Imagine a new patient presenting to your office with a painful eye and profoundly reduced acuity. There is no infiltrate, but the cornea appears hazy, perhaps edematous, though it’s difficult to tell. What would your working diagnosis be? What happens to your diagnosis if the patient is an extended wear contact lens user? What if they qualify their pain as superficial, or deep? What if they had a corneal transplant to this eye six months, or even 20 years, ago? What if they had a transplant, but to the fellow eye? Finally, what happens if your original treatment fails?
These situations come up periodically in my clinic and each subtle variation in history should generate a separate primary differential and treatment. Transitioning smoothly among these differentials, being able to separate the important clinical finding or historic element from the red herring, is key to effectively managing these patients.
Welcome to my first edition of Corneal Consult, a column in which I hope to explore the diagnostic and therapeutic challenges we face when dealing with corneal pathology and provide real-world, clinically useful practice pearls each edition.
In my first column, I’d like to introduce myself and share my background, training and current clinic environment, as well my future goals for this column.
My Clinical World
Most of you (statistically, it’s closer to “all of you”) don’t know me. I’m Aaron Bronner, an optometrist working in the Kennewick, Wash., office for Pacific Cataract and Laser Institute (PCLI), a multicenter, comanagement group.
PCLI was one of the first comanagement groups in the nation and was one of the earliest to perform Medicare-approved outpatient cataract surgery. Our mission statement is to provide the best care possible to our optometric referral network, and we deal exclusively with referral-based care.
At my facility, beyond the standard menu of cataract and refractive surgeries, we provide surgical and medical corneal care for a large part of Eastern Washington and Oregon. In addition to the 100 or so great ODs I work with indirectly through comanagement, I work directly with two skilled optometrists, Brian Johnson and Bruce Flint, and five gifted, gracious ophthalmologists, Jim Guzek, Jason Leng, Loren Seery, Ron Sugiyama and Marshall Ford—they all bear mentioning because they are, unwittingly, contributors to this column. (Thanks, guys!)
At PCLI, ODs maintain some level of involvement at all levels of perioperative and medical care—even in very complex medical cases, we stay involved with clinical decision making and will collaborate with our MDs rather than simply referring to our MDs for consultative services. It’s an exciting, sometimes stressful, way to practice and provides a phenomenal opportunity to continue learning. I hope to draw on this experience and make this column as useful to the readers as possible. In addition to clinical responsibilities, I also teach residents though the Jonathan Wainwright VAMC clinic in Walla Walla, Wash., and you’ll be reading about them from time to time. My Interests
I became interested in both corneal care and teaching during my residency, which was performed at Davis Duehr Dean Eye Care in Madison, Wis., about 10 years ago. During my residency, I rotated through some amazing ophthalmologic clinics; I spent about half of my time in the cornea clinic of Chris Croasdale, MD. During this time, I realized that, despite my training, I was a fish out of water with complex surgical or severe corneal disease cases—they were so far outside my experience I couldn’t formulate effective diagnoses or treatments.
After taking a mental accounting of how and why I was struggling, my initial step to remedying the situation was to observe Dr. Croasdale’s approach to clinical problems. First of all, he just knew way more than me. Given where I was in my career path, and where he was in his, there was nothing I could do about this gap—research and continued learning were the only tools I could use to help narrow that difference to a more acceptable margin.
But there was one area I could address immediately: the stark difference in how we mentally approached cases. He employed what I’d call a process-driven approach, while I, at the time, used a results-driven approach.
My First Practice Shift
My results-driven approach to clinical cases was perfected by four years of optometry school and its incumbent testing. I had learned to assess each finding not as a process taking place within the eye, but only as a piece of a puzzle that, once put together, led to a diagnosis—finding X is tied to diagnosis Y. In essence, I simply memorized a large number of findings and their respective diagnoses, and if a case I encountered showed enough associated findings, I would have a diagnosis. At its root, this results-driven approach was not based on any actual understanding of pathologic and physiologic processes, but on memorization. Perhaps this was less elegant, clinically, than an in-depth understanding of pathophysiology, but it was effective much of the time and was adequate during school.
Dr. Croasdale, however, approached cases quite differently. Rather than focusing exclusively on a finding tied to a diagnosis, his process-driven strategy emphasized what pathologic and physiologic process the finding represented within the eye.
This was a revolutionary discovery for me. By shifting from my own memorization-based approach to Dr. Croasdale’s process-driven approach, I focused on understanding the processes taking place and realized a deeper understanding of the pathology and the appropriate diagnoses, which was particularly useful for cases that weren’t textbook.
Though both of these approaches work when a clinician is familiar with the underlying diagnosis, the results-driven approach breaks down immediately when faced with an unfamiliar constellation of findings on non-textbook presentations. With no diagnosis tethered to these unfamiliar findings, an accurate diagnosis is impossible; a finding without a linked diagnosis becomes meaningless or, worse, confusing. Unusual cases demand clinicians interpret a series of often unfamiliar findings and assimilate them into a useful differential based on the processes taking place in the eye.
Once I realized this flaw, I sought, during my residency (and during my career), to better understand the disease processes
encountered in clinical practice. The tricky thing with learning in a postgraduate setting is that you never know what you didn’t know until you know it. For you to realize a gap in your knowledge base, someone who knows more has to point it out. I’ve tried to get around this limitation with literature research, practicing in a challenging clinical setting where I am routinely exposed to new things and, most importantly, collaborating with more experienced ODs and MDs (in addition to those already named, I’d be remiss if I didn’t mention Walt Whitley, OD, Doug Devries, OD, James Adamek, OD, and Jeff Urness, OD, as professionals from whom I’ve directly drawn a lot of information).
|The Bronner family—Aaron and Becky, Zoë and Liam—|
enjoying Disneyland at Academy 2016.
My Column Goals
I have two goals for this column. First, I hope to share some of these diagnostic and therapeutic associations and hopefully help you, too, realize a deeper understanding of what is actually taking place in corneal pathologies and their respective treatments. I believe understanding mechanisms involved will encourage a process-driven approach and benefit you in clinic.
Second, I’d like to revisit some of the vast corneal findings we learn about in our training. The nature of our optometric education requires us to assimilate so much information so rapidly that it becomes impossible to assign the appropriate context to register all of it in our long-term memory. I hope to re-explore some of these findings and help assign more clinical relevance to them to allow better recall.
It takes a certain amount of ego to think you can offer to teach a similarly credentialed group of colleagues, and academic lecturing is not my intention in these pages. A smart person once told me that “study is a means to an end, it isn’t the end itself.” As ODs, academic knowledge supports clinical practice, not the other way around. So while occasionally the column may delve into academics, I will always attempt to tie it back into a concept with clinical value. Each of the concepts I will discuss started as something I was initially unaware of, and upon learning the concept, felt it helped shape my clinical thinking.
I enjoy presenting information in a new manner, and I hope you enjoy the column and learn as much from my experiences as I have. Cheers!