San Antonio Medicine May 2024

Eye Care and Quality of Life

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BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

Ezequiel “Zeke” Silva, III, MD, President

Lyssa Ochoa, MD, Vice President

John Shepherd, MD, President-elect

Jennifer R. Rushton, MD, Treasurer

Lubna Naeem, MD, Secretary

John Joseph Nava, MD, Immediate Past President

DIRECTORS

Woodson “Scott” Jones, MD, Member

Sumeru “Sam” G. Mehta, MD, Member

M. “Hamed” Reza Mizani, MD, Member

Priti Mody-Bailey, MD, Member

Dan Powell, MD, Member

Ana Rodriguez, MD, Member

Raul Santoscoy, DO, Member

Lauren Tarbox, MD, Member

Nancy Vacca, MD, Member

Col. Elisa D. O’Hern, MD, MC, FS, Military Representative

Jayesh Shah, MD, TMA Board of Trustees Representative

John Pham, DO, UIW Medical School Representative

Robert Leverence, MD, UT Health Medical School

Representative

Cynthia Cantu, DO, Medical School Representative

Lori Kels, MD, Medical School Representative

Ronald Rodriguez, MD, Medical School Representative

Victoria Kohler-Webb, BCMS Alliance Representative

Carolina Arias, MD, Board of Ethics Representative

Melody Newsom, BCMS CEO/Executive Director

George F. “Rick” Evans, Jr., General Counsel

BCMS SENIOR STAFF

Melody Newsom, CEO/Executive Director

Monica Jones, Chief Operating Officer

Yvonne Nino, Controller

Al Ortiz, Chief Information Officer

Brissa Vela, Director of Membership & Corporate Partnerships

Phil Hornbeak, Auto Program Director

Betty Fernandez, BCVI Director

PUBLICATIONS COMMITTEE

Monica Jacqueline Salas, MD, Co-chair

Jennifer C. Seger, MD, Co-chair

Lokesh Bathla, MD, Member

Elizabeth Clanton, MD, Member

Erika Gabriela Gonzalez-Reyes, MD, Member

Timothy C. Hlavinka, MD, Member

John Robert Holcomb, MD, Member

Soma S. S. K. Jyothula, MD, Member

Kristy Yvonne Kosub, MD, Member

Jaime Pankowsky, MD, Member

George-Thomas Martin Pugh, MD, Member

Rajam S. Ramamurthy, MD, Member

Adam V. Ratner, MD, Member

John Joseph Seidenfeld, MD, Member

Boulos Toursarkissian, MD, Member

Francis Vu Tran, MD, Member

Faraz Yousefian, DO, Member

Louis Doucette, Consultant

Brissa Vela, Consultant

Monica Jones, Staff Liaison

Trisha Doucette, Editor

Deepthi S. Akella, Student

Moses Alfaro, Student

Victoria Ayodele, Student

Tue Felix Nguyen, Student

Andrew Ta, Student

Alixandria Fiore Pfeiffer, DO, Resident

Elizabeth Allen, Volunteer

Adelita G. Cantu, PhD, Volunteer

Rita Espinoza, DrPH, Volunteer

Natalie Reyna Nyren, PA-C, Volunteer

David Schulz, Volunteer

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Navigating the Intersection of AI and Healthcare in Bexar County

By Ezequiel "Zeke" Silva III, President, Bexar County Medical Society (BCMS)

Earlier this year, the BCMS 1853 Club welcomed Dr. Brent Fessler, Ed.D., MSL, to discuss the topic of "AI for the Everyday Guy (How to use AI at home/personal life)." The 1853 Club, a group of retired Bexar County physicians, meets regularly to explore various subjects. The keen interest in AI among our retired colleagues is a testament to its significance, not just for them but also for our active physicians and medical students. Understanding AI's impact on our practices and how we can navigate its challenges and opportunities is crucial for all of us.

BCMS' Role

BCMS has been a leader in addressing the intersection of AI and healthcare. At TexMed 2021, our BCMS delegation introduced a significant AI-related resolution, urging the TMA to examine the impact of augmented intelligence on healthcare in Texas (Resolution 421, Augmented Intelligence (AI) in Health Care).1 This initiative aimed to offer guidance for physicians on adapting to the challenges and opportunities presented by AI. The outcome of this effort was TMA's inaugural policy on AI (Policy 280.038, Augmented Intelligence in Health Care),2 addressing critical issues like nomenclature, disclosure, transparency and safeguards. BCMS' involvement in shaping the AMA's 2019 AI policy further underscores our commitment to proactive engagement with AI's evolution in healthcare (AMA BOT Report 21 Augmented Intelligence in Health Care H-480.939).3 More recently, the AMA provided the following update, AMA Principles for Augmented Intelligence Development, Deployment and Use.4

The Rapid Pace of Change

The digital health landscape, inclusive of AI, has seen remarkable growth, a trend accelerated by the COVID-19 pandemic. The FDA's approval of AI-driven medical devices, also referred to as Software in a Medical Device (SaMD) in early 2018, such as IDX-DR for diabetic retinopathy screening, marks a pivotal advancement. With over 700 AI SaMD products having received FDA approval, the healthcare sector is witnessing a transformative phase, particularly in fields like radiology (79 percent of FDA-approved devices) and cardiology (9 percent of approved devices).5

The Evolution of AI

AI's progression is rapid, transitioning from basic functions like detection and inference to more sophisticated capabilities. The emergence of generative AI and large language models like OpenAI and ChatGPT signifies a shift towards machines not just retrieving but generating information. This evolution has profound implications for the medical field and necessitates a thoughtful approach to regulatory frameworks.

BCMS, AI and the Future

BCMS is steadfast in its commitment to ensuring the responsible and ethical integration of AI into clinical practice. Our active partici-

pation in influential groups such as the AMA Digital Medicine Payment Advisory Group and the TMA Health Information Technology Committee reflects our dedication to advocating for policies that prioritize patient care while addressing physician concerns. Our engagement with legislative and regulatory bodies such as the Texas Artificial Intelligence Advisory Council highlights our commitment to influencing the trajectory of AI in healthcare.

We highly value the perspectives of our members and are keen to understand how AI is reshaping your practice. BCMS is dedicated to grasping the challenges and opportunities AI presents in clinical care, ensuring our community remains at the forefront of this technological evolution.

We invite all members to share their experiences and insights regarding AI in their practice. Your contributions are vital to our ongoing dialogue and efforts to shape a future where AI and healthcare converge in the most beneficial and responsible manner.

References:

1. Resolution 421, Augmented Intelligence (AI) in Health Care: https://www.texmed.org/uploadedFiles/Current/2016_About_ TMA/TMA_Leadership/House_of_Delegates/2021_Reports_ and_Resolutions/Res%20421%202021%20Augmented%20 Intelligence%20in%20Health%20Care.et(1).pdf

2. Policy 280.038, Augmented Intelligence in Health Care: https:// www.texmed.org/Template.aspx?id=59861&terms=joint%20 report%208

3. AMA BOT Report 21 Augmented Intelligence in Health Care H-480.939: https://policysearch.ama-assn.org/policyfinder/ detail/Augmented%20Intelligence%20in%20Health%20 Care%20H-480.939%20?uri=%2FAMADoc%2FHOD.xml-H480.939.xml

4. AMA Principles for Augmented Intelligence Development, Deployment and Use: https://www.ama-assn.org/system/files/ ama-ai-principles.pdf. Accessed on 3/30/24

5. Artificial Intelligence and Machine Learning (AI/ML)-Enabled Medical Devices: https://www.fda.gov/medical-devices/ software-medical-device-samd/artificial-intelligence-and-machine-learning-aiml-enabled-medical-devices. Accessed on 3/30/24

Ezequiel “Zeke” Silva III, MD, is the 2024 President of the Bexar County Medical Society. Dr. Silva is a radiologist with the South Texas Radiology Group, Adjunct Professor of Radiology at the UT Health, Long School of Medicine, and Vice-Chief of Staff at Methodist Hospital Texsan. He serves on the TMA Council on Legislation and is a TMA Delegate to the AMA. He chairs the AMA RVS Update Committee (RUC).

BCMSA Supports The Period Poverty Movement

By Julia Halvorsen, VP of Community Outreach, BCMSA

Successful community outreach really is as simple as identifying a need and responding to it. I joined the Bexar County Medical Society Alliance (BCMSA) specifically because of their history of service throughout Bexar County. Organized medicine is strong in Texas — the Texas Medical Association (TMA) and Texas Medical Association Alliance have a thriving nonpartisan legislative branch that works to promote enhanced health and wellness for all Texans. The TMA recently backed state legislation that eliminated the sales tax on menstrual products such as tampons and pads. The BCMSA learned about the prevalence of period poverty that brought about this legislation in the first place, and we decided to do something about it.

The Period Poverty Movement is gaining momentum across the country. There are several organizations that are making strides to address the issue, but we wanted to do something that was focused on the needs of our local community. San Antonio has a long and rich history of cultural diversity going back to the early 1700s. San Antonio is also the largest majority-Hispanic city in the U.S., with 64 percent of its population being Hispanic. The bulk of the available educational material addressing period poverty doesn’t take into consideration cultural values that are common in Hispanic culture. It’s perceived by some people to have undertones of hot-button issues like gender and sexual activity that might be in opposition to the values being taught in the home. Public health initiatives and patient education that fail to consider cultural beliefs and values will be minimally effective. Our Alliance members recognized the need for a period outreach program that is fact-based and conscientious of diverse cultural beliefs, so we developed a program tailored for our community.

Eighty-four percent of teens have missed a class or know someone who has missed a class because they were on their period and didn’t have access to period products. Two-thirds of low-income families have trouble affording period products. Three-fourths of menstruating children said that they have felt shamed or “dirty” because of their period. It's not uncommon for periods to start as young as 9 years old, so we recognized that we needed to provide menstrual supplies and education that are age-appropriate for a 3rd grader. The school nurses, counselors and teachers understand the needs of the children in a community extremely well, and are frequently the direct point of access for a child in need of resources, so we directly involved them in developing this project.

For information on the Bexar County Medical Society Alliance, scan the code:

While working with the school nurses in San Antonio Independent School District (SAISD), we learned that they have an annual budget of $200 to purchase supplies needed to address the health needs of the entire student body. Our Alliance members got together to make daily period kits containing enough pads for the school day as well as take-home kits with enough supplies to last for the duration of a monthly period. We assembled hundreds of these kits to distribute to schools. Some members contributed monetarily, some assembled kits and some delivered the kits to schools, but each of us believed that doing good can mean doing something small and, as a result, this project has made a big impact.

Julia Halvorsen is the Vice President of Community Outreach for the BCMS Alliance.

The BCMSA members contributing to The Period Poverty Movement

Julie Halvorsen with SAISD Nurse

Diabetes and the Eye

By Jake Trinidad, MD

Diabetes mellitus, a chronic metabolic disorder characterized by high levels of glucose in the blood, can lead to a multitude of complications, including several that affect the eye. Leveraging my experience as a practicing ophthalmologist, I aim to highlight in this article the imperative of a holistic care approach in managing diabetic patients, illustrating how vigilant eye health monitoring can act as a crucial early warning system for diabetes's broader impact. By closely and consistently observing these ocular changes, we possess the opportunity to utilize the eye as a mirror to one’s general health, thus mitigating the more severe consequences of diabetes.

Pathophysiology of Diabetic Eye Disease

The etiology of diabetic ocular pathology hinges primarily on the prolonged exposure to sustained hyperglycemia, which instigates a cascade of microvascular damage within the retinal vasculature. This phenomenon results in a state of tissue hypoxia, paving the way for the emergence of diverse pathological manifestations encapsulated within the umbrella of diabetic retinopathy. Moreover, the systemic hyperglycemia and concurrent vasculopathic changes not only potentiates the development of diabetic retinopathy, but also heighten the predisposition to other ocular comorbidities, notably cataracts and glaucoma.

What is Diabetic Retinopathy?

Diabetic retinopathy is the most common and one of the most serious eye conditions associated with diabetes. It is classified into two stages: non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR). NPDR is the early stage, characterized by swelling and weakening of the retinal blood vessels, which will eventually lead to blood and fluid leaking into the retina. As the condition progresses to PDR, tissue hypoxia and vascular damage leads to the release of vascular endothelial growth factor (VEGF). VEGF signals the proliferation of new, fragile blood vessels that grow on the surface of the retina and into the vitreous. These new vessels are prone to bleeding (vitreous hemorrhage) and can lead to scarring and retinal detachment, a severe complication that can ultimately lead to blindness. These ocular changes are avoidable with early detection and treatment.

Diabetic Macular Edema

Diabetic Macular Edema (DME) represents a critical complication arising from the progression of diabetic retinopathy. Characterized by the pathophysiological accumulation of intraretinal fluid within the macular region of the retina, this area can undergo cytogenic and vasogenic edema due to the breakdown of the inner blood-retina barrier, precipitated by chronic hyperglycemia-induced microvascular damage. The macula rests at the center of the retina, and is pivotal for central vision and high-resolution visual acuity. The resultant macular swelling and disruption of retinal architecture can lead to significant visual distortion and impairment. Notably, DME does not adhere to a linear progression within the stages of diabetic retinopathy, but can manifest across the spectrum of the disease, underscoring its role as a principal etiological factor in vision loss among the diabetic population. It is of utmost importance to diagnose and treat DME as early as possible with laser therapy and intravitreal injections to improve the long-term outcome of visual prognosis.

Management and Treatment of Diabetic Retinopathy

Management of diabetic eye disease begins first and foremost with the patient. Tight control of blood glucose levels, blood pressure and lipid levels is essential in slowing the progression of diabetic retinopathy. For those with advanced diabetic retinopathy or DME, treatments such as laser surgery (Panretinal Photocoagulation/ Focal Grid), intravitreal injections of steroids, anti-VEGF (anti-vascular endothelial growth factor) agents and vitrectomy may be necessary. The goal of each of these treatments is to seal

Right and left fundus photographs of retina demonstrating diabetic retinopathy. Image taken by Dr. Jake Trinidad.

