Knock Knock Eye: Waiting 45 Minutes for a 7-Minute Visit? Here’s Why
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Hello, everybody. Welcome to Knock Knock Eye with me, your host, Dr. Glockenflecken, your one-stop shop for all things eyeballs. I got some good eyeball stuff for you today.

I had an interesting case, which I'll talk to. Not a complicated case, but just kind of interesting, kind of fascinating. Might be something I've talked to. I've done like over probably a hundred of these. So it's a chance I've talked about this disease before. Has to do with blood. We're going to talk about eye blood.

Something that we don't see very often. We don't see a lot of eye blood in ophthalmology. But if we do see blood, it most likely is the eyes, unless you're an oculoplastic surgeon who does eyelid stuff. That's when the real bleeding, that's when we might actually get like five cc's of blood loss. Maybe even a little bit more.

But generally, not much. I might get my pinky a little bit on my pinky sometimes if I'm doing the cataract surgery. But in general, I'm having a bad time if I have a lot of bleeding. So anyway, we'll get to some clinic things that I saw, as well as a couple of post-op things that came up today in clinics. Kind of interesting stuff. But before we get to the eyeball portion of the show,

Uh, I'm going to talk about a thing. You know, I liked it at the beginning here. It's not all eyeballs that we do, uh, here on knock, knock. I sometimes I've been trained other areas of medicine, things that irritate me, things that I love, things that I hate, things that make me laugh, things that make me cry, things that make me show emotion.

So today I'm going to talk about a TikTok video I saw recently and I responded to it. So if some of you who have seen who I've only posted this on TikTok. So if you see me on TikTok, if you watch my videos on TikTok, you've probably seen this. But I saw a video came across my for you page about basically it was a woman asking, why is it OK for doctors to be extremely late in clinic?

And then what ensued in the video was about two minutes or so of just talking about how disrespectful it is for doctors. Why do doctors do this to us? Why are doctors being like this? They need to show more respect for patients and their time, all this stuff.

The comments, a lot of them had the same tone, right? Just like, man, what if like they're just doctors are terrible. It's all their fault. Why are they doing this? And there were some, a lot of comments actually that also defended physicians and so on.

This is one of those things. I see this argument come up from time to time on social media and in real life, honestly, because I work in a clinic half of my time.

And so this is an age-old conundrum, an age-old conflict of what exactly is going on. Why are you waiting for 45 minutes to an hour, maybe even more, to even just be brought back into the back, into the place where the medicine happens? And then you go to the waiting room and you're in there for another 30 minutes waiting for the doctor. What is happening? Why?

Why are the doctors just yakking it up in the hallway? Probably laughing at all the patients about how long they're waiting. No, we're not doing that. We are not doing that. But that's what a lot of people think we're doing. We're just, I got my feet up. I'm scrolling TikTok. That's not the case. That's not the case at all. And so I think that this is one of those things that I just...

If I could pick like five things, this would be one of them. The things that I wish we were all on the same page about both physicians, people that work in healthcare and people that have never worked in healthcare. I wish we just could share a brain. We could just, just connect each other's brains so that we just totally understand each other. That would be so nice. So let me just go over some of the things, the reasons why we might be running late. But first let's,

Part of doing this also is this is part of why I like to do education and my skits the way I do. I try to make it as accessible as possible. Maybe not some of the serious medical things, but the healthcare system stuff. I try to make it as accessible as possible because I want everybody to be able to learn something about the healthcare system. Not just people already in healthcare, but people that still experience the healthcare system.

And this, I feel like this subject is kind of in that same vein, right? It's like there's this thing that there's this big misconception out there. Like it's the physician's fault that you're waiting so long to see the doctor. And so let me just shed some light on this kind of similar to how I do with the healthcare system because a big part of this is the healthcare system.

So first of all, you got to know that we want to be as efficient as possible, just like you. I don't like staying in clinic an hour after it's supposed to be over, still seeing patients or charting or something or watching my scribe chart. But I also, I am respectful for my patient's time. I don't want to waste someone's time. It makes me very anxious sometimes.

And I don't, I'm, I'm unhappy when I'm not on time. Uh, when, because it means that we, you know, we're not running as efficiently as possible. I, I, I do not want to stay. I'm not just, just, just hanging out, not seeing patients or not working. Okay. Because you know, the clinic day had needs to end at some point. And so that's, that's the first thing. Like we were not doing, none of this is happening on purpose. I promise you that.

