Best Ophtho Consults?

[xaelia]

Our consult team received a one the other day from the open heart service....

action requested: consultation and treat
comments: pt. found right contact lense on shirt this AM and cannot find left contact lense. s/p aortic root repair and avr.

I'm sure someone out there can top a "lost contact lens" consult!

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[shiro1]

I had one once from an optometrist who told a 9 year old girl that she had retinoblastoma. When her worried parents asked what that was, he said (reportedly) "eye cancer." Her parents freaked out, had her entire church praying for her and immediately got her in to see me. I looked and looked, and did a scleral depressed exam, of both eyes (it was reportedly on the left macula) and couldn't see a thing. The only possibility was she had a mildly increased pigmentation in her maculas ou. I reassured the parents and had to try to diplomatically tell them that perhaps the optometrist had wanted to ensure that they followed up with the ophthalmologist about this. They weren't convinced and resolved to have their entire family be seen by me from then on. I had some trouble trying to dictate the letter back to the optometrist!

 

[bustbones26]

The ED at my hospital called up the opthalmology service for a consult to see an 84 year old women having headache and vertigo because she must be having temporal arteritis.

Her ESR was 14. If only the ED doc checked the outpatient chart they might have noted that this patient was seen by ENT for Meniere's disease.

That one was almost as good that 78 year old women in the ED who got the pregnancy test. I think I picked the wrong profession, how about you?

 

[JR]

I had an optometrist referal in my clinic several months ago: this poor guy was told that the blood vessels in the back of his eyes "were going to explode" if he did not see an ophthalmologist right away. My diagnosis: blonde fundus .

 

[JR]

That's pretty common (especially around July); I had a GCA r/o in a 34 yo the other day.

The ED at my hospital called up the opthalmology service for a consult to see an 84 year old women having headache and vertigo because she must be having temporal arteritis.

Her ESR was 14. If only the ED doc checked the outpatient chart they might have noted that this patient was seen by ENT for Meniere's disease.

That one was almost as good that 78 year old women in the ED who got the pregnancy test. I think I picked the wrong profession, how about you?

 

[PBEA]

In the last say 3 months, I've had two different ophthalmologists tell two different patients that they had glaucoma. One had optic atrophy secondary to burned out NAION, and the other was being treated based on the sole finding of IOP at 20 ou. I have the entire record. I dont' even want to mention all the 20/30 cataracts that "need to be removed", or how bout a marginally indicated procedure like LASIK, or lets talk about how "surgery is needed for this accomodative esotrope". What a bunch of hogwash, I mean don't you MD's learn that treating with drugs or surgery, is not always the best thing? You want to keep this up, I can go round and round.

 

[KHE]

On behalf of the optometrists, let me apologize for PBEA hijacking yet another one of your threads.

But I would caution you all to not jump up and down too much based on what patients tell you an OD said. I once had a patient come in telling me that her ophthalmologist gave her "permanent contact lenses" that she had been sleeping in for about 2 1/2 years straight. Her eye looked like a piece of meat. After treating her, I phoned up her OMD who explained to me that he said no such thing. He gave her "permalenses" which used to be made by Coopervision. They were NOT to be slept in and were to be replaced periodically. But the patient somehow heard "Permanent Lenses" out of "permalens"

I've had dozens of patients tell me that their last doctor told them to do something so outrageous, that no sane doctor would tell them to do such a thing. ie You can't sleep in 1-day disposables for 30 straight days. Yet somehow through their discussions, they came away with that impression.

I know of no OD who would diagnose eye cancer. Especially in a 9 year old. He may have been concerned about something for God knows what reason and as you suggest, clumsily used the word cancer to ensure the patient would keep the referal appointment. Even the most boneheaded OD would not confuse mild macular pigment changes with a retinoblastoma. I recall vividly in my early days when I was putting on the BIO to do an exam, a patient asked me what that thing did. I casually told them it was used to make sure that she doesn't have a giant tumor in her eye. The patient freaked out and cried "I HAVE A GIANT TUMOR IN MY EYE??????" Needless to say, I don't use that joke anymore.

So lets be cautious when we tell these stories. We've all made our share of boneheaded diagnoses and unneeded referals that upon reading the consult letter, you smack yourself in the forehead and think "DUH!" Without having actually been in the exam room when the referal was made, it's hard to judge.


And for the love of Christ, PBEA stop hijacking their threads and starting limp ass flame wars.

In the last say 3 months, I've had two different ophthalmologists tell two different patients that they had glaucoma. One had optic atrophy secondary to burned out NAION, and the other was being treated based on the sole finding of IOP at 20 ou. I have the entire record. I dont' even want to mention all the 20/30 cataracts that "need to be removed", or how bout a marginally indicated procedure like LASIK, or lets talk about how "surgery is needed for this accomodative esotrope". What a bunch of hogwash, I mean don't you MD's learn that treating with drugs or surgery, is not always the best thing? You want to keep this up, I can go round and round.

