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Anxiety and Eye Care – Perspectives

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One might wonder why an ophthalmologist would venture out of his comfort zone and into the area of psychology. Fair enough, and it is therefore important to note that this post does not constitute an expert opinion or formal psychological or psychiatric advice, but one eye specialist’s perspective during these challenging times we currently find ourselves in.

The past few weeks in private practice have left me with a distinct sense that people in general are “over it” – COVID19 that is. However, we are far from determining the full impact of this global pandemic and even more so, the impact of humanity’s reaction to it. I mean this in a positive sense as well – we continue to play a part in COVID19’s full impact and the degree to which it will be positive and/or negative.

The Pandemic with its global lockdowns has had its obvious ups and downs:

Extra time at home with family VS domestic violence and loneliness.

Innovation and rapid startups VS the collapse of large industries.

DYI projects and home workouts VS boredom, injuries and loss of routine.

The moments of pause and unity VS the politics and the panic.

Unprecedented research turnover VS poor quality publications and fake news.

Funny new internet memes VS the tragic loss of lives and livelihoods.

Another facet of this pandemic season that continues to strike me in my daily practice is the level and pervasiveness of anxiety and the challenges it brings. Some, those that seem more emotional or in touch with their feelings are experiencing fear in a big, almost tangible way, while those that are less emotional or perhaps see themselves as more practically orientated might “feel” okay, but their bodies are showing the signs with flare-ups of auto-immune conditions, overeating, lack of sleep and tension headaches. Below are five perspective on this collateral epidemic which I hope will be of use.

1. According to the Ophthalmological Society of South Africa ophthalmology patients are experiencing increased anxiety when seeking healthcare. Our patients generally fall in the vulnerable categories of those above 60 and with co-morbidities and it is important that this patient anxiety be addressed when consulting with patients.

Three recommendations for eye care practitioners to address anxiety are:

Do not move patient appointments unnecessarily – This creates doubt about the urgency or need of seeing the ophthalmologist.

Communicate with patients – Have your staff call patients the day before appointments to determine whether patients have any COVID risk factors and also to explain the practice COVID safety procedures to the patient.

Ensure that your practice has visible safety measures in place, so that patients understand that their safety is important to you. This include patient information in visible places in the facility.

2. The flipside of the coin is of course the stress that comes with medical and optometry practice. Being a healthcare provider is an enormous privilege, but keeping up both technically and financially with the relentless advances in equipment, increasing litigation, healthcare funding and the politics of healthcare are but a few of the issues that add to the inherent load of being a practitioner. Occupational health and safety and emotional wellbeing of providers are significant concerns and of increased relevance during the COVID19 pandemic. It has never been more important for healthcare workers to be supportive of each other and reach out to ask for help when needed.

3. I have personally had to learn from others and figure out a way to remain strong in this environment. Two sets of five help me stay focused and positive in a world that sometimes seems to be on fire with negative hashtags. The first five and in this order, which I learned from a good friend and excellent biokineticist, Bertie Herbst, make up a kind of big picture compass:

Faith

Fitness

Family

Finances

Fun.

The order is very important. I’m not going to discuss this in more detail here because I want to get to the second five, but when things seem out of control, this list helps me keep my priorities and my values aligned. The second five:

Pause

Feel

Think

Acknowledge

Choose

Pause – Perhaps the most difficult of them all, but I try to set aside as little as 15 minutes every day at a time during which interruptions are least likely to occur. (Before sunrise is usually the best!) I use noise-cancelling headphones, switch my phone to airplane mode, and make sure my visual scene is not too distracting.

Feel – Present day lifestyles are often a combination of information overload and never-ending to-do lists (which we need to deal with appropriately). When something eventually triggers our emotions, we tend to overreact. But as the cliché goes: We are human beings, not human doings. A daily pause is a good time to let emotions surface. Feel them. Name them. Then…

Think – Why do I feel this? Are my feelings based on reality? If they are, are they in proportion to reality or am I over-emphasizing something negative or selfish or preferred indifference? Are there realistic aspects in life that can help to counter negative feelings such as things to be grateful for or practical steps to address a bad situation? I think it is quite profound that we humans can almost stand outside of ourselves and evaluate what we are thinking and feeling. It is perhaps worth using this ability.

Acknowledge – This step adds significant time to the process, but there is little doubt in my mind that journaling or discussing thoughts and feelings with a spouse, trusted friend, counsellor or in prayer further add value to the routine.

Choose – Even more profound than our ability to assess our thoughts and feelings is our ability to choose our mental response to any situation, information, thought or feeling. As holocaust survivor Victor Frankl famously said, “Everything can be taken from a man but one thing: the last of human freedoms – the ability to choose one’s attitude in any given set of circumstances …” If making time to pause is not the most difficult, this step almost certainly is. And sadly, we often take the route of least resistance and surrender this freedom to choose and with it our self-control. Choose the positive, the practical, the best. Choose to be grateful. Choose to say sorry. Choose to forgive. Choose to be kind – to others AND to yourself. Choose today.

