Practical Pearls You Won’t Find in Textbooks


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Love the subtitle of this book, and the way in which it is organized.  Dr. Kushner’s liberal use of icons enables him to make points about complex topics in a comparatively light and refreshing way.

Screen Shot 2018-08-30 at 12.45.48 PM  Here are some of my favorite pearls as distilled from Dr. Kushner’s book:

  • “Zen listening” to the patient: the facts the emotions, the body language, how the conversation is affecting you, and what is not being said.
  • Dynamic retinoscopy is one of the most underutilized tests in pediatric ophthalmology.  For example, if an infant with high hyperopia is fully accommodating at near and is not esotropic, there is little likelihood that esotropia will develop.
  • When plus lenses at near aren’t sufficient to control accommodative esotropia, phospholine iodide is still a viable tool in countering the inward turn at near.
  • If a parent doesn’t think her child’s eyes are working together, use Bagolini lenses to show that they are.
  • Pre-surgical prism testing doesn’t always predict postoperative outcomes.
  • When you cut the Rx at the first visit, and anticipate that you will increase it on follow-up, be sure the parent knows this so that when you up the Rx they won’t feel “she’s getting worse”.
  • Many adults with early history of accommodative esotropia will have the ET decompensate as they approach presbyopia.
  • Unequal visual input from the two eyes is one of the most destabilizing conditions for patients with shaky fusion, as in intermittent exotropia.
  • Rxing monovision in adulthood may destabilize strabismus; restoring the full distance Rx bilaterally is known as “optical rescue”.
  • The trochlea is akin to a synovial joint and is subject to inflammation.  Sinusitis or autoimmune inflammatory disease can destabilize binocular vision, resulting in acquired Brown syndrome.
  • Visual acuity alone paints an incomplete picture of amblyopia, in which accommodation is usually subnormal and the crowding phenomenon results in extra time being required for reading.
  • Anisometropic amblyopia may respond well to treatment at an older age.
  • It is important to differentiate between improvement and cure.
  • In the absence of hard data to disprove your clinical intuition and experience, anecdotal evidence is valid.  As an example: “I have a strong (but unproven) impression that a child is more likely to successfully outgrow the need of a bifocal if it in incrementally decreased in strength a little bit at a time rather than going ‘cold turkey’ from a +2.50 add to no bifocal at once”.

Practicality and intellectual honesty are the hallmarks of Dr. Kushner’s career.  A great example is this slide that he put up at an AAPOS presentation in 2012 on the variability of outcomes in strabismus surgery.

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You might enjoy this brief five minute presentation, from which the slide above was extracted.

 

4 thoughts on “Practical Pearls You Won’t Find in Textbooks

  1. Two of my favorite quotes from this book are:
    “Unequal visual input from the two eyes is one of the most destabilizing conditions for patients with shaky fusion, as in intermittent exotropia.
    Rxing monovision in adulthood may destabilize strabismus; restoring the full distance Rx bilaterally is known as “optical rescue”.

    Thanks for bringing all of this to our attention, Len !

    Enjoy what’s left of the summer !

    Stan

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