 

[PBEA]

And for the love of Christ, PBEA stop hijacking their threads and starting limp ass flame wars.

First of all, ALL is fair in love and war. Second, why are you such a wussy, that you berate me for slapping down such ridiculous comments. One thing I've noticed is that OD's are so willing to eat their own young, for that matter OMD's are also so willing (OD's constitute their larger family NOT the rest of the entire medical community). Third, I will not stand by and have ANYONE tell me what I know.

 

[Mirror Form]

First of all, ALL is fair in love and war. Second, why are you such a wussy, that you berate me for slapping down such ridiculous comments. One thing I've noticed is that OD's are so willing to eat their own young, for that matter OMD's are also so willing (OD's constitute their larger family NOT the rest of the entire medical community). Third, I will not stand by and have ANYONE tell me what I know.

Consultants always make fun of the stupid consults they get. Notice that we're making fun of other professions besides just optometrists. You should stop being so insecure. I don't see any ER doctors taking this personally and getting all worked up.

 

[shiro1]

I hope I didn't cause another flame war with optometrists, because I have a great deal of respect for what they do. I've actually met the optometrist who sent me that child and he seems like a very personable, knowledgeable older optometrist. I also agree that patients can convert what we say into quite different interpretations. "I've never had cataract surgery!" while I'm looking at their shiny IOL, etc, etc. I didn't bring up the incident when I met with the optometrist, because it was from a few years ago, but the parents were adamant that "He walked in told us she had eye cancer and to follow up with an ophthalmologist!" I have to take things a face value, but listen to all reported statement from other docs with a huge grain of salt. It's not even just optometrists, supposedly a retina doc told a patient who just had cataract surgery that her surgeon didn't tie her sutures tight enough, so that is why she had endophthalmitis that permanently decreased her vision. The general ophthalmologist heard of this, was incensed, because she was very careful of her wound closure and went every day to the hospital 30 miles away to look in on this patient. Needless to say, she never referred a pt back to that retina specialist. All I really wanted to say that you get funny referrals sometimes. His hand written consultation request clearly stated "rule out retinoblastoma in left macula."

 

[smiegal]

First of all, ALL is fair in love and war. Second, why are you such a wussy, that you berate me for slapping down such ridiculous comments. One thing I've noticed is that OD's are so willing to eat their own young, for that matter OMD's are also so willing (OD's constitute their larger family NOT the rest of the entire medical community). Third, I will not stand by and have ANYONE tell me what I know.

I've gotten stupid consults from many people. They're funny. I've been wrong on consults I've sent to other people...it happens. I sent a trauma patient to our retina specialist 2 weeks ago with a supposed RD that turned out to be an unusual commotio. Maybe I should have told him "I will not stand by and have ANYONE tell me what I know."

Just to fire you up a bit, I saw 3 peds patients wearing +0.25 sph OU glasses last year from optoms. So there. I hope you feel more secure in the years to come.

 

[Caffeinated]

First of all, ALL is fair in love and war.

So which is this -- love or war?

 

[PBEA]

Consultants always make fun of the stupid consults they get. Notice that we're making fun of other professions besides just optometrists. You should stop being so insecure. I don't see any ER doctors taking this personally and getting all worked up.

Ok, I'm immature on these points, my apologies.

 

[PBEA]

I hope I didn't cause another flame war with optometrists, because I have a great deal of respect for what they do. I've actually met the optometrist who sent me that child and he seems like a very personable, knowledgeable older optometrist. I also agree that patients can convert what we say into quite different interpretations. "I've never had cataract surgery!" while I'm looking at their shiny IOL, etc, etc. I didn't bring up the incident when I met with the optometrist, because it was from a few years ago, but the parents were adamant that "He walked in told us she had eye cancer and to follow up with an ophthalmologist!" I have to take things a face value, but listen to all reported statement from other docs with a huge grain of salt. It's not even just optometrists, supposedly a retina doc told a patient who just had cataract surgery that her surgeon didn't tie her sutures tight enough, so that is why she had endophthalmitis that permanently decreased her vision. The general ophthalmologist heard of this, was incensed, because she was very careful of her wound closure and went every day to the hospital 30 miles away to look in on this patient. Needless to say, she never referred a pt back to that retina specialist. All I really wanted to say that you get funny referrals sometimes. His hand written consultation request clearly stated "rule out retinoblastoma in left macula."

