a way to just not have to be so stressed about medicine and

man, $2 million sounds about right. That sounds pretty good. Like, so thinking of it from that perspective is like, I, I understand, I understand how people could end up making that decision, but I do think it's making just the healthcare system worse. It's making patient physician relationships worse. It's worsening the situation we are in with, with, with

burnout and, and just feeling awful, pushing people out of medicine. Um, it, it just, I, I, I'm not a fan and that's not a surprise to anybody listening. Like you guys know, I, I abhor private equity. Uh, so I heard some people pushing back against me cause I was like, I was like big cheerleader. Yeah, go governor Kotech about, you know, outlawing private equity. Yes, let's do it.

I got a little bit of pushback. And basically what people who are, were not a fan of this law say is that, you know, all we're doing is limiting the choices that private physician owned private practices can make with regard to their practice. I hear a lot of like, there's a lot of struggling practices and this might be the only way out. I pushed back on that notion because private equity firms, they do not come after individuals.

failing practices. Why would they do that? Their whole reason for wanting to buy up a private practice is to get as much of a return on investment as they can as quickly as possible. And then they can sell off the practice to somebody else after five to 10 years. And so it's maybe even shorter than that. Maybe the timeframe is even shorter than that.

So they're not looking at struggling practices. We have a very well-run physician-owned practice, and we get approached by private equity firms all the time. When you're big enough and successful enough and you run very well, you're going to get the attention of private equity. Why would they want to buy a practice that's barely...

barely functioning. All right. Unless it's just to roll it up into a bunch of different, a bunch of other practices, which I guess is possible. So, but in general, in general, and there may be exceptions to this in general, like you're doing okay. If you're generating interest from private equity firms. Um, and so I think a big part of it is just obviously the money,

but just the convenience of it, right? You don't have to, it allows you to not have to work on recruiting and you don't worry as much about, you know, your exit strategy. You're going to get this big payout. And so I think the physicians who are making this decision have to weigh, you know,

doing something that's really just good for them and only good for them. Honestly, you sell your practice and

It's only going to benefit the people who own that practice who benefit financially. It's not going to benefit your staff. It's not going to benefit your patients. It's not going to benefit the younger associates who are part of your practice who didn't join the practice in order for it to be sold to private equity. They joined because they like what you do. They like the physician-owned nature of the practice. So you got to acknowledge it is really, it's a selfish decision. That doesn't mean it's a wrong decision.

But it is a decision that just benefits you. And if you want to make that decision, like it's your practice. You can do that. But I don't like it when people kind of delude themselves into thinking like it's actually a good thing for healthcare. It's a good thing for their patients. It's not. It's not. We have data that shows that private equity-owned hospitals, not private practices, but we have it on hospitals, are

provide, have better, have worse outcomes at higher costs than physician-owned hospitals. So it's, what we know is that it's just not as good. It changes culture almost immediately. I've heard from a lot of people, the culture of the practice changes.

And so I, I'm trying not to, I don't want to vilify physicians for choosing to sell because that's a, that's, it's a personal decision, right? You've built up a practice. Maybe you're, you're just, you're, you're strung out and, and, and burned out and ready to find a way out of practicing medicine. Uh, and so in comes this, this golden parachute, right? To 10 million dollars. Who among us, right? But,

I don't think it's the only option. And what this bill, what this law I think will do, I honestly think it will actually promote physician ownership because now these practices that are doing okay, they're doing fine. That's why they're attracting interest from private equity.

If they want out, well, they have to just think differently, right? Maybe it might be a little bit more work. You might have to do a little bit more in terms of trying to recruit younger physicians to come in and take over the practice, maybe buy it from you. Or maybe you have physicians that are mid-career who are looking to get into a state that has no threat of private equity, right?

Maybe they want to come in. Or maybe you sell your practice to another practice in the area. You merge your practice with somebody else and then they can keep going it, running it. My point is there's options. People talk about private equity like, oh, it's the only thing we can do as a private practice. If we want to retire, we have to sell. There's no other option. And maybe that's true in certain areas of the country where it's so common.

with private equity, there really is no other option. But man, what I can tell you as an owner in a physician-owned practice, that is that you have a massive recruiting advantage when you are physician-owned. Every graduate from residency who's in a field that has a private practice is

Uh, which almost any field you can have a private, but even, you know, anesthesiology, they, they don't have offices. They work in hospitals, typically surgery centers, like there's private practices for anesthesiology. So almost every practice, every specialty can have a private practice. Um, they, the new graduates, they are, they, they value physician ownership.