It may feel that way. You may feel really frustrated because you're waiting so long. We're not doing this to you on purpose. The second thing is the medical clinic can be very unpredictable. There are dozens of things in the day-to-day operations of a medical clinic that can come up that can just derail the whole morning, the afternoon, the whole day.

All right. I could have a patient come in with emergency. So I'm speaking from an eye clinic standpoint, an ophthalmology standpoint. But, you know, you can find these same things in in any specialty that that runs an outpatient clinic. So I could have a patient comes in, walks in with a trauma. They just got hit in the eye with a baseball.

They have high pressure in the eye. I need to manage that in the clinic or they could permanently lose their vision. I wasn't planning on doing that that day. That means multiple rounds of drops, checking pressure, going in and out of that room, ordering medications, documenting all this stuff, and sometimes talking to my colleagues in retina. Maybe the patient also has a retinal detachment. I got to manage that.

None of that was on the schedule. All right. And so that is something that it could, you could just have an emergency and you got to deal with that.

Um, you could, you know, most of my patients in my clinic are like over the age of 70, I would say the vast majority of them. Uh, what if somebody falls in the hallway, you know, they trip on over something, their Walker, I don't know. And, uh, and they fall, I need to assess that patient right away. Uh, decide, you know, did they hit their head? Does anything hurt? Do I need to send them over to the emergency department?

That's all that, that, and that just puts me further behind, right? We could have a piece of machinery or, or some of our, our equipment in the exam room break or somebody makes a mess of an exam room. Maybe someone throws up. We have, you know what, whenever I'm messing around with eyeballs, I'm talking specifically about the like 20, 20 something year old man out there, men, right?

You guys, you like to faint on us. You like to faint. And sometimes you like to throw up because someone comes near your eyes with something. All right. It's I'm, I'm, I'm not being sexist. It's, it's like 99% men. It really is. The young, you guys, you're, you're kind of, you're, uh,

You're a bit of a baby when it comes to things coming at you. I'm just saying, you can't help it. It's okay. It's just the way, something about our physiology. We're kind of wimpy when it comes to eyeball stuff.

So what if I have a patient that throws up in the exam room? I got to clean that room. We got to shut it down. We got to get it cleaned up. So another patient come in, it puts us behind. So all these different things that could just come up in the chaos of a clinic in which we see 30 to 40 patients a day. All right. So many things could happen.

And, but that's not even like the, the, the, those things, you know, whatever you just, you manage it as, as it comes, but there are more deep seated problems that are the real reason why your wait time might be extremely long. Uh, and they have to do with the way our healthcare system functions. Um, if it, if building a clinic schedule, if it was, uh,

100% up to the practicing physician, I promise you it would run more on time than it does. And I'm speaking like global, like in the grand scheme of all physicians out there in the US at least. The problem is with the slow death of physician-owned private practices,

due to a number of factors I've talked about a lot, declining reimbursement, more favorable reimbursement for hospitals. And so you get hospital corporations buying up practices. You have private equity coming in and buying up lots of specialty practices. Lots of ophthalmology has been bought up by private equity, dermatology. And the problem in UnitedHealthcare, Optum is buying up physician practices.

Optum is the number one employer of physicians in the US. And the problem is when you have these types of entities, private equity, health insurance companies, hospital corporations, they are run by and they are owned by people that do not have patient care experience, like direct. They have never been in an exam room taking care of a patient.

And so all of their business decisions are based not on patient care, but on how much money they can make, how much of a profit they can turn. And so there's only two ways you can generate profit in medicine, right? Or really in any business, you can cut costs. So they do that. Private equity firms, they cut costs. They get rid of physicians. They understaff clinics, get rid of people at the front desk, all right?

or they have to increase revenue. And the only way to do that in healthcare is to see more patients and bill more services. And so now you get into a situation where you're losing staff and you're asking the physicians to see more patients than they otherwise would normally. And so you have packed clinics,

um with short appointment times and then it just whenever you have something that happens in the day-to-day function of a clinic like i just mentioned that it just it amplifies the issue and you get these massive wait times and and so um there's a lot of health care system pressure causing the waiting to be what it is and the reason that it's getting worse and um and i that's that's a much

more difficult problem to try to solve because our healthcare system is just being pushed more toward corporatization. Shout out the state of Oregon, by the way. The Corporate Practice of Medicine bill has passed, I think, the Senate or was it the House? I can't remember which one's passed. Passed one of them. It's going to go to the next one. Has a very good chance of getting signed and passed. And this would limit

Private equity firms from coming in and buying up practices, which I think is great. It's great. Not a perfect bill because it does exclude non hospitals from the bill. So I'm not I'm not real thrilled about that. But I think it's at least it's something something to slow the tide of private equity owning all of health care.

