FALL 2019 | itech 1

As the prevalence of diabetes in America continues

to climb, practitioners are faced with questions

every day in their practices. Questions such as,

"Can I eat cake now? When will this diet be over?"

As simple as they seem, questions like these open the

door for a conversation that can change the lives of our pa-

tients, neighbors, parents, and possibly our own children.

Taken directly from the American Diabetes Association

2017 National Diabetes Statistics Report, the prevalence of

diabetes in 2015 was 30.3 million Americans, or 9.4 percent

of the population. Of that 30.3 million, approximately 1.25

million American children and adults have type 1 diabetes.1

At that time there were 1.5 million new cases of diabe-

tes diagnosed every year. If we followed that trend, we ex-

trapolate the number in 2019 to be close to 34.8 million

Americans affected today.

In 2015, diabetes was the seventh leading cause of death

in the U.S. with 79,535 death certiϐicates listing it as the

underlying cause of death, and a total of 252,806 death cer-

tiϐicates listing diabetes as an underlying or contributing

cause of death.2

As of March 2018, the cost of diabetes to the healthcare

system was $327 billion in 2017, and the average medical

expenditures among people with diagnosed diabetes were

2.3 times higher than what expenditures would be in the

Counseling patients to learn how to count carbs may improve overall health and vision

Understand diabetes and nutrition

FALL 2019SUPPLEMENT TO Ophthamology Times and Optometry Times

Building the Ophthalmic Tech'sCommunity of Practice

DIABETES CONTINUED ON PAGE 3

By Jennifer Stevens, OD, and Heather Whittington, RD, LD

FIGURE 1 Uncontrolled or poorly controlled diabetes may lead to signifi cant vision loss.

1

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FALL 2019 | itech 3

absence of diabetes.

These numbers are staggering—

especially in a disease that in many

cases can be prevented or treated

without pharmaceutical intervention.

Closer to homeI practice in rural West Virginia where

this disease is rampant. In the Centers

for Disease Control’s 2016 report, West

Virginia was ranked as the state with

the highest prevalence of diabetes in

the nation. With such a high number of

patients affected by this disease, it is

not one to be taken lightly.

Unfortunately, what I see in my

home state is an epidemic of the mis-

informed or the uninterested. So

many of my patients are unaware of

their last hemoglobin A1c numbers,

and more than half do not check their

blood glucose levels daily.

I wonder if the fact that diabetes

has become such a household word

that for many it has become less se-

rious.

When I ask patients if they were

diagnosed with cancer today and

their doctor recommended a change

to their diet as part of their treatment

plan, would they implement these

changes?” there is a resounding yes.

However, when this same question is

asked about diabetes, so many simply

ignore it.

This is why it is important for

eyecare providers and their staffs to

help inform the millions of diabetics

we encounter in our practices. Knowl-

edge is power. An understanding of

this disease process, its effect on the

eye itself, and how nutrition plays a

key role in its treatment can truly im-

pact our patients.

Type I and Type II diabetesLet’s begin by understanding the

pathophysiology of both Type I and

Type II diabetes. Glucose is one of the

body’s primary energy sources, and a

normal range of plasma glucose con-

centration is approximately 70 to 100

mg/dL. Hyperglycemia is deϐined as a

high blood glucose concentration and

thus classiϐied as diabetes.

In both Type I and Type II diabetes,

this is the primary destructive con-

cern. An elevated blood glucose level

causes damage to the small blood ves-

sels in the body, leading to the mal-

function or death of the organ af-

fected. When eexposed to high glu-

cose levels, vessels begin to leak like

a hose with a many small holes. Not

only are needed oxygen and other nu-

trients not going where they are sup-

posed to go, but leaked blood causes

the destruction of the cells it touches.

The difference in Type 1 v.s Type 2 di-

abetes relates to the reason for that

high blood glucose level.

Type I Diabetes is primarily an au-

toimmune disorder that selectively

destroys pancreatic beta cells so that

these cells cannit secrete insulin.

