I was the Executive Vice President and founding CEO of the American Academy of Ophthalmology for 17 years and the founding CEO of multi-health care systems. AMA.

Will we ever see a day when all parts of our bodies are covered by the same health insurance? Why should Eyes and dental be any different than the rest of my body?

That is a profound and vexing question. Many programs do cover eyes but somehow dentistry has escaped the medical package. I wish I could snap my fingers and repackage our insurance coverage as you desire. While refractions may not be covered, generally other opthalmic conditions are usually covered by medical insurance. (Assuming USA here.)

How do you feel about the state of the American healthcare system in general? Do you feel like being "at the top" of it as a CEO may skew your view?

I am a laboratory technologist, and it feels kind of grim down here.

I am with you presently as I am a senior citizen "plus." There have been many attempts at redoing our healthcare system, starting in the 60s, and none have made me feel as though it is substantially better.

Have you heard of Dr. Glaucomflecken on youtube? (real name is Dr. William Flanary) He's an ophthalmologist who does comedy videos about medicine and they're hilarious. But they also help shed light on good issues and he's done things like partnering with the surgeon general on health care workers taking care of themselves. I think he would be a good person to work with if you had a public initiative.

Edit: Here's one of his video shorts entitled "How to ace your ophthalmologist interview" https://www.youtube.com/watch?v=V-tl7s8aRHo

I have heard about him and seen his videos. He is creative, funny, and appropriate. We trained in the same program at Iowa, but many years apart.

Are all ophthalmologists Russian spies, or just Rand Paul?

You gave me a good laugh. Thank you.

Unfortunately I have another engagement at 12:15 US Pacific, I will look at these later and try to reply to those I have not yet answered. Thank you all.

How many years did it take you to adequately learn how to use a slit lamp?

Two years in all of its anterior and posterior segment views.

/u/FoeHammer813 asked "Hello Dr. Spivey, Thank you for taking the time to answer some questions! I am an M1 who is interested in Ophthalmology. What current research topics in the field are you most excited about or intrigued by? And what advice would you give to current medical students?"

Retina and glaucoma are the hottest developing areas. If you are interested in ophthalmology: study and become a well trained basic physician and connect with one or more eye departments who can give you good recommendations.

I was diagnosed with a central retinal vein occlusion almost a decade ago. When I first saw my ophthalmologist there were few treatments available aside from Avastin and laser. I am doing well, but am wondering if there is any new research on this condition? Thank you!

Regretfully, I do not know of any substantial improvement in treatment.

Hello, Dr. Spivey. Thank you for your dedication to medicine and for sharing your time with us today. I'm an American with a significant amount of experience as a patient within the US healthcare system. The way we distribute and pay for healthcare is an ongoing source of frustration and consternation for me. As a patient, I understand the argument for a 'Medicare for All' approach to this question, from repeated struggles to obtain necessary care and in dealing with mountains of paperwork. As a former CEO of healthcare organizations, what is your point of view? Thank you very much!

You ask an appropriate and painful question. Growing up in the world of private practice (although I was always an academic), we get stuck in our usual track. I think we will see a slow modification to a more "Medicare for all" approach. I hope we can maintain an initiative and high quality of education and care.

There is an old adage, and an awkward one, which describes people in private practice as "eating what they kill." Translated means, if you work hard you are financially rewarded. I do hope we can maintain initiative and quality in whatever system evolves.

is it normal for distance vision to worsen with age but no health issues? i'm close to 50 and wear reading glasses and progressives with a very light astigmatism. over the summer there were days my vision got noticeably worse. perfect health, no issues, no drugs no nothing. even exercise all the time. could have been altitude since i went from sea level to a mile above sea level

Very unusual that your distance vision would change significantly. Are your blood pressure and blood sugar ok? If this persists, you should see an ophthalmologist.

that's all OK. it's only some days and i'm waiting a few weeks after i came back to sea level to see if it happens again. i'm at -.5 or so and a few days over the last 6 weeks it was probably close to -1 but ok today

​

looking to run the NYC marathon in 2024 and training already so health isn't an issue. technically qualify already

Congratulations!

do you recommend LASIK ?

full honest opinion please

As someone who avoids surgery, as a myope (nearsighted and can't see in the distance) I have worn glasses successfully. If you hate glasses, lasik has now been proven to be safe and effective. A visit to the ophthalmologist who is doing lasik surgery is appropriate.

I never knew what an ophthalmologist was but found out in the last couple years as I was diagnosed with keratoconus. As someone who had quite severe progression I needed surgeries and had intacts placed and received cross linking in both eyes. Insurance refused to cover either of these even with letters of medical necessity.

As a founder of health care systems what’s your vision for treatment for rarer eye diseases that are often neglected by the system? Do you believe it’ll get better in the future as research becomes more available?

It should be dramatically better but I can't imagine why your insurance would not cover keratoconus. Both of those treatments are accepted and variously effective. Certainly cross-linkage is a basic treatment prior to treatment, presently. Corneal transplantation should be insurance accepted.

How come Herpes research is so sparse, when Herpes keratitis is one of the leading causes of *infectious blindness in the first world?

