Lecture: Cybersight Consult Best Practices + Case Presentations

This Live Lecture covers the following Cybersight topics:

• How to get a second opinion from an international sub-specialty expert
• International best practices for case presentation and history
• Mandatory vs. optional examination details for different case types
• How to add photos, videos and report attachments

Lecturer: Dr. Daniel Neely


(To translate please select your language to the right of this page)

DR DANIEL NEELY: Well, good morning. I’m Daniel Neely. I’m hosting today’s Cybersight webinar. Today is going to be a little bit different. Today is going to be an overview of not really just what Cybersight is, but giving you some tips as to how to use it better, so that it’s working better for you, and you’re getting what you need out of it. Let me bring up kind of an overview of what we’re going to do today. I’m a pediatric ophthalmologist at Indiana University. Also I’ve been a long time Orbis volunteer faculty member, I’ve been about 20 weeks overseas, in different places, and I’ve answered about a thousand of these consults. And I’ve done this for about 15 years, and I’m one of the consultants to the Orbis/Cybersight system. So I have a pretty good idea of how this works. But what I don’t always have a good idea of is… What do you need? What do you need differently from us? And what can we do to make things work better for you? So I would urge you today to try to send those questions to us today, and I’ll try to field questions. First of all, I’m gonna give you an overview of what Cybersight consult is, and some of the mechanics of how it works so you can understand it. And then we’ll talk about what makes a good consult. What information is critical. We won’t spend a lot of time on that, but I want to point out a few features of the consult system that you can take advantage of, specifically. Maximizing things like photos, attachments, videos, other files. So I’ll give you some demonstrations of how that really can impact the quality of the case. I also want to talk about this concept of private and public cases, and how you can search for cases, so that you can look for things that are of interest to you. So even if you’re not the one giving a consult, or asking for an opinion, you can see what other people have asked, and you can learn from that as well. And I think that’s a really valuable tool. We will talk about a couple interesting cases, and there’ll be a little slight question and answer with that. For educational purposes. But mostly I’m doing that to kind of highlight what some really nice consults look like. And what the strengths of them are. And then I’ll walk you through some of the new features that we have with discussion forum, the learn teaching courses, and then the library resources. You’ll notice that the Cybersight website looks different than it used to. So this is something that’s been evolving for the past five years, and it’s now going on to the next phase, where you’re gonna see a lot of new material being presented to you, a new format, and specifically some interactive things that I think you’ll find interesting. First of all, let me go on to ask you a question. One of our standard questions here. Poll question number one. Poll question number one is going to be… Who are you? I want to get an idea of who everyone out there is. Are you in a mixed group? In a room with a bunch of people? Are you an ophthalmologist? Are you an ophthalmologist in training? Whether that’s registrar or resident, fellow, or student? Nurse? Or an optometrist? And so all of you can vote on that now. And we’ll go ahead and show you the results of that. All right. So as is typical, most of us are ophthalmologists or ophthalmologists in training. We do have some optometrists today. Which I think is great. Sort of a new area for Orbis. And something we’ll see expanded. We should have some optometrist-specific webinars coming up in a few months. So we’ll close out that poll. One other thing. Let’s get a feel for if anyone has submitted consults before. Have you ever submitted a Cybersight consult or question before? Very easy. Yes or no. While you’re answering that, I’ll mention something to you, which I think is quite fascinating. And that is that about 50% of you have been joining us on mobile platforms. Smartphones. And I think this is really telling, as to where Cybersight is going in the future. And this is something that we’re keenly aware of. And we’re moving forward to maximize your mobile experience. So if things don’t work on mobile or we need to fix something, let us know and we’ll take care of it. So most of us actually have not submitted a consult before. So this is a perfect audience. I’m gonna show you just how easy this is, and what a powerful tool it is to aid you in education, patient care, something for the whole eyecare team coming up here. Okay. So we’ll close that out. Let me tell you briefly just who you’re dealing with, when you submit a consult. The volunteer faculty members for Orbis are people like me. Typically, they’re experienced academic physicians. Most typically they are subspecialists who are fellowship trained. Everyone has a minimum of five years experience, postresidency. Most of our Cybersight mentors have also been in the field. They’ve been in the places where you work. And have worked in your hospitals, or have been out on the flying eye hospital. And so they know what the situation is, most of the time. These people, again, they’re all volunteers. No one is paid to do these consultations that you send in. And I don’t really like that term, consultation. Because these aren’t really — you being told what to do. This is an educational process. You send a mentor some information. And tell that mentor what you think you’re doing. Or want to do. And that mentor looks at that, maybe asks you some questions, and then gives you some advice. Now, you don’t