Right and left fundus photographs demonstrating proliferative diabetic retinopathy. Image taken by Dr. Jake Trinidad.

leaking new blood vessels, reduce retinal swelling, and remove vitreous blood or scar tissue to preserve vision and prevent further damage to the eye. The rule is always: the earlier the intervention, the better the outcome.

Other Complications of Diabetic’s on Eye Health and Vision: Cataracts

Diabetes can also accelerate the formation of cataracts, a clouding of the eye’s lens that obstructs light from reaching the retina. People with diabetes tend to develop cataracts at a younger age and progress more rapidly than individuals without diabetes. Cataracts can be debilitating to a patient’s quality of life and can be corrected quickly with a minimally invasive surgery. Cataract surgery is one of the most performed and one of the safest procedures in all of medicine, and can greatly improve the quality of life of your patients.

Glaucoma

The propensity to develop glaucoma, a spectrum of disorders characterized by optic nerve damage, is markedly elevated in individuals with diabetes. Among the various forms of glaucoma, neovascular glaucoma, marked by the proliferation of new blood vessels on the iris and into the angle of the eye, can be the most devasting. As these vessels proliferate and scar the drainage structures, controlling intraocular pressure becomes exceedingly difficult, necessitating surgical intervention rather than conventional medication due to the intricacies of the disease process. Consequently, patients afflicted with neovascular glaucoma often face grim prognoses if it is allowed to advance unchecked. However, such dire outcomes can be averted through early detection and intervention strategies such as Panretinal Photocoagulation targeting the peripheral retina.

In summary, it is imperative for clinicians to recognize the substantial threat Diabetes Mellitus poses to ocular health, with the potential for vision loss if not diligently managed through timely detection and intervention. The ophthalmologic examination, particularly utilizing fundus photography, not only aids in diagnosis but also serves as a pivotal educational tool for patients, elucidating the profound impact of diabetes on vascular health. I have witnessed firsthand how this knowledge can catalyze a transformative shift in patients’ attitudes towards their health. Ultimately, the cornerstone for preserving vision in diabetic populations lies in meticulous glycemic control coupled with prompt detection, treatment and comprehensive care. Regular eye assessments are indispensable for all diabetic individuals, as various forms of diabetic eye pathology can advance stealthily without early warning signs. Therefore, it is recommended that diabetic patients undergo a thorough dilated eye examination at least annually, with increased frequency if pathology is present. As healthcare providers, it is our duty to underscore the significance of integrated management in diabetes care, ensuring our patients receive holistic support in safeguarding both their vision and overall well-being.

Jake Trinidad, MD, is a board-certified ophthalmic surgeon and clinician. A native of San Antonio, his educational journey took him from Clark High School to Trinity University and UIW, culminating in a medical degree from Indiana University School of Medicine. Following a residency, Dr. Trinidad chose to serve the community of his hometown, where he has practiced for nearly a decade. He is a member of the Bexar County Medical Society.

Fundus photograph of Panretinal Photocoagulation (PRP) laser for treatment of PDR. Image taken by Dr. Jake Trinidad.

Macular edema with exudate. Image taken by Dr. Jake Trinidad.

Regressed NVD with fibrosis after PRP with vitreous hemorrhage.

Image taken by Dr. Jake Trinidad.

Thyroid Eye Disorders of Graves’ Disease

By William R. Thornton, MD, FACS

The normal thyroid gland produces thyroid hormones, which regulate body metabolism. Hyperthyroidism is the state of overproduction of these hormones; hypothyroidism, the under production of these regulatory body hormones.

Thyroid function is determined through laboratory tests measuring if TSH (thyroid stimulating hormone) is low and gland is overactive, with T3 and T4 elevated above normal thyroid hormone levels.

Thyroid-related eye symptoms early in this disorder are a noted staring appearance, dry irritation of eyes, swelling (edema) of eyelids and orbital fat pads surrounding the eyes, creating a bulging out of the eyes (proptosis), and eyelid retraction preventing full eyelid closure.

This inflammation of orbital fat, and extraocular eye muscles and eyelid muscles worsens proptosis and exposure symptoms of the eyes including corneal abrasions, double vision and vision blurring with pain. Secondary glaucoma, which potential loss of visual fields can go unrecognized without a complete eye exam, is produced by stretching and compression of the optic nerve and potential loss of central vision and blindness.

Initial treatment is done with systemic steroids and antithyroid medications to relieve hyperthyroid symptoms of hypertension, tachycardia and anxiety/insomnia; to promote complete relief of overactive thyroid gland dysfunction, radioactive iodide (RAI ablation) and/or surgical removal of enlarged glands or rare tumors.

Despite all of the above treatment, even months to years later, the Graves’ Disease signs and symptoms may reoccur. This article to follow will emphasize a team approach to diagnose and treat and follow the thyroid patient with Graves’ Disease.

The relatively new intravenous therapy, monthly for seven months with Tepezza (Teprotumumab), costs as much as $16,000 per treatment. Some patients have reported complications of severe hearing loss, severe hyperglycemia, inflammatory bowel disease, and fear of fetal effects in pregnant women. Some patients have reported a return of symptoms.

At this time, this eye specialist recommends for patients with eye disorders of Graves’ Disease to have an experienced medical and surgical team to treat this complex lifetime disorder in a timely manner.

Combined Approach to Eyelid Surgery in Graves’ Disease

The phenomenon of eyelid retraction in patients with euthroid Graves’ Disease presents unique cosmetic and functional problems for the blepharoplasty patient. The cosmetic appearance of bulging eyes, or exophthalmos, is due in part to true proptosis (forward displacement of the globe from the orbit), and accentuated by retraction of upper and lower lids. This increased exposure of the cornea, particularly in sleep when the eyelid closure is incomplete, leads to corneal ulceration if not corrected. In lesser degrees of exposure, the symptoms of tearing, photophobia and foreign body sensation greatly hamper the patient’s visual comfort. The orbital fat pads in both upper and lower lids are excessive due to infiltration with abnormal lymphocytes and deposition of collagen and mucopolysaccharide material. This deposition produces fibrosis and also leads to marked enlargement of the lacrimal gland and extracurricular muscles. Severe strabismus with marked diplopia occurs frequently because of this orbital process involving the rectus muscles.

This article will be confined to the combined approach of blepharoplasty with levator aponeurosis recession with Mueller’s muscle extirpation for the upper lid retraction problem, and blepharoplasty with cartilage augmentation of the lower lid retraction. The technique to be described is one of several accepted techniques for management of this condition, but in my hands has proved to be the best approach for solving this problem, both cosmetically and functionally.

Upper Lid Retraction

The external approach via the blepharoplasty incision to the upper lid is my choice of combining the blepharoplasty with surgery for retraction. A portion of the excessive skin marked for removal by the usual “pinch” technique is preserved to avoid shortening the lid anteriorly, since the lid is actually lengthened by 3 to 5 mm to correct for the amount of retraction. Local anesthesia combining lidocaine and bupivacaine without epinephrine is used subcutaneously in the lid. Epinephrine is omitted because it will stimulate Mueller’s muscle (the smooth muscle underlying the levator aponeurosis) and create false lid retraction and an undercorrection. Due to the depth of the dissection and the shorter action of the anesthetic agent effect because epinephrine is omitted, intravenous monitored anesthesia is required to keep the patient free of pain and yet alert enough to monitor lid margin positions.

The skin is resected carefully with a Bard-Parker 15 blade, sparing the underlying orbicularis muscle fibers. The preseptal orbicularis muscle fibers are resected with straight Iris scissors. The best technique to avoid the levator aponeurosis in this excision is to place the scissors flat to the muscle plane and open the blades and press downward gently, taking only the muscle that is pressed into the blades across the lid margin length of the incision. The exposed levator aponeurosis with the underlying Mueller’s muscle is then resected superiorly from the superior edge of the tarsus approximately 10 mm with a cutting and stripping action of the Wescott sharp pointed scissors. To aid in the dissection, the lid is everted on a Desmarres retractor, and a bolus of 0.5 cc of local anesthesia is placed subconjunctivally just above the superior edge of the tarsus. This not only blocks orbital innervation to the subconjunctival space, but hydrolytically dissects the Mueller’s fibers from the adherence to the conjunctiva. The somewhat tedious

dissection, starting at the center of the tarsus and progressing medial and lateral from this point, spares the medial and lateral horns of the levator muscles. It is important to dissect all fibers off the conjunctive until all Mueller’s fibers are removed. The bluish cornea seen through the transparent conjunctiva is an indication that this dissection is completed. It is essential to the process to use the bipolar micro tip cautery and, for complete corneal protection, a corneal shield.

To evaluate the new level of the lowered lid margin by the dissection, the patient is placed in the full upright sitting position to measure the lid margin position in the straight-ahead eye position. The lid margin should lie approximately 2 mm below the superior limbus at the 12:00 position.

The blepharoplasty portion of this operation is completed by exposing the preaponeurotic and medial fat pads, carefully dissecting the multilayered abnormally thickened orbital septum from the pure fat lobules and resecting only fat. This is a very important point of technique in all blepharoplasty surgery, but particularly crucial to the success in the eyelid of the patient with Graves’ Disease. The orbital septum, usually thin and translucent, is quite thickened and opalescent from the process of fibrosis that characterizes the eyelid problem in thyroid ophthalmopathy. Failure to dissect only pure fat from this multilayered envelope of tissue will result in a shortening effect to the lid, essentially producing further retraction. It is also believed that too much cautery, dissection or hematoma formation in the orbital septum near Whitnall’s ligament causes postoperative lagophthalmos, which can be long-lasting and compromise any eyelid procedure.

If the lacrimal gland in the lateral third of the upper lid is quite thickened with fibrosis and is visible preoperatively, a fixation suture to the underside of the superior orbital rim can reposit it higher in the orbit after dissection of the thickened orbital septal fibers. Of course, the palpebral lobe cannot be resected without loss of reflex tearing, and most lacrimologists believe it is responsible for a significant portion of basal secretion of tears. It is, of course, better to leave this enlarged gland in place despite the cosmetic appearance of ultimately a severe dry eye only complicates the functional result. In usual fashion, 6-0 nylon interrupted sutures are used to close the blepharoplasty incision.

Lower Lid Retraction

The lower lid is usually retracted on 1 to 3 mm, but it is important to correct even a small amount of retraction in the lower lid to reduce the exposure of the cornea and bulbar conjunctiva, both in the closed and open lid positions. Retraction of the lower lid margin of 1 mm exposes approximately 27 to 33 mm2 of conjunctival surface. The less white of the eye showing above and below the corneal limbus gives the illusion of less proptosis.

The incision is placed in the usual subciliary line and carried out onto the lateral canthus. Lidocaine and bupivacaine with epinephrine are permissible as local anesthesia in the lower lid. The myocutaneous flap is dissected to the orbital rim. The three fat pads are again dissected free of the abnormal orbital septum, as described in the upper lid procedure. A minimal amount of lower lid skin is resected at the subciliary incision, just enough to close the incision smoothly. To prevent contact of suture ends with the cornea, 6-0 silk is the preferred suture for the lower lid closure.

Prior to this point in the procedure, an auricular graft is harvested from behind each ear under a posterior skin and subcutaneous tissue flap. An approximate 4 mm by 20 mm rectangular cartilage graft is then fleshed and stored in saline. Then a lateral canthotomy, inferior cantholysis and inferior cul-de-sac conjunctival incision is made just under the inferior edge of the tarsus. The lower lid retractors are stripped or incised to release the lid from its posterior imbrication. The graft is sutured with a running, interlocking suture of 6-0 Vicryl using a spatula eye needle to the superior edge of the tarsus and the lower lid retractor stump. The cartilage graft chosen for each eyelid is placed with the convex surface toward the skin, which gives a nice curvilinear shape to the lower line. The posterior surface of the graft is covered with conjunctival overgrowth within one week as the sutures dissolve. The conjunctival edges are not sutured together over the graft, because this will only vertically shorten the lid posteriorly. The inferior arm of the lateral canthal tendon is sutured with a double- armed 5-0 Vicryl, and the canthotomy is closed with 6-0 silk.

If it is necessary to narrow the lateral commissures for improvement in cosmesis, a small lateral tarsorrhaphy of 3 mm will complete the procedure nicely. The lateral tarsorrhaphy is performed in the usual fashion with denuding of the lid margin with a Bard-Parker 15 blade, suturing the cartilage with a double-arm 5-0 Vicryl suture, and externalizing the knot through the skin and then interrupted 6-0 silk in the skin.

Discussion

One of the most grateful patients in a cosmetic surgery practice is the thyroid ophthalmopathy patient with improved cosmesis and function after upper and lower lids retraction surgery. Patients with extreme proptosis so that eyelid closure is impossible should be considered for orbital decompression first, then eyelid surgery. If strabismus (usually vertical heterotopia) is present, extraocular muscle surgery is indicated before eyelid retraction surgery, for obvious reasons.

Cartilage shims may be used in both upper and lower lids, but most have found it unnecessary in the upper lid. I avoid any cartilage or preserved sclera in the upper lid due to the possibility of extrusions of suture or implant, which would have serious complications involving the cornea, and the thickening of the preseptal area, which is a significant cosmetic shortcoming.

Cartilage in the lower lid is well tolerated by the cornea because the graft is inferior to the cornea, and closure of the lids does not bring them into contact. Some surgeons have insisted on closing the conjunctival pocket overlying the graft. In eyes of the patient with thyroid disease this will only shorten the lid posteriorly and produce some recurrence of retraction.

Lateral tarsorrhaphies can be used judiciously to narrow the lateral palpebral fissures in patients with persistent temporal flare of the lids. A unilateral tarsorrhaphy can bring asymmetrical lid retraction patients.

The important aspect of the blepharoplasty to remember are: (1) avoid aggressive skin removal; leaving some redundant skin is a better cosmetic result, for too much skin removed will produce lagophthalmos and compromise the improved lengthening of the lid anteriorly;

(2) remove only fat, not including orbital septum, for shortening of the dense orbital septum will produce an internal retraction phenomenon; (3) avoid fat removal via the cul-de-sac conjunctival approach in the lower lid; proptosis usually makes the orbital fat pads extrude more anteriorly into the lid, but the operative space is very tight due to proptosis, and the orbital septum is difficult to dissect from the posterior approach; (4) maintain corneal protection at all time with either a corneoscleral protective shield or ocular lubricants such as carboxymethylcellulose sodium (Celluvisc, a long lasting lubricant drop).