So anyway, that's why. Trust me, we want to run on time. We really do. And it's so frustrating. I don't like it. I can't tell you, and this is something I mentioned in my video that I made. If there's one thing that we can do better as physicians and as medical practices, it's just communicate.

Right. It's, it's letting people know when they check in, you know, the doc is running about 45 minutes late today. You know, would you like to, would you like to reschedule or are you okay waiting? Something like that. Or just updating patients like, you know, if they've been waiting for 20, 30 minutes, don't give them an update. How much longer might it be? I can't tell you how many times though. And whenever I finally get into the exam room to see that patient who has been waiting for a while,

I always, this is what I always say. I say, thank you so much for waiting on me today.

That, that really, it really smooths things over because patients are, by that point, they've been waiting around. They've been waiting while they dilate. They've been waiting on the, there's doing a lot of waiting. So they're a little bit irritated and I can kind of tell the energy in the room. There's a little bit like, Oh, finally it comes in. And I just say that, thank you for being so patient with me. You know, I apologize for the way, you know, it's the day kind of got away from us. That acknowledgement, that,

And thanking them for doing their part, which is just patiently waiting for me, it smooths everything over. And so that's how I like to deal with it in the moment.

But man, the healthcare system pressures are real and it's affecting so many people, so many practices. And so I want us to all understand each other and understand this because it doesn't do anybody any good to sit here on social media, blame physicians for your weight and then physicians blaming patients.

for not being patient, for showing up late. And yeah, that is something that can happen too. Like if a patient shows up 15, 20 minutes late, like you try to work them in and that also puts everything behind. But we also have to give patients grace, right?

Who knows? Maybe there was traffic. Maybe they were waiting on an elevator. I don't know. There's any number of dozens of things that can happen to make a patient come in late. And so we got to give each other a little bit of grace both ways and realize that all of this is unpredictable. We need to communicate with each other better, but also realize the underlying problem

problem of the healthcare system is just amplifying this whole conflict and just making it so much worse than it needs to be. So patience. I love you guys. Thank you for being patient. Thank you for waiting on me to get this podcast out. Let's take a break.

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R-A-V-I-T-Z dot com slash knock knock to get more information on life insurance for physicians. Hey, Kristen. Yeah. I've been, you know, grossing you out about these Demodex mites, although I'm not sure why they look like adorable. Well, these are cute, but it's the real ones that kind of freak me out a little bit. Yeah, but I have some new facts to share with you about Demodex. Oh, great. All right. These mites have likely lived with us for millions of years. Oh, wow.

Yeah. Does that make you feel better? No. Like they're passed down through close contact, especially between mothers and babies. Oh, wow. Such a special gift for our daughters. They're born, they live, they crawl around, and then they die on your eyelids and in your lash follicles. Their entire life cycle lasts about two to three weeks, all spent on your eyelids. Well, thank you for that. This isn't helping, is it? No. How do I get rid of them? Well, it's

It's fun to gross you out, but we do have all of these. It's really common, but there is a prescription I drop to help with these now. Okay. That probably excites you. That makes me feel better. Any way to get rid of them, right? That's right. All right. Sign me up. Visit Mites Love Lids to learn more about demodex blepharitis, which is the disease that these little guys cause. Sure. Again, that's M-I-T-E-S Lids.

love lids, L O V E L I D S.com to learn more about Demodex and Demodex Blufferitis and how you can get rid of it. We're back. Uh, the funny thing about making that video where I basically, I just said all the things that I said just now, um, is that in the comments, I still had people all blaming each other. I still had patients talking shit about doctors and then go and doctors talking shit about patients and,

It's just, it's God, I wish we could stop fighting each other. All right. Other healthcare related news real quick. So this is very exciting. Arkansas was, is the first state to pass like a first of its kind legislation against pharmacy benefit managers. Finally,

It happened. A lot of states have tried. Texas has tried recently. There's lots of states that have tried. Arkansas did it. They signed it. It's law. It's that PBMs, specifically like CVS, I think was part of the legislation, can't own their own pharmacies. And I already saw that some CVSs have already shut down.

