Starting Your First Year of Practice

> By Molly Ritsema, MD

Starting your first year of practice is both exciting and harrowing. Here are a few recommendations to help ease your way:

1. Do something special for yourself before starting your new job. Completing residency is the culmination of many years of hard work; however, starting your practice will be full of challenges. Therefore, make sure you treat yourself to a well-deserved gift after finishing residency. Whether it is a long vacation or a new car, it is time to pause and reward yourself for completing many years of schooling.


2. Negotiate. Many of us fear that as physicians our business skills are weak. If you feel comfortable negotiating your employment contract, congratulations. However, do not be shy about having someone negotiate on your behalf if necessary. Consider hiring a consultant.


3. Learn how to code. We all muddled through coding in residency, but now your coding skills will determine how much revenue you bring into your practice or how quickly you are flagged for an audit. The Academy has excellent coding classes. Take one!


4. Do not get calm into state of being pleased with oneself . Most likely you will not be very busy when you start practicing. Do not spend your down time catching up on the internet or going home early. Get out there and start networking with community physicians or optometrists. Volunteer your services for the Lions Club or community health fairs. Get your name out.

Do not forget to study for the Boards. These are the final hurdles toward becoming a board certified ophthalmologist. Balancing your new job and family can be hard enough, but make sure you take time to study for the Boards… the end is in sight

Cerebral Infarct and Visual Field Progression
July’s Ophthalmology

Previous studies have linked silent cerebral infarct (SCI) with the presence of normal-tension glaucoma (NTG). Leung et al. take these findings a step further, providing evidence that SCI may also play a role in visual field progression.This study involved 286 eyes from 286 patients with NTG; 64 of whom had SCI and 222 who did not. They were followed every four months for 36 months for visual field progression. The researchers found that SCI was present in 29.6 percent of patients with progressive changes in visual field vs. 15.3 percent of field-stable patients. Cox proportional hazards regression analysis showed that disc hemorrhage, systemic hypertension and central corneal thickness were associated with field progression. The most common location of SCI was at the basal ganglia. After adjusting for other risk factors, NTG patients with SCI had a 61-percent higher chance of visual field progression compared to those without SCI.The researchers call for further studies on the relation of SCI and visual field progression.

Monocular Drug Trial Poor Long-Term Predictor

July’s Ophthalmology

For decades, ophthalmologists have accepted the monocular drug trial as a viable way of providing an estimate of long-term IOP reduction when initiating therapy with topical IOP-lowering medication. However, a study by Tony Realini questions the usefulness of this practice.The investigator studied 26 patients with ocular hypertension or open-angle glaucoma who each made five study visits: two on no therapy, one on monocular therapy with latanoprost and two on bilateral therapy. The monocular therapeutic drug trial did not provide clinically relevant information regarding long-term IOP reduction after starting IOP-lowering medication. Even the unadjusted IOP change in first-treated eyes—not incorporating the monocular trial adjustment—showed poor correlation with long-term IOP reduction.The author concludes that the monocular trial was no more informative than using the unadjusted IOP in the treated eye. Consequently, there is no value in leaving one eye untreated when trying to estimate efficacy.

Transitioning to microincision cataract surgery

OSN Supersite

When using smaller incisions, the primary fluidic consideration is the decrease in flow due to the narrowness of the phaco needle and sleeve. Poiseuille’s equation states that the flow of fluid through tubing is proportional to the radius of the tubing to the power of 4. This means that a small change in the tubing radius provides a much larger change in the amount of fluid flow. Remember the analogy of the drinking straw: With a narrow cocktail straw, you would need a large amount of vacuum in your mouth to draw a small amount of fluid. But with a larger drinking straw, just a small amount of vacuum in your mouth produces a good deal of fluid flow. When first trying sub-2-mm MICS, change the vacuum setting to a higher level, at least 50% above or even double your standard level with sub-3-mm surgery. In order to keep the maximum level of fluidic inflow and inflow pressure, which aids in preventing surge, keep the bottle at the highest level because you can always bring it down should you find the anterior chamber to be over-pressurized. Should you further wish to balance the fluidics, an outflow restrictive tubing can be used. A benefit of MICS is the small amount of fluid that is passed through the eye, with routine cases requiring just a fraction of the fluid of larger bore surgery.With improved phaco platforms and high-quality single-piece acrylic IOLs, the transition to MICS is relatively easy, with a minimal learning curve for the surgeon and improved results for the patients.

