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Optometry visit

Discussion in 'Optometry' started by Unty, Apr 7, 2012.

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  1. Meibomian SxN

    Meibomian SxN

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    Yeah, ok. So is there something wrong with documenting normal? Makes for an excellent teaching tool etc. I show the patients the effects of hypertension, diabetes, AMD, hypercholesterolemia; just to name a few. And Rev-Eyes is no magic bullet, hardly ever works. I never said "in place of". Interesting enough, I haven't seen studies saying the Optos missed anything. The study (which I witnessed as a student being done) actually showed DFEs can miss pathology because there's more variability between practitioners. Go figure...

    If its helpful in management of a known disease why would you not charge for it? Would you not explain that to the patient and they sign a BOV stating that if the insurance does not cover it then it is the patient's responsibility? Don't compare apples and oranges. Doing a test that may reveal more information about a known disease is normal eye care practicing. And the patient can always refuse any service. Nowhere did it say the OD presented it in a scamming way.


    The dentist is charging for the technology. Whether in your opinion its useful info or not is not your concern, its the patient's decision. So its wrong for a doctor to stock vitamins? Wow, you sound like a real profitable doctor; smh.


    Yeah, I guess you're the "give services out for free" type doc. Treat pathology on vision insurance type. And we wonder why we are in the state we're in now as a profession.
  2. PBEA

    PBEA Senior Member

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    no, you misread my topography example. When managing corneal disease I perform and regularly bill for corneal topography, which is paid by their medical insurance. But in my post I was offering a "corneal topography scan" to a hypthetical pt who has no complaints suggesting corneal disease, and I have no suspicion of corneal disease. In fact lets say that this hypothetical pt has no corneal disease. I am offering this test to this hypothetical pt in a similiar fashion as an Optos scan is often offered. Of course I could just use a slit lamp and cal it a day, but by trying to entice the hypothetical pt into paying for the additional test I might improve my........."profitability". Isn't that about the sum of it?

    I know this is tough to swallow but selling unecessary tests solely to become "profitable" is just plain wrong, and I am amazed you think that rationale is appropriate. I have no problem with "profit" as it were, but not under false pretenses. Let me ask you why not just raise your office visit fee and bundle the scan in to perform on everyone? (of course I would only suggest doing that if they are being dilated in the first place). Certainly not a perfect logic but a hell of a lot less "slimy" then the additional fee.
  3. PBEA

    PBEA Senior Member

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    Your dentist sounds like a vulture, preying on the relative ignorance of his pts. I know something close to squat about how measurable "antioxidants" are, but I can smell this bullcrap from a mile away. And it stinks.

    most pts are probably more trusting, then I am, in their doctor(s). And they can be easily taken advantage of.
  4. VA Hopeful Dr

    VA Hopeful Dr Senior Member

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    Unless the vitamins aren't carried in local drug stores (and have good evidence showing benefit), then yes I think that is wrong.
  5. mclem222

    mclem222

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    "Most doctors do not like screwing their patients, but we did not undertake this profession in health care to be paupers." - Meibomian Sxn

    Sums it up right here....
  6. Shnurek

    Shnurek

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    Do you like being poor? I agree with Meibomian in a way. I hope to practice by being the only OD in a small town and negotiate higher reimbursements from insurance companies to get away from people that place no value on the work they do. Preferably in a +10% medicare zip code and a state where oral steroids and injections are legal, to practice to the fullest extent of my license. Anyone know what I can do to secure externship positions in the boonies?
  7. Visionary

    Visionary Medical Retinologist

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    Yes, having a patient pay you extra money to document that they are normal is wrong, IMO. As per PBEA's example, you could go crazy with that logic. You could recommend topography, pachymetry, OCT, RNFL scanning, VF testing, Optos, etc. Heck, you could even bundle all those tests as a, let's say $200, screening for eye disease. You'd probably get enough gomers taking you up on it to make it profitable. Fact is, I seriously doubt patients are coming to you with the idea of paying for an educational session on eye disease. They either have a medical complaint or just want their glasses/contacts. The only out-of-pocket charge for my patients is $30 for refraction, unless they have an eye plan that covers it. If I order a test, and there's no billable pathology, there's no charge.
  8. mclem222

    mclem222

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    I will repeat this statement....

