T’was the night before Christmas, and all through the towns, not an optometrist was stirring-not even an online retailer promising glasses at low cost.
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T’was the night before Christmas, and all through the towns, not an optometrist was stirring-not even an online retailer promising glasses at low cost. The practice’s exam lanes were cleaned, and equipment stored with care, in hopes that St. Nicholas soon would be there.
A patient like St. Nick is not as rare as you think-minus the fact that he is thought to be 1,746 years old. The chance of seeing an older male patient with an elevated BMI, who is presbyopic with pink-rimmed eyes and rosy cheeks, is really quite good.
To embrace him and care for all of his problems is the challenge and can land you on the naughty or nice list.
Previously from Dr. O'Dell: The power of the celebrity spokesperson
From the first handshake it is unclear if he has warm or cold hands because his hands are covered in white satin gloves. His handshake is firm, and his gait steady on the way to the exam room.
These are the first cues to use in determining overall health for patients, young or old. A limp handshake can raise concern of a serious health condition-such as myotonic dystrophy.
Cold hands can indicate poor circulation, low blood pressure, hypothyroidism, and Raynaud’s disease. Dry hands can be seen in patients with hypothyroidism and omega-3 deficiencies. From the gait, one can determine if a patient has suffered past events such as stroke or suffers from arthritis.
Mr. Claus has an ocular history significant for presbyopia. He is fitted with what appears to be OTC, or perhaps elf-manufactured, reading glasses. In many images his glasses are seen low on his nose.
He is married with a past history of smoking ("stump of a pipe…held tight in his teeth" while the smoke "encircled his head like a wreath."), fortunately a habit he has given up.
His memory is in question as he makes a list that he is always “checking twice.”
Santa’s BMI is elevated with his apple shape-which often associated with men who have heart disease. With his age and elevated BMI, diabetes is a concern as half the adults in the U.S. over 65 years of age have diabetes or prediabetes-not to mention his diet consisting of cookies and milk.
He is active in the off-season to keep himself “lively and quick” for Christmas.
He has not been formally diagnosed with facial rosacea, but this is suspected from his rosy cheeks. This also raises concern before the exam of dry eye disease or demodex blepharitis.
As suspected, based on his age alone his distance acuity is not perfect, and he does have complaints of difficulty seeing on foggy nights. His acuity is not impaired to the point where he needs to stop driving his sleigh, but requirements vary from state to state.
This raises the question about international and interstate travel and vision restrictions-is there a universal law?
Extraocular muscles are normal, pupils normal, and confrontational field normal.
Giving a nod, on to the slit lamp we go!
Related: Understanding and defining MGD
Closed-eye evaluation shows, as suspected from those rosy cheeks, blepharitis with eyelid distention and collarettes hallmark for demodex infestation without the need for epilation (I was trying to stay on the good list!).
Tranisllumination of the meibomian glands and mild expression show mild gland atrophy and hyposecretion of the glands-meibomian gland dysfunction.
MGD is common for patients spending many hours on computers and in environments causing evaporative stress (artic winds).
For Mr. Claus, times have changed, and he now spends more time on the computer, sending greetings to young girls and boys across the globe-and researching toys.
Using vital dyes, it is clear that evaporative stress has caused a rapid tear break-up time and also lid wiper staining.
After dilation, Mr. Claus was also found to have cataracts. Though not visually significant at this time, it is something we will monitor.
Surprisingly, his fundus exam is very healthy. No sign of aging conditions, common for our patients, such as glaucoma or macular degeneration, and no sign of diabetic eye disease despite him fitting the mold perfectly.
Now the challenge-educating a patient who is asymptomatic to the need for treatment, especially with cataract surgery in the future.
“Mr. Claus, overall, your eye health is very good. You are developing cataracts in both eyes, which is why you’ve noticed more difficulty seeing on foggy nights. This will worsen gradually over time. As you become more symptomatic to changes in your vision or your vision declines, we can refer you to a cataract surgeon.
“Planning ahead, this will require some travel, but your aftercare can be simplified because many surgeons now inject the post-surgical medications, making it dropless. Also, it is important to start improving your ocular surface for the day of surgery and improve your comfort and vision now. The ocular surface is your eyelashes, eyelid margin, and the tear layer that covers your eye to hydrate it with each blink.
“From the exam, you have a combination of evaporative dry eye disease and an inflammation to your eyelid and eyelashes, called blepharitis. Treatments are available for both, but they are also both chronic conditions.
“Due to your busy schedule and also living far away for much of the year, I would recommend treatment today with TearScience LipiFlow. This will clear the obstruction to the glands in your eyelids causing the quick evaporation of your tears.This treatment takes only 12 minutes. Although not covered by your insurance, it is the best treatment for your condition-and you know the good gifts can be a bit expensive. For maintenance after the treatment I will have you use a tea tree oil-based eyelid cleanser morning and night.”
What I wish for the new year are many patients like Mr. Claus, who are dedicated to their annual eye exams and interested in preventative care.
My wish for all of you is the same-may 2017 be a prosperous one in which we continue to provide the patients we serve with the very best eye care.
Merry Christmas to all, and to all a good night.