They really do. The ones that are interested in business, that are interested in owning their own thing, right? Some people just, they want to be employees and that's fine. All right. They don't want to deal with the headache of that. And they go join a hospital system or Kaiser or even a private equity and they can be an employee. But people that have a little bit of entrepreneurship that are interested, haven't have some kind of interest in being an owner, the captain of their own ship, um,

You're going to have a massive advantage when you're a physician-owned practice. And so a state like Oregon passes this law. Now you can attract young physicians to your state and they know that the practice they're joining is not going to be sold out from under them to a private equity firm.

In my mind, that is a massive recruiting advantage, right? Hey, why would you go to California or Washington? Come to Oregon instead. Like we passed it. We have a law. Private equity can't buy up any more practices. Join us. Like I don't, I'm struggling to see how that could be a disadvantage, you know? So yeah, it limits the choice of what you can do as a physician owner. But sometimes I think we need to be protected from ourselves, right?

And if that means legislating private equity, like let's do it because we've seen what happens whenever, like we've seen the alternative. We've been living the alternative. Let's try something different. All right, let's stop doing the thing we know is bad for patients and do something different. And yeah, maybe it inconveniences physician owners of practices, but until I actually see that it makes healthcare worse, all right, I'm ready to try it. Let's do it.

All right, let's take a break. Hey, Kristen. Yeah.

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Okay, if you're still listening after my private equity rant, I've got one thing to do real quick, and then we'll jump into some of your questions. We'll address some eyeball stuff. So this is fun. I'm going to my alma mater for residency, Iowa. We have a big 100-year celebration of the Iowa Department of Ophthalmology. Big deal. Lots of...

I mean, Iowa, in case you don't know, it's one of the best ophthalmology departments in the world, in the U.S. at least. It's routinely, as if the, I mean, the U.S. News and World Report rankings honestly don't really matter. Maybe they matter a little bit, but it's frequently up there, right? Top 10. So it's a great place. We got alumni all over the country, all over the world. And so, so many people are coming back.

But this is an important event for another reason, because our chair is stepping down. He's been in the chair for like 20 years. Great guy. Fantastic. He's an oculoplastic surgeon, and he is known for being kind of a tough guy. You know, he's got that surgeon, that old school surgeon mentality. He's incredibly funny, but also can be a bit devastating to you in the operating room. He is known for those classic...

surgeon zingers, you know, given you, you know, he, he, he dishes it out. He can take it too. That's the thing, but he'll, he has, you know, all the, the, the jokes, the, the, the, uh, the devastating burns, uh,

that you would hear from surgeons sometime when you're a trainee, like that's class. That's this guy that Keith Carter. Fantastic. And, and I, there, there were times when I was a resident, I just, I would just bust out laughing in the middle of the operating room because of some of the, the, the, um, the insult, the insults that he would levy my way. Um, and,

And so, so what I, what I'm going to do, I'm coming there. They want me to do a little thing. I decided I'm just going to do a roast. I'm going to roast this guy. I'm going to, I'm going to, to give it back to him just as hard as he gave it to all of us. And what I decided to do was invite all as many former fellows of his, because he has, they have fellow two-year fellowship in plastics.

A lot of his former fellows are going to be there. I'm going to invite them all up and we're all going to take turns roasting this guy. It's going to be great. I can't wait. So I thought I've been last couple of days. I've been, I've been, um, uh, uh, I've been brainstorming and writing one liners. All right. So I thought maybe I could share some of them with you, uh, you know, because I think they're kind of fun. All right, here we go.

So these are, these are, these are one liners that you can, that, that, that we've, I, you know, some of them were, were, were given to me. I found some on the internet. I made up some of them, but I think some of these are very classic. You'll, you'll recognize some of these. All right. These are one liners in the OR, uh, insults, burns, whatever you want to call them. I've seen better hands on a clock. If that's the best you can do, can you try somebody else's best instead? I really liked that one. That's good.