It is extremely important before embarking on this procedure to verify that this is a patient with euthyroid Graves’ Disease. A full medical and ophthalmologic workup should be performed first to ascertain that this is a stable condition.

William R. Thornton, MD, FACS, is certified by the American Board of Ophthalmology and University Fellowship trained in the subspecialty of Ophthalmic/Facial Plastic/Orbital Reconstructive Surgery. Dr. Thornton is a member of the Bexar County Medical Society.

References:

1. Baylis HI, et al. Autogenous auricular cartilage grafting for lower eyelid retraction. Opthalmol Plast Reconstr Surg 1985; 1:23

2. Chlafin J, Putterman AM. Mueller’s muscle excision and levator recession in retracted upper lid. Arch Ophthalmol 1979; 97:1487 (see also Ophthalmology 1981;88:507)

3. Converse JM, Krupp S. Exopthalmos. In: Converse JM (ed) Reconstructive plastic surgery. 2nd ed, vol 3 (Philadelphia: WB Saunders, 1977:972-8)

4. Cooper WC. The surgical management of the lid changes of Graves’ disease. Ophthalmology 1979;86:2071

5. Dixon R. Surgical management of the thyroid related upper eyelid retraction. Ophthalmology 1982;89:52

6. Frueh BR, et al. Lid retraction and levator aponeurosis defects in Graves’ eye disease. Ophthalmol Surg 1986;17:216

7. Harvey JT, Anderson RL. The aponeurotic approach to eyelid retraction. Ophthalmology 1971;88:513

8. Henderson JW. Relief of eyelid retraction-a surgical procedure. Arch Ophthalmol 1965;74:205

9. Leone CR. Management of ophthalmic Graves’ disease. Ophthalmology 1984;91:770

10. Putterman AM, Fett DR. Mueller’s muscle in the treatment of upper eyelid retraction: a 12 year old study. Ophthalmol Surg 1986’17:361

11. Schimek RA. Surgical management of ocular complication of Graves’ disease. Arch Ophthalmol 1972;87:655

12. Waller RR. Lower eyelid retraction: management. Ophthalmol Surg 1978;9-41

Eye Allergies: Symptoms and Relief

By Priyanka Gupta, MD

Spring is in the air, but so is a yellow-green colored pollen from Live Oak trees here in San Antonio. You might have noticed this pollen clogging your pool filter, covering your car windshield or coating your outdoor table. This heavy pollen can linger in the air for weeks depending on whether or not it has rained. The resulting allergy and asthma symptoms can be miserable.

Classic Spring “Hay Fever” Symptoms Can Include:

• Rhinorrhea

• Nasal congestion leading to mouth breathing/snoring at times

• Postnasal drip

• Sneezing (can be repetitive and severe in some cases)

• Itchy nose, eyes, ears and mouth

• Red and watery eyes

• Swelling around the eyes

• Moody and irritable

• Tired

• Disturbed sleep

The ocular manifestations can be pronounced during March and April here in San Antonio, causing itching, watering, swelling and erythema. For patients with asthma, there may be an upswing of asthma symptoms: hacking cough, shortness of breath, chest tightness and even wheezing leading to asthma exacerbations every spring.

Some Tips to Help Battle the Spring Allergy Season Include:

1. Limiting your outdoor exposure as much as possible. Maybe exercise temporarily indoors, use more air-conditioning while in your car and consider wearing a mask.

2. Be sure to wash after every outdoor activity. That pollen can collect on hair and clothing so taking a shower and changing into clean clothing after outdoor activities will reduce your exposure to the pollen. Also consider taking your shoes off outside to not track pollen indoors.

3. Wipe off pets before they enter your home.

4. Begin taking your preventative medications now and definitely a couple weeks before the allergy season in the future.

Several Categories of Medications Can be Helpful:

Artificial tear drops help relieve eye allergies temporarily by washing allergens from the eye. A daily nasal saline rinse is very effective at helping keep nasal passages open naturally. Oral antihistamines may be somewhat helpful in relieving itchy eyes, but they can make eyes dry and even worsen eye allergy symptoms. Adding an oral decongestant PRN can temporarily relieve sinus pressure/drain-

age but is not a good long-term solution. Nasal decongestants also only relieve symptoms temporarily and should not be used on a regular basis. Antihistamine/mast-cell stabilizers are available in both eye drops and nasal sprays — most over the counter. They tend to work with less efficacy compared to nasal corticosteroids and nasal antihistamines. They are a good option when there may be a contraindication to being on antihistamines or topical corticosteroids. Corticosteroid nasal sprays are now available over the counter, and should be started two weeks before the allergy season and continued for the duration of the season for maximum effectiveness. Linking the nasal corticosteroid with a nasal antihistamine is a superior combination than just taking an oral antihistamine as it targets the nasal mucosa and ocular areas locally giving good local effects. There are several prescription nasal steroid/nasal antihistamine combinations that are available, and can be an excellent preventative strategy during Live Oak pollen season.

When all the efforts above fail, or leave a patient with suboptimal results, it’s time to call your allergist to consider allergen immunotherapy. Immunotherapy can help build the body’s tolerance. With immunotherapy, you get shots containing tiny amounts of the allergen. The dose gradually increases over time to help your body become immune to the allergens. A board-certified allergist can prescribe more intensive remedies to bring your current symptoms under control and develop a preventative plan using allergen immunotherapy that can help you avoid the misery of seasonal allergies in the future. Rather than reducing symptoms after they have started, allergen immunotherapy (“allergy shots” or “allergy drops”) helps your body develop resistance to the pollen particles so that your symptoms are significantly reduced and much less severe.  Allergy injections are the traditional immunotherapy treatment and are widely recognized as being quite effective. Oral allergy drops are now available and offer a convenient, safe and effective option for patients who don’t want to take allergy injections in the doctor’s office. Regardless of whether you choose shots or drops, an individualized extract prescription is prepared for each patient based on the results of specific allergy testing.

Priyanka Gupta, MD, is board-certified in Allergy-Immunology. Dr. Gupta received her BS from the University of Michigan and her MD at Michigan State University College of Human Medicine. Her internal medicine residency was completed in Houston at Baylor College of Medicine. Her Allergy-Immunology fellowship took her to Chicago at Northwestern University Feinberg School of Medicine, where she trained in both adult and pediatric allergic and immunological diseases. Dr. Gupta is a member of the Bexar County Medical Society.

Revolutionary Changes in Treatment of Age-Related Macular Degeneration

By Jeremiah Brown, Jr., MS, MD

Revolutionary events are happening in the treatment of age-related macular degeneration (AMD). Despite being the leading cause of blindness in patients over age 60, significant advances have occurred, leading to many additional years of useful functional vision for our patients.

Age-related macular degeneration is a multifactorial degenerative disease of the retina. Approximately 70 percent of the risk of developing macular degeneration is genetic. Environmental factors such as smoking, diet and UV light exposure also play a role. Lastly, the incidence of macular degeneration increases with age. In the early stages of this condition, small extracellular deposits called drusen build up at the level of the retinal pigmented epithelial cells (RPE) and Bruch’s membrane beneath the neurosensory retina. As time progresses, these deposits, along with chronic inflammation and oxidative stress, cause degeneration of the overlying photoreceptors, the light sensing cells in the retina and RPE (Figure 1). This slow gradual degeneration causes distortion and gaps in an affected patient’s vision. Eventually blind spots may develop and visual acuity can be reduced to as low as counting fingers, meaning that patients are unable to read any letters on the vision chart and can only count fingers held in front of them.

Nutritional supplements were demonstrated in two large clinical trials to have a beneficial effect in reducing the rate of progression to advanced stages of macular degeneration. These supplements contain vitamin C, vitamin E, zeaxanthin and zinc with supplemental copper. Epidemiologic surveys have also confirmed that a diet with green leafy vegetables such as spinach and kale, as well as oily fish such as salmon and tuna, at least one to two times per week, also have a beneficial effect in slowing progression.

Approximately one in seven patients with macular degeneration develops the exudative form of AMD. In these patients, neovascular tissue grows from the choroid into the retina, causing exudation, intraretinal edema and subretinal fluid (Figure 2). The neovascular tissue and surrounding edema produce blurred vision, distorted vision and ultimately, blind spots. Unfortunately, this exudation usually develops in the macula, resulting in loss of the most precious area of detailed central vision in our patients. Massive hemorrhages can also occur, resulting in abrupt severe vision loss.

For many years, it was suspected that macular degeneration had a genetic component. However, this was difficult to prove as most patients’ parents were no longer living and their children were too young to demonstrate phenotypic features of AMD. In the late 1990s, dramatic discoveries of activated complement fragments within drusen deposits helped to refine the search for genetic causes. In 2006, several groups simultaneously identified complement factor H as the locus conveying the most risk for developing age-related macular degeneration. Since that time, numerous other genes in the complement pathway have been implicated, and have been proven to add additional risk or convey benefit to the development of age-related macular degeneration.

Another revolutionary finding was understanding that vascular endothelial growth factor played a role in the development of choroidal neovascularization. Dramatic clinical trials in the early 2000s demonstrated that with an antibody-derived inhibitor of vascular endothelial growth factor, the abnormal vessels could be regressed and visual acuity could be improved. Prior to this discovery, there had been no therapy that could actually improve vision for patients with neovascular AMD. Today, intravitreal injections of inhibitors of vascular endothelial growth

factor are one of the most common procedures performed in the retina clinic. These injections result in maintenance of vision for millions of patients who would otherwise become legally blind.

The understanding that the complement pathway plays a role in the development of age-related macular degeneration has also led to revolutionary changes in the care of patients. In 2023, two medications were FDA approved for the treatment of dry AMD. Patients with “dry” or atrophic AMD may or may not develop neovascularization (Figure 3). However, they have progressive loss of the outer retina and RPE cells. This produces dense scotomas or blind spots. Today, patients with the atrophic form receive intravitreal injections to help preserve the retina and preserve visual function, such as reading, driving and recognizing faces. Inhibitors of complement C3 and C5 have proven to slow the growth rate of these atrophic lesions.

The future is becoming even brighter for patients with age-related macular degeneration. Current therapies enable a longer duration of effect, reducing the number of injections required to maintain vision. Gene therapy is a promising strategy to enable the retina to produce a protein inhibitor of vascular endothelial growth factor. This strategy may allow patients to go a year or more between injections compared to the five to six weeks required for many patients currently. Gene therapy may also prove to be an effective strategy for patients with the atrophic form of AMD, once again, reducing the number of injections required to maintain vision. Other strategies in clinical trials today strive to reduce inflammation in the retina via other pathways with the goal of greater efficacy, and hopefully fewer injections.

Age-related macular degeneration is a fascinating, scientifically challenging and impactful disease. This area of research is one of my passions, and it is so rewarding to see the effects of years of research reaching the clinic and preserving patients’ vision.

subretinal drusenoid deposits

degeneration. Nat Rev Dis Primers. 2021 May 6;7(1):31. doi: 10.1038/s41572-02100265-2. PMID: 33958600

Dr. Jeremiah Brown is a graduate of Harvard University. A U.S. Army veteran, Dr. Brown served as director of ophthalmology research at the U.S. Army’s Laser Research Laboratory at Brooks Air Force Base, a division of the Walter Reed Army Institute of Research. He has co-authored more than 25 peer-reviewed articles in ophthalmology research as well as textbook chapters. He is a frequent lecturer to ophthalmology residents as well as practicing ophthalmologists. Dr. Brown practices vitreoretinal diseases in San Antonio and Schertz, and is a member of Retina Consultants of Texas and the Bexar County Medical Society.

Figure 2. Neovascular AMD demonstrating choroidal neovascularization with subretinal and intraretinal hemorrhage. (Brown, Jeremiah. All About Macular Degeneration, AMD Association Meeting Houston, Texas, June 10, 2023.)

Figure 3. Atrophic dry AMD. This image demonstrates atrophy involving the foveal center. Numerous yellow drusen are also noted. Courtesy of Dr. Jeremiah Brown.

Figure 1. Signs of intermediate AMD with drusen and subretinal deposits. Fleckenstein M, Keenan TDL, Guymer RH, Chakravarthy U, Schmitz-Valckenberg S, Klaver CC, Wong WT, Chew EY. Age-related macular

Cataract Surgery in 2024

By Scott A. Thomas, MD

Cataract continues to be the most common cause of vision impairment in the United States and worldwide. The incidence is nearly universal in the later years of life. Studies have shown a variety of benefits of cataract surgery, including decreased depression indices, improved performance on Mini Mental State Examinations, decreased cumulative risk of falls in elderly patients, and others. Reduced rates of motor vehicle collisions have also been shown following cataract surgery. One study showed 79 percent of patients greater than 90 years of age were better able to manage activities of daily living, and 43 percent were still alive at the four-year follow-up. In short, reducing in the visual impairment, which comes inevitably with natural aging, is an essential intervention to prolong independence and quality of life among older people. Continued refinement in surgical techniques have incrementally made the surgery safer and more tolerable for patients. Experience and technology make it routinely rapid, minimally painful, and with a quick recovery.

Still, cataract surgery is a technically difficult procedure with a steep learning curve. I am approaching the 20th anniversary of performing my first cataract surgeries, as a PGY-3 resident. I remember the excitement and anxiety experienced by probably every surgical resident. The stakes were high, as phacoemulsification is a very dynamic surgery and things can go wrong in an instant, even before a supervising physician has an opportunity to intervene. Working under an operating microscope where the entire field of view is approximately 2.5 cm, and only the tips of the instruments are visible, was extremely awkward at first (see Figures 1 and 2). After many years and thousands of cases, the stress level is diminished, to say the least.