    Once you start viewing patients as potential profit centers or sources of income you instantly stop becoming a doctor and become no different than someone who owns a car dealership, nail salon, restaurant. When I go to a restaurant they try to upsell me to have me get drinks or apps. I expect that there...not in a doctors office.

    This type of behavior is not seen at a cardiologist office or even most ophthalmologists office, why should it be ok for us? We are not salesmen, we are doctors.
  9. Meibomian SxN

    Meibomian SxN

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    And that's what I said. Someone can give false pretense on anything. There was no indication the OD told this "physician" or anyone else that Optos is equivalent or better than DFE. They physician was just angry he paid for an out of pocket test.

    What's wrong with private labeling vitamins?

    Shnurek, there's nothing wrong with offering additional services in our practice. There's ony something wrong with those docs who are stuck in their ways and not the profitable type. Remember, its still a business that needs to generate revenue, by legit means.

    The test is not ordered for the sole purpose of 'fishing' for pathology. Its a technological test that has benefits over DFE (mostly convenience) and is should be charged for. Funny, I've never seen a patient that said "I wish I never got this test". Maybe its because I haven't examined too many "physicians" lately. :laugh:

    Wring again. Look at how they found out that a large percentage of interventional cards were doing stents on far more many people than supposed too? Or the fact that they have MRIs inside of malls that offer all types of scans. GO figure.
  10. VA Hopeful Dr

    VA Hopeful Dr Senior Member

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    I think its shady. Are you OK with private label contact lenses?

    There's nothing wrong with not wanting to do what you're doing. But the main purpose of any additional testing is to help the patient... making money off of that is secondary.

    How would you feel if your family doctor did a stress test on you every year (out of pocket)? After all, you COULD have CAD. Those tests pay very well for us, especially if cash. You just don't see that happening.

    Entirely different. A cath is the only way to be sure about the status of the coronary arteries. Retinal photos, especially undilated, are not the only way to exam the fundus... in fact, I'd be leary of any eye doctor that thought that was better than their DFE.
  11. PBEA

    PBEA Senior Member

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    If I got suckered into paying extra for a test that serves no purpose, then I would be pissed too.

    and thats the whole point
  12. Jibslider

    Jibslider

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    I don't need a study to show me that OPTOS has missed any pathology as I have seen it personally in the clinic. Often it can not image out to the ora, and often you are lucky if you get a view of the peripheral retina with it. Just last week I had a patient that had lattice 360 degrees (not even adjacent to the ora) on one eye that was easily viewed via DFE with a 20D lens, but the OPTOS could not image any patches of the lattice.
  13. Meibomian SxN

    Meibomian SxN

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    Why would anyone have a problem with that? Is that a gimmick to the patient too?

    Wrong. That's not the only way. And besides, the stents were being put in Px's that didn't even need them. And it was a large percentage of stents too. That's like me putting punctal plugs in people who's dry eye syndrome did not warrant it.


    I don't look at it as suckered, especially since it was a "physician" sitting in the exam chair. No one suckered him, he was just bitter for having to pay something other than a co-pay. duuuuh. :oops:


    Again, men lie/women lie but numbers don't. For each of these "the OPTOS missed pathology" stories, we can share the same amount of "DFE missed pathology" stories. The study comparing the 2 techniques showed that. Its called EVBM (evidence based medicine) if you did not know already.

    So again, I see nothing wrong with it being offered as an optional test, because its optional. :idea:
  14. Shnurek

    Shnurek

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    Or the prostate cancer overzealous treatment: http://www.nytimes.com/2011/10/07/health/07prostate.html

    mclem I know you probably hate getting advice from a 1st year opto student but nowadays Doctors are not that special. Maybe before the internet and in the 50's and 60's MDs were viewed as on the level of supreme court justices. But nowadays Doctors are just professionals and not anything special beyond that. Especially with the MDs losing their monopoly on medicine, the "high horse" factor is really dissipating. Almost anyone can look up certain pathology online. Medical information is all over the place and no longer in the minds of physicians only. So accept that you are a professional and make the most of it.
    Last edited: Apr 20, 2012
  15. OATAcer

    OATAcer

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    Doctors are and will always be a well respected profession. Research was done and women said that their dream spouse's profession is a doctor. Some for the respect, some for the money and some for both. Overall, in many cultures, they claim doctors highly prestigious people.

