debate on how to treat ocular disease

[drbizzaro]

I was having a debate with one of my colleages (a former classmate from my graduating class). The debate revolved around whether or not a commerical optometrist should treat ocular disease in the following situation:

a) The optometrist in the establishment has obtained 2-3 baseline VF's (24-2) in order to ascertain a reliable VF. In addition, they have 2-3 IOP measurements with pachy. readings. Through dilation and evaluation of the ON head, they conclude that there is evident nerve fiber loss, and along with VF nasal steps in each eye, and IOP's in the 30's, the doctor starts the pt on a glc drop trial to lower down the pressure. RTC 1 week.

b) The same situation as in A, however, the doctor does not start the pt on drops and sends them off because they do not have an OCT/GDX.

I argued A because, even though an OCT or GDX provides more information, the correlation between appearance of ON and VF, as well as high IOP's would lead me to a dx.

I'm curious as to other opinions on this.

Thanks

---

Members don't see this ad.

 

[EyeBaller]

In this example does it matter if the optometrist is "commercial?" The way I see your question is: "Can you diagnose and treat glaucoma without a GDx/OCT?"

The answer is simply yes.

The OD (whether commercial or not) has to decide whether they are comfortable treating this patient, if they are not then that should be the reason they should refer to another OD or OMD for evaluation and management, not because they don't have a GDx/OCT/HRT.

Like you say these are additional tools that are not necessary for a glaucoma diagnosis. In my opinion, the only last thing you need is a gonio to determine the type of glaucoma the patient has.

A small aside: Given the clinical data you provided what would be the real value of the GDx/HRT/OCT?
At this point you should have a treatment plan in mind. If the GDx comes back glaucomatous would this change your management? If the GDx comes back completely normal, would this change your management? I would hope not.

 

[eyestrain]

Yeah, I'm not seeing how a GDx is going to change whether I treat or not. It seems pretty cut and dried this person has glaucoma.

 

[drbizzaro]

In this example does it matter if the optometrist is "commercial?" The way I see your question is: "Can you diagnose and treat glaucoma without a GDx/OCT?"

The answer is simply yes.

The OD (whether commercial or not) has to decide whether they are comfortable treating this patient, if they are not then that should be the reason they should refer to another OD or OMD for evaluation and management, not because they don't have a GDx/OCT/HRT.

Like you say these are additional tools that are not necessary for a glaucoma diagnosis. In my opinion, the only last thing you need is a gonio to determine the type of glaucoma the patient has.

A small aside: Given the clinical data you provided what would be the real value of the GDx/HRT/OCT?
At this point you should have a treatment plan in mind. If the GDx comes back glaucomatous would this change your management? If the GDx comes back completely normal, would this change your management? I would hope not.

that's what i was saying to my colleage. I just wanted to see if people felt the same way

 

[drbizzaro]

Yeah, I'm not seeing how a GDx is going to change whether I treat or not. It seems pretty cut and dried this person has glaucoma.

I think my colleage is afraid to treat glaucoma unless she has more proof from a GDX or OCT that there is actual nerve loss. She was telling me that she feels she needs the GDX for more security.

 

[eyestrain]

I think my colleage is afraid to treat glaucoma unless she has more proof from a GDX or OCT that there is actual nerve loss. She was telling me that she feels she needs the GDX for more security.

More security? Isn't the fact there is visual field loss an indication that there is "actual nerve loss"? I'm not sure what she thinks is going on with IOPs in the 30s, nasal steps and visibly damaged nerves. This sounds like someone who wouldn't be comfortable treating it with all the information and data in the world.

 

[EyeBaller]

I think my colleage is afraid to treat glaucoma unless she has more proof from a GDX or OCT that there is actual nerve loss. She was telling me that she feels she needs the GDX for more security.

"Proof from a GDx.." Because the GDx is always right?

So ask her, if she had a patient with healthy nerves, clean visual field, pachs of 600, IOPs of 12, open gonio, no family history and a horrible GDx showing a thin nerve fiber layer. She would say this person had glaucoma? Or needs treatment?

Glaucoma is diagnosed by a doctor, not a machine.. It's sad that someone can't be sure in a case like this that the patient has glaucoma, or... at the very least needs treatment (as a patient having glaucoma and a patient needing treatment can be two different things).