have to do what that mentor says. You can do whatever you want. And that’s the beauty of it. But at least it’s like having a second opinion. And when I was early in my career, and in fact, still now, I’ve been doing this 20 years, but there are times that I’ll go to one of my senior partners and say — would you look at this? Does that all make sense? Am I on the right track? Does my plan — what I’m intending to do here — make sense? Or would you do something different? So I don’t think any of us are ever at a point where we’re beyond asking advice. Whether it’s a simple case or a complicated case. That just depends on where you are in your training. Again, all these questions are valid. And we should take advantage of this free resource. I mean, this is amazing. That we all get this for free. We have about 400 mentors, as I mentioned. Most of these, historically, have been in the US. The UK, Canada. But more and more you’re seeing mentors which are regional. And that’s nice, because some of these mentors are gonna have regional language skills. So we have mentors that are from Ecuador, Israel, South Africa, India, China. So this is another thing you’re gonna see really taking off and expanding with Cybersight. All right. So at this point, let’s go ahead and open up — see what Cybersight actually looks like. Go back to my screen share here. Okay. Get rid of this part. All right. So the Cybersight homepage looks like this. This is just kind of the public side of things. Usually once you’ve joined Cybersight, you kind of bypass this page. If you haven’t joined Cybersight, then — right here. Join the community. This is what we want you to do. And I just want to point out some interesting things. When you sign up for Cybersight — well, country. We need to know where you’re from. And I’ll just reiterate that mostly what we do is geared toward people in developing market economy nations. Okay? Don’t really like the word “Third World”, but I think you all know what we mean when we say developing economies. So this is not designed for someone in California, the United States, to submit a consult. Now, everyone is welcome to use the educational material. We really want that. There are so many great resources for people to use. But as far as the patient care activities, that’s mostly for people in developing countries. And if you’re not sure if you’re in a developing country, then here’s a list of countries that you can bring up, that shows where Orbis works on a routine basis. And some of these are more developed than others. But these are all places that have need for mentors. And so that’s where we work. All right. So that’s the… Creating an account. Now, once you have created an account, and you have a login, then when you log in, this is what you see. This is your dashboard. And the dashboard kind of orients you to everything that’s going on with you. First thing I want to point out is the right hand side. So the dashboard looks different than it did six months ago. Now instead of just seeing your stuff, we’ve got most of this dashboard dedicated to community activity. Because that’s really where the benefit of Cybersight is gonna come from. It’s not just the cases that you might do. It’s the cases that everybody is doing. So we want you to see what everybody is doing. And you can investigate these. And find people you know. Like Dr. Khauv here. Phara Khauv is a good buddy in Cambodia. We’ll look at some of his cases. He’s been an avid user and a great supporter of Cybersight. So you can see what’s going on. Now, not all of these are immediately viewable by you. When they’re open, if they’re marked private, those are ones that you don’t have access to. But we’ll show you how to look at the ones that are accessible. Before we start a new case, before I get into that, let me just show you… Here’s discussion on the left sidebar. We’ll come back to this. But this is the discussion forum section, where you can look for certain topics and see what people are asking questions about. Over here on the left sidebar we have the courses, again. We’ll come back to this, but I’m gonna orient you to it now. This has all the learning courses that we currently have and are redesigning. And it also has the resources, the library material, things like textbooks that have been scanned in, videos. So all that stuff is gonna be available in resources or the library section. So we’ll pop back to that in just a little bit. All right. So back to our homepage here. Another thing I want to point out before we get into the cases, in particular, is… Go to your profile. So here’s my profile. And this is… If you look at your profile, you can… This is great for if you’re looking for someone. Or if you want to learn about one of the mentors that you happen to be dealing with, you can go to this page, and see — you know, it’s a brief bio of what they do. And I think that’s nice to have that. So if you haven’t filled that out, fill it out. It also lists people’s languages and what their role is, whether they’re a mentor or user partner. One other thing I want to point out on profile, under your account settings… If you go to account settings here under profile, there’s a really cool thing here. Of course, this is where you can change your picture… Give yourself a new selfie here. But what I want to point out is right here. User profile. Open up user profile. One of the really cool features of the new Cybersight consult we’ve been using for a few years is this units of measure. Units of measure is specifically asking for visual acuities. So I have mine set to 20 feet. Pretty standard US system. Most of you, though, are using metric. Right? You’ve got 6 meter rooms, 4 meter rooms. And the cool thing about this is — if you’re not familiar with one system and converting back and forth, Cybersight does that for you now. So I set mine to 20 feet. You have yours set to metric. You see metric. I see 20 feet. And when we