As far as I've gathered info on it, it gets not a lot of funds and research institutes have to get crowd-sourced to start oncoming trial phases.

As a patient with Herpes Keratitis, who's unresponsive to Valacyclovir and gets recurrent outbreaks every 2-3 months since 10 years, that's a question I would really love to get an answer to, or atleast infos about.

Thank you for your AmA!

Edit: *

I can't directly answer your question, but I would recommend that you contact the National Eye Institute, which is within the National Institutes of Health. They are involved with many research activities outside the United States and they may be able to stimulate such research and connect you with any active research ongoing.

Have there been any long term studies for eye correction surgery?

Assuming you mean lasik, there are many studies that indicate the relative safety of the procedure.

I live in a country where Tuberculosis is rife. We often see TB of the pericardium; spine; abdomen and pretty much any joint. What ocular manifestations of TB should we be on the lookout for?

Uveitis. This can be in the anterior or posterior segment of the eye. It is quite common with severe tuberculosis.

Hello 👋 thanks for the time you’re putting on this. Some really interesting information your have provided already.

General question: is there any advice you can give to keep a healthy vision, similar to wash your teeth daily or do exercise for your body?

Another thing from someone that spends his entire day in front of a computer and reading: is this really bad for my eyes?

And third and final one: what’s your opinion on reading glasses?

Once again thank you 🙂

General question - Every once in awhile get a good eye exam because there are lid infections that are not severe, but irritating, and can be diagnosed and treated quite easily. As for exercises or cleanliness: no need for exercises and usual cleanliness should be adequate.

As to overuse of your eyes, if you have no symptoms you have no problems. If you are having such things as pain or double vision, regular breaks away from continuous usage is helpful.

Reading glasses - if you are very often at the computer and have reached a high level of hyperopia (needing glasses for close vision), reading glasses are helpful at the computer. Otherwise, bifocals or progressive lenses are certainly appropriate and very helpful.

Why is it so hard to find a pediatric ophthalmologist?

I would say it relates in part to the fact that pediatric ophthalmology is low income yet the practitioners are happy and provide tremendous service and care.

My son when through nasolacrimal duct procedures and we never paid less than $100 a minute for the doctor’s time, not sure I believe that… but US healthcare fees seem to benefit everyone between the doctor and the patient 😣.

Another subject, what can average people do to preserve eyesight into old age?

I would suggest regular evaluations to detect glaucoma in an early stage and cataracts so that surgery can be performed at a time appropriate to the visual reduction it is creating.

Are there any instances where vision improves with a pituitary tumor resection where the tumor was pushing up on the optic nerves, resulting in total loss of vision in the left eye? The eyes themselves are healthy and I had 20-20 prior to tumor growth.

Edit. I hope your AMA goes well!

How long post-op are you? If it is many months, the return of vision is unlikely.

I see youre wearing anti-UV glasses im the photo, are they actually useful? Do they actually help against dropping eyesight?

I have found them to be helpful but I could not say they are preventing any visual loss as I do not have it as yet.

Personal health: I’m a candidate for penetrating keratoplasty, DSAEK or DALK due to disciform keratitis. I’m 35, had near total vision loss in the eye since grade school. Where do you see artificial cornea development in the next few years? Risk of Recurrence of scar tissue development and complications from donor tissue keep me from jumping in.

Health Systems: what’s your favorite model for health system management/ownership? Non-profit, physician owned, investor owned, single payer?

There are a number of new developments, even with pig corneas. I think your concern if your vision is severely decreased is likely overdone, as the only option you have is to get a more clear cornea. The impact of donor tissue should not prevent you from considering surgery.

If you could trade eyes with anyone who would it be?

Many for beauty, none for vision.

How do you feel about the overarching trajectory of the US healthcare system’s transition to value-based care? If it’s not positive, do you think there are any feasible alternatives to the ever-more-expensive fee for service model?

Thanks for sharing your insights!

I am not aware of any alternatives, sadly.

What prompted your focus on educators and ophthalmic education rather than other ophthalmic subspecialities?

When I was in training at a highly rated program (Iowa), the faculty's idea of education was, "Watch me and do the same as I am doing." I thought there must be a better and more systematic approach. I became the first ophthalmologist to get a masters degree in medical education. It changed my life and I was able to impact opthalmic education, subsequently.

The liquefaction of the vitreous in the eye is what can lead to retinal detachments in people with high myopia. What Research is going on to identify synthetic or modified vitreous replacements to prevent this?

Retinal detatchments occur when there are strands of the vitreous remaining attached to the retina when the liquification process is occurring. If a person has flashing lights in the periphery of their visual field, sometimes cutting that vitreous strand will prevent retinal detachment. There is no need to replace liquified vitreous per se, and I am not aware of any research on the replacement.

Do you think the “2 year expiration” on eye Rx are outdated unless after a certain age? If you see well and have no issues, it is frustrating to be forced to go through an eye exam mainly for billing purposes.

Agree.

I am trying contact lenses for first time after 20+ years. What would be your advice for me to do next? I am scared of absolutely any side effects, even if small

Are you using the contact lenses to see better in the distance? If so, the alternate option is glasses as you know. If you are clinically improved with the contact lenses, fine. If you don't want to wear glasses, consider lasik.