Type II Diabetes is characterized

by insulin resistance in skeletal mus-

cle, liver, and adipocytes and defects

in insulin secretion by pancreatic

beta cells. These increase the over-

all level of glucose in the bloodstream,

which leads to leaked blood and de-

stroyed cells.

Keeping the body’s blood glucose

level stable is known as glucose ho-

meostasis. This is critically important

to the health of the body’s cells and

organs.

Food and insulinWhen people consume nutrients in

the form of food, the stomach begins

to break down this food into glucose.

This causes a sudden spike in blood

NUTRITION AND DISEASE

DiabetesContinued from page 1

DIABETES CONTINUED ON PAGE 4

FIGURE 2

Diabetic macular edema can result from leaking blood vessels in the retina.

2

$327BILLION

cost of diabetes to the healthcare system in 2017; people with diabetes have average medical costs 2.3 times higher than those with-out diabetes

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4 itech | FALL 2019

NUTRITION AND DISEASE

glucose levels, depending on the types

of food consumed.

Complex food structures like pro-

teins break down more slowly than

sugars or simple carbohydrates, thus

slowing the release of glucose into

the bloodstream. When glucose lev-

els rise, beta cells in the pancreas re-

lease insulin.

Insulin causes most of the glucose

absorbed after a meal to be stored al-

most immediately as glycogen in the

liver. It also suppresses the new for-

mation of glucose by the kidneys and

stimulates the uptake of glucose into

cellular tissues such as skeletal mus-

cles and adipose cells. This process

lowers the overall blood glucose lev-

els back into a normal range.

Type I diabetes is a progressive

loss of pancreatic beta cells, thus the

body does not have the correct level

of insulin required to create glucose

homeostasis.

In Type II diabetes there is still a

loss of pancreatic beta cells; however,

the primary cause of elevated glucose

is insulin resistance at the level of cel-

lular uptake.

This means that patients have a

normal insulin range with elevated

glucose levels because less of that glu-

cose is being absorbed by the cells

that are supposed to receive it.

Diabetic retinopathyDiabetes has both microvascular and

macrovascular consequences.

Diabetic retinopathy in the eye, ne-

phropathy in the kidney, and periph-

eral foot and hand neuropathy are mi-

crovascular in nature. Accelerated

central atherosclerosis causing stroke

and heart attack and accelerated pe-

ripheral vascular disease (poor cir-

culation) are macrovascular conse-

quences of diabetes.

Diabetic retinopathy is the leading

cause of vision impairment and blind-

ness among working-aged Americans.

The retinal vasculature is special-

ized to provide oxygen and glucose

to meet the high metabolic demands

of the retina. The cells in this part of

the body contain glucose transport-

ers that promote the ready uptake

of glucose but do not downregulate

this transport when high blood glu-

cose levels arise. This results in an in-

crease in glucose uptake into the ret-

inal vasculature when blood glucose

levels are high and thus a higher level

of damage to the retinal vessels.

Diabetic retinopathy is the result

of damage to the retinal microvascu-

lature system.

Retinal neurons are also sensitive

to this hyperglycemia-induced dam-

age causing the presence of macu-

lar edema and retinal neurodegener-

ation.

Types of diabetic retinopathy de-

pend on the severity of the disease.

Generally, retinopathy is considered

to be non-proliferative (no new blood

vessel growth) or proliferative (new

blood vessel growth).

New blood vessels are formed in

the body when signals from dying

cells are sent out. These new ves-

sels are fragile and prone to leakage,

which in turn causes more retinal

damage.

Treatment options for patients

often depend on the level of severity

within these categories. Surgical in-

tervention includes intraocular phar-

maceutical injections to stop signals

for new growth or laser photocoagu-

lation to destroy abnormal blood ves-

sels or other retinal cells, thus re-

ducing the overall retinal oxygen de-

mand.

Watch the carbsAs the old saying goes, “An ounce of

prevention is worth a pound of cure,”

and so many patients wish they could

turn back the clock and erase the poor

dietary decisions that put them in

need of such advanced treatments.