communicate back and forth, the software on Cybersight converts it automatically, and we don’t have to do any mental math. Just trying to facilitate all that stuff. That’s a really cool feature. So go in and set your preference for units of measure. Below that, we’ve got primary languages and secondary languages. So you can say… Well, if possible, I want my consult to be in Spanish. And then I want English as number two. And if we have a Spanish-speaking mentor, who is qualified to answer your question, it’ll go to them. And if not, then we’ll roll it over to your second choice, which was English. And you can do that for up to three languages. So that’s a really awesome feature. And we’re hoping to really expand this language-specific and region-specific… These options for our users. Because I think that’s gonna make it easier for all of you to use this amazing system. All right. So let’s get out of that. Let’s get onto the cases. And talk a little bit about formats here. Close some of this stuff out. We’ve got too much going on. All right. So cases. We still do… If you open up cases, we still have that traditional dashboard, where you can see what’s waiting for you. New request. So I know I’ve got one new message from Dr. Khauv, that I mentioned earlier, and I need to get on that. These will be color-coded. If they’re urgent. We’ve got your in-progress cases. So these are cases that haven’t been closed out yet. So there’s still an open dialogue going on with all of these patients. If you’ve created a draft, but you didn’t submit it, you’ll see that appear here. So you can start a case while you’re in clinic with a patient. Put down the pertinent exam information. And then save it. And then come back and finish your consult question after hours. So that’s one way to kind of do this on the fly. Is to just put in that basic information, save a draft, come back to it later when you have more time. And that way it won’t slow you down in the clinic. And that’s a really cool way to do some things like take a few pictures. Put in the patient’s name. Save it. Keep going. So I would urge you to use this save draft option. And then you can see all your closed cases. So like I said, I’ve done about a thousand of these. I’ve got a thousand closed cases I can go back and look at. And these 1,000, almost, closed cases that I have — you can look at these. Once they’re closed, you can go in and search these cases, and I’m gonna show you how to do that in just a little bit. And I think that’s one of the really powerful things of the new Cybersight system. So for a new case, just go back home… So you can see what it looks like. There are two ways to start a new case. One is here on the sidebar. We have… You can pop open the sidebar. And we have general question or patient case. And for this first one, I’ll use… I’ll just use this. So you can see what a general question looks like. So I will start one. General question. What is a general question? This is a question that’s not about a specific patient. This is something that’s about… A disease in general. This is something about refraction. How to transpose plus to minus cylinder. So it could be about a surgical technique. So anything that’s not about a patient that’s in your clinic. All right. It does have the same categories as a consult, though. Okay? So you can see we’ve got all these subspecialty categories. Optometry. And nursing. Biomed. Anesthesia. So make your eyecare team aware of this. We want questions from your anesthesiologists. We want questions from your biomedical engineers. We want questions from your nurses. Now, once that gets selected, if it’s put down as nursing, it’s not gonna go to me as an ophthalmologist. It’s gonna get directed towards one of our ophthalmic nurses. Okay? Same thing with biomed. It’s gonna go to one of our biomedical engineers. Now, when you get into subspecialties, the reason we have all of these is if you have an oculoplastic question, I’m a pediatric ophthalmologist. I’m not the best person to answer that. If you put down oculoplastics in the category, it goes to an oculoplastics person. And that’s just to get you the best information. And it also speeds things up, so it doesn’t have to be shunted around ’til someone feels like they can answer it. Now… Okay. So let’s just go… I’m just gonna put it on strabismus, since that’s what I do. Now, over here it says “mentor”. Assigned upon submission of case. In general, unless you know someone, so if you’ve worked with someone, if you and I have been out on programs together before, or we just know each other, then we will have kind of an unlocked relationship, and my name will appear here. So if I want to ask myself a question, I can. So Dr. Khauv and I worked together, so if he’s submitting a question, he will see my name and he can send it to me, or if he doesn’t like me, he can specifically send it to someone else. So this works both ways. But the whole thing is to… If you know someone, it’s nice to keep that relationship. If you don’t have someone who’s a specialist in that area, just leave it like this. Assigned upon submission of case. We’ll get it to someone qualified to answer your question. Okay? Now, I’ll point out that some of these things have little red asterisks next to them. This is required information. We need to know what the question’s about. We need to know where to send it. Subject. This is just so that we all have some brief idea of what you’re asking about. So strabismus, pediatric ophthalmology… Might put Brown’s syndrome. And then just open text. Write your question down. So these are very simple open text questions. Again, not about specific patients. All right. So we’re not gonna go into that any more, although… Okay. I should mention this. Choose file. You can add files to general questions and to consults. So choose file. When you look at that, it just has choose file, one tab. So you can go in and you can… Add your