Just as for a musician or an athlete, repetition is an excellent teacher. Performing the same procedure over and over grants cataract surgeons the opportunity to refine their techniques both in the operating room and the clinic. The pre- and post-op care of the patient in the office has its own demands and over time can also be made more effi-

cient and satisfying for both patient and surgeon. There are, however, certain slightly vexing issues that I repeatedly have to address in clinic.

Things I Wish My Patients Knew About Cataract Surgery:

1. “Do you take the eye out to work on it (on the back table)?” This one usually came from the patient’s uncle who swears that when he had cataract surgery, the eye was removed and reinstalled after the cataract was taken care of. I have considered replying that the extraocular muscles, optic nerve and various arteries and veins would object to such treatment, but I usually just assure the patient that the eye will remain in the orbit at all times.

2. “I want the cataract removed but no lens implant.” I’m not sure what motivates this request. The human eye requires about 60 diopters (D) of focusing power, and the cornea provides about 40 D. The crystalline lens provides the other 20 D. If that power is not replaced during cataract surgery by implanting an intraocular lens, the aphakic eye will be severely out of focus. This was the case in the 1950s and 1960s, before IOLs were available. Patients had to wear aphakic spectacles (aka “Coke bottle glasses”). With modern IOLs, there is a good chance the patient will not need prescription spectacles at all. When I further explain that the IOLs are inert, will last a lifetime and cannot be seen or felt by the patient, the objection melts away.

3. “During surgery, I don’t want to feel anything.” Patients are often rightly apprehensive about the prospect of a surgery inside their eye. Some respond by avoiding it as long as possible. But when they can no longer delay, they may expect to have no awareness of the procedure at all. Alas, this is more than I can promise. Routine cataract surgery is done with topical anesthesia (local anesthetic eye drops usually with supplemental lidocaine in the anterior chamber); some degree of conscious sedation is commonly used but general anesthesia is rarely considered. Increasing levels of seda-

Just another day at the office.

tion bring increasing levels of anesthesia risk, which are simply not justified in an ambulatory procedure lasting 10 minutes. Sedation is often delivered intravenously, but liquid oral diazepam and even sublingual ketamine/midazolam lozenges are used. I tell patients the sedative will be used to help them relax but is not intended to render them completely unconscious. A few minutes discussing risks of deeper anesthesia usually convinces the patients they can handle more than they initially thought. Minimizing anesthesia risk also keeps cataract surgery open to many patients with significant comorbidities. For patients suffering from end-stage pulmonary disease, cancer or heart failure, severe visual impairment dramatically reduces their quality of life. In other words, people with limited life expectancy shouldn’t be condemned to blindness as well, if it is in our power to help.

4. “How long after surgery until I can lean over?” This one has historical significance. In the early- and mid-20th century, cataract removal by the intracapsular method required a large incision encompassing one-third to one-half of the entire corneal diameter, and there were no micro-sutures to close the incision. It was very unstable for weeks. However, typical phacoemulsification surgery is done through a 2.4mm self-sealing incision, which is quite stable upon leaving the OR. While eye rubbing is discouraged for a few days, if the patient bends over after surgery, nothing will fall out.

5. “Do I stop taking my blood thinners?” No. Extensive research has shown that routine topical cataract surgery on anticoagulants has no increased risk of perioperative hemorrhage, but discontinuing anticoagulation has a risk of thromboembolic events.

Tremendous resources have been invested in technology to improve refractive outcomes and approach true spectacle independence. Femtosecond laser-assisted cataract surgery (FLACS) was introduced almost 15 years ago but after initial enthusiasm, utilization has declined. Contrary to popular understanding, the laser does not remove the cataract; rather it creates two corneal incisions and the circular capsulotomy needed to access the lens nucleus; thereafter the surgery proceeds with the intraocular ultrasound aspiration probe as usual. Some surgeons rely on the technology while others find it to be a time-consuming add-on that provides little to no proven benefit to patients over manual surgery.

If the benefits of laser-assisted cataract surgery are doubtful, the improvements in intraocular lens (IOL) technology are not. Modern IOLs and methods of surgical planning can correct myopia, hyperopia and astigmatism in most patients with a high degree of accuracy, but presbyopia correction remains the most vexing refractive error. No IOL technology currently available can reproduce the seamless adjustment of natural accommodation in a healthy young phakic eye. Current iterations of diffractive multifocal IOLs (e.g. PanOptix, Alcon) reliably produce good uncorrected vision both near and far, but patients may experience various types of visual disturbances of night vision, and a modest reduction in contrast sensitivity. The Light Adjustable Lens (RxSight) offers the unique ability to adjust the lens power several times in the weeks following surgery, with brief office treatments of directed UV light. This allows a fine tuning of any residual refractive error, with some degree of presbyopia correction.

All these technological improvements come with a cost, some of which is passed onto the patient in an era of declining third-party payer reimbursements. Given the near-universal incidence, low risk nature of the procedure, it is not surprising that cataract surgery is the most commonly performed procedure in Medicare Part B, and its greatest expenditure. It is therefore also not surprising that it has been the subject of multiple rounds of reimbursement cuts. From 2010 to 2020, surgeon reimbursement by Medicare allowable charges fell 22 percent. At the same time, cataract surgery is widely accepted as one of the most cost-effective medical interventions. Continued economic pressure may bring further changes in common practice, such as immediate (same-day) bilateral sequential cataract surgery, or surgery in office suites rather than certified ASCs.

Like many medical advances, modern phacoemulsification cataract surgery has had a tremendous impact on millions of people, restoring physiologic function, which increases quality and probably quantity of life. Everyone reading this article (including the author) is likely to experience the degradation of vision due to cataract, and the efficient process of reversing that degradation. Without hyperbole, cataract surgery is the most cost-effective medical intervention for improving quality of life. It is satisfying and humbling to repeatedly and frequently provide this life-changing service to my patients.

Reference:

American Academy of Ophthalmology, “Cataract in the Adult Eye Preferred Practice Pattern”

Scott A. Thomas, MD, has practiced comprehensive/cataract ophthalmology in San Antonio and surrounding areas since finishing residency in 2007. He practices at the San Antonio Eye Center. Dr. Thomas is a member of the Bexar County Medical Society

The author at work.

Pediatric Ophthalmology and Strabismus: Little Patients, Not So Little Problems

By Charles S. McCash, MD

It’s a busy Tuesday in the Pediatric Ophthalmology clinic. Our first appointment involves a worried mother of a 6-month-old boy who is concerned that he may have crossed eyes. After the usual complete eye examination and refraction (checking for a need for glasses), the child is found to have only epicanthal folds but not true esotropia. The mother is reassured that he has normal eyes and no treatment is needed at this time. She is given a pamphlet with photos to demonstrate the difference between pseudostrabismus and true esotropia, and the child is scheduled for a six-month follow-up with the Orthoptist to double check the eye alignment before discharging the patient.

The next patient has a similar presentation. The 7-month-old girl’s parents note that the family has been seeing the left eye crossing constantly since the child began to make good eye contact. After a similar examination, she is found to have a large angle of esotropia (crossing of the eyes), along with amblyopia in the left eye, but an otherwise normal eye examination. The family is counseled that she has infantile esotropia and amblyopia. Because the right eye is becoming preferred, the parents are given patching over that eye to correct the amblyopia. Older children with amblyopia may also be treated with atropine drops, but in younger children, patching is more frequently used. The parents are also cautioned that it is very likely that she will require strabismus surgery to correct the eye alignment once the vision is equal in the two eyes. They are also informed that sometimes more than one surgery will be necessary. Follow-up is scheduled in two months to recheck vision with the Orthoptist.

Later in the morning, a 3-year-old boy is brought in for the new onset of crossed eyes. He has no other neurological issues and is doing well developmentally. His examination shows intermittent crossing of the eyes but also, he is found to have a high degree of hyperopia (farsightedness) at +5.00 diopters in each eye. Discussion with his family includes the fact that normal farsightedness is no more than about +3.00 diopters at this age, and his excessive farsightedness is causing the intermittent crossing. Fortunately, this is usually easily corrected with glasses to eliminate the need for focusing, and the patient is unlikely to require surgical correction. He will be seen for follow-up in a few months to ensure that the eyes are straight with glasses and the vision is equal, but as long as both of these are the case, no additional treatment will be required.

As the day progresses, another family presents with a concern that their 7-year-old girl’s eyes are drifting out intermittently, which has been occurring for a while but has worsened recently. Examination confirms that their suspicions are correct, with an otherwise normal examination. For this patient, the ability to control the drifting, or the lack thereof, will dictate the treatment plan. As long as the child has good control of their eye alignment, then observation is prudent. If the control is poor, or is worsening over time, then various options for treatment are available. For younger children, a trial of alternate patching may help them to recognize the deviation when it is present, and therefore control it more effectively. Overminus glasses (overcorrection of nearsightedness to induce focusing and convergence of the eyes) can also sometimes be helpful but ultimately, surgical correction is an option if control remains poor.

During the day, nearly 100 patients may pass through visits with the multiple providers in the clinic, with strabismus, amblyopia and other problems as varied as childhood cataracts, glaucoma, tear duct obstructions, chalazia, retinoblastomas, orbital cysts, ptosis and various other eye problems. Some kids are more agreeable with the eye exam than

others, particularly with regard to getting the dilating eye drops, but most all can be coaxed through their examinations through a mixture of spinning light toys, movies on the television in the room, singing and various other distractions.

Around lunchtime, adult strabismus patients are scheduled. These patients can have quite complicated forms of strabismus, with etiologies ranging from broken-down childhood strabismus, restrictive or mechanical problems such as scarring from previous trauma, retinal or glaucoma surgeries, or Graves’ disease. Others may have extraocular muscle weakness due to cranial nerve palsies, damage due to neurological problems such as tumors, or neuromuscular issues such as myasthenia gravis. Examination of these patients can be quite time-consuming, and often starts with an extended examination of their eye alignment with an Orthoptist prior to meeting with the Pediatric Ophthalmologist. Additional workup is often needed, including imaging and laboratory studies. Each patient is counseled at length regarding treatment options. While observation is almost always an option for adult strabismus patients, most have chosen to come to a pediatric office because this was no longer working well for them and they are seeking other treatment options. These can include prism glasses, particularly for elderly patients with diplopia who normally wear glasses and have only small eye deviations.

Many of the adult patients, however, ultimately opt for surgical correction to correct functional problems such as double vision, eye strain or fatigue, or social issues such as being asked who they are talking to, or why they aren’t making eye contact with someone. Interestingly, many of these patients are quite surprised to hear that surgical correction is an option, as they have been told for years that they are “too old” for strabismus surgery, though that is rarely the case. We have corrected patients as old as 90 years old, surgically, in order to improve their double vision, which will hopefully improve their quality of life, restore the ability to drive in some cases, and reduce the likelihood of falls due to stumbling.

When necessary, strabismus surgery is performed as an outpatient procedure. Both general and local anesthesia are options in adults, though children are routinely done with general anesthesia. Surgeries are generally quick, lasting under 20 minutes of surgical time per muscle corrected, plus anesthesia time. Patients generally only require topical treatment postoperatively, along with acetaminophen or ibuprofen for pain. Patching is normally not necessary for children, though adults may be patched overnight. The only statistically significant risk is that the patient may require additional surgery in the future, though for the majority of patients, only a single surgery is necessary.

After a long but interesting day in clinic, the staff and doctors go home tired but satisfied with the problems solved today, and looking forward to new patients that will present tomorrow. Sometimes alleviating the parents’ concerns is even more of a challenge than keeping the children calm and distracted, but this can normally be overcome with a little extra time and a few more answered questions. At the end of each day, the challenges of treating the patients (and sometimes the parents, too) provide a challenging and rewarding experience that keeps us coming back day after day.

Charles S. McCash, MD, specializes in Pediatric Ophthalmology and Eye Alignment Disorders at the Children’s Eye Center of South Texas. Dr. McCash is a member of the Bexar County Medical Society.

Screen Time and the Impact on Children’s Eyes

By Manpreet S. Chhabra, MD

In the current digital age, children are spending more and more of their time with devices like smartphones, tablets, computers and televisions, whether for school, work, entertainment or exercise. A study published in 2011 showed that about 47 percent of children indulged in more than two hours of screen time for entertainment purposes, but that number increased to 98 percent in the United States in 2019. A lot of attention has gathered on the impact of screen time on kids.

Some of the Effects on Children’s Eyes Include: Eye Strain or Fatigue

Extended use of screen time can lead to symptoms of eye fatigue or asthenopia characterized by discomfort of the eyes, strain and headache. There can be more strain on the eyes by any glare on the screen. If kids are focusing on the screen from close distances, this can further aggravate the fatigue as the eyes need breaks especially when focusing up-close for long periods of time.

Dryness and Eye Irritation

Prolonged periods of screen time can lead to dryness of the eyes and eye irritation. Based on the studies, we tend to blink much less when focusing intently on the screen and that leads to eye dryness. The eyes need a clear tear film for clear vision.

Myopia

There have been several studies that have shown the correlation of excessive screen time with the development of myopia or near sight-

edness. Limited outdoor time, along with extended stretches of screen usage, can lead to further progression of myopia that can have more visual consequences for these kids.

Some of the Other Effects on Overall Health Include: Sleep Disturbances

Sleep patterns are disrupted because of screen exposure before bedtime. There is suppression of melatonin, a hormone responsible for sleep-wake cycle regulation, that disturbs the sleep cycle. Blue light emitted from the screens alters the body’s natural circadian rhythm, which makes it more difficult for kids to fall asleep.

Physical, Social and Emotional Health

Prolonged screen time use leads to a sedentary lifestyle that replaces physical activities and can result in an increased risk of obesity and other health issues. This also leads to lesser social interactions and more social isolation, and can interfere with the development of social skills. Excessive screen time can also impact the emotional health of children, causing anxiety, stress and mood disturbances.

Strategies and What Parents Can Do: The 20-20-20 Rule

The eyes need a break since focusing on the near tasks can lead to discomfort. Encourage your children to follow the 20-20-20 rule — take a 20 second break every 20 minutes to look at something 20 feet away — and this leads to lesser eye strain. This approach can allow the eyes to reset and refocus, alleviating eye fatigue.

