Patients

Optometry can become routine.  I enjoy difficult cases such as diplopia, diseases, and fidgety children, although it can be stressful at times.  I especially love talking to my patients.  Initially it was really tiring...talking to 20 different people everyday and becoming emotionally connected to them.  I learned to be a little less attached, yet address their main issue and empathize with their personal struggles.

Few of the patients I encountered:
1. Shortly after the CRVO and multiple testing episodes, I had a 60ish-year-old patient who was distant and gave terse answers at the beginning of the exam.  After she was told that she may need an LPI to prevent angle closure glaucoma, she wasn't too sure if she was going to do it. She said she wasn't sure of how many days she has left--she was diagnosed with metastasizing breast cancer less than a week ago.  "Going to spend time with my grandkids now," and she just went about her normal routine. I was on a rollercoaster of emotions that week.
2. Genius elementary school brothers who wore thick glasses and read thick books about all sorts of subjects like archaeology since the age of 5.  They got bored easily and outsmarted all the loopholes doctors tell children to get them to comply, so we had to work and think quickly.  Though they were keen to what was going on, they were scared shitless when it came to drops.  The older one cried so much with his gangly legs kicking the chair.  He was in agony and shriveled up in the middle of the chair because the drops were "so painful"....He said he would rather eat potatoes for the rest of his life or something than get another drop in his eyes.  It was a spectacle to see haha.
3.  I had a three year old girl who kept showering her parents with kisses while they were talking to my staff doctor.  She climbed up her father's lap, grabbed his face downward with her small hands, kissed his cheeks once, and stayed there with her arms around his neck for a bit.  Then climbed on her mother's lap, brought her mother's face down, softly kissed her cheek, too, and clung into her for about an equal time.  Then went back to her father, repeat.  It was as though she wanted to make sure they got equal treatment of love hahah it was so adorable.
4. Another 70-something-year-old patient would not give me answers.  I would ask, "One or two?"  He would either not respond or say "Yeah."  It made me pretty frustrated because I thought he was upset at me for no reason, so I told him, "It'll be difficult to achieve the best prescription for you if there are no answers."
"Yeah."
"Okay, is one or two more readable and clear?"
"Yeah."
I learned that he had been recently diagnosed dementia when his wife came in after her own exam.
5. If you're going to get married, then really mean the vows you take at the alter.  Marriage may not be everything, because I understand that things can change...but the unconditional and undying support patients and their spouses have for each other in the exam room brings me so much hope.
  - I had a late 80 year old patient who had multiple sclerosis and was wheelchair-bound.  She came in with her 90 year old husband.  He was a retired physician, still strong and healthy enough to carry her in and out of the chair.  WOW
  - I've had a 70-ish year old patient who had Parkinsons and his wife spoke so lovingly and gently to him, and walk out linking arms.
  - I have also been with patients who had gone through traumatic marriages and are still finding strength.
6. If you are not going to get married, then that's cool too!  There was a sprightly lady who was engaged three times and never married.  She said it was the best decision she made in her life.
7. Patients who look like celebrities...and things.  I saw a Hayden Panettiere (even my staff doctor said so!) and another who...looked like a classic garden gnome...........like..he must have been the model for the first garden gnome sculpture....okay I will stop.


Reflection:
1. I am so thankful for my family's good health
2. There are a lot of twins in this world.
3. I love the two nurses who work with me.  One is a middle-aged Iranian and the things she tells me cracks me up.  We also philosophize life during break time or in between patients.  I've always had close Iranian friends, so it doesn't surprise me hehe.
4. I learned that many of my patients, both men and women, have depression and anxiety, and are on medication for that.  I do think it's because this world expects us to be superhuman and have perfect lives.
5. The women in the best conditions were housewives.
6. Sounds cliche, but definite generation gap.  I see the elderly come in with their library hard cover books and the youngins playing with parents phone/ipad.
7. I really love working with the kids.  They make my day so much better--its just the way they think and the things they say.  It's so pure and the world seems brighter, clearer, warmer....

Country music

I really like country songs...they are more innocent and sweet - really tired of hearing about sex, alcohol and drugs on the radio.

Some think about when we will have our first Asian president, but I wonder who the first Asian country singer will be....Is that too bizzare?  Is it like having a black person on a K-pop group?  PERHAPS.

Here are some current and classic ones I enjoy!

Update

Sounds stupid but I joined a support group with pts who have had CRVO.  Many of them were surprisingly young with perfectly normal health (negative test results).  I read a lot of the posts and was kind of depressed.  None of them resolved and were talking about getting their usual anti-VEGF injections...

10% non-ischemic CRVO resolves
15% non-ischemic CRVO become ischemic

I really want to have a good cry but am so afraid that it will swell up my veins and make things worse.  I'm pretty sure the dull ache I am feeling is the swelling of my veins.  I know my VF is decreased because it's so bothersome I can't see as clearly and brightly as my right eye.