Administering povidone-iodine before cataract surgery reduces organisms

Administering povidone-iodine before cataract surgery reduces organisms
Eur J Ophthalmol. 2009;19:560-564.

"Use of 5% povidone-iodine for 3 minutes resulted in a statistically significant reduction in proportion of culture-positive swabs (87% vs. 30%, P < .001), mean number of species (0.96 vs. 0.30, P < .001) and growth of [coagulase-negative Staphylococcus]," the study authors said. "No such changes were observed in the control group."
The prospective, controlled study looked at 54 patients who had unilateral phacoemulsification. The eye that underwent surgery received 5% povidone-iodine for 3 minutes, and the eye that did not undergo surgery acted as control.
Swabs were taken from both eyes before application of 5% povidone-iodine and 3 minutes after application. Coagulase-negative Staphylococcus was the main species on the culture-positive swabs

Intrastromal Voriconazole and Fungal Keratitis

July’s AJO

Prakash et al. evaluated the role of intrastromal injection of voriconazole in the management of deep recalcitrant fungal keratitis.
Their study included three eyes of three patients with deep stromal recalcitrant fungal keratitis not responding to topical antifungal medications. Patients received voriconazole 50 µg/0.1 ml injected circumferentially around the fungal abscess in the corneal stroma. Before the intracorneal injection, all three eyes had gradually worsening lesions on topical medications.
After the voriconazole injection, a faster reduction in the size of corneal infiltration was documented and a complete resolution of the ulcers was seen within three weeks in all cases. The authors conclude that targeted delivery of voriconazole by intracorneal injection may be an effective method to treat cases of deep-seated recalcitrant fungal keratitis responding poorly to conventional treatment modalities.

Risk Factors for Complications After Congenital Cataract Surgery

Risk Factors for Complications After Congenital Cataract Surgery
July’s AJO

Kuhli-Hattenbach et al. investigated individual risk factors for the development of complications in children undergoing pediatric cataract surgery.The authors reviewed the records of 67 eyes of 44 children who underwent congenital cataract surgery in the first 18 months of life. They performed a limbal-approach bimanual lens aspiration, a posterior capsulorhexis and an anterior vitrectomy without IOL implantation for all children. The mean follow-up period was 39 months.The most frequent postoperative complications were late-onset open-angle glaucoma (11 percent) and vitreous hemorrhage (11 percent), whereas early-onset glaucoma (5 percent) was less common. Secondary cataract was observed in seven eyes (9 percent). A family history of aphakic glaucoma in first-degree relatives, cataract surgery in the first three months of life and nuclear cataracts were strong predictors of late-onset glaucoma. Secondary cataract formation was associated strongly with lensectomy in the first five months of life. The diagnosis of postoperative hemorrhages was associated significantly with the presence of persistent fetal vasculature.

The authors conclude that potential risk factors for complications after congenital cataract surgery include young age at the time of surgery, a family history of aphakic glaucoma, nuclear cataract or persistent fetal vasculature syndrome. They also note that it is not clear how the results might differ if an IOL had been implanted at the time of surgery.