    Sent from my Galaxy Nexus using Tapatalk
  16. Shnurek

    Shnurek

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    haha, too bad the opposite doesn't really matter
  17. PBEA

    PBEA Senior Member

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    I know you dont look at it as suckered, and the fact that it was a physician patient is not relevent. What IS relevent is that you think its ok to dupe people into believing that a TOTALLY unecessary test is worth paying extra money for. Its a scam, and you are a scammer.

    Have you no shame?
  18. mclem222

    mclem222

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    PBEA, you view patients as a person to be helped. Meibomian views patients as a piggy bank. You will never convince him that this behavior is not right. This is the same way that most criminals think that what they did was totally fine...madoff, gecko, mob bosses...He is just trying to rationalize it...Whatever..it is his cross to bear...We will probably end up seeing him on American Greed the TV show.
  19. Meibomian SxN

    Meibomian SxN

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    How is the fact that he was a physician not relevant? I'm sure he knows as a physician that what his insurance covers is sufficient for an exam. Again, its just a case of a disgruntled customer who is bitter that they paid more than their co-pay. Boo-hoo. This was further proven because he bitched & moaned about paying an ALREADY discounted contact lens fee. I can tell by that that you're not good at taking patient histories.

    Its not duping. Who are you to decide what's unnecessary or not? Some doctors do not have a problem with their patient's getting dilated. Many of the patients who come to me with vision plans opt of of DFEs, regardless of what horror story I may tell them. I'd prefer an OPTOS over a nondilated exam. And I have seen the technology in both MDs & ODs offices, none of which I have ever heard "this takes the place of your dilation". Maybe you need to get out of your stuck in a rut ways and offer something different to the patients. You sound pretty bland to me. And clueless.


    No, its just as an OD, I am used to selling medical devices and services to people. An oMD rarely gets into discussions about contacts, glasses, magnifiers etc. They mostly sell their service only. I would not expect the one track minded oMDs on here to understand that. They're typically horrible at business and make bad financial decisions; documented fact. And they're control freaks at times. If someone does not want the test offered, simply circle no. End of story.

    And it sounds as if they've rubbed off on you some. As they say "you are the company you keep". And that's not a good thing. :eek:
  20. hopeful04

    hopeful04

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    Hi,

    Just thought I would chime in with a few reasons why I love screening photos.
    We offer screening photos to everyone. We are not pushy about it, but feel like everyone should have the opportunity to have the test if they want it.

    In the last week I have had two patients that should consider the photos a good investment.

    Patient 1: 45 yr old male, generally good health but has just started treatment for relatively asymptomatic hep C. He just needed new glasses and did not want to be dilated. He opted for screening photos. I did the exam, including undilated fundoscopy and everything looked ok. I went over his retinal photos at the end of the exam and because they are blown up so much more than my 90D lens view, I saw a faint roth spot on the edge of the photo. So I forced him to be dilated and found 2 more. I called his Gastroenterologist who ran bloodwork and his WBC and RBC counts had bottomed out. He got a blood transfusion and stopped his meds. His GI said his hep C med nearly killed him. Yes, i could have forced dilation in the first place, and yes, I could have picked up on the roth spot with my 90d but I tried to find it again before I dilated him and I just could see it. Nobody can convice me that a magnified static view of a posterior pole is not better than fundoscopy in many cases (not for depth obviously).