I know I'm not dying but I feel like doing absolutely nothing.  Sulking is bad, but it really sucks especially when you are in the profession and you KNOW that all you can do is wait.  You KNOW there is no treatment and nothing that can be done.  You KNOW all the mechanisms and you can't help it at all.  What good is knowing all this?

Waiting is trying my character.  All I can do is turn to God and pray that it won't get worse.

Thursday June 12 / Friday June 13: Carotid ultrasound, X-ray, Echocardiogram

- So far, blood-works from yesterday are normal, although I, myself, am suspicious of my d-dimer result.  I read online that normal is 254, but mine was 340.  The doc considered it normal though...
- ANA: NEGATIVE. TAKE THAT!
- I am beginning to notice a slight desaturation of reddish hues and my left eye is starting to have dull pains.  I dunno if it's because I am more aware of the condition I have that I am imagining it, or it's actually how I feel.
- I think I'm going to start exercising more.  Going to try swimming at the pool every night for 20 minutes.
- Carotid ultrasound was clean.  The tech was horrible though.  Pressed really hard on my neck with no warning or education.
- X-ray came out clean.
- Echo cardio-gram is to be determined.  Tech was nicer though.  She pretty much pressed really hard on my left boob.  It was a procedure of confusing emotions because sometimes she would be rubbing on my ribs which would make me laugh uncontrollably, and then other times it was boob-sandwhich time which made me want to cry.

UPDATE:
echo cardiogram: everything looks healthy and good.

Wednesday June 12: Retinal specialist, Physician, and more blood work

Retinal Specialist:
- My friend and classmate who is also out in San Diego for rotations came out to see me and my eye.
- The tech was amazing and kind.  He made me feel very comfortable.  Honestly, I came in an excellent mood and felt as though everything would pass.  That perhaps what happened to me was completely idiopathic.
- I still see 20/20, no APD (though mild anisocoria) and pressures are normal 20 mmHg
- We do an OCT of ONH and macula.  Slight superior macular thickening (no signs of edema though) and extremely swollen ONH (totally out of the normal limits, which is strange because my optometrist and neuro-ophthalmologist said my ONH was somewhat swollen...does that mean it's worsening?).  Right eye is happy as a cow.
- OMD comes in and flips my world upside down.  He makes me super scared.  He says that I should take this matter very seriously because it can be life threatening (possible clotting or autoimmune disease), it can go to the other eye, and I can go blind from this.  He says if it does not resolve, I can get neovascularization, will be needing regular VEG-F, and will be needing to see him every month for the first six months.  My head feels prickly and faint.  He asks, "Did I scare you?" F*** YEAH.
- What's horrible is that the other day, my neuro-ophthalmologist said not to worry too much about Lupus because it was unlikely, but this dude is saying "Oh yeah, you are very close to it, I would be very suspicious of it."  He also confirmed that my eye can stroke out by being on an airplane.  Lots of thoughts and images zoom past me: driving would be restricted, I don't know what kind of optometrist I'd be (or worse, if I stroke out both my eyes what the hell would I do with my life, I'd plead for a education refund lol, but seriously), quality of life would SUCK...getting injected every once in a while, medical bills...ugh.  If I did have clotting disorder or autoimmune disease, would I be able to have kids?  But strangely, it didn't make me hate God.  I was just curious to know why this was happening, since everything that occurred previously in my life happened for a reason and I witnessed and experienced it.
- I call my dad and I feel tears swell up.  I tell him everything because my dad is so good at keeping calm and dealing with hard news.  So thankful he is my dad.  He asks me, "Do you want to tell mom?  Or should I?"  Definitely dad. I tell him that it's not fair because I haven't even Europe--and the thought that I finally get to see Europe with my very eyes and stroking out on the airplane horrifies me.  God, where are my priorities haha...
-  Fluorescein Angiography: God what a B!!!TCH.  This hurt a lot even with the "baby needle."  Apparently not too much dye was able to get into my system because I "flexed my arm."  But photos were taken anyway.  This was the first time seeing my left eye. When staff doctors tell you, "You will KNOW when you see someone has a pathological disorder"--you KNOW.   Man, it made my stomach sour and in a twist to see how disgustingly engorged my veins were.  It was utterly disgusting.  Usually it's a 2/3 ratio of artery to vein, but my left eye was a gross 1:6 or even 1:7.  Hemes and CWS along the veins and my ONH was not distinct at all.  I had no reaction to the sodium fluorescein, but my pee was a brilliant yellow green--like some kind of hazardous chemical you see in cartoons.
- Good news:
  --> there is perfusion, thus non-ischemic CRVO
- Bad news:
   -->  prognosis is unknown.  the retinal doc will need to monitor every month for the next six months to make sure I don't get neovascularization or worse, neovascular glaucoma.
   --> still dont know the cause, more lab tests need to be worked, EKG, and ultra sound of carotids to be done.