And I guess it's not C, it's Aetna, or CVS owns Aetna actually. So anyway, they're the ones that are mostly affected because I guess they have a huge presence in Arkansas, but they can't own their own pharmacies. I think that's how it works. And so it'll be phased in obviously over time.

but it's very, it's, it's awesome. And of course the PBMs, the PBM lobby, there's very upset. So this is a breach of freedom, whatever the, we're going to be poor now. I don't know what, what a massive conflict. Do you want to talk about conflict of interest? PBMs does conflict of interest city. It's, it's, uh, I mean, to be able to set your own

Set the formulary for a health plan and then also force your customers who are on that health plan to go to your own pharmacy and can only get the medications that you set from the for the formula. It's like it's all a conflict of interest.

And fortunately, the Arkansas folks who make laws, they recognize that. So thank you, Arkansas. And I hope many, many more states will follow suit. Now that we have this law, then hopefully it's like the dominoes will keep falling because I guess that's how it works in lawmaking, how a bill becomes a law. I don't know, something like that.

So great. That's good. Good news. Good news. It's so nice to be able to talk about good things that happen in our healthcare system. I wish we didn't even have PBMs, but that's a goal that's much further down the road. Oh, here's another kind of cool thing, something that I just learned about.

is, um, about the healthcare system. It's amazing how like you can just still like learn new things about how our healthcare system works because it's that complicated. You guys, it is so complicated. There's little nooks and crannies. You can just find yourself in like, oh, that sucks. Wow. I didn't know that.

So here's a question that maybe I'm sure a lot of people already knew this. I actually, it kind of flew over my, under my radar, over my radar, under my radar is how exactly reimbursement for a specific specialty or a specific surgery or treatment or physician office visit. How do, how does the physician reimbursement actually get set? How does it get set? Um,

So I learned about the specialty society, what's called the RVS update committee. All right. This is a committee of physicians. It's a volunteer committee. They have all the different specialties are represented here. And I think it's done through the AMA. They get together and they basically have like a big fight because they're all trying to show their worth.

So through this committee, they determine basically how much each physician in this particular specialty should get reimbursed for different things. I'm simplifying it. Okay. I'm not going to go there because I don't really know the ins and outs of everything, but they, the cost, they decide, they determine the cost of providing each service and

By dividing it into three different components, okay? There's the physician work component, there's the practice expense component, and the professional liability insurance component, whatever. But it factors in things like how long it takes a surgeon to do a particular procedure, what's the post-op care like, what are the resources required to perform that service for patients, right?

And what happens is they duke it out in this committee, and then they take their recommendations, because they actually can't decide anything for sure, but they take their recommendations and give it to CMS. And that's what determines what our reimbursement is going to be through Medicare, or at least partially what determines our reimbursement.

And so when your reimbursement gets hit for something, it's because that committee in part that committee determined, Oh wait, Oh, they're getting paid a little bit too much for doing that kind of surgery. I didn't know this. I didn't know about this committee, but if any of those committee members are, are, are, and this is all, by the way, the information they get to determine like how long a, a surgery takes or something is done by surveys. They give surveys out to like a hundred, a bunch of people. All right.

And all those surveys that you probably delete from your email. And so, but anyway, so if any of the committee members are listening, cataract surgery takes roughly six hours, a long time, very quite a while. Okay. I mean, who knows what could happen? It could be anyway. So just, just throwing that out there.

Um, yeah, a little, a new little, uh, a wrinkle. And this is probably known by a lot of people, but I just had no idea that that's how it worked. It's a, this, this little, little fun, little things that pop up. Okay. Let's talk about eyeballs. I promised you some eyeballs, promised you some blood. So we don't, we don't do, as I mentioned earlier, we don't do a lot of blood and ophthalmology. The bloodiest. I really, I'm not talking about eyelids cause there's lots of blood in the eyelids.

The bloodiest thing I'd ever seen for an eye surgery is something called a Gunderson flap. All right, it's called a Gunderson because some guy named Gunderson decided to put his name on it. It's a conjunctival flap. So we use this in patients who have severe neurotrophic keratopathy or some other corneal disease.

