Aldo Arroyo

June 30 – July 3

Immersion Reality

On Monday, I was not entirely sure how to apply what we learned in the first class of the clinical immersion program to the real-world clinical environment. It wasn’t my first time entering an OR, but I was surprised because this time felt different. Before, I was used to just observing and admiring the procedures — and I still do. However, the big difference now is that I have experience in the biomedical engineering field, so I saw the OR not just as a place where a procedure is performed on a patient, but as a complex system, where instruments, workflow, and decisions are all part of what makes it possible.

The AEIOU method was very helpful since I didn’t have a solid starting point for observation. This framework helped me identify aspects of good design that support clinical workflows, as well as areas that I believe could be improved.

Good Design

Goldmann Applanation Tonometer – Glaucoma Clinic with Dr. Pathik P. Amin

The Goldmann Applanation Tonometer is the gold standard device used to measure intraocular pressure (IOP), which is crucial for diagnosing and monitoring glaucoma.

Activities: The patient is seated at a slit lamp, resting their chin and forehead on the support frame to minimize movement. The doctor attaches a new tonometer tip to the device. After applying anesthetic drops and fluorescein dye, the provider carefully brings the tonometer tip into contact with the cornea. While observing through the slit lamp, the doctor adjusts the dial until the fluorescent semicircles align, which indicates the patient’s IOP.

Environment: The tonometer is attached to the slit lamp and can be smoothly rotated to examine each eye without needing to reposition the patient. The lights in the room are dimmed so the doctor can see the fluorescein rings clearly during the measurement.

Interactions: Before the measurement, the patient receives topical anesthetic and fluorescein drops, which prevent discomfort and enhance the visibility of the corneal surface. The doctor maintains constant communication, offering reassurance and instructions to help the patient remain still and relaxed.

Objects: The most critical object is the tonometer tip, as it directly contacts the cornea and plays a key role in the accuracy of the reading. Other essential tools include the slit lamp, anesthetic drops, and fluorescein strips.

Users:

• The doctor, who operates the device independently and ensures proper alignment and measurement.
• The patient, who follows instructions to stay still and comfortable throughout the procedure.

Bad Design

Debridement Eyelid Orbitotomy with Irrigation Tubes – Dr. Tran, Plastics Main OR

This procedure was performed to treat a severe infection around the eyelids and orbit. Through an eyelid orbitotomy, surgeons removed infected tissue and placed small tubes to allow medication to reach the affected area directly. This helps control the infection and protect the eye and surrounding structures. The design issue observed in this procedure mainly involved the irrigation tubes. In my opinion, they could be improved in terms of flexibility, anchoring, and size. These changes could potentially make it easier for surgeons to place them and more comfortable for the patient, who may have these tubes attached to their face for an extended period.

Activities: The surgical team worked together to create a plan, discussing two different irrigation tube options. Small incisions were made around the affected area to place the tubes. The surgeons and support staff discussed the best way to position the tubes. The process of inserting and positioning them appeared somewhat improvised and invasive, though necessary.

Environment: The operation room setup was somewhat messy; since the team was testing the tubes, some liquid spilled from the table onto the team’s clothes and shoes. A staff member brought towels to place on the floor to manage the mess.

Interactions: Each person had a different task: one person inserted the tubes, another cut them to the correct length and held the opposite end coming through the skin, another person suctioned blood and cleaned the area, and another managed the instruments.

Objects: Some tools used during this procedure included surgical scissors, forceps, a scalpel, and two different types of catheters/tubes. As mentioned before, some issues were noted with the tubing, particularly related to flexibility, size, and how well they functioned during the operation.

Users: The surgeon and assistants coordinated closely throughout the procedure, communicating clearly to ensure each instrument was handled at the right moment. They gave precise instructions and worked together to keep the process organized and efficient.

During this second week I get used more to the clinic and OR environment. I could notice that one of the parameters more used in these environments is the pressure in the eyes that’s why I choose a monometer to measure intraocular pressure.

I did research both the Goldmann applanation tonometer, so its patent is not the device at itself, hence to the type of system use to measure the pressure. This system works by propelling a small, lightweight probe toward the cornea and measuring how it rebounds. The speed of rebound correlates with the pressure inside the eye.

While observing its use, I noticed a few practical limitations. Small hand movements or improper angles can affect the reading. Also, variations in corneal properties like thickness can introduce some error so it have a lot of variability. Still, the device represents a major advancement in accessibility and ease of use. Reading the patent helped me better understand the engineering principles behind the tool and how it transformed routine eye care.

Kontiola, A. (2000). U.S. Patent No. 6,093,147 A: Apparatus for measuring intraocular pressure [Patent]. U.S. Patent and Trademark Office. Filing Date: February 22, 1999; Grant Date: July 25, 2000

For this blog post, I’ve chosen to share my weakest template focused on the issue of poor adherence to eye drop regimens among patients with chronic eye conditions such as glaucoma or dry eye disease.

       Needs Statement:

Patients with chronic eye conditions need a way to reliably and correctly instill eye drops because current methods result in poor adherence, leading to worsened visual outcomes and preventable complications.

Population: Patients with chronic eye conditions (e.g., glaucoma, dry eye disease) who rely on long-term eye drop regimens.

Opportunity: They need a way to improve adherence and proper instillation of eye drops.

Outcome:Improved medication compliance would lead to better treatment outcomes, such as reduced vision loss, fewer complications, and lower healthcare costs due to avoided disease progression.