Physician:
- AMAZING AND KIND.  He made me feel much better about myself.  He said it was likely to be idiopathic since no signs of thrombosis or clotting factors or autoimmune disease is seen.  I told him itty bitty details of symptoms that turned out to be normal and fine.  He said mono had NOTHING to do with this and that at least 80% of adults have mono.  That I am young and healthy, he doubts anything bad is the cause and that I just happened to be unlucky to have it.  But he thinks it will resolve.  He orders more blood tests: thyroid, createnine test, TB (the gold standard to see if I actually do have it or not, all my results have been borderline positive.  dammit, I hate the word borderline).

Phelbotomist: 
- Different phlebotomist this time.  I requested if she could just keep talking to me to distract me and she did a pretty good job, but nothing too memorable except that she lived in an area where a gunman shot three people a few days ago....
- This time ELEVEN VIALS.  God, both my veins were already pretty bruised and so she had to use a butterfly to get it in.  This one felt like it was taking forever.  I felt my left hand tingle, but I kept squeezing the stress ball with my life.  It's not the pain that gets me, but the concept of blood being taken out of me that makes me feel faint.
- This time they had juice!  I chose apple juice and went to dinner with my friends to forget all that had happened.  I realized we are talking like adults now....talk about work and money.

- Today I was very thankful for my friend Lawrence.  He was calm and composed the whole time, which helped me stay calm.  For the past week, I had desperately wished my parents were nearby, so it was comforting to have him.  Thank you, Law.  I felt like I was on an emotional rollercoaster, especially today.
- At night I kneeled and prayed to God to please heal my eye and my body.  I would do anything for Him to just make sure they went back to normal.  I repeated it at least 100 times before bed...

Monday June 9: MRI with and without contrast

- I check into my MRI site early in the morning and I see an 80ish-year-old lady with a patch over one eye being wheel-chaired outside.  The nurse and old lady are taking a break and looking at the trees outside.  I immediately panic and think, "Will I become like her?  I am too young for enucleation!"
- At the MRI place, the people at SHARP are super friendly and nice.  They give me some paper work to fill out and they go over what will be happening.
- I am lead by a very pregnant technician (are pregnant ladies allowed to be working with MRI's?) and told to change into a gown.
- I am given a warm blanket (as though it just came out of the dryer), head phones with a choice of what station I want to listen to on Pandora, and a pillow to lift my knees in a more comfortable position.  A portable button is placed in my hand to squeeze if I ever panic.  I can hear the pregnant lady's voice through my headphones, "Okay, Sandra, we're going to start!"
- I lay down and the machine squeezes my head in place so that I won't move.  My heart is beating fast.
- They place me half way into the machine to take a scan of my orbit and I squeeze my eyes shut.  Trying to hold still so the process gets done quickly.
- I feel like I am in a washing machine of overalls.  I hear a lot of loud banging as I listen to "Rude by Magic!"  Not bad though.  Strangely feel calm...
- "Okay now for the contrast."  They use a catheter and inject galadium inside my veins.  They have to hold my right arm to make sure I don't fidget because I told them I wasn't too good with needles.  I'm digging my nails into my palms as she pushes the galadium into my veins. It didn't hurt much (thank God) and I don't feel any difference in sensation.
- Same thing done, except Pandora isn't working so the loud banging seems is louder than ever.  I keep praying, "Please, please let it be okay."
- I go back to work to see my own patients, which I very much enjoy.

- I get a phone call that my blood results are all normal thus far, except Lupus is just a hair below borderline.  I am told by my neuro-ophthalmologist not to worry, I am still considered normal.  I have a sigh relief, but I still need my ANA results which is 97% sensitive to Lupus diagnosis.
- I also get another phone call that MRI came out clean!  But my optometrist says, "It's better to have an autoimmune disease than a mass."  I don't know how I feel about that comment.

Friday June 6: Neuro-ophthalmologist and blood

Neuro-ophthalmologist
- I was given the wrong address--the OMD did not work at that office that day, and had to drive another 15 minutes.
- Out of all the other Sharp hospitals, this one is perhaps the least attractive one hahah
- Neuro-ophthalmologist is very kind, helpful, and calm.
- Advised to take 325 mg of advil and get some blood work done.
- While driving, I notice the circumvection current in my right eye.  Cool.