Guidelines for Screen Time

The American Academy of Pediatrics (AAP) provides recommendations on screen time limits, some of which include eliminating or minimizing media exposure, other than video chatting, for children under the age of 18 months. For older preschool-age children, there are appropriate media limits. Having a strategy and establishing clear guidelines for usage of screen time can reduce eye strain and fatigue and other impacts on health. The AAP recommends families develop their own personalized media use plans.

Screen Position

The screen on your child’s laptop or desktop computer should be positioned slightly below the eye level. This should be in a way that the child looks down on it and not up. Looking up at a screen can lead to dryness as it leads to a wider opening of eyes. Also, children should be encouraged to work on a larger screen rather than a smaller phone as children’s eyes must work harder to focus on smaller screens and those that are closer. Encourage your children to position the screen at least an arm’s length away. In fact, a 1-2-10 rule should ideally be followed, implying the mobile phones to be positioned at one foot away, laptops and desktops at two feet and televisions at 10 feet. This also helps in reducing neck and shoulder strain.

Screen Settings and Glare Elimination

The font can be adjusted, especially on smaller screens, to about twice as large as the child can read comfortably, and that can help alleviate eye strain. Modifying screen settings, such as brightness and color temperature, also helps in minimizing the effects of blue

References:

1. Maniccia DM, Davison KK, Marshall SJ, Manganello JA and Dennison BA. A Meta-analysis of Interventions That Target Children's Screen Time for Reduction. Pediatrics 128, e193-e210

2. Madigan, S, Browne, D, Racine, N, Mori, C and Tough, S. Association Between Screen Time and Children’s Performance on a Developmental Screening Test. JAMA Pediatrics 173, 244-250

3. Trott M, Driscoll R, Irlado E, Pardhan S. Changes and correlates of screen time in adults and children during the COVID-19 pandemic: A systematic review and meta-analysis. EClinicalMedicine. 2022 Jun;48:101452

4. Coles-Brennan C, Sulley A, Young G. Management of digital eye strain. Clin Exp Optom. 2019;102(1):18–29. 10.1111/ cxo.12798

5. Nyugen P, Le LK, Nyugen D, et al. The effectiveness of sedentary behaviour interventions on sitting time and screen time in children and adults: An umbrella review of systematic reviews. Int J Behav Nutr Phys Act. 2020;17(1):117. 10.1186/s12966-02001009-3

6. Wang J, Li Y, Musch DC, et al. Progression of myopia in schoolaged children after COVID-19 home confinement. JAMA Ophthalmol. 2021;139(3):293–300. 10.1001/jamaophthalmol.2020.6239

light exposure. The eyes work harder when there are more reflections on the screen. The glare settings can be adjusted for comfortable viewing.

Sleep Habits

The American Academy of Pediatrics (AAP) recommends that children should not sleep with digital devices such as smartphones, computers and televisions in their bedrooms. The AAP also recommends no devices or screen exposure for one hour before bedtime.

Outdoor Activities

Encouraging outdoor time and activities exposes children to natural light, which is helpful for visual development and may help delay the progression of myopia or nearsightedness.

Eye exams should be part of children’s regular healthcare schedules. Children may not be forthcoming when they have vision issues or blurriness. At a minimum, annual vision screenings at your pediatrician’s office during well checks should be ensured. If any issue or problem is detected during these screenings, the child’s pediatrician may refer the child to a pediatric ophthalmologist.

Screens offer great educational value and entertainment opportunities, but their pervasive use has raised concerns about the negative impact on children’s eyes and physical, cognitive, social and emotional health. Fostering a balanced approach by combining the screen time limits with outdoor activities, regular breaks and appropriate screen positioning can help children safely navigate the highly digitalized world while mitigating the potential risks and preserving their eye health and overall well-being.

7. Foreman J, Salim AT, Praveen A, Fonseka D, Ting DSW, Guang He M, Bourne RRA, Crowston J, Wong TY, Dirani M. Association between digital smart device use and myopia: a systematic review and meta-analysis. Lancet Digit Health. 2021 Dec;3(12):e806-e818

8. Huang HM, Chang DS, Wu PC. The Association between Near Work Activities and Myopia in Children-A Systematic Review and Meta-Analysis. PLoS One. 2015 Oct 20;10(10):e0140419

9. Harrington SC, Stack J, O'Dwyer V. Risk factors associated with myopia in schoolchildren in Ireland. Br J Ophthalmol. 2019 Dec;103(12):1803-1809

Manpreet S. Chhabra, MD, is a board-certified ophthalmologist with focus on Pediatric Ophthalmology and related conditions. He did his ophthalmology residency at the University of Cincinnati in Ohio and pediatric ophthalmology fellowship at the Northwestern University in Chicago. Dr. Chhabra has over two decades of clinical experience in his field. He practices at Alamo Pediatric Eye Center, and is a member of the Bexar County Medical Society.

Enhancements in Extracurricular Medical Education at the Mobile Eye Screening Unit

By Sarah Traynor Poor, Harsh Madaik, Kannan Freyaldenhoven and Jared J. Tuttle, with Daniel A. Johnson, MD, MBA

Vision is seen by many as an essential component of quality of life. In San Antonio, the prevalence of vision loss (3.08 percent) exceeds both the national average (2.17 percent) and the Texas state average (2.24 percent).1 This vision loss can often be attributed to treatable eye diseases including cataracts, glaucoma and diabetic retinopathy. In response to the burden of these eye diseases on the local community, many local groups have directed their resources towards prevention and detection efforts. One such undertaking is the Lions Mobile Eye Screening Unit (MESU). At the MESU, UT Health San Antonio (UTHSA) student volunteers and community members offer eye screenings that include visual acuity, intraocular pressure and visual field tests to underserved areas of South Texas. As part of their mission to improve eye health in the San Antonio area, student leaders at the MESU have embarked on multiple projects to better understand the population they serve and improve screening capacity.

COVID-19 Screening Trends

The first project assessed trends in visual acuity (VA) and intraocular pressure (IOP) before and after the COVID-19 pandemic. The pandemic changed the landscape of healthcare significantly, and not just in emergency departments and ICUs. Many national ophthalmology societies recommended against non-emergent eye screenings and treatments to reduce COVID-19 transmission.2 To explore whether the global changes of 2020 would be reflected in local community eye health, VA and IOP failure rates at 10 MESU screening locations were compared before (September 2018 - June 2020) and after (May 2021 - December 2022) the start of the COVID-19 pandemic. At

the sites visited by the MESU, IOP fail rates increased significantly compared to the start of the pandemic. Near and far VA fail rates also increased significantly at two of the MESU sites. The public health crisis of COVID-19 may have exacerbated existing public health issues in San Antonio and made concerted community interventions even more necessary.

Training Video

The second project aimed to improve volunteer preparedness by creating a training video on how to conduct an eye screen. Most student volunteers (90 percent of those surveyed) had no prior experience operating ocular testing equipment.3 While student volunteers usually learned how to conduct a screening by the end of the event, the on-the-job training impacted efficiency and organization. In response to these challenges, MESU student leaders created an 8-minute training video and distributed it to volunteers before the event. The video presents the correct operation of screening instruments, the role of the volunteer and basic eye terminology. After the event, a short survey was given to students to determine the video’s efficacy. The survey asked questions about students' comfort level with performing an eye screening before and after both watching the training video and attending the MESU event. Survey results indicated that watching the training video significantly improved the self-reported preparedness of student volunteers, with hands-on experience at the event providing additional confidence. Improving volunteer training has increased the quality of eye screenings, increasing the potential benefit of the MESU.

English-to-Spanish Script

For the third project, MESU student leaders sought to improve the Spanish-speaking capacity of volunteers. In Bexar County, Texas, 41 percent of households speak Spanish as their predominant language.4 Although a previous study revealed that up to 45 percent of MESU screening participants preferred Spanish, student Spanish-speaking ability is lacking.5 Seventy-three percent of the volunteers rated their Spanish speaking ability at either a 1 or 2 on a 1 - 5 Likert scale.6 To improve Spanish speaking ability amongst volunteers, an English-to-Spanish script was created and distributed to volunteers at each event. While the script did not allow for the level of nuance and personalization that Spanish fluency would, it helped volunteers guide screening recipients through testing more comfortably. Pre- and post-surveys were distributed to volunteers to assess Spanish-speaking competence and evaluate script efficacy. Both self-reported confidence in conducting an eye screening in Spanish and interest in improving Spanish-speaking abili-

References:

1. Lundeen, EA, Flaxman, AD, Wittenborn, JS, Burke-Conte, Z, Gulia, R, Saaddine, J & Rein, DB. (2022). County-Level Variation in the Prevalence of Visual Acuity Loss or Blindness in the US. JAMA ophthalmology, 140(8), 831–832. https://doi. org/10.1001/jamaophthalmol.2022.2405

2. Toro, MD, Brézin, AP, Burdon, M, Cummings, AB, Evren Kemer, O, Malyugin, BE, Prieto, I, Teus, MA, Tognetto, D, Törnblom, R, Posarelli, C, Chorągiewicz, T & Rejdak, R. (2021). Early impact of COVID-19 outbreak on eye care: Insights from EUROCOVCAT group. European journal of ophthalmology, 31(1), 5–9. https://doi. org/10.1177/1120672120960339

3. Traynor Poor, S, Tuttle, J, Freyaldenhoven, K, Madaik, H, Lloyd, C, Mojica, D, Johnson, DA. (2024, February 3). Implementation of Video Training for Mobile Eye Screening Unit Volunteers. 2024 CSL Conference UTHSA, San Antonio, TX. Retrieved from https://doi.org/10.13140/RG.2.2.27466.95683

4. U.S. Census Bureau. (2022). Household Language. American Community Survey, ACS 1-Year Supplemental Estimates, Table K201601. Retrieved from https://data.census.gov/table/ ACSSE2022.K201601?q=bexar county&t=Language Spoken at Home&d=ACS 1-Year Supplemental Estimates

5. Yanev, P, Membreno, R, Han, R, Mella, J, Hill, J, Johnson, DA. (2018). San Antonio Vision and Eye Studies (SAVES): Impact of Demographics and Insurance Status on Prevalence of Eye Exams. American Academy of Ophthalmology 2018 Conference, Chicago, IL

6. Freyaldenhoven, K, Tuttle, J, Madaik, H, Gaspar De Alba, J, Mojica, D, Johnson, DA. (2024, February 3). Enhancing Spanish-Language Capacity Among Volunteers at Bexar County Eye Screenings. 2024 CSL Conference UTHSA, San Antonio, TX. Retrieved from https://doi.org/10.13140/RG.2.2.17400.62727

ties increased significantly after using the script. The English-to-Spanish script represents an important step for the MESU as volunteers seek to connect with the San Antonio Spanish-speaking population.

These three projects are part of an ongoing effort to maximize the Mobile Eye Screening Unit’s capabilities to improve eye health and quality of life in the community. Data collection like the COVID19 study provides greater understanding of the community’s needs, and procedure improvements like the training video and English-toSpanish script improves the quality of screenings the unit can provide. Alongside these efforts, the MESU trains volunteers who are interested in ophthalmology, helping to cultivate a passion for the field and teach the next generation of eye care specialists with a public health focus. Through these efforts, the MESU aims to improve not only the current landscape of public eye care, but also the quality of life of future patients in the South Texas community.

Daniel A. Johnson, MD, MBA, is the Herbert F. Mueller Chair, Department of Ophthalmology at UT Health San Antonio. He specializes in the management of uveitis/ocular inflammatory disease and cornea and external diseases. Dr. Johnson is a member of the Bexar County Medical Society.

Sarah Traynor Poor is a medical student at the Long School of Medicine at UT Health San Antonio, Class of 2027, and the 2024 student president of the Lions Mobile Eye Screening Unit. She enjoys applying her background as an ophthalmic technician when volunteering at the Mobile Eye Screening Unit.

Harsh Madaik is a medical student at the Long School of Medicine at UT Health San Antonio, Class of 2026. Harsh is interested in the public health applications of ophthalmology and preventative health education for irreversible eye diseases like glaucoma.

Kannan Freyaldenhoven is a medical student at the Long School of Medicine at UT Health San Antonio, Class of 2026, and the 2023 student vice president of research for the Lions Mobile Eye Screening Unit. Kannan enjoys using his background in Spanish to help deliver effective screenings to those served by the MESU.

Jared Tuttle is a medical student at Long School of Medicine at UT Health San Antonio, Class of 2026, and the 2023 student president of the Lions Mobile Eye Screening Unit. Jared has a passion for improving access to patient care within the community, across all languages and backgrounds.

36 Fabulous Foods to Boost Eye Health

(This article originally appeared on the American Academy of Ophthalmology® website. Published April 07, 2023. By Celia Vimont; Reviewed by Brenda Pagan-Duran, MD; Edited by David Turbert)

If you’re looking for a diet that’s healthy for your eyes, here’s some good news: The same diet that helps your heart and the rest of your body will help your eyes. Plus, you’ll enjoy many delicious choices. Here are 26 vision-healthy foods and ideas for a diet rich in fruits, vegetables, beans and fish.

Why Is Nutrition Important for Good Vision?

“Some nutrients keep the eye healthy overall, and some have been found to reduce the risk of eye diseases,” said Rebecca J. Taylor, MD, an ophthalmologist in Nashville, Tennessee. Eating a diet low in fat and rich in fruits, vegetables and whole grains can help not only your heart but also your eyes. This isn’t surprising: Your eyes rely on tiny arteries for oxygen and nutrients, just as the heart relies on much larger arteries. Keeping those arteries healthy will help your eyes.

What Should I Focus On for Eye-Healthy Eating?

Orange-colored vegetables and fruits with vitamin A

Perhaps the best-known eye-healthy nutrient is vitamin A. Your retina needs plenty of vitamin A to help turn light rays into the images we see. Also, without enough vitamin A, your eyes can’t stay moist enough to prevent dry eye. Carrots are a well-known source of vitamin A. Sweet potatoes provide even more vitamin A, Dr. Taylor said. “A sweet potato has more than 200 percent of the daily dose of vitamin A doctors recommend.” Fruits, including cantaloupe and apricots, can be a good source of vitamin A.