Using the AEIOU framework, I made the following observations:

• Activities: Many  patients forget to apply their drops on time or use them incorrectly.
• Environments: Drops are usually administered at home, where patients are often alone and lack reminders or supervision.
• Interactions: Little interaction occurs with caregivers or digital reminder systems.
• Objects: Bottles are difficult to squeeze, especially for patients with arthritis or limited hand strength and also is hard to remeber when and how meny times they have used the drops.
• Users: Individuals managing glaucoma, dry eye, recovering from eye surgery, or people who use eye drops
  

  Seconday Research

  A recent study on dry eye disease (DED) found that 70–80% of patients did not know the recommended frequency for eye drop use.

  Additionally, 61.3% used drops only when symptoms appeared, not as prescribed. This suggests poor adherence due to lack of education, over-reliance on symptoms, and possible trivialization of the treatment.

  Feasibility:

• Intellectual Property Landscape: Multiple patents exist on eye drop assistive devices (e.g., auto-dispensers, guiding sleeves).Commercial Solutions:”Autodrop Eye Guide” helps align bottle to eye.”Nanodropper” reduces drop volume and waste. Still, these do not address behavioral compliance or cognitive impairment.

 Viability:

General Market Assessment (Just glaucoma):

Just glaucoma affects over 60 million people globally, with many relying on lifelong eye drop therapy.

TAM (Total Addressable Market) Calculation:

Approx. 3 million people in the U.S. with glaucoma.

If 50% need adherence tools and solutions cost ~$50/year:

TAM = 1.5 million × $50 = $75 million/year (U.S. only)

Global TAM could easily exceed $500 million/year.

Conclusion

Many people who use eye drops struggle with correct and consistent use. Common issues include forgetting doses, using the drops incorrectly, or not understanding how often to apply them.

While tools like Autodrop and Nanodropper help with application, they don’t fully address behavior or routine. There’s a strong need for solutions that make it easier for users to remember, track, and apply their drops as prescribed.

Improving adherence can lead to better eye health, fewer complications, and more effective treatments.

References

Uchino, M., Yokoi, N., Shimazaki, J., Hori, Y., & Tsubota, K. (2022). Adherence to Eye Drops Usage in Dry Eye Patients and Reasons for Non-Compliance: A Web-Based Survey. Journal of Clinical Medicine, 11(2), 367. https://doi.org/10.3390/jcm11020367

Kinast, R. M., Sanchez, F. G., Rees, J. P., Yeh, K., Gardiner, S. K., Dawes, J., … Mansberger, S. L. (2022). Eye Drop Adherence With an Eye Drop Bottle Cap Monitor. Journal of Glaucoma, 32(5), 369–373. https://doi.org/10.1097/ijg.0000000000002166

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1: The Appointment Begins

A glaucoma patient arrives at the clinic for their routine follow-up. A technician greets them, performs a quick vision check, and measures their intraocular pressure (IOP). The reading is noted in the patient’s chart.

2: Doctor’s Pre-Assessment

Before seeing the patient, the glaucoma specialist reviews the file:

• Last visit’s IOP and target pressure
• Prescribed medications and dosage schedule
• Prior visual field tests and imaging
• Any notes on adherence or reported side effects

The doctor mentally frames what the current IOP should be if the patient has been faithfully using their drops.

3: The Eye Exam

The patient enters the exam room. The doctor examines the eyes using a slit lamp, checking for cataracts, inflammation, or any ocular abnormalities. Then, using Goldmann tonometry, the doctor takes another IOP reading in order to have a more precise measurement since this meausrements tend to have variability.

They compare this new value with both the earlier technician’s reading and historical trends.

Branching Points---> Is the patient compliant with their drops?

   Branch A – Patient is Compliant

The IOP is within target range. The eye exam shows no signs of progression and optic nerve appears stable. The patient confirms they’ve been using their drops daily, as prescribed. They haven’t noticed any side effects and have no trouble remembering their schedule.

Outcome:

• Doctor confirms that the glaucoma is stable.
• No changes to treatment.
• A follow-up is scheduled in 4–6 months.
• Patient is encouraged to keep up the great routine.

   Branch B – Patient is Not Compliant

The IOP is higher than expected. The optic nerve shows subtle signs of progression compared to past imaging. Visual field results have declined slightly.

The patient could admit that they often forget to take the drops or sometimes skip doses due to irritation, cost or simply is just progressing.

Outcome:

• Doctor discusses the importance of adherence and reassesses the treatment plan.
• Options are considered:
  1. Changing drops or frequency of use
  2. Adding a second medication
  3. Referral for laser trabeculoplasty/surgery if progression continues
• A shorter follow-up window is scheduled
• The patient is given resources or tips for improving medication compliance.

 4: After the Visit

The patient goes to the front desk, schedules the next appointment, and picks up any new or refilled prescriptions from the pharmacy.

Types of Medical Codes Used: CPT, HCPCS, and ICD-10

i. CPT (Current Procedural Terminology)

Examples in ophthalmology/glaucoma:

• 92083 – Extended visual field test (perimetry)
• 92133 – Scanning optic nerve imaging (OCT for glaucoma)
• 99213 – Established patient follow-up visit (mid-level exam)

CPT tells what was done, the procedures performed during the visit.

ii. HCPCS (Healthcare Common Procedure Coding System)

Examples in ophthalmology/glaucoma:

• A9270 – Non-covered item or service
• J3490 – Unclassified drug (often used for eye drops)
• V2599 – Miscellaneous intraocular lens

HCPCS codes identify what was used or provided, especially for billing medications or equipment.

iii.-ICD-10 (International Classification of Diseases, 10th Revision)

Examples in ophthalmology/glaucoma:

• H40.11X1 – Primary open-angle glaucoma, right eye, mild stage
• H40.11X3 – Primary open-angle glaucoma, right eye, severe stage
• Z91.120 – Patient noncompliance due to medication side effects

ICD-10 codes explain why the care was provided — they justify procedures and allow tracking of disease progression, especially for chronic conditions like glaucoma