Um, it's a way to heal the cornea. So if the surface of the eye, if the cornea, if it, for some reason, it just has no, like the, the, the nerves are shot. Maybe a patient had a, a terrible chemical burn, uh, or just a limbal stem cell insufficiency. Cause you have to have stem cells that are like kind of right or where the, where the conjunctiva meets the cornea. That's where your stem cells are that help regenerate your cornea. Um,

If you lose those for one reason or another, then that can cause what's called neurotrophic disease or where you have a loss of nerve innervation to the cornea. You get neurotrophic disease. The cornea basically degenerates. It breaks down. You get big corneal abrasions that don't heal, pain. The cornea might melt internally.

It might perforate. And one way to treat that is with a Gunderson flap. I had to do one of these once in residency and it absolutely is the reason I don't like doing any kind of conjunctival surgery. I don't like teresium. I don't like doing transplants and I don't know. I just don't, I don't like, I don't like conjunctiva.

And so, but the way you do it, what you do is you have to like dissect the patient's conjunctiva and you just basically use the conjunctiva, like a big flap of conjunctiva and you just put it, suture it over the cornea. And there's a lot, especially as you get older, there's a lot of blood vessels in your cornea and it is just a bloody mess. Like probably pushing like eight or nine cc's of blood. I'm serious. It's a lot.

Almost a thimble full, you guys. So anyway, that was the bloodiest eye procedure I can remember doing in a while. But let's talk about eye bleeding in the back of the eye because I had a patient. Let me tell you about this patient is an interesting one. So young kid, 24, I want to say.

Came in as an urgent add-on. The way the add-ons work in our clinic is I always have, me and my partners, we always have a spot in the morning and a spot in the afternoon that we keep open until like the day, the day of. And so patients come in or patients call in, they have some kind of issue that sounds concerning enough, our schedulers can just slot them in. We always have spots available. So we can always get a patient in if we need to.

And usually those spots get full, get filled with something. So this time it was a patient, a young kid. And his complaint was that he all of a sudden noticed a kind of a big giant cloud just come into his vision and it just stayed there. All right. So when I hear cloud and he described it as a cloud,

The first thing, the most common thing I would say would be like, all of a sudden you get like new floater and people describe floaters in all different ways. Dot spot strands, clouds, spider webs, sheets, people describe in all different ways. So I was like, okay, well, this could be like a sudden onset of a floater. The weird thing is, is the age you don't really hear about a lot of people like young people can get floaters. I have floaters. I'm calling myself young. I'm 39. Um,

Um, but people in their twenties get floaters, especially people who are nearsighted. So possible. It's kind of unusual though, for like a big sudden onset of a, like a giant floater that affects the vision. But that's why he got an appointment the day of, because he made it, it sounded like a big new floater, which obviously, uh,

We've talked about before, if you have a sudden onset of a lot of floaters or big floaters or maybe flashes of light, we're worried about a retinal tear or retinal detachment. So that was what the scheduler was. The triage, our triage person was thinking. So they got him on the schedule, brought him in. And we checked his vision and 20-20 in the other eye. In the affected eye, he was 20-60.

This is weird. This is different. This is not your typical floater, if it's a floater at all, because floaters you can see through. Floaters are translucent. They're annoying. They kind of get in the way, but you can move them around by moving your eye around, right? They're floating around in the middle of your eyes. You can manipulate them to a certain extent. And so in my mind, I'm thinking, I see the vision. I haven't even gone in to see the patient yet. I'm just looking at the workup. I'm like, oh, that's weird. 2060. And you can't refract. So I always have

Anytime a patient comes in and they have a decrease in vision to a certain level, our technicians know that they need to at least try to refract the patient because maybe he just all of a sudden figured out he has a refractive error. That happens sometimes.

People don't realize they have one eye that's more nearsighted than the other eye until they actually, for some reason, kind of close one eye. Like, whoa, I can't see out of that eye. Turns out they're nearsighted. They've been nearsighted for a while. They just suddenly noticed it. Because most of the time, people don't go around with one eye closed. It happens. The sudden realization that you have a problem in one eye, a problem that might have been there for weeks or months, actually more common than you think.

So they did the refraction to see if, okay, is this just a glasses issue? If we could get this kid to see 20, 20 out of that eye, I'm much more reassured. All right. That's most likely going to be just a refractive error. He needs glasses. That's all he needs, but nope, no improvement could not refract him any better.