4. It is probably best to finish off with perspectives from two experts. Sandton counselling psychologist, Sacha Proctor recently commented on the importance of gratitude during difficult times (&6B).

“It is ok to allow yourself to feel the emotions you are dealing with right now: Sadness at the issues going on in the world. Loss and possible loneliness from not being able to see those you love during this time. Anxiety about loss of income or financial stress.

However in order to cope, we need to eventually focus on ways to remain hopeful.

Gratitude is one of the most powerful ways to cultivate joy in the midst of difficult times. It is also a buffer against anxiety and depression for many people.”

Her two images added to the post highlight the benefits of gratitude and how to incorporate it into our thinking.

5. Author and internationally renowned neuroscientist, Dr Caroline Leaf gave further practical tips for mentally dealing with toxic negativity:

“Emotions are highly contagious and can affect your mental and physical health so it’s important to create a healthy emotional environment…which can include some negativity! But how do you protect yourself from too much toxic negativity, especially during quarantine? Here are some tips I use and gave my patients:

  1. Recognize that emotions, moods, thought are contagious – check in with what is triggering you and why. Recognize what the negativity is doing to you mentally and physically.
  2. Remove yourself from that [triggering] person by putting up [healthy] boundaries if you feel like you are being affected negatively.
  3. Protect your mind by visualizing the negativity contained in a box far away from you.
  4. When the negativity reaches out to you, visualize a suit of armour on you deflecting the negativity off you.
  5. Boost your mental health “immune system” by focusing on something that makes you smile!
  6. At the right time (when emotions aren’t high) talk to the other person about how their negativity is hurting you, but be careful not to use harsh words. And remember to always stress that you could be misreading them. Don’t make assumptions! Often their negativity could be due to some internal conflict they are having and they are just projecting or trying to make sense. Ask them how you can perhaps help overcome the constant negativity. [Or perhaps it is time to confront your own negativity with kindness and positive perspectives…]
  7. Remember – focusing on the negative for a little bit with the intention of being proactive is good! Thinking about the worst case scenario can help prepare you if it ever happens (solution focused). However, ruminating without trying to find a solution is toxic. Negative thinking itself is not harmful – it’s how you do the thinking and for how long. Ideally you do not want to spend more than 10-15min and always try to end with a solution in place.

At the end of the day – you cannot control other people’s actions thoughts or words. You can only control what you think, say and do.”

Time-sensitive Elective Surgery

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Did you know? – During COVID-19 lockdowns, many doctors and patients have struggled to get authorization from their insurers for medical and surgical procedures because these were deemed “elective”. However, elective simply means that the doctor and patient can “elect” the day, time and place to perform a procedure optimally. That is, in a familiar environment, with familiar staff and instruments, a rested surgeon and a stable, nil per os patient. Elective does not mean that there are no time-sensitive aspects to a procedure. In fact, elective procedures are essential, because they minimize urgent procedures, which in turn minimize emergency procedures.

Take cataract surgery for example. Very elective. We might as well do it 5 years’ time rather than now, under lockdown. Right? Not exactly. First, cataract surgery has been shown to reduce the risk of all-cause mortality; the vulnerable become less vulnerable. Sure, most cases can be delayed to some extent without harm. However, there are many intrinsic time sensitive elements to cataract surgery. The older a patient gets, the harder a cataract becomes, and at some point it can become hard enough to make surgery more difficult. Some cataracts contribute to narrowing of a delicate angle inside the front of the eye and this can cause acute glaucoma. Cataracts can obscure the view of the back of the eye and interfere with the evaluation and treatment of other pathology like nerve thinning and retinal bleeding. Workers delivering essential services now face increased demands in some sectors and risk accidents as their cataracts become more symptomatic. The list goes on.


Remember that the decision to treat or not lies with the patient, a qualified and trusted doctor, and the respectful discussion between them, not with your medical aid or their medical advisers.

Neuro-ophthalmology

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WHAT IS A NEURO-OPHTHALMOLOGIST?

Technically, in South Africa, such a person does not exist. After first becoming a general practitioner or medical officer and then going on to specialize as an ophthalmologist (also called an eye specialist or ophthalmic surgeon), a doctor can go on to specialize even further in a subspeciality (sometimes called super-specialization). This is normally through a very intensive type of residency program called a fellowship and in ophthalmology this is almost always done at an overseas centre. Subspecialities include corneal surgery, glaucoma, neuro-ophthalmology, ocular oncology, oculoplastics, orbital surgery, paediatric ophthalmology, refractive surgery, uveitis, vitreoretinal surgery and medical retina. However, in South Africa not all subspecialities are formally recognized and registered, and these include those that fall under ophthalmology. Eye specialists still indicate their expertise and practice scope by saying that they have a fellowship / extensive experience / special interest in a specific subspeciality. There are also large areas of overlap between the different subspecialities, including neuro-ophthalmology. In short, all ophthalmologists in South Africa have been trained in neuro-ophthalmology, but it is not a separate field of sub-specialist practice recognized by the HPCSA.