One method to offer patients is

learning how to count carbohydrates

in their diets. Carbohydrate counting

is a ϐlexible, relatively easy-to-under-

stand meal plan for patients with dia-

betes.3-7

Carbohydrates are the main nutri-

ents that affect postprandial glycemic

response. They begin to raise blood

glucose within approximately 5 min-

utes after eating, and they are con-

verted to nearly 100 percent blood

glucose within about 2 hours.

Carbohydrate counting focuses

on the total amount of carbohydrates

consumed rather than the source of

carbohydrates. For that reason, this

meal plan is more ϐlexible, and no

foods are completely forbidden.

When counseling patients on dia-

betes management, it is important to

ϐirst educate yourself on which foods

contain carbohydrates.

9.4%of the U.S. popula-tion in 2015 had diabetes, which equates to 30.3 million Americans; 1.25 million have Type 1 diabetes

DiabetesContinued from page 3

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FALL 2019 | itech 5

NUTRITION AND DISEASE

Items that contain little to no carbohydrates are considered “free foods.” Patients are allowed as much of these that they desire. These include:

– – Cucumbers

– – Green leafy vegetables

– – Carrots

– – Tomatoes

– – Broccoli

– – Celery

– – Other non starchy vegetables

– – Coffee

– – Tea

– – Other unsweetened beverages

Other foods that contain no carbohydrates are proteins and fats. Examples of protein include:

– – Meat

– – Fish

– – Poultry

– – Cheese

– – Eggs

– – Peanut butter

– – Cottage cheese

– – Tofu

Examples of fats are:

– – Butter

Common foods containing carbohydrates include:

– – Breads

– – Cereals

– – Pasta

– – Grains

– – Rice

– – Beans

– – Starchy vegetables (potatoes, corn, peas)

– – Fruit and fruit juices

– – Milk

– – Yogurt

– – Regular soda

– – Beer

– – Fruit drinks

– – Jams and jellies

– – Cakes

– – Cookies

– – Candy

– – Other sugar-containing foods

The term “carbohydrate serv-

ing” means one carbohydrate serv-

ing is equal to 15 g of carbohydrate.

A general guideline for most patients

is three to four carbohydrate serv-

ings per meal (or 45 to 60 g of carbo-

hydrate).

Patients will often be prescribed a

speciϐic amount of carbohydrate serv-

ings per meal by a registered dieti-

tian (RD) or certiϐied diabetes educa-

tor (CDE). Working with a RD or CDE

will help individualize the diet plan

to each person’s lifestyle or likes and

dislikes and hopefully lead to better

compliance.

Listed below are food groups with examples of common carbohydrate servings:

STARCHES:

– – 1 slice bread

– – 3/4 c unsweetened cereal

– – One half English muffin

– – 1/3 c cooked pasta, spaghetti or rice

– – 1/2 c mashed potatoes, corn or peas

FRUITS:

– – 1 small fresh fruit (4 oz)

– – 1/2 c canned fruit (in natural juice)

– – 17 grapes

– – 1/2 c fruit juice (4 oz)

DAIRY:

– – 8 fl oz skim, 1%, 2%, or whole milk

– – 1 c plain yogurt

– – 1 cup plain or vanilla soy milk

FIGURE 3 Hands can provide patients with a quick reference for serving sizes.

8 fluid oz or 1 cup is equivalent to the size of the fist.

1 oz is about the size of the thumb.

1 teaspoon is the tip of the thumb.

3 oz is the palm of the hand.

1/2 cup is a handful.

3

DIABETES CONTINUED ON PAGE 6

FIST8 fluid oz or 1 cup

FIST

PALM3 oz

HANDFUL8 fluid oz or 1 cup

THUMB1 oz

THUMB TIP1 tsp

T

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6 itech | FALL 2019

NUTRITION AND DISEASE

– – Oils

– – Margarine

– – Mayonnaise

– – Cream cheese

– – Nuts

– – Seeds

– – Avocados

– – Sugar-free salad dressings

Tools can help simplify carbohy-

drate counting. For example, looking

at food labels, using measuring cups,

or eyeballing foods with your hand as

a size guide can provide guidance (see

Figure 3).