And so I go in, um, you know, whenever you have a, a, a significant enough decline in vision, I like to check the pupils myself. And so I go and I do a pupil check, normal pupils. Okay. So what does that help me? That helps me know whether or not it's an optic nerve problem. So if I check the pupils and I don't see what's called a relative afferent pupillary defect, by the way,

The one thing I encourage non-ophthalmology, I've said this time and time again, if there's one eye exam thing you'll learn, it's how to recognize an RAPD, especially you emergency physicians out there, all right? Know how to recognize that because that is immediately, you know, big problems. Optic nerve problem, ischemic optic neuropathy, giant cell arteritis, some of the big bad actors in ophthalmology you can diagnose by diagnosis.

recognizing an afferent pupillary defect so anyway that's what i'm looking for and basically what that is it's a swinging flashlight test to go from one eye to the other both eyes when you go when you shine the light in their eye they should constrict but the affected eye the eye that's had optic nerve damage will actually dilate because it's not sensing as much light as the good eye

But his pupils are normal. So I know that it's not an opting nerve problem. His pupils are looking just fine. And so at that point, you know, we got vision, we got pressure, we got the pupil exam. I'm dilating this patient. So we put the dilating drops in. I go back in about 10 minutes later and I look back there and it's blood. I see blood. You see it. It's all, there's a bunch of red, wispy blood that's focused. It's like, it's like, it's all dilated.

kind of sitting right on top of the macula, which is why you couldn't see well, because he had this thick red, bright red blood sitting right on the macula. All right, so now I know what we have. Well, I know what the finding is, but not quite what the diagnosis is. I know he has a vitreous hemorrhage. So what are the most common causes of vitreous hemorrhage? The most common cause is what's called a hemorrhagic vitreous detachment.

But again, he's young. We usually see that in people who are in their 50s, 60s, 70s. When you get to that age, the vitreous, that jelly that fills the back of your eye, it kind of pulls off of your retina and just floating around in the middle of your eye, in the middle of your vitreous cavity, the back part of the eye. Well, when that happens, when that vitreous pulls off of your retina, it can tear a blood vessel and cause a bleed.

We call that a hemorrhagic vitreous detachment. So is that possible in this patient? Yeah, it's possible. But again, he's pretty young. His vitreous is going to be quite formed at 24. So I got to look for other, I got to think about what else this could be. What's another common cause of vitreous hemorrhage? Diabetic retinopathy. So I could rule that out pretty quickly. The kid has no diabetes.

And even if he did have diabetes, I could look in the other eye. And if I don't see any diabetes, any diabetic retinopathy, any diabetes, can't see the diabetes in your eye. If I look in the unaffected eye, the normal eye, the eye with good vision, I don't see any diabetic retinopathy, very unlikely you're going to have a vitreous hemorrhage from diabetic retinopathy in the affected eye. So that's another way you can kind of

knock that down lower on your differential. If I looked in the good eye and I saw, whoa, he's got like severe diabetic retinopathy, there's flame hemorrhages, there's cotton wool spots, there's maybe even some neovascularization, okay, that's most likely what the diagnosis is gonna be of the vitreous hemorrhage. But 24, no diabetes, no diabetic retinopathy. And so at this point, I'm kind of like,

I'm getting a little bit nervous. I got to figure out what could this be? Could it be like a vein occlusion? But that's also very strange. Some kind of acute retinal necrosis from herpetic disease, like basically some kind of infection, toxoplasmosis, something weird. We're getting into zebras now. But then it kind of dawned on me. Oh, okay.

I bet I know what this is. And so I asked him a question. You know what I asked him? Have you had any coughing or sneezing lately? And he said, yeah, my allergies have been killing me. We're in Oregon, you guys. It's springtime in Oregon. All right. The people, I feel so bad for the people that moved to Oregon from other parts of the country, having never experienced springtime here because my God, the pollen.

It is bad. It is so bad for people. I can see it is allergic conjunctivitis season right here in Oregon. He says, yeah, my allergies have been really bad. I had a sneezing fit the other day. I was like, well, when did the bleeding start? He's like, oh, yeah, it was about that time, like around then. It's just like the brown, the change in my vision all of a sudden occurred. So I was like, well, that's what happened.