Fruits and veggies rich in Vitamin C

Vitamin C is critical to eye health. As an antioxidant, vitamin C helps protect the body from damage caused by some things we eat, unhealthy habits and environmental factors. Fried foods, tobacco smoke and the sun’s rays can produce free radicals — molecules that can damage and kill cells. Vitamin C helps repair and grow new tissue cells. Good sources of vitamin C include citrus fruits, such as oranges, tangerines, grapefruit and lemons. Lots of other foods offer vitamin C, including peaches, red bell peppers, tomatoes and strawberries. Antioxidants can prevent or at least delay age-related macular degeneration (AMD) and cataracts, according to the Age-Related Eye Diseases Study (AREDS).

Vitamin E

Another important antioxidant is vitamin E, which helps keep cells healthy. Vitamin E can be found in avocados, almonds and sunflower seeds.

Cold-water fish with omega-3 fatty acids

Diets rich in omega-3 fatty acids from cold-water fish may help reduce the risk of developing eye disease later in life, research suggests. These fish include salmon, tuna, sardines, halibut and trout. “Omega-3’s are good for tear function, so eating fish may help people with dry eye,” Dr. Taylor said.

Leafy green vegetables rich in lutein and zeaxanthin

Lutein and zeaxanthin are antioxidants found in the pigments of leafy green vegetables and other brightly colored foods. They are key to protecting the macula, the area of the eye that gives us our central, most detailed vision. Kale and spinach have plenty of these nutrients. Other foods with useful amounts of lutein and zeaxanthin include romaine lettuce, collards, turnip greens, broccoli and peas. And while not leafy and green, eggs also are a good source of these nutrients.

Beans and zinc

The mineral zinc helps keep the retina healthy and may protect your eyes from the damaging effects of light. However, zinc can lower the amount of copper in your body, which we need to help form red blood cells. Fortunately, you can increase both at once with all kinds of beans (legumes), including black-eyed peas, kidney beans and lima beans.  Other foods high in zinc include oysters, lean red meat, poultry and fortified cereals.

Should I Get Eye-Healthy Nutrients Through Vitamin Supplements?

Eating the right food is the best way to get eye-healthy nutrients, Dr. Taylor said. “In general, most Americans can and should get enough nutrients through their diet without needing to take supplements.”

People who have macular degeneration are an exception. “In this case, taking supplements is recommended by the Age Related Eye Disease Study 2, a follow-up to the AREDS (Age-Related Eye Disease) Study. Talk with your ophthalmologist if you or a family member has AMD,” Dr. Taylor said.

No matter your age, it’s not too late to start eating healthy, she said. “So many of my patients focus on a healthy diet only after they’ve been diagnosed with a serious health problem. Start eating well now to benefit your vision and your health for the rest of your life.”

How Does the Labor Shortage Impact Value-Based Care?

By Reshma Beharry, DHA

How does your organization align with the value-based model for the future in the midst of the labor crisis? Value-Based Care (VBC) is a healthcare delivery model under which providers — hospitals, labs, doctors, nurses and others — are paid based on the health outcomes of their patients and the quality of services rendered. Through financial incentives and other methods, value-based care programs aim to hold providers more accountable for improving patient outcomes while also giving them greater flexibility to deliver the right care at the right time. The transitioning from a volume-based to a value-based model can have many limitations as well as benefits. Once executed successfully, there are many benefits to be derived from the transition from volume-based to value-based. However, there continues to be a major setback: labor. While staff shortages existed pre-pandemic, we are now experiencing a combination of unprecedented labor pressures, a smaller pipeline of healthcare graduates, complicated care reforms and an aging population — propelling the industry into an ongoing crisis. There are also key elements such as burnout and depression within the healthcare workforce.

At the heart of the VBC models is a robust, team-oriented approach, often led by the patient’s PCP. Patients are not left to navigate the healthcare system on their own. The multidisciplinary care team may include case managers, mental health specialists, social workers, pharmacists, dieticians, educators, psychologists, health coaches, administrators and others. While not all team members provide direct medical care, they work together with the patient and caregivers to help identify and address each patient’s healthcare needs. Teams are expected to focus on prevention, wellness, strategies and coordination throughout the care continuum — priorities especially important for those managing chronic conditions.

The benefits of VBC include improving operating costs to deliver care more efficiently and effectively. As hospitals eliminate waste, improve quality and reduce costs, they will increase patient volume. Attracting a high volume of patients is the key to counterbalancing loss

of volume that comes with a value-based system. Payers will recognize that a particular hospital is a top performer, and it will be included in their networks. The benefits from the EMR applications once implemented successfully will be tremendous once it is being fully utilized.

Shifting focus from volume to value is a central challenge. The advancements in technology and electronic medical records can have significant advantages such as reducing medical errors, eliminating unnecessary and repetitive procedures, and organizing medical records. If the quality of care is continuously being improved, then the patient’s outcomes are being improved, financial status is improved, the number of readmissions is drastically reduced, and the image of the healthcare organization improves. Periodically, the standards and the performance must be measured and improvements must be made where necessary. With labor in short supply and workforce engagement suffering, automation of tasks can reduce administrative burdens to help clinicians focus on care. Organizations must deploy technology that works for clinicians — not against them — to enhance engagement and provide resources to ease their workload. Improvements in care coordination, quality and patient satisfaction must be ongoing.

There will always be some changes in any healthcare organization since the healthcare industry is dynamic and is constantly changing. A continuous-improvement goal-setting process based on lean principles should help healthcare organizations achieve higher levels of satisfaction and productivity.

Dr. Reshma Beharry, DHA, is the Doctor of Healthcare Administration at Healthcare Administrative Consultants, with over 15 years of experience in healthcare, clinical operations and finance. She received her DHA from Walden University, and her published doctoral research is on “Antibiotics and the Quality of Life for People Over 65 years.” Dr. Beharry is a member of the ACHE and the Bexar County Medical Society.

Does Having a “Y” Chromosome Make Being an Expert in Women’s Health an Oxymoron?

By Timothy C. Hlavinka, MD

The year was 1982. I was a sophomore med student. We were in Corpus Christi visiting my in-laws when my mother-in-law sat me down at the kitchen table early one morning before anyone was awake. "Tim, I think I'm going through menopause (she was 41 at the time), but the doctors say I'm crazy and it won't happen for another 10 years!" She listed her symptoms ... night sweats, hot flashes, vaginal dryness, low libido, lack of energy, difficulty focusing — so from me, "Gretchen, it sure sounds like menopause to me. Let me research it and get back with you." I have noted that it is a wise practice to listen very carefully to one's mother-in-law, and pay close attention to what is being said. This was my first and most critical introduction into the uniqueness of the menopausal experience in women, and in the need to provide assiduous personal research, data analysis, and draw my own conclusions.

I researched it. The contemporary Ob/Gyn textbooks and journals were not much help. There was little there to guide me in counseling her. It would be decades until the dearth of high-quality research into women's health issues came into public awareness. Fast forward to 1996, my fifth year in practice. My spouse (also 41 at the time) began having symptoms of early menopause. We struggled to find someone

to believe her that it was possible; her mother having gone through the same process at the same time did not seem to register at all with any of the providers. Thus, began what became an all too familiar pat on the hand moment, with the statement, "It must be something else, but we don't know what it is exactly." From me, "Could it be menopause? Her mother went through the same thing at the same age?" Another tsk tsk moment, "Doctor, why don't you focus on being a husband and not a doctor, and let us be her doctors?" I will not communicate what went through my mind at the time, but it was not pretty.

National Institutes of Health (NIH) began the Women's Health Initiative (WHI) studies in 1991. The studies would proceed for 15 years. 160,000 women ages 50-79 were studied. The cost was enormous at the time. The findings were first released in 2002. The hubris and bias of the members of the NIH panel that leaked the findings about breast cancer increases in women on HRT to the Washington Post have been well-documented. Wanting no part of scientific analysis absent their own interpretation of the data, the results exploded in the media and frightened women stopped their hormones immediately without consulting their doctors.

At that time, my practice had a large number of women with pelvic floor disorders and prolapse, incontinence, recurrent UTIs and interstitial cystitis, all of whom had significant improvements in their clinical conditions and symptoms with HRT. Within weeks of stopping their hormones, they began coming in with worsening symptoms and prolapse. I struggled to find a provider locally sympathetic to the plights of these women. I found two organizations, North American Menopause Society (NAMS) and International Society for the Study of Women's Sexual Health (ISSWSH), that were doing independent data analysis of the WHI and countering the clinical recommendations made from the findings. The controversy continued despite evidence of the flawed data analysis and recommendations made from same by the NIH.

What happened next is best summed up by the referral of a patient from a local internist, "Go see Hlavinka, he's the only one I know that will give you THAT STUFF!" As if I were prescribing anabolic steroids, or worse. I studied. I researched. I learned. I attended meetings of ISSWSH and NAMS. I documented outcomes. Those were lonely days for HRT prescribers.

Ultimately enough light was shed on the flaws of the WHI, but its impact on women and providers' thinking persists. What I know for certain is that every single woman that comes in my office has a unique experience with peri-menopause and menopause, and their care must be approached with an individuality that reflects that experience. Each woman is an N=1 in my practice. That unique approach has privileged me to be able to discover a number of women with premature ovarian insufficiency. The youngest is 21. It is not at all uncommon to find the condition in women in their 20s currently.

I have daughters now, thus initiating the third phase of my keen interest in women's health. One can only hope that First Lady Jill Biden's initiative on research in women's health begins to overcome that lack of gender appropriate and pertinent research. It is far past time for it.

For additional reading: www.whitehouse.gov/briefing-room/ statements-releases/2024/03/18/fact-sheet-president-biden-issuesexecutive-order-and-announces-new-actions-to-advance-womenshealth-research-and-innovation/

Timothy C. Hlavinka, MD, is the Medical Director of Vidamor Medical and has been a member of the Bexar County Medical Society for three decades. The father of five and grandfather of four, he firmly believes that the power of collegiality among physicians has great potential to bring us lasting and effective changes in healthcare. Dr. Tim is anxious to hear your stories.

Dr. Ferdinand Ludwig Herff:

A True Pioneer

By Gabriella Bradberry

In 1850, German physician, Ferdinand Ludwig Herff, immigrated to San Antonio, Texas, where he would establish himself as one of the most significant medical pioneers in Texas history. Throughout his 60-year career, Dr. Herff built a legacy trademarked by a myriad of surgical feats, the establishment of medical practices and organizations, and his role as a civic leader.

Dr. Herff’s historic chronicle began in 1820 Germany, his birthplace and the setting of his adolescence. It was there that he received his education, studying under influential medical scientists, observing and learning techniques that would soon fuel his own innovations. In 1843, he demonstrated dexterity for treating tuberculosis and amputations as a surgeon in the Hessian Army. Eventually in 1847, the political climate in Germany urged Dr. Herff to relocate to new frontiers; thus, he began his career as a medical pioneer in San Antonio, Texas.

Long before the days of modern advancements and urban development, San Antonio did not boast the major hospital systems it has today, and surgical operations were not yet common practice in Texas. As a result of this early stage of medical evolution, many Texans were fearful of surgical intervention, much to the distress of doctors and patients alike.1 Nonetheless, Dr. Herff knew an able surgeon such as himself could save countless lives and continued the pursuit to help all he could.

Prior to today, doctors did not dedicate their careers to a singular specialty. Dr. Herff was a prime example of this, essentially practicing everything that piqued his interest. As a result, his surgical resume is filled with feats from many different medical areas such as reconstructive plastic surgery, ophthalmology, gynecology and beyond.

Dr. Herff’s career was filled with many firsts. He was one of the first surgeons in the United States to successfully perform a hysterectomy, execute an appendectomy, recognize hookworm, and perform vision-repairing cataract operations.2 Not only did he perform surgeries from expansive areas of medicine, but his operations also took place at any available location; due to necessity and lack of operating rooms, Dr. Herff was known to perform surgery in patients’ homes, out in the open public, and even famously, the Menger Hotel lobby.

One of his most notable accomplishments occurred during an operation in front of the San Fernando Cathedral.3 Onlookers watched as Dr. Herff performed a cataract removal operation on a Lipan Apache chief as his assistants fanned away flies. Undeterred by

Dr. Ferdinand Ludwig Herff, 1820 – 1912 Courtesy of Patrick Heath Public Library

the unfavorable conditions, Dr. Herff ultimately was able to restore the formerly blind chief’s vision. Years later, this achievement would be further recognized and honored by Lipan warriors. Despite invading neighboring land, the warriors shot an arrow with a white feather onto Dr. Herff’s property as a testament of continuous great respect for the doctor.2

Such respected operations granted Dr. Herff a reputation that preceded him. At the beginning of Dr. Herff’s Texas medical career, he had to fight local superstitions that viewed hospitals solely as a place to die rather than receive treatment. What made Dr. Herff stand out as an agent of change and gain public trust was his high success rate. During Dr. Herff’s time working for the Hessian army, he was able to observe correlations between surgical sanitation and lowered rate of patient infection. As a result, Dr. Herff was known for his copious

use of soapsuds and became a trailblazer in antiseptic surgery.1 During a time where surgeons washed their hands solely after an operation rather than before, his hygiene regimen was revolutionary and yielded a high surgical survival rate.