Pay attention to the Serving Size

and Total Carbohydrate sections on

food labels. Total carbohydrate in-

cludes the grams of sugar, sugar alco-

hol, starch, and dietary ϐiber per serv-

ing size.

For example, how many carbohydrates are in this meal?

– – 1 1/2 c of Cheerios

– – 1 small banana

– – 8 fluid oz of 1% milk

– – 1 egg

The correct answer is 60 g or

4 servings of carbohydrates. The

Cheerios contain 30 g, banana is 15

g, milk is 15 g, and an egg contains 0

carbohydrates.

Wrapping upSo let’s pull this together. Carbohy-

drate counting is a meal-planning ap-

proach to help those with diabetes

maintain blood glucose control. If you

have a patient who is struggling to un-

derstand the importance of diabetes

and diet encourage them to consult a

RD or CDE to help them master their

carbohydrate-counting skills.

Remember that for many patients

a diagnosis of diabetes is frighten-

ing and overwhelming. Understand-

ing the information and implementing

a plan is hard, and many people give

up before they start. Support is a big

part of success. Suggest that at least

one family member act as a patient’s

“cheerleader.” Fostering a team men-

tality can make all the difference. To

help patients be successful diabetics,

their eyecare providers need to be a

part of the team.

Understanding the pathophysi-

ology of diabetes, its damaging ef-

fects to the body, and dietary counsel-

ing techniques can be the ϐirst step in

helping improve the quality of our pa-

tients’ lives.●

References1. American Diabetes Association. Standards of medical care in diabetes—2007. Diabetes Care. 2007 Jan;30(suppl 1):S4-S41.

2. The Pharmacist & Patient Centered Diabetes Care; National Certifi cate Training Program. American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care. 2007;30:S4-S41.

3. American Diabetes Association. Healthy Food Choices Made Easy. Available at: https://www.diabetes.org/nutrition/healthy-food-choices-made-easy. Accessed 9/11/19.

4. American Dietetic Association, American Diabetes Association. Exchange Lists for Meal Planning. Chicago, IL, Alexandria, VA: American Dietetic Association, American Diabetes Association; 2003.

5. Thomas E. Survey reveals shortfall in pediatric nurses' knowledge of diabetes. J Diabetes Nurse. 2004;8:217-221.

6. Warshaw H, Bolderman K. Practical Carbohydrate Counting: A How to Teach Guide for Health Professionals. Alexandria, VA: American Diabetes Association; 2001.

7. Warshaw H, Kulkarni K. American Diabetes Association Complete Guide to Carbohydrate Counting. Alexandria, VA: American Diabetes Association; 2004.

A diagnosis of diabetes can be frightening

and overwhelming; to help patients succeed,

eyecare providers need to be part of the team

DiabetesContinued from page 5

1.5MILLION

new cases of diabetes are diagnosed every year; in 2019 that means close to 34.8 million Americans have diabetes

Heather Whittington, RD, LD, graduated from

West Virginia University in 2008 with a degree in

human nutrition and foods. She has worked specif-

ically with oncology, renal disease, diabetes manage-

ment, and weight loss. She is a member of the Academy of Nutrition

and Dietetics and the West Virginia Academy of Nutrition and Dietetics.

Jennifer Stevens, OD, completed her Doctor of Optometry degree

from the University of Alabama at Birmingham School of Optometry

in 2010 with BSK Honors. Following a residency in ocular disease, she

joined her parents at Whittington Eye Care Associates in her hometown of

Charleston, WV. She is a member of the American Optometric Association and the West

Virginia Association of Optometric Physicians (WVAOP). She has served as the Education

Chair for the WVAOP since 2012. jlstevens22@gmail.com

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VALUE YOUR PATIENTS

Follow CARE to value patients as individuals and build trust

By Adrienne M. Campos, COA

of what a technician should know for

their interactions. I use the acronym

CARE:

– – Care

– – Attention

– – Responsiveness

– – Empathy

Confi dence

Take pride in your appearance; having

a clean uniform or professional attire

shows that you are serious about your-

self and your work.