See if you can find a way to help with this surgery aside from leaving the room. I've heard that one. Was your medical degree written in crayon on loose leaf paper? Another medical degree one. Which cereal box did your medical degree come in? That's creative. I like that. You've had an incredible amount of success for a surgeon with two non-dominant hands. Oh, God. This is a classic one. Could you suture a little faster, please? The fibroblasts are winning. I like that.

Healing by secondary intention. That's a really common one. I see your hands are moving. Let me, let me get you some pop. Well, I see your hands are not moving. Let me get you some popcorn to eat while you watch this movie of me doing surgery. Oh, it just cracked me up. It's so good. Remind me again. Are you helping the patient or the disease? That's a classic. That's a classic.

Uh, suture any slower and the wound will close by secondary intention. It's just, it goes on and on. If you have any, if you guys can come, you know, there's any classic surgeon burns that, uh, that they, they give out to, uh, you as a, as a med student, as a resident, as a fellow, um, or as a scrub tech anesthesiologist, whatever it is, uh, send them my way. I want to hear them. I love, I love this stuff. This is like, this is what makes, uh,

my videos. Like I, this is the kind of stuff I just, I eat it up, uh, because then I can, I can make videos of this. This is like the classic conflicts that, um, that I love and I love turning it back around, right. Having it not be the attending against the, this is why, why these, uh, you know, so many, uh, you know, all the, um, what is it? The skits like people will do skits

The fourth year med students will do skits, uh, making fun of the attendings. The residents will do skits, making fun of the attendings. This is why this is so popular. Everybody loves this stuff. It doesn't work the other way around, by the way, like attendings. Like what if the attendings made like skits about the residents or med students? That would be horrifying, wouldn't it? That's just bullying. That's, that's all punching down. You don't do that. You punch up. All right. So I think, uh, anyway, I'm excited about this. It's happening in a couple of days. I'm heading down to Iowa. Uh,

Hell of a trip to get to Iowa, by the way, but it's great. If you've ever been to Iowa, you, you, you fly into Cedar Rapids, uh, and you drive down to Iowa city. And if you, Cedar Rapids has a Quaker oats factory, that's like one of the big industries, uh, is Quaker oats. And, um, the, uh, if you fly in on just the right day, the whole town smells like captain crunch berries. It's, it's, it's incredible. So I'm excited. Uh, let's see.

Okay. So let's get to some, why don't we do some eyeball stuff, huh? All right. I got some good questions from you guys. I talked a little bit about eye color change surgery on the recent video that was posted. You know, that's something I like to rail against every now and then. I got some great comments. Talked about pupils. Oh, this is the episode where I did a deep dive on the iris. Irides, we like to say.

All right. So at cytopath, these are all on our YouTube channel at Glock and Fleckens. Hey, I might read your comments someday. So did you leave a comment? Tell me what you think. Do you have any questions about eyeballs? Let me hear them. So at cytopath, not a veterinary ophthalmologist. I am a veterinary pathologist, but I'm here to say that goats, horses, sheeps, sheep, sheep, sheep, and some other grazing herbivores not only have rectangular pupils, but

but that the pupils rotate to remain parallel to the horizon. I had no idea. I thought they were just static. They're always the same looking pupil, horizontal. That's amazing. They rotate to remain parallel to the horizon. This helps them regulate how light enters the eye and gives them better vision to watch for predators while grazing.

The more I hear about veterinary ophthalmology, the more I want to be a veterinarian. Can I go back to school and become an ophthalmologist in different types of mammals? Maybe even some non-mammal. I could do some reptile, reptile ophthalmology. Why not? How does that all work? Do you just become, is it like medicine? You become a, like human medicine, general ophthalmology, general veterinary school.

And then you go and do your like veterinary ophthalmology residency. But then when you do or a fellowship or whatever you want to call it. But then do you like subspecialize in a type of class like reptiles, mammals, insects? I do like, well, how did I just I just want to know how it works. I'm sure there's something I could Google, but I want you to tell me instead.