    Patient 2: 50 yr old female, cant remember her medical hx, but spent the night in the ER with nausea and stomach pain, was released with no diagnosis. Had screening photos taken. She was having a hard time with testing because of her nausea and I could not get great retinal views because she was so light sensitive, so I did my best with fundoscopy and then used a panoptic then looked at her photos. She had MANY very faint cotton wool spots. I sent her back the ER with a note from me - she called a few days later from the hospital thanking me because she had a perforated gastric ulcer, was bleeding internally and was going into shock. She needed emergency surgery.

    So, I know that I am a good doctor and I do my best to see the retina well whether it is through a dilated pupil or undilated, but a good quality retinal photo that I can zoom in with is so very useful. I do wish everyone would get photos. But I also wish I could just make it part of the exam and didn't have to charge them for it, but hey, we do run a business too. There are also months where I don't see a thing in a retinal photo, but I still like to see them.
  21. Shnurek

    Shnurek

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    mclem why don't you give up all of your income to be on par with the 45 million Americans that are on food stamps. Lets see how cushy your life will be then.
  22. Shnurek

    Shnurek

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    Really touching stories. I hope to be able to do this for my patients some day. May I ask where you practice? Rural, suburban, urban setting?
  23. mclem222

    mclem222

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    A dilated exam wouldve picked up roth spots or cotton wool spots. These stories are anecdotal. How many normal photos have u taken to get those two patients. In your words there is a month that goes by with normal photos. Why not do a flurescein or bscan on everyone.

    Meibomian it is clear that you have rationalized your behavior. Yes you are right it is everyone else who has the problem. Your clinical skills must be so weak u need this photo system to augment your income.

    Shrunek just because we face loss of income or lower reimbursements does not mean we should start ripping off people. That is the rationalization of a crook or entitled person. Entitlement is seen in the food stamp group.
  24. Meibomian SxN

    Meibomian SxN

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    Thank you for the example cases. :thumbup: Just shows how lame and bland the other docs are. Smh. I had 2 people today who could not be dilated because they had a job orientation and the other a job meeting. They were very appreciative of the technology. Good thing they weren't examined by some of these other one track mind eye doctors. :eek:

    Wow, you sound like you need a vacation. So outdated and stale, you must still have that light olive green paint with the matching rugs in your office. Smh.
  25. thiaeyemd

    thiaeyemd New Member

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    :)
    Last edited: Apr 22, 2012
  26. Busacca

    Busacca

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    There is obviously a lot of controversy surrounding optomap. I feel like i've heard this same type of debate several times over. If the O.D. from the OP was really doing this test without telling his patients there would be an out of pocket charge, and then billing them later, I think most of us would agree that's wrong. It would be like eating "free samples" at Costco and then being charged for it at check out. I have a hard time believing this OD is doing that because it seems like a sure fire way to lose returning patients.

    Its ignorant that you imply that ODs are the only ones guilty of unethical practice in an attempt to increase profits. All professions are after the almighty dollar and have plenty of "practice building tips" that most of us would argue to be unethical. Shoot, I bet we all have a story or 2 about a dentist doing a little upselling... If the patient understands the purpose of the test in question, the costs and benefits, and consents to it, is the Dr. somehow ripping off the patient?

    For example: Wellness Exams/Executive medicine. These are very popular and generate a lot of profit for the clinics that do these exams. It is bascially running a whole bunch of tests, for which the person has no complaints or symptoms that would cause the test to be indicated, and charging out of pocket for it. Sounds familiar. Here is a link to the tests that the mayo clinic will do for you if you sign up for their executive medicine exams: http://www.mayoclinic.org/executive-health/screening.html
    Notice that eye exams and glaucoma screening in on the list.
    Now the idea of these exams is to catch a problem before the patient becomes symptomatic and maybe the treatment/prognosis would be better. By this logic, would it be ok for a OD to offer out-of-pocket OCT of the ONH/MAC because it could catch some of the earliest signs of pathology? What do you guys think about these wellness exams, are they unethical too?
  27. mclem222

    mclem222

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    Two counterpoints

    1. The wellness/exectuve testing is advertised as its own separate exam etc.. It is promoted as a "get every test for those who want it all done". That is different than going to the internist and then having him say "you could get an ultrasound of your testicle but that will be an extra $50 fee" There is no upsell with these wellness exams. People actively seek these out. You don't have Farmer Jones coming in for a routine exam and then getting "upselled" to get an MRI like he went to the honda dealership.