As a fellow technician, I

always carry myself in a

manner of respect, cour-

teousness, empathy, and

attentiveness. I allow patients to feel

valued as an individual—not just a

chart number.

Keeping these traits top of mind

during your clinic day will lead to a

great experience for your patient,

which will build an amazing rapport

that will lead to trust from the pa-

tient.

I developed important key factors BEST TECH CONTINUED ON PAGE 8

FALL 2019 | itech 7

CARE

C = Confi dence

A = Attention

R = Responsiveness

E = Empathy

TECHNICIAN TO CLINICAN

Become the best tech for your patient

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8 itech | FALL 2019

FIRST ENCOUNTERS

Patient Rapport

Always look professional and presentable—the

patient will fi nd you approachable

Always greet your patients with a smile—show the

patient you are friendly

Always introduce yourself—inform the patient of

your role in the practice

Observe your patient's mannerisms, including the

way he walks and talks; if he is disabled, off er

assistance

Make eye contact with the patient—the patient

feels acknowledged as a person, not simply as a

patient

VALUE YOUR PATIENTS

Best techContinued from page 7

This information will also drive

the examination and what steps will

be required to follow-up with what

was discussed.

It will also allow you to start

thinking like a clinician and not just a

technician going through the motions.

EmpathyDoctor’s ofϐices tend to make patients

uncomfortable. Sometimes patients

get the feeling of coldness and indif-

ference from the ofϐice and its staff,

which makes patients not want to be

there.

Make the patient's experience en-

joyable. Greet every patient with a

smile, convey that you are happy to

have them come to the ofϐice. Show

empathy and establish a rapport with

patients, especially elderly patients

who may need help moving around.

Offer help, especially if they come to

the visit without a companion.

Some patients might be going

through difϐicult times that you know

nothing about, so try to be under-

standing and, in a sense, read the sit-

uation.

Being a healthcare professional

means you have a career in helping

people and making a difference. It

shouldn’t be viewed as simply a pay-

check or a way to pay the bills. I got

into the ϐield to help people and make

a difference in someone’s life other

than my own. I like to view every sin-

gle person in my exam chair as a fam-

ily member, friend, and—more impor-

tantly—myself.

Case exampleI had an experience many years ago

with a new patient, a 55-year-old male

whose chief complaint was blurred vi-

sion and eye fatigue. I proceeded with

gathering a past ocular history (POH),

past medical history (PMH), surgical

and family histories, and a review of

systems (ROS).

The patient had no corrective eye-

Learn all medical conditions, and

become familiar with all medica-

tions and their side effects. This will

help you determine what testing is re-

quired. This comes across to the pa-

tient that you know what you are

doing, and in that moment, trust is de-

veloped, giving the patient the reassur-

ance that she came to the right place.

Technicians should obtain their

knowledge of the ϐield through study-

ing or taking CE (continuing educa-

tion) courses. The more information

we know, the better we can help ser-

vice our patients properly. That way,

the physician has all the necessary

tools they need to better diagnose

and treat the patient.

AttentionPay attention to your patient’s move-

ment or mannerisms. Especially for es-

tablished patients, changes may indi-

cate something new going on systemi-

cally or a recent injury.

Give your patient your undivided

attention and make her feel valued. I

know complete attention is more dif-

ϐicult with the advent of electronic

medical records (EMR), but it goes a

long way when you acknowledge your

patient as a person instead of a chart

number.

It is important that technicians

don’t lose sight of the human interac-

tion; that is the essence of health care.

ResponsivenessListening to the patient’s chief com-

plaint and history of present illness

(HPI) and taking a thorough history—

including all medications—is key. This

will inform how to move forward with

testing.

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FALL 2019 | itech 9

VALUE YOUR PATIENTS

wear for distance or near acuity.

When checking visual acuity, I no-

ticed he was consistently missing

the ϐirst and last letters of the Snel-

len chart. With pinhole, he corrected

to one line more but still couldn’t fully

see the whole line. I then refracted

the patient and encountered the same

occurrence.