Blood work:
- I call in to get my blood drawn possibly today or tomorrow.  I get very woozy when I think about blood being taken out.  Should I mentally prepare myself or will I be suffering in anticipation?
- The lady who answers says, "Whoa girl, you have A LOT of tests that need to be done."
  Me: "Do you think you know how many vials they may take?"
  Lady: "Not sure, but it's a lot of vials."
  Me: "Aww man!!  What time are you guys closed?"
  Lady: "5, come anytime!"
- I drive on over to see if I'm brave enough to get my blood drawn--I want answers now, but I'm such a pansy.  I ask the girl at the front counter of the laboratory center, "Can you estimate how many vials will be filled if I choose to get blood drawn today?"
  Girl: *looks up my info* "Dang, I'd say ten."
  I shout: "TEN???" I cover my mouth.
  Girl's eyes are super big and looks right and left, then whispers: "Were you the person who called in earlier??"
  I whisper back: "Oh, yea...probably.  Aww, I don't know if I can do this.  I might faint."
  Girl sits up straight and says in normal volume, "You aint gonna faint on me and you can do this.  Your blood replenishes like that *snaps fingers* We have orange juice.  You can stay as long as you want afterward to make sure you are okay."
  Me: "....Let me go to the bathroom."
  Girl: "Will be callin' your name shortly!"
- My name is called and my vein is selected.  I pull my arm away immediately as she brings the needle closer to my arm.  Girl, who used to be called Lady and now will be called Phlebotomist: "Girl, you can't do that.  You will make me poke you and get myself poked--it's dangerous!  I'll be talking to you the whole time, now stay still."
- In it goes, feels like a pinch and I hear the vials get filled up.  But Phlebotomist is talkin to me and we converse.  I learn that she is one year older than me and is making money to go to PT school.  I also learn that her brother's son and sister's son are born a week apart.  She is kind and good at distracting me.
- Phlebotemist: "Done!  Nine vials!  That's not to bad!"
  I'm pretty sure I had a weak smile and ask if I can take a picture of my blood.
- There is no orange juice :(  I get two cups of water instead.
- I drive home dilated and happy-ish....

SL 25 yo Asian Female

CC:
Left eye has an "amaurosis fugax" sensation inferior nasally.
Began sometime in April.
Initially occurred suddenly and lasted more than 30 minutes, now about 30 seconds to 5 minutes.
Occurs spontaneously, more often when getting up from laying or sitting position.
(-) associated symptoms: (-) HA, pain, diplopia
**Pt notes at the time it first occurred,
    - Optos was taken immediately with no abnormalities to extent seen .
    - an intern performed fundus and found no spasming of BV or abnormalities to extent seen.
    - pt talked to faculty and was told it was likely ocular migraine, so no dilation was performed that day.

PmedHx:
+ N/A
+ mononucleosis (resolved in spring 2013)
+ low blood pressure: 94-110 / 70

FmedHx:
+ hypercholesteremia: father, grandfather on fathers side
+ stroke/aneurysm in uncle (father side) when he was 19 yo
+ migraines: father, mother, sister
(-) glaucoma, diabetes, HTN

VA: 20/20 OD, OS at distance and near
IOP: 20 OD, OS note: this is the norm
Pupils: PERRL (-) APD equal in size
EOM: Full and unrestricted (-) pain, diplopia noted

Visual Field - SITA standard C-30-2 
OD normal
Mild OS attitudinal defect.  Pt did not notice any part of vision missing, although left eye seems a bit "darker"

Amsler Grid
(-) defects OD, OS

Fundus and BIO
OD normal (-) holes, tears, retinal detachments
       C/D: 0.20 round, pink healthy rim, distinct margins
       Macula: (+) foveal reflex, flat
OS (-) holes, tears, retinal detachments
      + Swollen optic nerve (-) distinct margins, pallor C/D: ~0.20 cannot tell due to swelling
      + Cotton wool spots along arcades and nasal; none near macula
      + Flame hemorrhages along arcades and nasal; none near macula
      Macula: (+) foveal reflex, flat

note: doctor does not have OPTOS........

Optic Nerve Evaluation
Red cap test: (-) differences noted
D-15 saturated: normal
D-15 desaturated: 
- first attempt, desaturated red hues were mixed up
- second attempt normal

Differentials
1. N-AION (A-AION, although unlikely due to age and no note of pain, jaw claudication)
2. CRVO

Due to:
1. Clotting disorder
2. Vasculitis
3. Mass compression: clot, tumor, inflamed vessel...etc.
4. Autoimmune disorder


Ruled out: 
Glaucoma (side note: pt's pachymetry 600 um OD, OS)
Brain mass (-) bilateral VF loss, abnormalities in gait, speech, HA...etc.

Referrals/Orders made:
1. Neuro-opthalmologist
2. Retinal-ophthalmologist
3. MRI of orbit: with and without contrast
4. Blood tests: platelet count, CRP, ESR, various anti-body panels
5. Fluorescein Angiography
6. OCT to evaluate retinal thickness

Advised
- 325 mg aspirin PO qD
- patient not to go on airplanes in case eye strokes out due to change in pressure!!!