I don't know about her but I'm not sure I want too many of my (future) patients walking around with IOPs in the 30s.. whatever their nerves/fields and GDx look like..

 

[Ben Chudner]

I think my colleage is afraid to treat glaucoma unless she has more proof from a GDX or OCT that there is actual nerve loss. She was telling me that she feels she needs the GDX for more security.

Go back and ask her about what the previous poster suggested. What would she do in that situation when the GDx came back normal? I doubt it would, but if it did would that allow her to feel comfortable not treating? She needs to remember that all of our tests for glaucoma (IOP, Pach, Gonio, TVF, GDx, HRT, OCT, RTA, etc) only give us pieces of the puzzle. Treatment should be based on the whole picture.

 

[drbizzaro]

Go back and ask her about what the previous poster suggested. What would she do in that situation when the GDx came back normal? I doubt it would, but if it did would that allow her to feel comfortable not treating? She needs to remember that all of our tests for glaucoma (IOP, Pach, Gonio, TVF, GDx, HRT, OCT, RTA, etc) only give us pieces of the puzzle. Treatment should be based on the whole picture.

I asked her today, and she said her preceptor at one of her externship sites grilled it into her head that you cannot treat glaucoma without an OCT or GDX.

 

[EyeBaller]

I asked her today, and she said her preceptor at one of her externship sites grilled it into her head that you cannot treat glaucoma without an OCT or GDX.

 

[lazerlight77]

delete

 

[eyestrain]

I asked her today, and she said her preceptor at one of her externship sites grilled it into her head that you cannot treat glaucoma without an OCT or GDX.

 

[drbizzaro]

yeah, the exact same thing i was thinking when i was speaking with her. However, I didn't want to get into a heated debate with her because she's the type of girl that feels she's right no matter what. I just left her with a friendly comment: "to each their own".

 

[KHE]

I asked her today, and she said her preceptor at one of her externship sites grilled it into her head that you cannot treat glaucoma without an OCT or GDX.

I am skeptical of that claim. Even the dimmest of practitioners knows that you do not need an OCT or a GDx to diagnose glaucoma. I would submit that your friend misunderstood what her preceptor was trying to tell her.

 

[eyestrain]

yeah, the exact same thing i was thinking when i was speaking with her. However, I didn't want to get into a heated debate with her because she's the type of girl that feels she's right no matter what. I just left her with a friendly comment: "to each their own".

I don't know if this girl is your friend or not, so I don't want to be a total ass, but she sounds like one of those docs who will be feeding the local OMD all of the pathology she sees.

 

[rpames]

RNFL info is great, but not the final word. As Dr. Chudner said, it is only part of the puzzle. I have had a number of patients who had all the signs, but the GDx came back ok. I still started treatment. There are many who graduated with me who refused to think for themselves. If there is not a machine to tell them what to do, they were afraid to make decisions on their own.

Dr. Bizzaro, you were right. GDx/OCT/HRT/RTA are nice, but not needed to treat.

 

[362.04]

There is a whole lot talk here.

1. RNFL imaging has a place in our armentarium and serves as an adequate rationale for objective evidence that a patient falls below the population norms for the integrity of the RNFL.

2. The visual fields are functional tests and depend upon patient input. The usual wisdom is three visual fields done on 3 separate times to ensure that a visual field is actually present. OHTS says that a visual field defect on the first try will more likely be absent on the following try. Therefore, to treat on just the first visual field is a bit chancey. Like in diabetes, of course, if there is a profound visual field defect, then a confirmation field may not be necessary.

3. Glaucoma is definitively diagnosed as a condition that progresses. In this regard, you may suspect glaucoma on initial testing, but until there is a time interval between the next visit, there is no evidence of progression. The defect then might be related to another medical condition.

4. We should be careful to assume that visual field defects aren't related to any other kind of optic nerve head pathology or visual pathway pathology. There are other conditions that can mimic glaucoma fields but may not be amenable to topical antiglaucoma medications.

5. For example, you can have a field defect, a large optic nerve head cup, but normal RNFL thickness. I wouldn't call this glaucoma. I would look for other pathology. They might not need glaucoma treatment.