FDA approves Crystalens HD in quarter diopter steps

OSN Supersite


ALISO VIEJO, Calif. — Bausch & Lomb has received approval from the U.S. Food and Drug Administration to begin marketing its Crystalens HD in quarter diopter steps in the United States, the company announced in a press release.Bausch & Lomb will make the quarter diopter steps available for fourth-generation Crystalens models HD500 and HD520 in the ranges of 18 D to 22 D and expects to make a wider range of diopter steps available by the end of the year, the release said."Quarter diopter steps for the Crystalens 5-0 have been enthusiastically accepted by surgeons, so we have now added them to the HD model. We still remain the only presbyopic channel lenses available in the U.S. in quarter diopter steps," Mike Judy, vice president of global surgical marketing for Bausch & Lomb, said in the release.Bausch & Lomb will begin shipping the Crystalens HD in quarter diopter steps on July 16

Glaucomatous Visual Field Loss May Not Lead to Total Blindness

July’s Ophthalmology
A retrospective chart review study by Much et al. demonstrated that the prognosis for treated patients with end-stage glaucoma may be better than previously thought. This research focused on a predominantly African-American population with end-stage glaucomatous visual field loss defined by a central island of vision of 10 degrees in radius or less.
Investigators included 84 eyes of 64 patients (78 percent African-American) with an average follow-up of 8.34 ± 3.1 years. They found that 14 eyes lost more than three lines of visual acuity with eight of these eyes progressing to a visual acuity of 20/200 or worse. Few eyes in the study experienced a complete blackout of their central visual field due to glaucoma.
The authors conclude that progression to blindness is not the norm in treated patients with end-stage glaucomatous visual field loss, and they encourage ophthalmologists to share these relatively optimistic findings with patients

Sneezing Reflex With Sedation and Anesthetic Injection

July’s AJO

Ahn et al. compared the frequency of reflex sneezing occurring during periocular anesthetic injections with and without intravenous sedation.
In a retrospective study of 722 patients undergoing oculoplastic surgical procedures, the patients who received a periocular anesthetic injection under intravenous sedation served as the test group of 381 subjects. Those who received a periocular anesthetic injection without intravenous sedation served as the control group of 341 subjects. The absence or presence of reflex sneezing in both groups was recorded and compared using chi-square analysis.
Of the 381 patients who received periocular anesthetic injections under intravenous sedation, 19 exhibited a vigorous sneeze. Conversely, none of the 341 patients who received periocular anesthetic injections without intravenous sedation sneezed.
The authors point out that all operating room personnel should be aware of this unusual and potentially dangerous sneeze phenomenon in order to reduce potential ocular complications.

Glaucomatous Visual Field Loss May Not Lead to Total BlindnessJuly’s Ophthalmology
A retrospective chart review study by Much et al. demonstrated that the prognosis for treated patients with end-stage glaucoma may be better than previously thought. This research focused on a predominantly African-American population with end-stage glaucomatous visual field loss defined by a central island of vision of 10 degrees in radius or less.
Investigators included 84 eyes of 64 patients (78 percent African-American) with an average follow-up of 8.34 ± 3.1 years. They found that 14 eyes lost more than three lines of visual acuity with eight of these eyes progressing to a visual acuity of 20/200 or worse. Few eyes in the study experienced a complete blackout of their central visual field due to glaucoma.
The authors conclude that progression to blindness is not the norm in treated patients with end-stage glaucomatous visual field loss, and they encourage ophthalmologists to share these relatively optimistic findings with patients

IOP Fluctuation and Visual Field Progression

July’s Ophthalmology

Using data from the Advanced Glaucoma Intervention Study, Caprioli and Coleman found that long-term fluctuation in IOP is associated with visual field progression in individuals with low mean IOP, but not in those with high mean IOP. The investigators only included eyes that had one surgical intervention. To calculate the mean IOP and IOP fluctuation in this study, the investigators used only IOPs from the surgical intervention up until the time of first evidence of a declining visual field.The study involved 301 eyes of 301 patients. Visual field progression was detected in 78 eyes (26 percent) and associated with three variables: greater IOP fluctuation, argon laser trabeculoplasty and older age. In their model, IOP fluctuation in the low mean IOP group was associated with visual field progression. This association was not seen in the high mean IOP group.Given these findings, the authors suggest that clinicians may want to rethink target pressure, perhaps considering IOP modulation rather than IOP reduction when exploring treatment options.