Dr. Herff was able to evolve the local mindset to view surgery in a positive light, and soon his waiting room was consistently filled with patients eager to meet him. Not only was Dr. Herff notable for his surgical successes, his compassion for the less fortunate had patients flocking from as far as 100 miles to receive lifesaving treatment. 2

Although he treated many notable patients, he was recognized for his great servitude for the indigent. For many years, Dr. Herff was unwilling to place monetary values on his services, accepting only the occasional quarter for treatment. While he eventually had to establish proper billing to support his practice and family, his lasting spirit of humanitarianism remained well-known.1 It was reported in 1886 that Dr. Herff went on to perform approximately 12 percent of major operations in Texas.2

The achievements of Dr. Herff stemmed far beyond the surgical accomplishments within his individual practice. In 1853, Dr. Herff would become a charter member in the founding of the Bexar County Medical Society and Texas Medical Association. He would go on to help establish other medical organizations, serve on the Texas State Board of Medical Examiners, and function as an instrumental component in the establishment of San Antonio’s first hospital. 4

Throughout his 60-year career, Dr. Ferdinand Ludwig Herff worked tirelessly to amplify the standards of medical practice to what they are today. His impact serves as an exemplary example of innovation, perseverance and compassion. Dr. Herff’s impact remains hugely significant, establishing him as a pillar of the San Antonio community. His legacy will be eternally celebrated by both the Bexar County Medical Society and medical history.

References:

1. Herff, PF. (1973). San Antonio. In L.L. Barder (Ed.). The Doctors Herff: A Three Generation Memoir (Vol I, pp. 34-46). Trinity University Press

2. Belasco, J. (2015, Mar 2). Herff had major impact on local health care. San Antonio Express-News. https://www.expressnews. com/150years/education-health/article/Dr-Ferdinand-Herffhad-major-impact-on-local-6103351.php

3. Herff, P. III. (2023, May 11). The Herff Legacy. (Newson, M. & Vela, B.) [Personal communications]

4. Stembridge, VA. (2019, Oct 24). Herff, Ferdinand Ludwig. Texas State Historical Association Online. https://www.tshaonline. org/handbook/entries/herff-ferdinand-ludwig

Gabriella Bradberry is the Admin/Communication Specialist for the Bexar County Medical Society.

Dr. Herff (standing second from left) in surgery with his son, John (standing fourth from left). Courtesy of “The Boerne Book” by Brent Evans.

Kris King Celebrates 25 Years with BCVI

By Melody Newsom, BCMS CEO/Executive Director

Kris King, Director of Software Services for Bexar Credentials Verification, Inc. (BCVI), recently celebrated his 25th anniversary with the company. I sat down with Kris to gain insight into his long-standing service to BCVI, and his professional and personal growth over the last 25 years.

What different roles have you held at BCVI?

I started with Bexar Credentials Verification, Inc. on March 22, 1999 with the title of Vice President of Information Systems. It was a new position and the specifics of my role were, at best, fluid. At its peak, my department had five software developers. Robert “Bob” Needs was the president and founder of BCVI. Bob died unexpectedly in May of 1999. After the dust settled, Bexar County Medical Society (BCMS) stepped in to provide leadership and guidance, and the titles of “president” and “vice president” no longer seemed appropriate. My title was changed to Director of Software Services, and my “software development department” was downsized to one person. Much to my surprise, they kept me.

How have you seen Credentialing change over the last 25 years?

In 1999, Bob Needs’ vision was for BCVI to be a nationwide credentials verification organization (CVO). If you ever met Bob, there was no question that he was going to make it happen. He was truly a source of enthusiasm and encouragement. When Bob died, BCVI almost died with him. The company was in far worse shape than Bob had made known. It took five years and several changes of leadership to right the ship.

I won’t get into the changes in credentials verification, but I will say that many medical societies and CVOs have gone by the wayside over the years. For some reason, BCMS and BCVI have found favor in God’s eyes. He has blessed us with some wonderful leaders.

my absolute favorite project has been to virtualize all of our servers, and make many major upgrades in security and backups. I have a whole new appreciation for redundancy, security, isolation, redundancy, backups, replication, and redundancy.

Describe the different offices/buildings you have been in the past 25 years.

Our home for many years was on 202 West French Place, just around the corner from the San Antonio Community College. The building had a “grill” mounted to the exterior, and it wrapped all of the way around. It was the strangest building that I had ever seen.

In 2004, the building was sold with the goal of someday building a new home for BCMS. In the meantime, BCMS signed a 10-year lease in the First National Bank building at 6243 IH-10.

We moved into our beautiful new building at 4334 North Loop 1604 West in January of 2015. It is quite impressive with state-of-theart technology.

Why have you stayed for 25 years?

I realized early on that God was guiding my career path. He has always put me in the right place at the right time. My role at BCVI was tailor-made for me, although, it didn’t feel like it at first. It never gets old or boring. The people are wonderful, and it is nice to be needed and appreciated. Like any job, there are difficult seasons, but my philosophy has been that if God wants me to move on, He will make it happen.

How would you describe our company culture?

Do you have any favorite projects you’ve worked on during your time here?

In general, software and website development can be pretty rewarding, but developing a system that takes you from a file room full of paper files, to a paperless system with no file room at all was pretty exciting. It took me a while to jump on the virtualization bandwagon, but a nasty ransomware attack back in 2019 taught us some hard lessons. It was painful, and definitely a major learning curve, but

Anywhere you have people, you will have conflicts, but I have always felt valued and respected. The staff and leadership have been great. I’ll add one thing that stands out for me. I know that this might ruffle feathers for some, but BCMS and BCVI staff will gather occasionally to share a meal, and we always say grace beforehand.

What are your favorite memories from your time here thus far?

We have had some wonderful staff outings, which include golf, fishing tournaments and a Missions game. Christmas, Thanksgiving and staff birthday/anniversary parties are also great.

How has your personal life changed in the past 25 years?

My son was born shortly after my hire date, and he has recently graduated from college. I have less hair, more wrinkles and more arthritis. I will also admit that the word “retirement” has started to creep into my vocabulary. Two things that have not changed in 25 years are my keyboard and my chair. Both still work great!

Melody Newsom is the CEO/Executive Director for the Bexar County Medical Society. She has been with the company for 24 years.

Kris King, Director of Software Services, BCVI, and Melody Newsom, CEO/ Executive Director, BCMS

In Memoriam Mary Nava

November 15, 1963 - April 2, 2024

Mary Elizabeth (Cano) Nava worked in the healthcare industry in San Antonio her entire career, spending the last 24 years at the Bexar County Medical Society as the Chief Governmental Affairs Officer. She served as liaison to the BCMS Legislative & Socioeconomics Committee, BCMS Public Health & Patient Advocacy Committee, and BCMS Delegation to TMA. Mary will be greatly missed and remembered fondly by the physician members and staff.

Mary was born in Victoria, Texas on November 15, 1963, to Gloria Cano and the late Robert Cano, Sr. She graduated from Industrial High School where she was valedictorian of her class, drum major of the band and head twirler. She went on to graduate from the University of Texas in San Antonio with a Master’s Degree in Business Administration.

Mary treasured being a dedicated mom to her two children, Edward Martin Nava, Jr. and Erica Nava. In addition to her mother and her two children, Mary is survived by her loving husband of 37 years, Edward Martin Nava, Sr.; her brothers and sisters, Robert Cano, Jr. (Kailyn), Bertha Ann Villarreal (Albert), Sylvia Blessing (Robert) and David Cano (Summer); and many special nieces and nephews.

“She was a true warrior for our physicians and patients and gave countless hours of her life to this cause. My deepest condolences to her family and friends. She will always be in our thoughts and prayers.”

- Rajeev Suri, MD

“Mary was such a wonderful person and an incredible advocate for medicine. We both feel blessed that we were able to know her and work alongside her these many years.”

- Alexis Wiesenthal, MD

“Mary was a beautiful person inside and out and is not someone that can be replaced. We truly are better off for having known her and having the privilege of working with her.”

- Marcia Collins, TMA

“In the Eye of the Beholder”

Artist’s Note: Acrylic on canvas. Finding beauty and joy in life is an incredibly unique process to everyone, both physiologically in how our eyes convert light into stimuli, and personally in how we interpret what we see. I created this piece as my personal reminder to look out for the things that brought me joy.

The 1853 Club Luncheon April 2, 2024

It is always a joy to catch up with friends! The 1853 Club is one of the many benefits of being a BCMS member. This retired physician group promotes the wellbeing of retired physicians through education, socialization and peer-support. During our latest luncheon on April 2, our members met with Jeff Fair, the Vice President of Economic Development and Cybersecurity with the Greater San Antonio Chamber, who presented on the “Economic State of Our City.”

The next luncheon for the 1853 Club will take place on July 9, 2024, at 11:30 a.m. at the BCMS headquarters. Save the date for our fall 1853 Club luncheon on October 1, 2024. Spouses or guests are welcome to join.

If you are interested in receiving information about this and other 1853 Club events, please contact the BCMS Membership Department at 210-301-4371 or membership@bcms.org.

Public Health Fest: Celebrating National Public Health Week

On Thursday, April 4, 2024, BCMS physicians, medical students and BCMS Alliance members participated in Metro Health’s Annual Public Health Fest at Mission County Park with the BCMS “Ask a Doctor” booth. The BCMS Alliance gave away bicycle helmets with bicycle safety tips, and BCMS passed out documentation on Child Immunization and Vaccination Hesitancy. There was live entertainment by McCollum high school’s Mariachi Band, refreshments, giveaways and more.

Each year during the first week of April, the City of San Antonio Metropolitan Health

District (Metro Health) celebrates National Public Health Week. This is a time to recognize the contributions of public health and highlight issues that are important in our community. This year’s national theme is “Protecting, Connecting and Thriving: We Are All Public Health,” emphasizing the importance of relationships and collaborations to meet the goals of public health

Special thanks to Julia Halvorsen and Jenny Shepherd from the BCMS Alliance, Dr. John Nava, BCMS Immediate Past President, Dr. Leah Jacobson, BCMS Past

President, and medical students from both UIW and Long School of Medicine, including Geoffrey Deckard, Gisela Ortega, Carlos Alvarado and Cristian Castaneda.

For more information on National Public Health, visit www.sa.gov/health.

For Vaccination Hesitancy Information and COVID-19 information, visit the BCMS website at www.bcms.org/CVMEL.php.

2024 Fiesta Kick-Off Paint and Sip Mixer

The Bexar County Medical Society hosted the 2024 Fiesta KickOff Paint and Sip Mixer at Kinected Coworking. Several physicians, medical students, practice managers and Circle of Friends members joined the event.

This event offered an opportunity to network and learn about each other’s professions and services of our Circle of Friends members. The evening ended with a fun painting session that everybody enjoyed. Looking forward to 2025!

THANK YOU

Shop Businesses Who Support BCMS

BCMS Business Directory

We encourage you to use our friends of medicine businesses whenever you or your practice need supplies or services.

ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor)

Sol Schwartz & Associates is the premier accounting firm for San Antonio-area medical practices and specializes in helping physicians and their management teams maximize their financial effectiveness.

Christopher Davis, CPA 210-384-8000, ext. 118 cdavis@ssacpa.com

www.ssacpa.com

“Dedicated to working with physicians and physician groups.”

ASSET WEALTH MANAGEMENT

Aspect Wealth Management (★★★ Gold Sponsor)

We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

Michael Clark, President 210-268-1520

mclark@aspectwealth.com

www.aspectwealth.com

“Your wealth. . .All aspects”

BANKING

Broadway Bank (HHH Gold Sponsor)

Healthcare banking experts with a private banking team committed to supporting the medical community.

Thomas M. Duran

SVP, Private Banking Team Lead 210-283-6640

TDuran@Broadway.Bank

www.broadwaybank.com

“We’re here for good.”

The Bank of San Antonio (HHH Gold Sponsor)

We specialize in insurance and banking products for physician

groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Brandi Vitier 210-807-5581

brandi.vitier@thebankofsa.com

www.thebankofsa.com

Amegy Bank of Texas (HH Silver Sponsor)

We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Robert Lindley

SVP | Private Banking Team Lead 210-343-4526

Robert.Lindley@amegybank.com

Denise Smith

Vice President | Private Banking 210-343-4502

Denise.C.Smith@amegybank.com

Scott Gonzales

Assistant Vice President | Private Banking 210-343-4494

Scott.Gonzales@amegybank.com

www.amegybank.com

“Community banking partnership”

Synergy Federal Credit Union (HH Silver Sponsor)

Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

Synergy FCU Member Services

210-750-8333

info@synergyfcu.org

www.synergyfcu.org

“Once a member, always a member. Join today!”

CLINICAL DIAGNOSTICS

Genics Laboratories (HHH Gold Sponsor)

Genics Laboratories offers accurate, comprehensive and reliable results to our partners and patients. Genics Laboratories is committed to continuous research, ensuring our protocols are always at the peak of current technology.

Yulia Leontieva Managing Partner, Physician Liaison

210-503-0003

yulia@genicslabs.com

Kevin Setanyan Managing Partner

210-503-0003

kevin@genicslabs.com

Artyom Vardapetyan Managing Partner

210-503-0003

www.genicslabs.com

“Accurate results in record time.”

Livingston Med Lab (HH Silver Sponsor)

High Complexity Clia/Cola accredited Laboratory providing White Glove Customer Service. We offer a Full Diagnostic Test Menu in the fields of Hematology, Chemistry, Endocrinology, Toxicology, Infectious Disease, & Genetics.

Robert Castaneda, CEO

210-316-1792

Robert@livingstonmedlab.com

www.livingstonmedlab.com/home “Trusted Innovative, Accurate, and STAT Medical Diagnostics”

CREDENTIALS VERIFICATION ORGANIZATION

Bexar Credentials Verification, Inc. (HHHH 10K Platinum Sponsor)

Bexar Credentials Verification Inc. provides primary source verification of credentials data that meets The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) standards for healthcare entities.

Betty Fernandez Director of Operations

210-582-6355

Betty.Fernandez@bexarcv.com

www.BexarCV.com

“Proudly serving the medical community since 1998”

FINANCIAL ADVISORS

Oakwell Private Wealth Management

(HHH Gold Sponsor)

Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor

512-649-8113

SERVICE@OAKWELLPWM.COM

www.oakwellpwm.com

“More Than Just Your Advisor, We're Your Wealth Management Partner”

Elizabeth Olney with Edward Jones (HH Silver Sponsor)

We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney Financial Advisor

210-858-5880

Elizabeth.olney@edwardjones.com

www.edwardjones.com/elizabeth-olney

"Making Sense of Investing"

FINANCIAL SERVICES

Aspect Wealth Management (HHH Gold Sponsor)

We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

Michael Clark, President 210-268-1520

mclark@aspectwealth.com

www.aspectwealth.com

“Your wealth. . .All aspects”

Hancock Whitney (HHH Gold Sponsor)

www.hancockwhitney.com

Since the late 1800s, Hancock Whitney has embodied core values of Honor & Integrity, Strength & Stability, Commitment to Service, Teamwork, and Personal Responsibility. Hancock Whitney offices and financial centers in Mississippi, Alabama, Florida, Louisiana, and Texas offer comprehensive financial products and services, including traditional and online banking; commercial, treasury management, and small business banking; private banking; trust; healthcare banking; and mortgage services.