He had what's called valsalva retinopathy. A valsalva maneuver is when you bear down. When you cough, you kind of bear down, you tense your, you tighten up your abdominal muscles and you produce a cough. You're doing a valsalva maneuver. Same thing when you sneeze. You're forcefully blowing things out of your face holes.

And when you do that, when you increase that pressure enough, if you have a big hearty dad sneeze, it can increase the pressure kind of on your eyes and just compress things and cause trauma to basically just burst a little blood vessel in the back of your eye.

And so I was like, that's kind of what happened here. Now, the good news about this, he's going to be just fine. All right. The retina is okay. There's no retinal tear, no retinal attachment. That little blood vessel, it'll heal up just fine. And the blood will resolve. The body resorbs it. It kind of brings it back. And then two or three months later, it's completely gone. It's going to be kind of annoying for him for a bit. You know, he's going to be hanging out with blood in his eye and not see very well.

One thing that can help in that situation is being upright as much as possible. Even sometimes sleeping like with your head a little bit elevated because you just allow gravity to pull that blood a little bit lower in the eye. And basically all you want is a good visual access. You want to be able to have the light come and hit the fovea unobstructed by any bleeding. So if you get that blood to settle into the bottom of the eye,

You're in much better shape as far as your vision. Just don't shake your head real hard because it would mix up that blood again. So be a bit of a couch potato while that stuff is resolving. And then for some reason, the blood doesn't resolve. You can always go in, surgery, vitrectomy, go in and just remove the vitreous and remove the bleeding with it. So that was the curious case of my 24-year-old with sudden onset vitreous hemorrhage.

And it's always fun, you know, because you get young people, especially this happens. I'd say anybody under 50, they just don't, they're not aware of eye diseases that could happen to them. You know, you get people in their 70s, 80s, they're almost like...

expecting something to happen, right? Like they're expecting to get macular degeneration. They're expecting to get like their anxiety is like, oh, it's probably glaucoma or something. People under 50, no. There's like, it's eye problems are not on their radar at all. Just assume you're going to be seeing what you're seeing. Maybe you need glasses, but that's it.

And so when a young person comes in and they have a sudden decrease in their vision, even a relatively mild one, like this kid, like 2060, that's not bad vision, but it is whenever you're normally seeing 2015 huge change. It's so, I love being able to diagnose them with something that's going to get better because I can look them in the eye and be like, don't worry. You're not going blind. You're going to be just fine. Your vision's going to be okay. And it's just like,

like the tension just, you can watch it, they just leave their body. Sometimes they're like, oh God, thank goodness. Or I've even had people shed tears because they're so happy to know that they're not going blind. It's a scary thing to think that you're losing your vision. And so that was one of my experiences

Favorite little things that happen. And then other, I mentioned, oh, I had some post-op things. I'll make this one quick. This was sometimes when you put an artificial lens in the eye, you can get what's called a dysphotopsia afterwards. It's kind of interesting. It's like the brain has to get used to this new artificial lens in the eye compared to the old cataract lens.

And so what ends up happening sometimes is patients can temporarily get this reflection that they see everywhere they look. It's like a little arc of light off to the side of their eye.

It's not a flash. It's just like light that's there. I liken it to a reflection. And it can be very bothersome for people, sometimes to the point where we have to remove the lens and do a different type of lens or a different material lens. And I haven't looked at the data recently to know if there's any way to predict which patients are going to experience this, but it's not...

I'll take a page from the internal medicine playbook. It's not uncommon for this to happen. And so I just kind of reassured the patient, but that was, that was kind of, I'd have that conversation probably once or twice a week with people. It's like, it's okay. A little reflection, that's going to go away. Your brain, you just have to neuro adapt. I have to convince people that their brain will get used to it. It will. So anyway, those are the,

Not a whole lot of exciting things. Sometimes you don't want a clinic with a lot of exciting things. But that's it for Knock Knock High for today. Thank you all for listening. I'm your host, Will Flannery, also known as Dr. Glockenpluckin. Thanks to my executive producers, my wonderful producers, Aaron Cordy, Rob Goldman, and Shanti Brick. Editor and engineer, Jason Portiz. Our music is by Omer Binzvi. Also, thank you to Lady Glockenpluckin for letting me record this at 8 o'clock at night while she puts the kids to bed.

Knock Knock High is a human content production. We'll see you next time. Knock Knock. Goodbye.