Episode 26 - Eye Know

Episode 26: Eye Know

The sun rises over the San Joaquin Valley California. Today is September 4, 2020.

It should be not surprise to us that evidence shows the use of marijuana during pregnancy affects the development of the nervous system of the fetus. More than 500,000 live births were analyzed retrospectively from the Canadian birth registry and it showed incidence of autism spectrum disorder (ASD) was higher in children born from mothers who used marijuana during pregnancy compared with non-exposed children (4 versus 2.4 diagnoses per 1000 person-years). Incidence of intellectual disability and learning disorders was also higher in marijuana-exposed children. So, remember to counsel your pregnant patients to avoid marijuana[1].

Do you think that patients with obesity have a higher prevalence of musculoskeletal pain? You think? And what’s a common prescription for chronic pain? Yes, you guessed it, it’s opioids. So, you think obesity and opioids are linked? Articles published in the American Journal of Preventive Medicine (AJPM) [2] and Journal of American Medical Association (JAMA)[3] showed a clear link between obesity and opioid use. Patients who are overweight have 24% incidence of long term opioid use, while the incidence in patients with severe obesity was 158%. Again, incidence is 24% in overweight vs 158% in severe obesity. That’s crazy, the most common chronic pain associated with obesity and opioid use was back pain and joint pain. Now you know it, two of the most popular epidemics, obesity and opioids, go hand in hand.    

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.

“Success is not final; failure is not fatal: It is the courage to continue
that counts.” –Winston S. Churchill

Success is such a complex term! Success for you may be different than success for me. Success is not final, just as failure is not fatal. Our life has ups and downs and that’s what makes it interesting. 

I’d like to thank all our listeners for their support in our mission to educate, and sometimes to entertain you. It has not been easy to produce this podcast. Thanks to all the brave residents who have overcome their fears to record in front of a microphone. This week we have reached some milestones. We had our download number 1,000, and today the last resident of the 2019-2020 group is participating in the main part of the podcast. I was planning to end this season, but I’m happy to inform that some people offered to record more, so we may have an additional episode, before closing this season. I’m planning to change our format after hearing some suggestions from our residents.

I’m pleased to present to you Dr Garmendia today. He is here to share some of his wisdom with us. Dr Garmendia, we are closing this season of the podcast with you. So you are the cherry on the cake, no pressure. So, let’s relax and have fun.

Question number 1: Who are you? 

My name is Fermin Garmendia, I am a third-year resident of the Rio Bravo Family Medicine Residency Program. I was born and raised in Cuba where I went to medical school. I came to the US in 2010 and, after several years and some sacrifice, my dream came true. For me, being a family medicine doctor is a privilege. It is diverse and challenging. I have some hobbies, I like watch movies, eat in a good restaurant, passing time with friends but what I enjoys the most it is travel by car, so far yet a short family, my wife, our dog and me. We like to explore and be in several places and California is the opportunity, it is beautiful. I still have a big list of places to visit. 

Question number 2: What did you learn this week? 

This week I saw a patient with a subconjunctival hemorrhage. I can picture the face of some colleagues... it is nothing weird or maybe not the most interesting topic, but for some patients (and even for many doctors) this could be frightening. Patients get desperate when they realized the problem, and often those who see someone with subconjunctival hemorrhage may think this is caused by physical trauma. It is common, I have seen many patients with subconjunctival hemorrhages and almost always the treatment is reassuring him or her that it will gradually resolve on its own in few weeks, no need for any treatment, except for some artificial tears for symptomatic relief. We should explain our patients why this event could have happened. This is the interesting topic that I would like to talk about.

Subconjunctival hemorrhage 

Patients are generally asymptomatic. Typically, the patient is unaware of the problem until they look in the mirror or someone else lets them know.

A red, bloody eye can look scary, but it is usually harmless and often heal on its own.

Causes of subconjunctival hemorrhage

The eye’s conjunctiva contains a lot of tiny blood vessels that can break easily. Rupture of capillaries may happen spontaneously or with Valsalva effect caused by coughing, sneezing, straining, or vomiting (this is because they briefly raise blood pressure in veins and can cause capillaries to break) and trauma, even rubbing your eyes too hard can cause capillaries to break. 