    2. Dentists upselling is what separates them from physicians. What percentage of MDs upsell and in the frequency of us or the dentists. Everyone quotes Dentists as doing sketchy upselling and they do. Just because they do doesnt mean we should also. We should aim to be better than that.
  28. Tippytoe

    Tippytoe

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    Been faintly following this tread. Let me say first off-- The orginal poster is 100% right for being pissed the OD screwed him (if he did). I'd be pissed if someone did a photo on me and didn't tell me it was an extra cost.

    Although, I do agree dentist are the worse for this. They seem to do any test they want and just present a bill to you (not an insurance company) at the front desk with a card with your return date (with no input from you). No dentist has ever told me that they are going to do x-rays and it will be an $85 additional cost. Just another reason I think dentist have it better than another other health profession..........and are the most crooked. But that's another story for another time.

    Speaking of other docs that 'throw in that little extra'. We have a few ophthalmologists here that push multifocal IOLs like they are the greatest things since the wheel. There is a $300 extra charge for the "Precision Vision" test (fancy autorefractor) and $4,000 extra if you want Restor or Rezoom or Crystalens. I have no problem with the options as long as they are presented before hand. But these 2 guys present it this way:

    "Well Mrs. Jones, your Medicare covers your cataract surgery if you want to have the old fashioned way to do it and we can't guarantee you will gave good vision and you will still have to wear reading glasses. OR, if you choose these new tests and with this up-to-date newest surgery, you will be able to see far and near and should never even need any glasses".

    Now which would you pick? This is what the patient hears: Well, Dr Jack said I could have the old fashioned surgery that won't be very good or I can pay extra for the really good surgery. They hear: Good surgery vs. Bad surgery for my eyes. Who in their right mind would pick a lesser surgery for their eyes and vision?!

    So they sucker a bunch of people into multifocal IOLs (I see most of them in post op). The success rate is about as good as multifocal contacts (50%). The OMDs are $4,000 richer vs. $800 for a medicare cataract surgery. The OMDs don't care about the bad outcomes because they don't plan on ever seeing them again. It becomes the ODs problem to explain why they spent thousands of dollars extra and still have to wear reading glasses.:p

    Also we have a retina OMD that gets most everyone he sees to purchase eye vitamins from his office and puts them on auto pay which bills their credit card every month. Very few patients question him becuase, after all, he is the retinal specialist.

    There's all types everywhere.

    For the record, I do a digital retinal photo on every patient for free. I include it in the routine exam. There is nothing as good as having a nice retinal photo, taken by a tech and beemed to my exam rooms for me and the pt to look at. It instantly shows the "working area" of the retina. I can glance at it and know if there is haze (cataract) any posteior pole retinopathy (diabetic/HTN), nerve (glaucoma). So in a one second glance, I can pretty much rule out all of that before I refract. There is nothing like spending 10 minutes trying to refract through a 20/80 cataract or blood in the macula and then later finding out why they couldn't see.

    Dilation for peripheral retina view on anyone that will agree to it (for no extra fee of course).
  29. mclem222

    mclem222

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    If the omds are presenting it like that they will eventually get their million dollar lawsuit and pay the piper.
  30. Zorro12

    Zorro12

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    Do you see them b/c you comanage or them or do they come to you pissed about dropping all that cash? If it is comangement, why not send to somebody else? Most referring ODs around here would not tolerate that out of the OMD and would refer to one of the other very willing cataract surgeons in our area.