 

[drbizzaro]

RNFL info is great, but not the final word. As Dr. Chudner said, it is only part of the puzzle. I have had a number of patients who had all the signs, but the GDx came back ok. I still started treatment. There are many who graduated with me who refused to think for themselves. If there is not a machine to tell them what to do, they were afraid to make decisions on their own.

Dr. Bizzaro, you were right. GDx/OCT/HRT/RTA are nice, but not needed to treat.

thanks for the feedback! that's what I was hoping to hear.

 

[drbizzaro]

There is a whole lot talk here.

1. RNFL imaging has a place in our armentarium and serves as an adequate rationale for objective evidence that a patient falls below the population norms for the integrity of the RNFL.

2. The visual fields are functional tests and depend upon patient input. The usual wisdom is three visual fields done on 3 separate times to ensure that a visual field is actually present. OHTS says that a visual field defect on the first try will more likely be absent on the following try. Therefore, to treat on just the first visual field is a bit chancey. Like in diabetes, of course, if there is a profound visual field defect, then a confirmation field may not be necessary.

3. Glaucoma is definitively diagnosed as a condition that progresses. In this regard, you may suspect glaucoma on initial testing, but until there is a time interval between the next visit, there is no evidence of progression. The defect then might be related to another medical condition.

4. We should be careful to assume that visual field defects aren't related to any other kind of optic nerve head pathology or visual pathway pathology. There are other conditions that can mimic glaucoma fields but may not be amenable to topical antiglaucoma medications.

5. For example, you can have a field defect, a large optic nerve head cup, but normal RNFL thickness. I wouldn't call this glaucoma. I would look for other pathology. They might not need glaucoma treatment.

Interesting take on the whole issue. I agree 100% with what you have to say, and particularly like your example in point #5.

 

[ddown]

A bit off topic, but why would you have the patient back in 1 week after starting Tx? I'm assuming the patient would be started on one of the "first line" drops such as a prostaglandin analogue or beta-blocker and would need at least 1 mos. for the full efficacy to be known.

 

[EyeBaller]

A bit off topic, but why would you have the patient back in 1 week after starting Tx? I'm assuming the patient would be started on one of the "first line" drops such as a prostaglandin analogue or beta-blocker and would need at least 1 mos. for the full efficacy to be known.

You're right, a prostaglandin would need up to a month, but I would probably see them in about 2 weeks.. check on compliance/ADRs, and you should have a decent decrease in IOP.

However, 1 week for a beta-blocker is plenty of time they have a fast onset time.

 

[362.04]

I think the argument is a bit misleading. It shouldn't be named how to treat ocular disease. It should be named any patient with any kind of abnormal findings.

The question here is really an optometrist in the aforementioned setting has the prerogative, the leeway or the initiative to treat or evaluate a patient that is not just a "well eye" visit. Really, an abnormal eye or visual system and may include pathology outside the visual system. Can or is the optometrist so situated be inclined or be able to examine adequately the other systems to ensure it is an ocular condition only?

Hmmmmm.

 

[DrEyeBall]

I don't know if this girl is your friend or not, so I don't want to be a total ***, but she sounds like one of those docs who will be feeding the local OMD all of the pathology she sees.

And the problem with that is what?

Is there something wrong with someone referring a patient who has something that they feel could be best handled by another doctor?

 

[eyestrain]

And the problem with that is what?

Is there something wrong with someone referring a patient who has something that they feel could be best handled by another doctor?

My point is that a lot of these docs will send everything out to an OMD instead of another OD. Red eyes, glaucoma suspects, anything out of the ordinary. Instead of sending them to another OD who is fully capable of treating it, they send the patient to OMD and another patient winds up thinking the OMDs are the ones to go to for REAL problems. Plus, the OMDs get sent a lot of stuff from ODs that's relatively easy to treat, which has to perpetuate their feeling that ODs are *****s.

 

[KHE]

And the problem with that is what?

Is there something wrong with someone referring a patient who has something that they feel could be best handled by another doctor?

In theory, no but if this person is sending out "all the pathology she sees" then it is reasonable to think that a significant amount of that pathology does not need surgical or ophthalmological intervention and could just as easily be referred to another OD who IS comfortable handling it.