Less common causes include: Diabetes, HTN, COPD that makes patient cough often; medications that can make you bleed easily such as aspirin or blood thinners like coumadin. 

Diagnosis of subconjunctival hemorrhage

The diagnosis is confirmed by having a normal vision and the absence of discharge, photophobia, or foreign body sensation.

The blood is typically reabsorbed over one to two weeks, depending on the amount of blood. 

Treatment of subconjunctival hemorrhage

No specific therapy is indicated, but If subconjunctival hemorrhage is recurrent or if the patient has a history of bleeding disorder or blood dyscrasia, or if the patient is on anticoagulant therapy, then an underlying hematologic or coagulation abnormality must be considered.

I recommend that we should examine the patient always with a slit lamp or magnifying glass, and stain the eye with fluorescein if you suspect trauma to see any associated corneal injury, such as a corneal laceration or abrasion, or other structures of the eye, especially in patients who wear contact lens.

Referral to Ophthalmology

An ophthalmologist should be consulted for the following patients: 

Suspicion of a leaking eye or intraorbital penetration

Signs of traumatic hyphema

Conjunctival lacerations >1 cm in length that will require suturing

Foreign bodies that are deeply embedded, subconjunctival, or associated with a conjunctival laceration

____________________________

Speaking Medical: Amaurosis fugax 
by Xeng Xai Xiong, MS3

The medical term for the day is amaurosis fugax. I don’t know about you, but for me this word sounds like a mystifying spell that can wake up the dead.  Amaurosis fugax [Suspense sound effect] comes from the Greek "amaurosis," which means dark, and the Latin "fugax," which means transient. Therefore, it refers to a transient loss of vision in one or both eyes.  Aww, I thought this word would have a deeper meaning.  

I first encounter this word, during my internal medicine rotation when a patient presented with weakness on one side of the body, facial drooping, and a transient loss of vision, aka amaurosis fugax. One of the causes of amaurosis fugax is a thromboembolism that blocks the ophthalmic artery and retinal arterioles which results in transient loss of vision.  This symptom can be seen in a patient with stroke. Until next time, remember the word amaurosis fugax [Suspense sound effect].  

_______________________________________

Speaking Medical: Anisocoria
by Li Liang, MS3

Hello, I’m Li, a 3rd-year medical student, and I want to introduce another medical word of the week, Anisocoria.  I will give you a brief introduction of anisocoria and soon I will expand on this topic. We have three levels of definition depending on how hungry your brain is. First level, anisocoria is when a patient has unequal pupils. The second level of defining anisocoria is by explaining the etymology of the word. Anisocoria comes from the Greek “An”: Not, “iso”: equal, “cor”: Pupil of the eye, and the Latin: “ia”: Disease, pathology or abnormal condition.  

Our last level as well as the medical definition of anisocoria is defined as an impaired pupillary dilation (parasympathetic nervous system) or constriction (sympathetic nervous system). There is more than meets the eye, and finding which pupil is the abnormal one may be challenging. What can give you clues is history of ocular trauma, old photos (ptosis, ocular deviation, chronic anisocoria), topical medications, drug/toxin exposures, associated ocular and neurological signs and symptoms. I will teach you how to tell which eye and pupil is abnormal. There are some physical evaluations to differentiate which eye is considered the bad eye because it’s not always the “small eye”. 

Stay tuned to learn more about anisocoria on your next episode.

____________________________

Espanish Por Favor: Matriz
by Claudia Carranza

Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is matriz. Matriz comes from the Latin word “matrix” which means mother and is used to describe a cavity inside females in which babies are carried. Yes, matriz means UTERUS! You will most likely use this term when you want to ask if the patient has their uterus vs if they’ve had a hysterectomy. 

You can say “Señora, ¿todavía tiene su matriz?” which means: “ma’am, do you still have your uterus?”. Another instance in which you may hear the word matriz is when asking about uterine cancer, you can ask “¿Ha tenido cáncer de matriz?” “Have you hade uterine cancer?” Instead of matriz, you can also use the more formal term útero but most people will understand you better when you say matriz.