    FYI: I do about 95% monofocal lenses. I tell every patient about the options of multi vs mono vs torics in the interest of informed consent. I am very happy with toric results, not so much with multifocal. I will do multifocals, but the patient basically needs to sign in blood they understand they will not see 20/20 at near and will not have the quality of vision they did when they were 25 years old.
  31. Tippytoe

    Tippytoe

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    I co-manage with him (and some come to me just to complain :p ). He truely is the best cataract surgeon in the area. It's unfortunate he runs his office (with large optical) like a car dealership (extra for everything). I do get tired of having to give a 15+ minute 'warning' to everyone going in for surgery that they don't have to get the multifocal lenses if they won't to. I have to tell them he is going to push it, and tell you it's better, and tell you how great it is .......blah, blah, blah. Ironically, this great cataract/Lasik surgeon wears reading glasses himself but usually tries to hide it from patients :)

    I do have a better surgeon (or at least as good) to refer to but he's 45 minutes away. He's not a high pressure sales guy so it's much easier and less stressful for the patient. The ones that don't mind the drive (and same day surgery) go there. I'm fortunate that I do have great sub-speciality ophthalmologists to refer to (retina, glaucoma, cornea). No neuro OMDs around. Must be a low paying specialty :). Best strabimus guy is an OD turned OMD.
    Last edited: Apr 26, 2012
  32. mclem222

    mclem222

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    Retina. 2007 Oct;27(8):1119-24.
    Sensitivity and specificity of the optos optomap for detecting peripheral retinal lesions.

    Mackenzie PJ, Russell M, Ma PE, Isbister CM, Maberley DA.
    Source

    Department of Ophthalmology and Visual Sciences, Vancouver Hospital Eye Care Centre, University of British Columbia, Vancouver, Canada.

    Abstract

    PURPOSE:

    To compare the sensitivity and specificity of the Optomap Panoramic200 wide-field confocal scanning laser imaging system for detecting peripheral retinal lesions.
    METHODS:

    Optomap images were obtained in patients with known retinal pathology. Two masked retinal specialists evaluated Optomap images to identify lesions requiring referral to a retinal specialist. Their performance was compared to gold standard examination with scleral indentation performed by a retinal specialist. Sensitivity was calculated overall and again for lesions that were found on clinical examination to require treatment. These sensitivities were calculated separately for lesions posterior and anterior to the equator. Specificity was calculated from fellow eyes that were found to have no pathology on clinical examination.
    RESULTS:

    For retinal lesions posterior to the equator, sensitivity was 74% (95% confidence interval [95% CI] 61%-87%) overall for all lesions and 76% (95% CI 59%-93%) for lesions requiring treatment. For anterior lesions, sensitivity was 45% (95% CI 28%-62%) overall and 36% (95% CI 14%-58%) for treatable lesions. Specificity was 85% (95% CI 63%-100%).
    CONCLUSIONS:

    So basically Optomap picked up 74% of peripheral lesions and 45% of anterior lesions...pretty freaking weak if you ask me..Unless you guys are missing 26% and 56% of lesions respectively (maybe thats what the retina guys think we atleast miss..so the optos map is a step up compared to an OD) ..Then again, getting paid for somethign will convince a lot of peopel to do stuff that is sketchy.
  33. Visionary

    Visionary Medical Retinologist

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    ^ low to moderate sensitivity = poor screening

    A good screening tool is one with high sensitivity. That is, you want to not miss any pathology, even though you may have a high false positive rate.
  34. PBEA

    PBEA Senior Member

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    I have serious doubts whether those who sell optos scans care whether or not it is any good at doing what they claim it does. As they do not order the test for any clinical necessity, it would seem the only relevent condition for them is whether it makes money or not.
  35. syma

    syma

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    SDN 2+ Year Member
    I just got a serious twitch at the words 'multifocal IOLs'
  36. Visionary

    Visionary Medical Retinologist

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    As I've said, I think it's a good tool, but for documenting pathology or for wide-field angiography. Not a good screening tool. Honestly, those who market it to patients as a substitute for DFE should give the disclaimer that "I have >50% chance of missing a problem in your eye with this device, but if you want to pay for it, you can."
  37. Meibomian SxN

    Meibomian SxN

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    And you're 99% ? So where's the comparison study? How much pathology did the McClem, Visionary and others miss? Yeah, that's what I thought.
  38. Visionary

    Visionary Medical Retinologist

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    That's the point. It IS a comparison! How do you think they got the percentages, for crying out loud?

    Sent from my Droid Incredible on SDN Mobile

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