You did bring up another flame war! I, of course, have seen many cases where patient history is VERY non-contributory, where objective findings are the "rule of the day", and I definetely do not put all my stock in a patients comments regarding, another doctors "diagnosis", or even their symptoms. Like you said "a BIG grain of salt". Big deal, what I find more amusing are actual patient histories, I once had someone tell that urine was a good cleanser for contact lenses. Now that is friggin' hysterical.

 

[PBEA]

I've gotten stupid consults from many people. They're funny. I've been wrong on consults I've sent to other people...it happens. I sent a trauma patient to our retina specialist 2 weeks ago with a supposed RD that turned out to be an unusual commotio. Maybe I should have told him "I will not stand by and have ANYONE tell me what I know."

Just to fire you up a bit, I saw 3 peds patients wearing +0.25 sph OU glasses last year from optoms. So there. I hope you feel more secure in the years to come.

Good, we should all admit our relative weakness' (and strengths), I know I learn everyday. I was not implying that I know everything. Actually that last comment, "I will not stand by and have ANYONE tell me what I know", was totally out of context, and I'd like to withdraw that from the record.

Thanks for the fire, but I've got plenty. As to your 3 peds pts, I've no idea what the hell that's about, maybe you should check the calibration on your lensmeter.

 

[PBEA]

So which is this -- love or war?

Ah, Caffy. Can I say both?

 

[Photon Catchers]

I was actually really enjoying stories from my fellow colleagues about what sorts of fun consults we can expect. Is there any way we can get back to the point of the thread?

 

[Mirror Form]

I was actually really enjoying stories from my fellow colleagues about what sorts of fun consults we can expect. Is there any way we can get back to the point of the thread?

I stayed up pretty late to see a consult for "retinal hemorrhage." Only thing I could see in the supposed location (which was confirmed later by our retina doc) was a vortex vein.

 

[drgregory]

right after i graduated i treated the crap out of a corneal dellen with mild spk for about 10 days with vigamox. needless to say, it didnt help much. i had our corneal fellow take a peek, and he still teases me to this day.

whoever posted the +0.25 for pediatric patients comment - i couldnt agree more. nothing fires me up more than seeing a new patient who presents with habitual of +0.25 OU. we have an OD in our area who must be largest purchaser of stock +0.25 lenses. an out of town friend of mine was going to send his son to him for an exam just to see if he'd end up being Rxd +0.25 lenses. i dont know if he ever got around to it. id like to kick this OD in the groin - he makes the rest of us look bad. hes the classic spectacle peddler that belittles optometrists.

 

[shiro1]

I had a good one last year from a hospitalist. Patient was in the hospital for some other reason, but had a history of MI, CABG, etc. and had a mild subconjunctival hemorrhage. (Actually I was impressed that the internist knew that was what it was.) Reason for inpatient ophthalmology consult: "Can we start him on ASA?"
"Yes." I'll collect my $280 now.

 

[JR]

One of my classmates had a consult from a medicine team to come and evaluate a patient with a prosthetic eye, which was "painful and drained pus". He went to the floor and found a patient with phthisical eye from long-standing previous issues. He then called up a medicine intern and told him: "look, if we were going to make a prosthetic eye for someone, wouldn't we make it better looking then this?!". He is a funny guy .

 

[DrQuinn]

I try not to consult ophtho, because I know how busy your residency is (and how nice your home call SHOULD be). Although two years ago, I saw a 6 year old kid in the Pedi ER... referred to us from a Spanish speaking only clinic, for "red eye for 10 days, no better after treatment." I did my exam, fluoresceined him, and, holy crapola, I swear if it wasn't a dendritic pattern.

I blinked. No way. I've read about it in my text, seen it on my EM boards, but, no way. Here? Today? This is crazy.

Yup. That sureeeeeeeee looks like a dendrite to me.

Let's call ophtho.

me: "dude. I swear I have a 6 year old kid with HSV, I saw dendrites."

PGY3: "WTF?!? Are you $#$#ing stupid? Come on Quinn, that kid would have to be a prostitute or we gotta call child protective services. You really expect me to come in to see what you think is a 6 year old with HSV on their cornea?"

me: "bro, its a dendrite, like it came out of a movie."

PGY3: "grrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr, FINE I'll be in, dammit, this is such a BS consult."

5 minutes after seeing the patient, the resident says "uh, yeah, so we should put him on viroptic..."


kinda cool.

I know ALL the subspecialties can talk about really crappy consults, both from the ED, the community, the inpatient docs, and the other services. It is frustrating, I know, to get a page for a new consult in the ED/ICU or whatever. But we should ALL be able to LAUGH about it the funny ones and not take them personally. Like a previous poster said, you have no idea exactly what happened at the time of the initial impression. I'm in the ED, probably the focus of 99% of all the specialties hatred.