Now you know the Espanish word of the week, matriz.

____________________________

For your Sanity: What is civilization?
by Lisa Manzanares

Someone once asked anthropologist Margaret Mead what she considered to be the first evidence of civilization. She answered: a human thigh bone with a healed fracture found in an archaeological site 15,000 years old. Why not tools for hunting? or religious artifacts? or primitive forms of communal self-governance? 

Mead points out that, for a person to survive a broken femur, the individual had to have been cared for long enough for that bone to heal. Others must have provided shelter, protection, food and drink over an extended period of time for this kind of healing to be possible. 

The great anthropologist Margaret Mead suggests that the first indication of human civilization is care over time for one who is broken and in need, evidenced through a fractured thigh bone that was healed.

This story was told by Ira Byock, an authority on palliative medicine, in his book The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life.

________________
Jokes: A nurse is on her way home, pulls out a thermometer out of her pocket and says, “Great, now some a**hole got my pen.”

How many optometrists does it take to change a light bulb? 1 or 2, 1 or 2, 1 or 2.

Conclusion: Now we conclude our episode number 26 “Eye Know.” Dr Garmendia briefly explained the diagnosis and treatment for subconjunctival hemorrhage, you may say “I know”, but you for sure you learned something new today. Xeng surprised us with his clear explanation of amaurosis fugax, or sudden loss of vision, and Li explained how to say unequal pupils in an educated way, anisocoria. And without warning we went from the eye to the uterus and Dr Carranza taught us the Spanish word Matriz. How did you like our reflection about human civilization? And to close, Dr Saito gave us a piece of humor to please our audience.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Fermin Garmendia, Claudia Carranza, and Xeng Xai Xiong, Li Liang, Lisa Manzanares, and Steven Saito. Audio edition: Suraj Amrutia. See you next week! 

_____________________

References:

Jansson, Lauren M, MD, Infants of mothers with substance use disorder, UpToDate, https://www.uptodate.com/contents/infants-of-mothers-with-substance-use-disorder?sectionName=Marijuana&topicRef=8350&anchor=H19&source=see_link&mkt_tok=eyJpIjoiWXpFNFpURmhNVEE0WkdFdyIsInQiOiJ3ZDhUcTI5XC9BZFhGSzhtZXdkSnRCcVNXM0lGZXJHM1ZMNzdNSExHZ3BFeFRvdjJ3Ymc5cmtha2xvMVppKzhmRzJOMEluMHhKYUdxUldtVURmdmR3WWcyZXFZcm1ycjNxK2ErdGlIeUl5ZlgrU09adFwvOTJqbDQzUm9uak9tTzFRIn0%3D#H19, last updated: Aug 20, 2020.

Stokes, Andrew, PhD, et al, Association of Obesity with Prescription Opioids for Painful Conditions in Patients Seeking Primary Care in the US, JAMA Network Open. 2020;3(4):e202012. doi:10.1001/jamanetworkopen.2020.2012, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763785, accessed on September, 2, 2020.

Stokes, Andrew, PhD, Obesity and Incident Prescription Opioid Use in the U.S., 2000–2015, American Journal of Preventive Medicine, Published: March 27, 2020, DOI: https://doi.org/10.1016/j.amepre.2019.12.018

AMA Recognizes Obesity as a Disease, The New York Times, July 18, 2013. https://www.nytimes.com/2013/06/19/business/ama-recognizes-obesity-as-a-disease.html

A 15,000 year old bone and the Fall 2013 issue of Reflectionshttps://divinity.yale.edu/news/15000-year-old-bone-and-fall-2013-issue-reflections

Boyd, Kierstan, Subconjunctival Hemorrhage, American Academy of Ophthalmology, April, 23, 2020. https://www.aao.org/eye-health/diseases/subconjunctival-hemorrhage-cause

Gardiner, Matthew F, MD, Conjunctival Injury, UpToDate, Last updated: Sep 27, 2019. https://www.uptodate.com/contents/conjunctival-injury