general question. Let’s see. What do I have here? I can say I have a general question about transposition procedures. So you can go and you can select multiples. All at once. And add them like that. Or you can go in… And add these one at a time. And just keep clicking it to add more. Okay? So lots of different ways that you can do that. But there’s no limit as to how many attachments you can put on there. All right? And so we’ll skip this access for now. Let’s go into the cases, though. All right. So that’s just general questions. What about patient cases? So start a new case. Right here. We’re gonna start a new case. And it’s gonna be a patient case. So I saw someone today. And I’m not sure about it. And I have a question. About — again, I’m just gonna go — strabismus. And I think Dr. Neely is amazing, so I’m gonna send this question to him. He always is so smart. All right. But you could have easily just said… Just send it to whoever is next available for pediatric ophthalmology. I don’t care who gets it. So I’m gonna keep it on my name. We have to have an age. This is a red asterisk. This makes a difference with a lot of these conditions. So you have to put down age, and you have to specify months, years, weeks. Sex. Sex frequently makes a difference in ophthalmology. A lot of these genetic conditions can be sex chromosome-related. And so we need to know male/female. Lots of things have different predispositions. And especially with the names, names in different countries — it’s not always gonna be obvious to a mentor if it’s a male or a female. So please — it’s not required, but please go ahead and fill out gender for that reason. History. All right. So history is really important. You can almost answer most of the consults, just based on someone giving you a good history. And a very small number of description/physical exam findings. So the ocular exam is critical. We need… It’s pretty standard stuff in medical training. But you need to know, again, the age, the sex, the severity. What’s the visual acuity like? The time course. Was this at birth? Was this acquired? Is it acute? Is it chronic? Is it intermittent? Is it constant? And don’t neglect not only past medical history for the patient, but medications, if they might be relevant, or social history. Family history. Especially with pediatrics, and some of the retinal conditions. Pretty much all of these ocular conditions have some family history clue that if something — if people are going blind from glaucoma in their 40s, then that probably applies to your patient, and you need to know that. If their uncle and their grandfather went through that. So that seems like pretty basic stuff, but it’s critical. Once we get past that, again, visual acuity is critical. This is ophthalmology. We need to know what they can see. So again, you can pick your format, and it gets converted automatically. Visual acuity — if they can’t do visual acuity, then we go back to what we do with infants and non-verbal people. Steady, unsteady, fix and follow, count fingers, hand motion, so there you see — 20-foot scale. If you put down metric… Now we’re in a 6 meter scale. Put something down… Because we have to have something down… And you need to know if that’s uncorrected, no glasses, or a pinhole simulation of correction, or if they’re in glasses, best corrected. So right now, a lot of this other stuff is visible. And it takes up a lot of real estate. And we don’t like that. We’re gonna be collapsing all this down, so this stuff is hidden from you. It’ll be there if you need it. But you won’t have to scroll through all this. I don’t see any red asterisks. None of this stuff is required after visual acuity. So if you have this information, and you think it’s relevant, put it in. If you don’t think that any of this stuff is relevant, skip it. Go on to stuff that is relevant. Keep it simple. Now, some things are more relevant for some subspecialties than some. So here in pediatric ophthalmology, intraocular pressure is optional. But if you go to the glaucoma template, there’s gonna be a red asterisk and we’re gonna say you need to tell us what it is, or at least what your estimation is. So we’ll skip all that. Patient consent. You are sending information out about your patient. And you should have their consent. That’s an Orbis requirement. That we have their consent. And I think it’s appropriate. You’re responsible for getting that consent. We don’t track that. We don’t store it. We don’t police that. But we need to have you acknowledge that you’ve obtained the patient’s consent. If you would like an official Orbis patient consent form, you can download one here on the left side. A PDF file here. So you can save as a draft, if you’re busy right now. Come back to this later. I don’t have a lot of time, so I’m gonna save and continue. And I forgot my amazing history. Don’t do this. This is just for us. Visual acuity. See? Epic fail. All right. Let’s go down and let’s keep clicking through. Okay. Now… I brought up… So that first green is generic. Every template you go into, for the subspecialties — glaucoma, retina, neuro-ophthalmology, strabismus — everything looks the same to that point. This second screen, the reason there’s the save and then on to the second screen, is that now the subspecialty templates diverge. There would be a glaucoma-specific template now, asking about OCT, gonioscopy, visual fields, or retina, asking about angiograms. I brought up pediatric ophthalmology, because it has this kind of complicated strabismus template. And we’re gonna clarify this. I don’t think we did a very good job of making this intuitive. And so I’m using this one, because I really want to point stuff out that I think you should be taking advantage of. All right? So this patient has two straight eyes. So I’m just gonna put that they’re fixating with both. Or if they have strabismus, then you let us know if they’re alternating or fixating right or