Upon further examination, con-

frontational visual ϐield (CVF) yielded

bilateral restriction in temporal ϐield,

extraocular muscles (EOM) were full,

and Amsler grid was blurred without

distortion. Pupils were round and nor-

mal, and no afferent pupillary defect

(APD) was found.

On slit lamp exam, corneas were

clear, anterior chamber was deep and

quiet, and trace nuclear scl erosis was

found. Intraocular pressures (IOP)

were over 20 mm Hg in both eyes.

I considered possible glaucoma,

but the patient had no family history. I

treated this case as a glaucoma work-

up.

Pachymetry showed the reading

of the microns as thick and helped to

lower IOP to high teens. Automated pe-

rimetry, dilation, and optical coher-

ence tomography (OCT) of the optic

nerve were performed.

I came across a troubling view on

the visual ϐield results. I presented it

immediately to the physician, and he

determined it was bitemporal hemi-

anopsia. Viewing the OCT, the retinal

nerve ϐiber layer (RNFL) was within

normal limits, and macula was clear

of ϐluid.

The physician sent the patient for

a brain magnetic resonance image

(MRI). Results showed a substantial

tumor in the patient’s optic chiasm.

The patient was referred to a neuro-

surgeon who immediately performed

surgery. The neurosurgeon said if the

tumor had not been found, it may have

caused the patient's death.

Months later, the patient followed

up with our ofϐice and was extremely

grateful. He believed he was able to

have an extended life and preserved

vision because of the care he received

from us.

Moving headYou will come across countless sce-

narios with your patients—whether

due to their present illnesses, current

medications, and new concerns. We

as technicians are the front lines, the

ones who start the exam for the phy-

sician.

It is our job to identify concerns

prior to the exam and relay them to

the physician. If you have the com-

fort level from your physicians to per-

form testing with what you saw in

your exam and relay your ϐindings to

the physician, they view you as a clini-

cian, not a technician.

It is about the passion to keep ed-

ucating yourself and to never stop

learning. It is also the passion to want

to better yourself by becoming certi-

ϐied in the ϐield and advancing skill lev-

els in the examination. Think outside

the box, and start thinking like your

doctor would think.

Keep in mind we are all in this ϐield

to help make a difference in someone’s

life by showing her that we care about

her and her well-being as well as her

visual and ocular heath.

If you follow these key points, you

are on your way to becoming the best

technician for your patient.●

SOMETHING TO KEEP IN MIND

Know your diseases—they will infl uence your

testing choices

Keep chief complaints and HPI separate

Take into consideration age factors for adults

Some medications will have visual side eff ects

Pay attention to medical conditions or disorders

with pediatric patients

Focus on the reason why patients are in the offi ce

or which specialist referred patients

BE AWARE OF THE TIME TAKEN WITH THE PATIENT;

AVOID INTERRUPTING THE OFFICE FLOW

Adrienne M. Campos, COA, is a certifi ed ophthalmic technician at Columbia Hospital Ophthalmology. She serves as an

instructor for JACHPO and volunteers with non-profi t Virtue Foundation for medical missions. She is certifi ed in clinical

research in retina and glaucoma.

adrienne.quiles@gmail.com

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10 itech | FALL 2019

TECH JUDGMENT

In the course of helping patients,

it is possible technicians may en-

counter unique situations. While

some translate directly to care,

other concerns regarding privacy or

legalities might arise, and technicians

should know what to do (or not do) if

they happen to come across them.

I address three memorable cases I

was involved in and review the relevant

points outside of the standard medical

or vision care of the patient.

CASE 1: PrivacySCENARIO: New patient, age 22,

comes in with her boyfriend. The front

desk staffer relays that both patient

and boyfriend smell like they have re-

cently been “smoking” and winks at

me. I take the patient and her boy-

friend back and begin the work-up.

She presents with a medical history

that sounds like a corneal abrasion and

clearly has a subconjunctival hemor-

rhage OS. She gives permission for her

boyfriend to stay in the room during the

work-up.