But that's amazing. Remains parallel. It makes me want to turn a goat upside down. I want to see the changing of the pupil with the horizon. That's really cool. Thank you for that. All right.

At Acure Jacobs says, please give us an aqueous humor segment. I think I mentioned that. I didn't think anybody would take me up on that. Why does it look like? What does it look like? Why remove it? How much is in there? What's with replacing it with gas and oil? Hmm. Good question. So,

Should we talk about humors? Let's talk about the humors. All right. Aqueous humor is actually kind of interesting. All right. So aqueous humor is the fluid that fills the front of your eyeball. So we're talking about the space in front of your iris. So your eye is constantly making fluid and draining fluid. So when you have glaucoma, typically that's because you either make too much fluid or

or you don't drain the fluid well enough, and the fluid builds up just like water in the bathtub, plug in the drain, gonna fill up, but it's a closed system, so the pressure goes up, you start losing vision. So the aqueous fluid is produced in the ciliary body.

So the ciliary body kind of sits just behind the iris. That's what allows you to accommodate. There's a muscle in there in the ciliary body that helps you to accommodate and to see up close if you're under the age of 50.

If you're over the age of 50, too bad. Your ciliary body has degenerated enough to where it doesn't really contract anymore. But that is where all the aqueous fluid is made. So the aqueous fluid is made there and then it travels. So there's a flow to it. It flows around the edge of the iris through your pupil

And then it, it goes into, it drains in the, in front of the iris, in the angle of the eye. It's called the trabecular mesh work, right where the cornea, that clear covering on the front of the eye, you guys know what the cornea is by now, uh,

right where the cornea meets the iris in the angle you actually can't see it with the naked eye you have to use special prism lenses to to see it um it will or mirror lenses i should say um and then that's that's where it drains all right so you have this constant flow of aqueous humor now the aqueous as opposed to the vitreous is actually it's very important um actually you know what let's take we got i'm gonna come back and tell you what's in aqueous fluid all right let's take a quick break

So, Will. Yeah. You're always teaching me things about Demodex mites, your 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-L-I-D-S dot com to learn more. This ad is brought to you by Tarsus Pharmaceuticals. All right, what is the composition of aqueous fluid? There's a bunch of electrolytes in it. There's bicarb. There's potassium. So anything you would find in like blood plasma, mostly,

You'll find an aqueous. Now, the aqueous has to be clear. It's a clear fluid, all right, because you don't want something turbid. If it's turbid, you have some kind of horrible infection in the eye, all right? So it's clear fluid, but it has all these growth factors. It has electrolytes, bicarb. All of it, the purpose of it is to provide nutrients to the cornea. That's really what you're providing food to the cornea.

And so that's why if you lose flow of aqueous in the eye, because in glaucoma, that's what can happen. You don't have flow of aqueous because the drain is plugged up. And so it's not flowing. You start to get a swollen cornea because the cornea is not happy. All right. You need all that stuff flowing around and nourishing your cornea.

Also, the flow, the constant production and drainage, it allows you to take like waste products and, you know, dead cells and blood cells and white blood cells that might get into the front of the eye. You just, it drains out, it drains out. So you need that constant flow, maintains eye pressure, maintains the health of the cornea, keeps the cornea clear and transparent, ensuring proper transmission of light for vision and

And, uh, uh, it's also, um, but it's different than the vitreous. The vitreous as opposed to the, as opposed to the aqueous, it's a vestigial organ structure. It's not really an organ. It's a structure. You're born with a bunch of, of, of embryonic structures. Like there's this big stock that goes from the front of the eye to the back of the eye that degenerates, but you, the, the, the, the, the,

the structure of the back of the eye, the posterior segment, basically behind your lens, it's filled with this jelly-like structure called the vitreous. You don't actually need that. It doesn't provide any real purpose. That's why whenever you have something happen to your retina, if you have a retinal detachment,

and you have surgery to repair retinal detachment, what the retina surgeon will do is cut up all that vitreous, all that jelly, and just remove it because you don't need it. It's not causing any problem. Actually, it does cause problems. It doesn't provide any productive thing. Like, you know, it doesn't help you in any way. It just hurts you because the vitreous can pull on your retina and cause retinal tears and retinal detachments. So you don't actually need the vitreous. Sometimes you have to take it out because it's causing problems.