left. Okay? Now, that’s important for strabismus, so that does have an asterisk. So these are the asterisks or H-type, overaction, underaction, that you see with motility templates. If you want to show something is overaction, like 2+ inferior oblique overaction, put it on there. Otherwise, they’re just zeroes. Everything is normal. Measurements. So this needs some grid bars. The tic-tac-toe bars between the measurements. But at the very least, show us what your primary position strabismus measurement is. If they have 20/18, put it in there. Generally, as a minimum for strabismus, you should have this primary position distance, and you should have a near measurement, whether it’s with the bifocal, with correction, without correction, or maybe all three, depending on what the problem is. So maybe this is without correction. That’s what we should have. That’s a couple measurements. If you don’t have prisms, estimate it. If you have right and left, up and down, put those in. These oblique ones I myself don’t use very often. They’re there if you need them. But head tilts — throw those in there. Let’s just keep burning through this, so we can go to some case examples. All right. Uploading pictures. This is a strabismus template. So we do have a specific one, where you can throw in pictures in different positions. So let’s choose a file here. And I’m gonna go back to my guys here. So this one is up and left. I’ve prelabeled. Here’s a left. I’m gonna put left in there. And there’s left. And I know I have an up and left, so I’m gonna choose up and left. And there he is. Okay. So if you have pictures in the different cases, you can throw those in there. Other attachments. This is for all the subspecialties. Other attachments. This is where you can really make consults outstanding. If you want to put in diagrams, you can put in diagrams. If you want to put in… Here’s an OCT. Let’s put in OCT. You can put in as many pictures as you want. I’m gonna put in that OCT. All right? What about videos? This is relatively underutilized. It used to be we had a little bit of trouble getting videos uploaded. So I think people stopped doing them. But there’s no limit on the file size that you can upload. And you can put as many pictures and files and visual fields, et cetera, that you want. Throw them in there. And then your mentor can watch those. All right. So let’s just go ahead and let’s talk about private and public. We want people to allow access on the cases. Why do we want that? Because those are the ones that are publicly searchable, and our whole community here, Cybersight people, can learn from them, rather than just one on one. But if you have a sensitive case, or something that you really don’t want other people to see for whatever reason, you know, that’s fine. You have that option. We’re not gonna force you to share cases. So if you want to keep it private, you can. We will never override that. But we strongly encourage “allow access”, and sometimes we’ll ask you — do you mind if we allow access? But ultimately, you have the final say. So let’s say allow access. And let’s submit that case. Oh, yes. So we skipped over this. Diagnosis. The new consult system has a special SNOMED diagnosis system. So SNOMED is an abbreviation for the systematized nomenclature of medicine. That means diagnoses are standardized. They don’t always seem like they’re the right one that you want, or you can’t find what you like, but just start typing, and this thing is intuitive. So let’s say this guy’s got a Brown syndrome. So then as I start typing… Anything that’s Brown comes up. But let’s say… If he had macular degeneration… All right? So we start getting into things that have “macula” in them. Yeah, okay. He’s got a macular retinal cyst. That sounds cool. Let’s add that. Macular retinal cyst. Now, if I didn’t like that, I can remove it. Boom. Take it out. However… Esotropia. All right. Let’s say this guy’s just got alternating esotropia with V pattern, but he’s also got associated strabismus. So if I just put DVD, that doesn’t work. All right? It doesn’t like abbreviations. All right. So after I typed enough, I finally got to a couple options. Dissociated vertical deviation, or I guess in this case, this one has esotropia with dissociated vertical deviation. I’m gonna add that. It’s kind of a pain in the neck, but why did we do this? In the old system, it was just free text and you couldn’t search for diagnoses. Now we have a defined list of diagnoses that you have to pick from. Which means you can also go back and search from it. So by limiting it to a smaller set of standard diagnoses, it makes this system searchable, and that’s something we can all take advantage of in the future. We have this tremendous database of searchable diagnoses. Search cases that you can go back and look at. Treatment plan. Let’s skip that. And just keep that rolling. Time is flying by. All right. Well, our next poll question was… Go ahead and launch that poll question. I think we’ve already talked about it. But you guys can answer this for me, as if we haven’t seen it already. I’m gonna cancel this case, because that stuff is gonna take a while. Get out of screen share here for a minute. There we go. All right. Stop sharing. Poll question. Did you know you could attach videos to consults and questions? Most of you did know that, but some of you didn’t. So those who didn’t know, start doing that. I’m gonna look at questions and answers for a second. Someone wants to know the name of the music. All right. Lawrence and Jonathan will get back to you with the name of the music. And they say it’s very nice. That’s a cool question. Let’s have some questions about Cybersight too. What else do I wanna do here? Let me talk a little bit… So I just submitted a question, right? I just submitted a consult. Now what happens? Now it goes to a mentor. So I submitted a pediatric ophthalmology question. It’s gonna go to the pediatric ophthalmologist. What’s the turnaround on that? We want it to be 24 hours. We want you on these patient-specific questions — we want you to have an answer back in 24 hours. And we monitor that. For general questions, that aren’t about a particular patient, well, those are less urgent, of course. And so our time frame for that is 72 hours. Now, every day, our team twice a day is going through the open cases, to see if they’ve been answered, or if they’re over their time limit. If they go over the time limit, we will roll it over to another mentor. Or we’ll get ahold of the mentor who’s not answering. We’ll say — hey, can you answer this question? This person needs this answer. So we are trying to keep that to a minimum. And we’ve been… It’s not there yet. But we’ve cut the answer response time in half. Over the past year or so. And our goal is to get it down to those levels. 