ME: I see the red spot on your white part of

your left eye. Can you tell me about that?

PATIENT: It happened earlier today.

We were parked at a stop sign and as

soon as the car moved forward, it hap-

pened. (She giggles and looks at boy-

friend who smiles but is obviously un-

comfortable.)

ME: Did something hit you in the eye at

that point? It may be important for the doc-

tor to know.

PATIENT: OK. (Pauses.) When the car

moved, my "cigarette" hit me. It does

not hurt much even though it is a little

bit blurry, but when my boyfriend saw

the red spot he said we should go see the

eye doctor. (She blushes.) Please don’t

let my father see these records.

ME: (Thinking: OK.) I’ll let the doctor

know. Thanks. Let me check your vision and

quickly peek at your eyes, then doctor will

come in to check.

I chart the history about lack of pain in

that eye, but don’t write that I smell mari-

juana—or that she asked for the visit infor-

mation not to be divulged to her father. (I

was thinking: Wow, that’s a large abrasion,

she’s in no pain, and they both smell like they

recently smoked marijuana).

CONCERN: Privacy has clearly been

brought forward by the patient.

– – What else should you ask? What

shouldn't you do?

– – Do you really write all that in the

chart? Could I have done anything dif-

ferently?

– – How does our ofϐice restrict infor-

mation, and what can be restricted?

Taking care of the patient’s abra-

sion and redness is generally straight-

forward.

I needed to investigate the mari-

juana smell and the privacy concerns I

had to, so I ask the ofϐice manager and

also tell the doctor before she sees the

patient.

HERE IS WHAT I LEARNED:

1. 1. Not many people in the ofϐice knew

about our policies on how to restrict

chart access to outside entities. The

Privacy Rule under theHealth Insur-

ance Portability and Accountability

Act (HIPAA) was implicated, so we all

had to know who to ask about it.

It turns out the patient could prevent

her father from ϐinding out; that might

refer to it. Some states might also have

their own rules, so we checked that, as

well.

2. 2. I also learned that we needed to

restrict the billing records for this visit

from outside access from her regular

insurance coverage because that also

came up when we explained things to

the patient.

Unusual case histories and implications on careKnow how to spot out-of-the ordinary information

By Paul M. Larson, MBA, MMSc, COMT, COE, CPC, CPMA

Paul M. Larson, MBA, MMSc, COMT, COE, CPC, CPMA, is a senior consultant with Corcoran

Consulting Group. He twice served as president of the Association of Technical Personnel in

Ophthalmology (ATPO). He also served as president of the Consortium of Ophthalmic Training

Programs and on the American Society of Ophthalmic Administrators’ (ASOA) Board of Gover-

nors. plarson@corcoranccg.com.

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FALL 2019 | itech 11

TECH JUDGMENT

CASE 2: Redness and pain that don't match upSCENARIO: Established contact lens

patient presents with severe pain

OS and mild pain OD. He tells me the

right eye but not the left is red. “I was

swimming in a lake a couple weeks

ago with my contacts on. I was ϐine at

ϐirst, but neither eye seems to be get-

ting better,” he says

ME: Were you wearing your contacts while

swimming? Any goggles?

PATIENT: Of course I was wearing

my contacts. I don’t have goggles.

ME: On a scale of 10, how painful is it?

PATIENT: In my left, it is a 10, and in

my right, only a 3 or 4.

ME: (After taking visual acuities and look-

ing at each eye) You say the eft side is most

uncomfortable?

PATIENT: Yes. At ϐirst it was the right,

but in the last few days the left is much

worse. Nothing I do has helped.

ME: Have you seen any other doctors since

this began?

PATIENT: Sure, but they did not help

me so I left that out. Is that important?

ME: I’ll be sure to let the doctor know and

he can decide. Let’s get more information.

CONCERN: Lots of pain but not very

red in that eye. Only a few conditions

cause this.

– – What do you want to know that

we didn’t already ask? Part of my learn-

ing in this situation was that I should in-

quire next time about:

– – What contact lens solutions is the

patient using? How often is the patient

replacing his lenses? Be sure the answer

is honest.