John Riquelme

San Antonio Market President 210-273-0989

John.Riquelme@hancockwhitney.com

Larry Anthis

Corporate Banking, Relationship Manager

210-507-9646

Larry.Anthis@hancockwhitney.com

Serina Perez

San Antonio Business Banking

210-507-9636

Serina.Perez@hancockwhitney.com

Erik Carrington

Texas Regional Wealth Management Manager 713-543-4517

Erik.Carrington@hancockwhitney.com

GERIATRICS/PRIMARY CARE

Conviva Care Center (HHH Gold Sponsor)

Conviva’s value-based care model allows physicians to deliver high quality, personalized care and achieve better outcomes, while feeling free to focus on health equity and patient outcomes.

Kim Gary

Senior Physician Recruiter 812-272-9838

KGary4@humana.com

www.ConvivaCareers.com

“Fuel Your Passion & Find Your Purpose”

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD

Anderson Cancer Center (HHH Gold Sponsor)

UT Health provides our region with the most comprehensive care through expert, compassionate providers treating patients in more than 140 medical specialties at locations throughout San Antonio and the Hill Country.

UT Health San Antonio Physicians

Regina Delgado

Business Development Manager

210-450-3713

delgador4@uthscsa.edu

UT Health San Antonio MD

Anderson Mays Cancer Center

Laura Kouba Business Development Manager 210-265-7662

norriskouba@uthscsa.edu

https://uthscsa.edu/

Appointments: 210-450-1000

UT Health San Antonio 7979 Wurzbach Road

San Antonio, TX 78229

HOSPITALS/ HEALTHCARE SERVICES

Equality Health (HHH Gold Sponsor)

Equality Health deploys a wholeperson care model that helps independent practices adopt and deliver value-based care for diverse communities. Our model offers technology, care coordination, and hands-on support to optimize practice performance for Medicaid patients in Texas.

Cristian Leos

Network Development Manager

210-608-4205

cleos@equalityhealth.com

www.equalityhealth.com

“Reimagining the New Frontier of Value-Based Care.”

HR HUMAN RESOURCES

Insperity (★★Silver Sponsor)

Insperity’s HR solutions offer premium service and technology to facilitate growth by streamlining processes related to payroll, benefits, talent management and HR compliance. We provide the tools to help you lighten your administrative load, maximize productivity and manage risks – so you can focus on growth.

Fran Yacovone

Business Performance Advisor

210-558-2507

fran.yacovone@insperity.com

Dayton Parker Business Performance Advisor

210-558-2517

dayton.parker@insperity.com

www.insperity.com

“Insperity’s mission is to help businesses succeed so communities prosper”

INSURANCE

TMA Insurance Trust

(HHHH 10K Platinum Sponsor)

TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a complimentary insurance review. It will be our privilege to serve you.

Wendell England

Director of Member Benefits

512-370-1776

wendell.england@tmait.org

800-880-8181

www.tmait.org

“We offer BCMS members a free insurance portfolio review.”

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor)

With more than 20,000 healthcare professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of healthcare for patients by educating, protecting, and defending physicians.

Patty Spann

Director of Sales and Business Development

512-425-5932

patty-spann@tmlt.org

www.tmlt.org

“Recommended partner of the Bexar County Medical Society”

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor)

We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Katy Brooks, CIC 210-807-5593

katy.brooks@bosainsurance.com

www.thebankofsa.com

“Serving the medical community.”

MedPro Group (HH Silver Sponsor)

Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more.

Kirsten Baze, RPLU, ARM

AVP Market Manager, SW Division 512-658-0262

Fax: 844-293-6355

Kirsten.Baze@medpro.com

www.medpro.com

IT – TELEMEDICINE SERVICES

LASO Health Telemedicine and Rx App (★★★ Silver Sponsor)

LASO Health is the industry’s only solution that makes health care

services accessible, cost-transparent and convenient. Its mission is to reinvent “health care” in the United States by empowering every individual and employer, insured or uninsured to have easy, timely, predictable, cost-effective care.

LASO combines an intuitive, mobile superapp with a marketplace of virtual and in-person health services to give customers a one-touch, onestop-shop, comprehensive health solution.

Ruby Garza, MBA

210-212-2622

rgarza@texaskidneycare.com

www.lasohealth.com

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HH Silver Sponsor)

From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol

210-413-8079

tom.rosol@henryschein.com

www.henryschein.com

“BCMS members receive GPO discounts of 15 to 50 percent.”

PHYSICIAL SUPPORT SERVICES

Provider's Choice Scribe Services (★★★ Gold Sponsor)

Our accurate and complete documentation helps our customers focus on what’s most important, their patients. Let us take on the task of documenting your patient encounters, it’s what we do.

Yoceline Aguilar COO

915-691-9178

yaguilar@pcscribes.com

Luis Chapa

MD/CEO

210-796-4547

lchapa@pcscribes.com

www.providerschoicess.com

“An Unparalleled Scribe Experience”

BCMS Business Directory

PRACTICE MANAGEMENT

Equality Health (★★★ Gold Sponsor)

Equality Health deploys a wholeperson care model that helps independent practices adopt and deliver value-based care for diverse communities. Our model offers technology, care coordination, and hands-on support to optimize practice performance for Medicaid patients in Texas.

Cristian Leos

Network Development Manager 210-608-4205

cleos@equalityhealth.com

www.equalityhealth.com

“Reimagining the New Frontier of Value-Based Care.”

PROFESSIONAL ORGANIZATIONS

Healthcare Leaders of San Antonio (HH Silver Sponsor)

We are dedicated to nurturing business connections and professional relationships, exchanging knowledge to enhance leadership, and creating career opportunities for healthcare and other industry leaders in a supportive community.

David Neathery

President 210-797-8412

healthcareleaderssa@gmail.com

Gary Meyn, LFACHE

Vice President 210-912-0120

gmeyn@vestedbb.com

https://healthcareleaderssa.com/ “Come, Learn, Connect!”

The Health Cell (HH Silver Sponsor)

“Our Focus is People”

Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

Kevin Barber

President 210-308-7907 (Direct) kbarber@bdo.com

Valerie Rogler Program Coordinator 210-904-5404

Valerie@thehealthcell.org

www.thehealthcell.org

“Where San Antonio’s Healthcare Leaders Meet”

San Antonio Medical Group Management Association (SAMGMA) (HH Silver Sponsor)

SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

Jeannine Ruffner President info4@samgma.org www.samgma.org

RETIREMENT PLANNING

Oakwell Private Wealth Management (★★★ Gold Sponsor)

Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community.

Brian T. Boswell, CFP® QKA Senior Private Wealth Advisor 512-649-8113

SERVICE@OAKWELLPWM.COM

www.oakwellpwm.com

“More Than Just Your Advisor, We're Your Wealth Management Partner”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor)

Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Mike DeQuattro

Director of Operations - Texas & New Mexico

210-918-8737

Mike.DeQuattro@ favoritestaffing.com

“Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

Eleos Virtual Healthcare Solutions (HH Silver Sponsor)

Empowering physicians for a Balanced Future. Our virtual health associates alleviate administrative burdens in the evolving healthcare landscape, combatting burnout. Join us in transforming healthcare delivery, prioritizing your wellbeing and patient care.

Pedro Caretto, VP of Business Development

786-437-4009

pcaretto@eleosvhs.com

www.eleosvhs.com

TRANSCRIPTION SERVICES

Provider's Choice Scribe Services (★★★ Gold Sponsor)

Our accurate and complete documentation helps our customers focus on what’s most important, their patients. Let us take on the task of documenting your patient encounters, it’s what we do.

Yoceline Aguilar COO

yaguilar@pcscribes.com 915-691-9178

Luis Chapa MD/CEO

210-796-4547

lchapa@pcscribes.com

www.providerschoicess.com/ “An Unparalleled Scribe Experience”

2023 BMW M440i

By Stephen Schutz, MD

BMW M440i Gran Coupe, European Model shown

As we march inexorably towards a plug-in automotive future, it’s worth pausing here and there to recognize notable internal combustion engines.

In fact, it’s worth taking a moment to recognize internal combustion engines in general. Somehow these amazing contraptions work by injecting mixtures of gasoline and air into three, four, six, eight or more combustion chambers under high pressure, ignite those mixtures causing a series of explosions, then use the energy released by those explosions to move a 4000lbs vehicle forward at speeds that can comfortably exceed 100MPH. And these engines do this so safely and with so much reliability that we never give what they’re doing a thought. As internal combustion engines begin to fade away, I hope we appreciate how much they’ve given us over the 100 years or so that we’ve had them.

The notable engine I’d like to highlight in this review is the BMW in-line six-cylinder engine. While BMW’s straight sixes didn’t really register in this country until the introduction of the first generation 5-series sedan in the USA in 1975, the venerable Bavarian company actually introduced its first in-line six in 1933.

Still, it was the classic late ‘70s 530i sedan that catapulted BMW into the U.S. luxury car market mainstream, and the classic 3.0L in-line six with its otherworldly smoothness and unique sound was the main reason why.

Fast forward 49 years and the BMW straight-six engine still rules, in this case boosted by turbocharging and sitting in the 2023 M440i coupe. Amazingly, the much-evolved version of BMW’s classic motor now produces 382HP, thanks not just to twin turbochargers but also to a 48-volt mild hybrid assistance system. Plus, all that now gets you impressive fuel economy of 22MPG City and 31MPG Highway. Lest you think that’s no big deal, allow me to remind you that the 1975 530i was able to muster just 174HP with discouraging fuel economy figures of 16MPG City and 18MPG Highway. And of course, all 1970s engines polluted much more than modern versions do.

Not surprisingly, the M440i coupe is fast, as evidenced by a 5.2 second zero-to-sixty MPH time, and it handles and brakes well, too. I once owned a 2018 M3, and the “not a real M-car” M440i felt almost as fast as that wonderful car in all circumstances. I guess I’d say that unless an extra five to 10 percent of performance and a few M-emblems are important to you, save the additional $16,000 or so that the M4 costs and get the M440i.

One amusing side note: in the 1970s, racing BMWs sported a bespoke BMW M-badge that told the world that this was a “true” M-car that raced. Over the years many very special BMW M-cars for the street have come and gone, but none ever got to wear that badge, including the two M3s I owned. My test M440i car had it, and I wish it didn’t. Sigh…

The M440i’s exterior design is very good. The folded, almost origami, sheet metal looks muscular, and the front- and tail-light modules are as contemporary as anything for sale today. BMW’s iX and XM SUVs

have been criticized for being too Avant guard for their customers, but that’s not a problem for the 4-series. It’s a good-looking car.

Unless you don’t like the “beaver teeth” grille. I like it, especially on the very handsome M3 sedan, but some observers don’t, so make sure you take a good look before you click on “buy it now.” It’s not an understated design element.

The M440i’s interior is standard BMW fare, which is to say excellent. Everything is right where you left it the last time you were in another BMW, and I like that. Keeping things familiar is to be applauded and, let’s be honest, BMW has solved the problem of putting things that need to be in the touchscreen menus there, and keeping things that should be buttons and knobs there. Thank you, BMW. And thank you Audi, too, for convincing BMW that gauges should have black backgrounds, white numbers and red needles. That also works.

The BMW M440i is a fast, stylish coupe, which I am happy to recommend enthusiastically. The fact that it features one of the last classic BMW in-line six-cylinder internal combustion engines is just a bonus (I would say, a big bonus). No electric vehicle can ever have that “Riz.”

As always, BCMS’ Phil Hornbeak will help you get the best deal on any new car or truck you want. Call him at 210-301-4367.

Stephen Schutz, MD, is board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine magazine since 1995.

Kahlig Auto Group

11911 IH 10 West San Antonio, TX 78230

Coby Allen 210-696-2232

Audi Dominion 21105 West IH 10 San Antonio, TX 78257

Anthony Garcia 210-681-3399

Northside Ford 12300 San Pedro San Antonio, TX

Marty Martinez 210-477-3472

Kahlig Auto Group

North Park Lexus at Dominion 25131 IH 10 W Dominion San Antonio, TX

James Cole 210-816-6000

Kahlig Auto Group

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Raymond Rangel 210-308-0200

Northside Honda 9100 San Pedro Ave. San Antonio, TX 78216

Jaime Anteola 210-744-6198

Kahlig Auto Group

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Domingo Saenz 210-341-3311

14610 IH 10 West San Antonio, TX 78249

Tim Rivers 832-428-9507

Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX

William Boyd 210-859-2719

Land Rover San Antonio 13660 IH 10 West San Antonio, TX

Cameron Tang 210-561-4900

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave. New Braunfels, TX 78130

Matthew C. Fraser 830-606-3463

Kahlig Auto Group

North Park Lexus 611 Lockhill Selma San Antonio, TX

Jose Contreras 320-308-8900

North Park Lincoln 9207 San Pedro San Antonio, TX

Sandy Small 210-341-8841

Kahlig Auto Group

North Park Subaru at Dominion 21415 IH 10 West San Antonio, TX 78257

Phil Larson 877-356-0476

Mercedes Benz of Boerne 31445 IH 10 West Boerne, TX

James Godkin 830-981-6000

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

Chris Martinez 210-366-9600

Kahlig Auto Group

9455 IH 10 West San Antonio, TX 78230

Jordan Trevino 210-764-6945

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Spencer Herrera 210-581-0474

North Park Toyota 10703 Southwest Loop 410 San Antonio, TX 78211

Justin Boone 210-635-5000