24 hours. Or 72 hours. Okay? So we’re on that all the time. Okay. Also, if you send your consult to a mentor who is not available, or they’re not comfortable answering your question, they have a button, where they can reassign it to another mentor, or they can reassign it to a different subspecialty. So we have options that will happen semi-automatically, to get your question to the right place. But that builds in a delay, obviously, if they have to reassign it. And that’s where you selecting the appropriate question or diagnostic category at the beginning speeds things up, and you’ll get an answer more quickly. So keep that in mind. I’m gonna open a case. That we can look at and talk about. So let me go back to my screen share. Okay. I’m gonna do a retina case first. We talked enough about pediatric ophthalmology all the time. So don’t ask me any questions. I don’t know anything about this. Not true. A little bit. But cut me a break. So this is a retina case. Dr. Mai in Vietnam, and Dr. Ulrich is answering it. Pediatric retina. So pretty subspecialized area. And we’ve just recruited a few more of these. But that’s why the subspecialty selection is so important. Not all of our retina specialists — in fact, most of them not really comfortable with pediatric retina. So we have a core team that tends to get those questions. And that’s very helpful. That’s why we have that category. So this is a 7-year-old, blurry vision for a few months. Okay? Gender. Male. And that’s good. Because if I had looked at that name — I have been to Vietnam five times. I couldn’t tell if that’s male or female. That’s why that’s here. Visual acuity. I’m seeing it in feet. Which is good for me. That’s what I’m comfortable with. 20/40 and 20/32, and that’s best corrected. This is not blurred vision from a refractive error. Something is not off too far, but something is not right. Pressures… There’s a lot of stuff here. Scroll through it. Medical history. Normal gestational history. That’s always important with kids in particular. Fluorescein angiography was added. See attached photos. Now, diagnosis — there’s some tentative diagnosis is there’s some cystoid macular edema. And they think that maybe it’s suspected Best disease. And maybe planning to just watch this. Okay? But look what they did. They added some nice cool photos here. That we can enlarge. So here’s a nice OCT. You can see some subretinal fluid there. Also has that retinal deposit. Right? And we’ll go back to the case here. Now… Not everyone is gonna be able to add all these kind of cool images. If you can, do it. But if you can’t, give a good description. Look at this right here. Description. Abnormal finding in the posterior segment. Both eyes. Raised yellow lesion at the macula, with serous detachment. Now, I’ll bet you that the retina specialist receiving this consultation already has about a 95% probability of what they think this is. And that’s just how easy it can be. Give a nice description like that, and then back it up with some pictures, if you can. So what was that? It was raised yellow lesion in the macula, with serous detachment. Well… Look at that. Okay? So preview button… If that’s too hard to see, then make it bigger. Open it up. And there’s that yellow stuff. All right. Back to the case. We see yellow stuff. But we also have an FA. Preview of the FA. Or open it up. Look at that FA. So now, now you’re really cooking here. This is — the retina guys are gonna be like — yeah, look at that. There’s some leakage there. I think I know what this is. All right? And all that’s been thrown on there. All right. So the mentee, the doctor in Vietnam, thinks it’s Best disease. And is concerned about the serous detachment. So what are we gonna do there? So the mentor says… I agree. We need to rule out Coats disease. So this is what it’s all about. We don’t want people just to focus on one thing. Let’s keep in mind the differential diagnosis. Because, again, this is not to tell people what to do. This is a teaching process. And the way you teach is to throw out alternative suggestions, and explain why you’re doing that. And also to ask questions. So maybe Dr. Ulrich has a question. He wants to say… Well, do you have a picture of the periphery? Do you have an FA of the periphery? Because I want to look for aneurysms out there, that might look like Coats disease. Maybe this stuff is just exudate that’s tracking in from the temporal periphery, where there are some leaky vessels. Throwing that out there for the differential diagnosis. And then some basic management options. Coats disease would need laser to those non-perfused areas, plus or minus anti-VEGF, and that’s why it’s important to consider that. Treat the peripheral leakage, this macular exudate might go away in Coats disease. That’s why it’s important to keep this in mind. Best disease, probably less you can do. It’s usually just observational. However, both of these conditions can have choroidal neovascularization. So Best disease can be observed, unless there’s choroidal neovascularization. That’s important, because