– Were the other medications pills or

drops? Who prescribed them and when?

Was there a good or bad response?

– Did the patient have “person-to-

person” contact with someone with an

eye infection?

– – When was the ϐirst onset of symp-

toms for each eye? Have there been

changes since onset? Did the patient use

a hot tub?

– – Was either cornea uncomfortable

before the swimming?

Final diagnosis showed that each eye

had a different problem:

1. 1. OD: bacterial corneal ulcer. It re-

solved fully with treatment.Final vi-

sual acuity was 20/20 corrected.

2. 2. OS: Acanthamoeba keratitis.

Treatment of the eye may take 6+

months to resolve (if deep). Final vi-

sual acity was 20/100 corrected. The

patient may eventually require a cor-

neal transplant in this eye.

This was my ϐirst time as a tech

working up a patient with this dis-

ease. After the doctor explained some

things, she sent me to learn more on

the Centers for Disease Control (CDC)

website.

CASE 3: Why is the patient wearing a facial mask?SCENARIO: Established patient re-

turns for a follow-up visit. He was last

seen two weeks ago for an intraocu-

lar pressure (IOP) check; the doctor

changed his drops and he is back to

see if IOP has responded.

He is wearing a surgical mask that

he was not wearing on the previous

visit. His uncle comes with him to

exam the room.

ME: I show you as taking meds only for hy-

pertension and the new eye drop.

PATIENT: Yes.

ME: May I ask why you are wearing the

mask?

PATIENT: That’s because my relative

is sick , and I don’t want to catch it, too.

ME: I’m so sorry. Can I help?

PATIENT: The doctors say he is going

to need special medicine, but I think you

might want to get a mask for yourself

and also for my uncle sitting with us—

he’s the sick one. I did not want to scare

anyone in the waiting room.

ME: Right away! (I get a mask and show

the uncle how to put it on). The doctor will be

in to check your eye pressure next. I’ll let the

doctor know about your uncle, too.

PATIENT: Thanks. We are headed

to the TB clinic next. His other doc-

tor told him he might have something

called “XDR.” I don’t know what it is.

CONCERN: A communicable disease

could be present in your clinic at any

time. Always be aware, and if you sus-

pect it, get all the information needed

to protect yourself, your patients, and

other staff.

Let the doctors know. Restrict the

patient and caregiver to the exam room

they are in now until cleared by your

doctor.

In this example, I learned about “ex-

tensively drug-resistant tuberculo-

sis” (XDR-TB). Promptly ask for help on

what to do next if something does not

seem right. It might not be a big deal—

but it could be.

ConclusionTechnicians will run into out-of-the-

ordinary things at some point in their

careers. Sometimes your radar goes

up on the exam, and others will hap-

pen while taking the history. At either

point, your actions as a technician can

be sight-saving as well protect yourself

and others from potentially communi-

cable diseases. Ask for help when you

are unsure.

Communicate your concerns to the

doctor before she encounters the pa-

tient even if you haven’t charted it yet

becausethe ϐinal decision on what

should (or should not) be in the medical

record lies with her.

Don’t forget that patients have pri-

vacy and legal rights and those state

and legal regulations must be followed.

I have also learned that having a good

“poker face” is helpful.●

References1. U.S. Department of Health and Human Services. The HIPAA Privacy Rule. Available at: https://www.hhs.gov/hipaa/for-professionals/privacy/index.html. Accessed 9/12/19.

2. Lorenzo-Morales J, Khan NA, Walochnik J. An update on Acanthamoeba keratitis: diagnosis, pathogenesis and treatment. Parasite. 2015;22:10.

3. Centers for Disease Control and Prevention. Acanthamoeba Keratitis Fact Sheet for Healthcare Professionals. Available at: https://www.cdc.gov/parasites/acanthamoeba/health_professionals/acanthamoeba_keratitis_hcp.html. Accessed 9/12/19.

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ES119031_OPITECHSUPP0919_CV4_FP.pgs 09.17.2019 01:11 UBM blackyellowmagentacyan