BTW, the last two consults I called to ophtho:

girl spilled hot soup in her eye, ran to her friend, who THEN put super glue in her eye. Now, I can handle a thermal injury to the orbit, I can handle superglue, but not both.

second, MVA with an avulsed eyelid. Gross.

Regardless, I think the optho residents (usually by the time they're PGY4s) are some of the coolest, most knowledgeable, and most willing to teach surgical subspecialists out there....

Q

 

[Redhawk]

Inpatient consults I've heard about in the past year:

Consult: Eval for cataract surgery

Consult: Eval for glasses

Consult: Patient on amiodarone (2 separate occasions)

Consult: Patient on hydroxychloroquine (d/c'd 1 year ago)

Consult: Patient in psych ward - h/o uveitis 4 years ago - no current sx

 

[Visioncam]

While some of these stories are funny, my feeling is that we are in a service profession. As such, we are here to provide a service to patients, referring physicians, optometrists, etc.

Ophthalmologists are also guilty of referring patients with nothing. For cataract surgery preops, the patient can say "my back itches now" which will almost lead to a dermatology consult, psychiatry consult, pre-op clearance with the internist, etc.

If the patients or referring physicians were so smart, more than half of the referals would dry up. In a residency, one wants fewer simple consults but I presume once in practice, these pay for the kids' college tuition.

 

[shiro1]

Speaking of superglue I had a great one come into my office urgently first thing in the am. 30ish lady had been evidently digging around in her purse for her tube of glue to put her fake eyelashes on WITHOUT her contacts on and deliberately superglued her eyelids together. I usually just unceremoniously cut the lashes, but she got enough of her lid margin (and she was pretty wussy) so I just sent her home on frequent warm compresses and it came apart in 2 days. Evidently she was a great source of hilarity for her kids!

Another time I had an urgent call from an urgent care doc because he was using a new skin glue to repair a forehead lac on a 10 year old. It was a much looser consistency than he was used to and before he knew it it had slid down the side of his nose and firmly fused the poor kids lids together. Again, warm compresses got them apart in a few days. To his credit the doc offered to pay for this consult and any follow up exams as the family didn't have any insurance.

 

[Wallachia]

While some of these stories are funny, my feeling is that we are in a service profession. As such, we are here to provide a service to patients, referring physicians, optometrists, etc.

Ophthalmologists are also guilty of referring patients with nothing. For cataract surgery preops, the patient can say "my back itches now" which will almost lead to a dermatology consult, psychiatry consult, pre-op clearance with the internist, etc.

If the patients or referring physicians were so smart, more than half of the referals would dry up. In a residency, one wants fewer simple consults but I presume once in practice, these pay for the kids' college tuition.

additionally, you wouldn't want to have a failure to diagnose lawsuit on your hand because the patient's itching back was actually an unsual manifestation of a cancer

 

[PDT4CNV]

additionally, you wouldn't want to have a failure to diagnose lawsuit on your hand because the patient's itching back was actually an unsual manifestation of a cancer

Especially if the itching is after a hot bath...

 

[TropicalFish]

From my 1 month of consult service:
1. From gen surg: cataract ("but he's going to be here for 2 weeks!")
2. from peds: off and on blurry vision x1 yr in uncontrolled diabetic. on exam: 20/20 OU
3. from PM&R: visual loss OS 4 yrs ago
4. from SICU team: fungus in eye, w/ no + fungal blood cx, but + cx for Coag neg Staph
5. from FP ICU: blurry vision after stroke, resolved after pt put glasses back on

there'll probably be more stories!

 

[schistosomiasis]

TropicalFish: don't take this the wrong way but I have seen 20/20 with florid proliferative diabetic retinopathy, needing urgent PRP (although this would be unlikely in a peds patient).

Lamest consult: eyeglasses for peds patient

Funniest consult: psychiatry intern phones me to tell me patient is seeing "little green men running around, rule out ocular condition"
I respond, "so do you expcet me to do a dilated exam and see little green men on the retina?"
They hung up on me before I could say anything else- hey, I never refused to see the patient!

I agree with above poster that other services (like medicine) probably think my consults to them are stupid, so we probably shouldn't laugh too hard at them... one of my colleagues was once told by the (helpful and usually good) ER doc that a patient could follow up on Monday after a trauma, but my colleague insisted on going in... patient had a ruptured globe and was urgently taken to surgery... so no matter how stupid a consult sounds, it's best to take it seriously.....

 

[shiro1]

Saddest consult I've had in awhile:

4 y/o brought in by mom for a complaint of "Seeing a big monster in front of his eyes when he closes them." Of course, completely normal complete eye examination.

This would have been funny until you find out the back story... this kid had evidently been sexually abused from infancy until mom managed to get away from dad recently How can you sexually abuse an infant!!!!