now if we have choroidal neovascularization, maybe we’re not gonna just observe. So back and forth, just discussion, and now we have macular OCT. And the macular OCT… Let’s open it up. Macular OCT… There’s our foveal pit. Looks like we have some macular neovascularization. Along with the subretinal fluid. So now, with this discussion, the management has changed. Now the mentor says — okay. You’ve got neovascularization with this leakage. Give anti-VEGF monthly, until the fluid has resolved, or if there is no response after three injections. There had been a question about photodynamic therapy. PDT in Best disease. What is the role of PDT to treat choroidal neovascularization in Best disease? Good question. And again, this is part of the educational process. Ask these questions. Don’t just get one answer. Find out more. And Dr. Ulrich says… All right. No role for PDT in Best disease. In that way, it’s perhaps different from Coats. Coats, you would perhaps be doing some lasering. So that’s how this works. Rather than show you another case, well… Actually, one more. I had some poll questions on this, but I’m gonna skip them so I can just show you another case. And I’ll show you how the video can come into play. So my buddy, Dr. Khauv, in Cambodia — he had a question here about a kid, seven years old, and he’s got some motility issues, and a head tilt, and I’ll just scroll down and show you the meat of the case here. So here’s that motility diagram that we talked about before. Now, this kid is not elevating that left eye very well. All right? And Brown’s syndrome, which this could be… They’ll frequently not only in the adductive position but also in the abductive position, they may not have normal elevation. So he’s got some measurements here, primary position, in left hyper… And look how great it is to have these nice pictures. Left eye preview. Not going up very well. But up and left… I’m sorry, up and to the right… Look at that. Not going up at all. Boom. Two pictures, you can make this diagnosis. And so a picture is sometimes worth a thousand words. Right? There’s a reason people say that. Looks pretty good everywhere else. But… One cool thing that he did… Which I really appreciate… Is he gave us some follow-up. So we talked about the case. He took it to surgery. And then he was like… Showing… Looks like he’s got a little surgery going on there, did traction test. Let’s see. What have we got here? We’ve got a movie. That’s cool. All right. And that movie is downloading, but I’ve already… It’s going pretty quick. So it’s gonna open in just a second. He’s sent me all these nice postop pictures. And I really appreciate that. And something that you want people to do is — tell us how people did that we talked about. Everyone is really — wants to know that. They want to know — did things go well for you? Downloads. That’s really nice for the mentors, to get that feedback. And you can continue to have discussions about this stuff. What to do next, if it didn’t turn out. So here’s that video that Dr. Khauv attached. It’s got this nice intraoperative traction test. And you can see that that eye won’t go up and in towards the nose. All right? So it feels tight. So it’s just kind of… It’s not just fun and interesting. It’s helpful to get those kind of — that kind of feedback. So here he has surgery. And then maybe we have a discussion about… Well, what happens next? And what happens next… So if the surgery didn’t turn out the way that we wanted it, then we have an ongoing dialogue about… Well, okay. We’re gonna do something different. We’re gonna watch for a few months. What’s the next surgery we’re gonna do? So those kinds of cases — keep them open until you’ve kind of revolved the problem. Once you’ve revolved the problem, just a reminder — go ahead and close the case. Because once you close the case, then it’s searchable, and everyone can take a look at it. And let’s do that. Because that’s something we need to do. We’re down to, like, five minutes here. Here’s a question. I’ll get this question. So the question is: What does Cybersight get from this? Financial disclosures, et cetera? I don’t get anything. So… I mean, there’s no… This is just doing this, because we’re good people. And this is, you know, Cybersight is an NGO. A non-governmental organization. They’re here to serve and help people. That’s what we do. This is free advice. There are no ads. There’s no money going anywhere. All right? Orbis is a charity organization. And our goal is to educate eyecare teams, and pass it on. And then that’s what it’s all about. Here’s a question about visual acuity scale. I did not see 5 meters, which is used in our French setting. Interesting. And the question is why? Well, the answer is… Because I’ve never heard of a 5-meter system. That’s a really good point. If that’s a common finding, then we need to throw that on there. And I apologize that we didn’t do that already. But that’s exactly the kind of feedback we need. If something like that is missing, and we don’t know everything — tell us. That’s something that’s probably super easy for us to just throw in on the next update. So 5-meter setting. Lawrence, make a note of that, and we will set that up. All right. And let’s go… Let’s go… Yeah. So let’s look at… Back to the dashboard. Okay. Close that case out. View public cases. Gotta touch on this, before we finish. So here at the home dashboard, save — you don’t really have a case to submit. You’re just kind of curious. You want to know about — see what’s going on. I’m just gonna select all. See what comes up. So I’m gonna now have access to every public Cybersight case. And you can see they’ve got them all. They’ve all come up. I can get rid of some of those if I want. So if I didn’t want all of them, I would go back, and I would say… Okay, deselect all. I don’t want all of those. I just want to see cool glaucoma cases. Because glaucoma is awesome. So we’re gonna search