Is it possible to have lasik without "side effects"? Being sensitive to light and such.

Yes I was wearing glasses for 20+ years.

Yes it is possible to have very minimal if any side effects with lasik. However you must be aware that a certain percentage of people do have visual sensations that are usually not difficult to deal with.

Is it possible for a severe TBI to cause retinoschschisis? Say a person gets into a bad accident where they’re thrown from the vehicle and hit their head? How long does a person have to get to emergency care should they see signs of retinal separation?

Thanks!

It is quite uncommon to have a retinal detachment if it is simply a head injury. If there is retinal bleeding or other disruption of the anterior segment, indicating very severe ocular trauma, there is so much more to do for the rest of the body prior to ocular intervention.

Does AREDS really do anything for macular degeneration?

It supposedly decreases the likelihood of macular degeneration, but I have never been convinced that is true. It does not do anything in the treatment of macular degeneration in my opinion.

how big of a joke is Rand Paul and his fake board?

As big as you want to make him.

how does the united States compare to European countries in terms of quality of care?

I have had the opportunity to view world ophthalmology over the past fifty years. European ophthalmology was the best in the world at the beginning of the 20th century. It of course is variable, but German, English, Dutch ophthalmology and many others have excellent, high level ophthalmic care. India has also some of the very best of care. The availability of care in many countries, including India, is inadequate. 90% of vision loss is in low and middle income countries.

What simple things should 20-30yr old people do/avoid to keep their eyes in a good shape? Thanks

Live as clean a life as you can, and use your eyes in any way but not hyper-excessively. It seems simple and it really is.

I am a general doctor and i have my residency exam next month, is there any chance that you could share your medical notes so i can study them? I would love to see how are they!

I was trained so long ago that paper didn't exist. Parchment is difficult to transmit, sorry.

What recommendations would you give the average patient in seeking ophthalmology care? Whether it's self-advocacy, locating the best caregivers, or anything that immediately comes to mind...

I'm curious because I keep hearing so many anecdotes about people having to self-advocate for quality care from health providers. With the prevalence of "I've done my own research" types, how does one best balance respect for the profession and self-advocacy from the perspective of "I know what I feel and perceive within my own body"?

Thank you for your time.

This is a very good question and not straightforward to answer. As I have needed care from non-ophthalmic physicians, I go by what my colleagues have to say about a specialist. You may not have physician friends, but you certainly have friends and they have ophthalmologists. Ask at least 3-4 who they have had experience with and select from those recommendations.

/u/madpoontang asked "Where are we in finding earlier diagnostic methods for glaucoma? Are we making way in learning more on the choroidal/pachychoroid diseases? What about TPA for C/BRAO? Antivegf implantations for AMD?"

There is very active research in methodologies of determining glaucoma earlier. I cannot honestly address the other aspects of your question.

Hello Dr. Spivey, Thank you for doing this AMA. I’m currently a premed student applying to medical school. I’ve always been interested in ophthalmology and was wondering if you had any recommendations as to what I should look for in a medical school if I wanted to pursue ophthalmology in the future?

I think you will be aware that there are many very, very good programs in ophthalmology across the medical schools in the US. Go to a good medical school and search for your most desired residency, and perform, perform, perform.

Why are you involved with the Ophthalmology Foundation?

I have involved with global ophthalmology since I spent time in Vietnam in 1965-66. I was the leader of the International Council of Ophthalmology (ICO) for many years. More recently, the new leadership had different plans and I have joined many people who were involved with the ICO, creating the Ophthalmology Foundation. We are heavily involved in education, fellowships, and support of a number of educational initiatives worldwide. Global ophthalmology is a growing area and the Ophthalmology Foundation is becoming a leader in this space.

Opinions of NPs and PAs acting without MD/DO supervision?

The most important part of NPs and PAs education and practice is to know their own limits and to try not to exceed them. Working without supervision is what many of them are expected to do and the well-trained will ask for guidance or refer when they know their capabilities are inadequate in any particular individual.

My wife at her last eye exam had the doctor say he cant do anything for her vision as its not correctable by glasses but only one of her eyes is affected. Should she be seeing another doctor or have an MRI?

It is impossible for me to say, but if that situation existed in my family, I would see either a neuro-ophthalmologist or a retina specialist if I didn't know what the problem was.

Why did you choose to go into ophthalmology?

Because it is a exquisitely lovely specialty with many subspecialty areas, and many definitive cures such as cataract surgery, strabismus surgery, many corneal problems, and even now retinal and glaucoma problems. Also, the people in ophthalmology tend to be very bright, very precise, and very nice.

How come after I had cataract surgery and got toric lenses I got secondary cataracts and need secondary cataract surgery? Why U no just hit the thing with a second laser the first time?

Not everybody develops opacity of the posterior capsule after surgery, so it is not considered appropriate unless when any surgical procedure is not indicated. I am sorry you had that not-infrequent situation.

Why is it important to focus on training the next generation of ophthalmologists and ophthalmic educators?

We always want to improve our knowledge and care. The next generation must be better and brighter than we were.