And so they'll remove the vitreous. And so, and then what happens whenever you remove the vitreous? Well, the, the, that space is just replaced with the normal aqueous fluid that your body just produces. So the eye will just fill back up with, with, with basically aqueous fluid, which is transparent. All right. So your body fills that space that was being maintained by the vitreous jelly. Um,

But so, and then there was a question here as far as, you know, what can you replace it with? Can you replace it with gas? Who comes with oil? Well, often to help, to help keep the, sometimes to help keep the retina attached, what the retina surgeon will do is they'll take out the vitreous, but then replace it with silicone oil. And that silicone oil helps to keep the retina

pushed back against the outer wall of the eye. So it keeps it attached. So you can use silicone oil. You can use gas. Gas is another common. Gas doesn't last as long as silicone oil. So if you have a really severe retinal detachment or you have maybe a patient has had multiple different retina detachments,

and they just keep detaching, then sometimes they'll put silicone oil in the back of the eye, which just provides constant pressure to keep the retina attached as well as possible. Most commonly, you'll use air. Pretty much every time you do a retinal detachment repair, there's some kind of air bubble that's put into the back of the eye, and that does the same thing. That's why patients will be tasked to position themselves

So like if you have an air bubble and just air, you know, it floats, right? And so think about it. If you have an air bubble that you want that air bubble in the back of the eye to be pushing the retina to allow it to reattach to the back of the eye, then you have to

Hang out with your head down or maybe down and to the right or left or, you know, in certain, basically your surgeon will tell you based on where your retina detachment is, what part of your retina is detached. Your surgeon will tell you, okay, we need you to position your head in this way for 50 minutes out of every hour, something like that.

And let me tell you, that is worse. That it's the worst part of retina. Like going and getting eye surgery is sounds like a scary part. It's not scary. Your surgeon knows what they're doing and you'll most likely be asleep or at least very heavily sedated for that kind of surgery. But it's afterwards where you have to position. That's hard for people. I mean, because a lot of patients are older.

Right. Most patients who get retinal detachments are probably in their 50s, 60s. And I know even for me, like it'd be hard to like position my back will start hurting if I'm positioned. I can't lay on my stomach for that long. That wouldn't feel very comfortable. But that's what you have to do for like 45 to 50 minutes out of every hour for like several days. It can be really, really physically demanding and challenging to do. But sometimes you got to do it.

to keep your retina attached. So yeah, gas and fluid, it's usually SF6. But sometimes we'll get air that comes up into the front of the eye as well. And that's okay. As long as there's not too much air that actually blocks the drainage system of the eye that can give you a really sudden, you know, rise in your eye pressure. In general, we don't put a lot of air in the front of the eye. We don't, it's, it's not a, not very often that that happens.

Sometimes you have to remove the fluid though. That was part of the question here from Acure Jacobs. And we'll do that if we need to very, very quickly decrease the pressure in the eye. So we'll do what's called an anterior chamber tap. Basically, we could do it right there in the exam room. We just put a 30 gauge needle.

inside into the front of the eye through the cornea and just allow the excess aqueous humor to just drain out of the eye so it's a way to very rapidly decrease eye pressure

So the AC tap, we don't have to do that very often. That can be a little bit tricky to do, especially if someone has a lens because you don't want to use with that needle. You don't want to stab the lens or cause any damage to any other structure inside the eye. But but yeah, it can be done. So good question. That's all I'm going to that's all I'm going to torture you with about aqueous humor. That's all you need to know.

I think I had to know like the exact chemical composition of aqueous whenever I was studying for boards, but I have since lost that information for sure.

And then one more, this is a great question. Oh, I love this question. Okay. At Jim Belter too, how or why do the optic nerves cross? Is it at the corpus callosum? No, it's not. Is there a reason why each eye affects the opposite brain hemisphere? So this is one of those great questions that you get from people who are not in your field.

That you just kind of, because you're so in depth into your field and so subspecialized, you don't even think about these questions sometimes. Like I never, I can't say I've ever really thought, okay, why exactly this?