only glaucoma cases now. All right, and we have 95 closed glaucoma cases. And you get the little synopsis here. Diagnosis. You don’t have to scroll through all 95 for the diagnosis. You wanna see just one particular kind… Click here. Let’s look at the diagnoses. So I want only primary congenital glaucoma. So now I see I have ten cases of those. All right. So now I have ten cases of primary congenital glaucoma that I can look at. And I’m not Dr. Fredrick. And you’re not Dr. Tuyen. But we can all learn from this case. So we open it up. And we have a 9-month-old female, elevated pressures in the 30s, and we can see what they discussed. All right? What the surgery plan was. So we have access to all that. And I think that’s really the… That’s really the power here. Of the new Cybersight system. To be able to go through all of that. So searching cases. Also by location. Okay. I just want to see primary congenital glaucoma. That’s in Vietnam or in China. Let’s go back. And I’m gonna select all. So we’re gonna get every single case that’s closed and available. And so now I have all the cases. Location, again. I want only South African cases, or I want only cases in Romania. So you can do that. So if you live in Romania and you only want to see Romanian cases, go for it. Diagnosis… Again, you can type in any diagnosis up here. All right? Best disease. We saw that. Let’s see if we have any other cases of Best disease. All right. And so we have… 53 results that are perhaps related in some way to Best disease. Now, we may need to filter that out. Because it looks like maybe some of these are coming up in weird categories. Users. So if you want to see just a particular user’s cases, or mentor, you can do that. If you want to see program cases, that are just from the flying eye hospital, et cetera, you can do that. Or dates. You can look at this every week. I’m just gonna look at the cases for the past week. And every week I’m gonna look at the new cases that have come up, so I can learn from those. You can do that. If you only want to do it once a month, then look at the past month. That’s a really cool thing, I think. So that whole search function and using public cases is something that’s really underutilized. So that’s why we would encourage people to really leave cases open. Because it’s the community aspect of this that is really gonna make it more powerful. Than it is currently. Let me just check in. Last couple of questions. Can we send already managed and closed cases for learning? Or only ongoing cases? Yes. So here’s a question. I’ve got a cool case that I did last month. Can I share that? Absolutely. So I would do that still as a patient-specific case. So you had a cool case of Stargardt’s disease. Upload it. Send us the information. Any pictures you have. When you send it to a mentor, tell them — you think that’s what the diagnosis was. And this is what you did. And they’ll look at it and they’ll say… Yeah, that was nice. Nice job. Way to go. Super. Or they’ll say… Yeah, you had a good outcome, or this or that, but maybe think about this. Maybe they’ll throw in some teaching points. Then we can close that case out, and everyone will see that case. So I think that’s awesome. If you have some great cases, add them to the system. This will be fantastic. And the bigger we make this database, the better of an educational tool it will be. All right. So I didn’t get to everything today. We haven’t talked about some of the new features, like the discussion forums, or the interactive learning tools. But we’ll come back to that. We’ll do another informational webinar, where we’ll spend more time looking at the resources side and the educational side. And maybe do some more of these cool cases. Oh, we’re gonna do two quick poll questions. Because I want to know the answers to these. Launch poll number 7, please. All right. So we touched on just a couple case studies. But how interested are you in seeing more case studies, where we — maybe not just one faculty member, but maybe we have a panel of two or three? So, like, when you go to meetings, and they have difficult cases, workshops, how interesting would that be to you? Because I think it would be really cool to have live interactive discussions, have people submit cases, and then we can discuss them. You guys can ask questions about them. And our expert panel can give you opinions. All right? Let’s see the results of that. Good. So let’s at least some level of interest there. I think we’re gonna be on that pretty soon. I’ve been dragging my heels, but we’re gonna get up and ready. One more question and we’ll be done. What about live surgical demonstrations? We have the ability immediately on the airplane to broadcast surgeries as webinars. And we’re trying to do it in institutions. So I could broadcast from my OR, or UC Davis. We’ve done that. And maybe eventually the reverse is true too. You can send your videos to us, and we can mentor while you’re operating. Most of you are interested in that. We’ll get on that. I’m glad to see no one was preferring to just watch YouTube or EyeTube. Okay. We appreciate you coming today. Until we do the next webinar, explore the discussion forum, explore the resources, watch for resources to be added almost weekly. There will be new things under the resources, and they’re different from what we’ve historically shared with you. These are new and interactive. It’s gonna be fun. Everyone have a good day and thank you for your time. Write to us. [email protected] if you have any questions and we’ll answer those offline. Thank you.

March 13, 2017

Last Updated: October 31, 2022

3 thoughts on “Lecture: Cybersight Consult Best Practices + Case Presentations”

  1. This is a awesome walk through on Cybersight Consult. I’m going to share the recorded webinar with partner hospital so they can utilize the website even when there’s no HBP happening.


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