Neuro-ophthalmology deals with disorders related to the nerves that travel between the brain and the eye as well as the brain itself with its various visual interpretation, control and integration areas. The nerve tissue of the visual system starts in the eye as the neuroretina. (Most people have at least heard about a condition called retinal detachment. This is a separation of the neuroretina from the rest of the tissue inside the eye. More about this in future.)

Groups of ophthalmic conditions that typically fall within the scope of neuro-ophthalmology are the following:
• Persistent vision loss such as that caused by damage to the optic nerve, strokes or brain tumours.
• Temporary vision loss like the aura some people see before the get a migraine or the curtain-like obscuration caused by a very small stroke in the eye.
• Visual illusions, hallucinations and other so-called higher cortical (located in the brain) visual disorders. This is a very complex group of conditions, including for instance, an inability to recognize familiar faces, an inability to read what one has just written, or being unaware that one is missing half of one’s visual field. Although relatively common in patients with previous strokes, they are easily missed or misinterpreted and it is important to help these patients get proper evaluation for neuro-rehabilitation.
• Double vision and eye movement disorders. Controlling the completely harmonious voluntary and involuntary movement of our eyes is another complex function of the brain and brainstem. When this control breaks down and specifically, when one or more of the three nerves that supply our eye muscles are damaged, we can no longer focus on two identical images for the brain to fuse together, but instead see two different images at the same time, causing tremendous discomfort.
• Other abnormal eye movements including the involuntary, jerky back-and-forth movements called nystagmus.
• Abnormal pupillary reactions, for instance an asymmetry in the sizes or reactivity of one’s pupils.
• Eyelid and/or facial abnormalities like twitching, uncontrollable blinking, eyelid retraction (abnormal staring gaze) and Bell palsy.
• Pain of the eye, the face (“around the eye”) or headache (pain “behind the eye”).
• Non-physiologic or nonorganic eye disorders, in which a patient has visual complaints even though there is nothing wrong with a person’s visual system.
• Systemic (“whole body”) conditions associated with neurological problems. A few big ones are infections (HIV, tuberculosis, syphilis and herpes virus), cardiovascular (diabetic vasculopathy, hypertension, high cholesterol) and auto-immune (including multiple sclerosis, thyroid dysfunction, systemic lupus, sarcoidosis and myasthenia gravis).

Do you know someone who needs neuro-ophthalmic evaluation?

Glaucoma: MIGS and LASERS

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Before I start the counselling process with a newly diagnosed patient, I usually ask them what their current understanding of a specific condition or procedure is. In the context of glaucoma, the answer is usually either “high pressure” or “it causes blindness”.

 

There is so much more to glaucoma. Yes, it CAN cause blindness, but doesn’t have to. Yes, the intra-ocular pressure is often high, but not always. I recently wrote a post for Sandhurst Eye Centre‘s Facebook Page on some of the advances in glaucoma surgery, and in it I mention useful posts by my colleagues on the same page. Have a look, and see our other recent social media posts as well.

Cataracts

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CATARACTS – Globally still the leading cause of blindness despite being fully treatable. In fact, cataracts are preferably treated when they are not too hard and haven’t yet caused total blindness. Contrary to what I’m commonly asked, a cataract isn’t something that grows in or on top of the eye. Rather, it is the eye’s own natural lens that becomes opaque. These opacities are caused by damage to the lens’s crystalline fibers due to aging, metabolic disorders, trauma, etc. Our latest social media feeds focus on some general info and updates related to cataracts. Have a look!

Age-related Macular Degeneration

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AGE-RELATED MACULAR DEGENERATION (AMD) is a major cause of permanent vision loss, affecting the central vision of millions of elderly people worldwide. Despite remarkable advances in recent decades with regards to not only our understanding of the disease process, but also our ability to slow some of the devastating effects thereof, the search is still on for ways to truly halt the progression of AMD and hopefully even reverse it. For more on this, check out some of the most recent links in our social media posts.

Glaucoma

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GLAUCOMA is the leading cause of irreversible blindness in the world (Quigley, 2006). An interesting case comes to mind where a patient presented with high eye pressures and cavernous damage to his optic nerve, both typical of glaucoma. Was this patient genetically destined to develop this problem, or could it have had something to do with the steroid nasal spray that’s been used chronically? This week’s social media posts and reposts focuses on various aspects of the disorder, including the roles of diet and medical steroids.