Is there an optic chiasm in the, in the midbrain of the eye? So it's not in the corpus callosum. All right. So, well, I guess it's, it's kind of in the, maybe it isn't the corpus. I don't know exactly like the structure compared to where the corpus callosum is in the midbrain, which the corpus callosum might be in the midbrain. I'm not sure. I need to review my neuroanatomy, but it's the, the, the decussation, the crossing of the nerve fibers that coming from your optic nerve, um,

They cross at the optic chiasm, which is right adjacent to your pituitary gland, kind of right in the middle of your brain. And so I'm pretty sure it's not in the corpus callosum. Someone fact check me on that. But it's in the optic chiasm. But that question of like, well, why does that happen?

Like, I don't know. I get like, it's, I guess I've never really had to think about that or so I actually did some research into this. So exactly why, and it makes sense. It makes sense when you think about it. Logically, I just never had to like, actually like mentally come up with an answer here, but it makes sense. So the, one of the biggest reasons that you need to have a crossing of those fibers to the other side of the brain is to help

enable binocular vision and depth perception. So you get partial crossing of the optic nerve fibers because it's partial. That's another thing people don't realize. It's not like the right eye optic nerve completely crosses over to the left side of the brain and vice versa. No, it's actually just like half of the fibers. It's not quite half, but for the sake of argument, you can just think of it as half.

half of the fibers cross over. The other half stays on the right side of the brain. So you have half of the fibers from each optic nerve that cross to the other side. What that does, it allows the merging of those signals from both eyes. So you have each part of the brain has input from each individual eye. And so that allows the eyes to just work together

together and have basically overlapping visual fields that give you depth perception, that give you that wonderful binocular vision. I don't know for sure, but animals that do not have, we're coming back to veterinary medicine again, animals that do not have binocular vision are

I, I, maybe they don't have that crossing. Maybe they have each individual hemisphere of the brain is, is just purely focused on each eye. But if you want to have the eyes working together to have overlapping visual fields, give you that stereopsis, then you need each hemisphere to have input from each eye.

All right. So I think that's kind of the best way I can, I can explain it. It also having that crossing, um, apparently it's more efficient to get the signals from the eye to the, the cortex. So it's just faster. It's like a faster route to the occipital lobe. And that's a, a, a, an evolutionary advantage that I read about that some people think is that, um,

By crossing at the chiasm, it creates more of a direct pathway for information from the visual fields to reach the appropriate brain region. This may have been an evolutionary advantage allowing for faster processing of visual information and more effective responses to stimuli. So anyway, that's another thing. And just hand-eye coordination as well, right? So anyway, there's probably a ton of reasons why.

but that's what I could come up with is, is mostly that binocular vision depth perception is a, is a, is a big one. Um,

But then how does that affect that? But then you also have decoction throughout the brain, not just with regard to vision, but with, with your, your motor movements as well. So I don't know. I, we're now we're starting to, we're getting a little bit outside my area of expertise. We're in the neurology land and I don't have my gold rimmed aviators. Um, and my hair is not long enough to,

to expound intelligently about this topic. So we're going to leave it at that, everybody. I want to thank you for listening. Go leave a comment on our YouTube channel at Glockenfleckens. That's where I get all of these comments that I've been talking about here. We'll try to do a deep dive again on another topic. I guess we did Aqueous Humor today. That was good. There's not really a whole lot to talk about with the humors.

But there's so many different parts of the eye we could do. We still haven't done the lens. We could do the retina. We could do photoreceptors. We could do a whole episode just on photoreceptors. God, that might be pushing your attention span. If I really wanted to just get rid of my audience, I think I'd just do a whole episode on visual photo transduction. How about, does that sound, you want to hear about Opsens?

Oh, man. Do I have some information about opsins? Okay. Anyway, we'll stop there. Thanks to my executive producers, Aaron Cordy, Rob Goldman, and Shanti Brick. Editor, engineer, station producer. Our music is by Omer Binzvi. I am Dr. Glockenplugin. Thank you all. We'll see you next time. Bye. Bye. Goodbye. You're with Glocken.