can an optometrist detect a brain tumor

[UTaustin90]

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hi all:

I was reading a story online about how an optician detected a brain tumor. Is this possible if someone comes in complaining of nausea and blurred vision, an optometrist can dilate the eyes and see a growth in the brain?

 

[Shnurek]

Yes, but not necessarily in the way you described. An OD can diagnose a brain tumor; usually a pituitary non-secreting tumor because of the visual field loss associated with the pituitary adenoma enlarging itself until it starts pressing on the optic chiasm.

Unless of course you consider the retina a part of the brain then yes a tumor can be visible through dilated pupils.

 

[VA Hopeful Dr]

Yes, but not necessarily in the way you described. An OD can diagnose a brain tumor; usually a pituitary non-secreting tumor because of the visual field loss associated with the pituitary adenoma enlarging itself until it starts pressing on the optic chiasm.

Unless of course you consider the retina a part of the brain then yes a tumor can be visible through dilated pupils.

My first thought was noticing increased ICP (dad picked up a blocked VP shunt that way once).

 

[syma]

papilloedema

 

[luckyfeet]

So basically if the eyes are dilated, you can pick up on a growth in the brain? Then refer to a neurologist because how can an optometrist be sure it's a tumor if there is no MRI?

 

[Shnurek]

So basically if the eyes are dilated, you can pick up on a growth in the brain? Then refer to a neurologist because how can an optometrist be sure it's a tumor if there is no MRI?

If its not an eye tumor then the OD cannot treat it. If it is an eye tumor and it is benign like a nevus then the OD can watch it and if it starts growing then you can refer out but until then they are fine. I mean the neurologist doesn't treat the tumor either. The neurosurgeon just cuts it out.

 

[mclem222]

Actually Shrunek...sometimes chemo and radiation are used to remove tumors and neurosurgeon doesn't do anything. A radiation oncologist would treat the tumor.

 

[Shnurek]

I did not state the contrary. Neurosurgery or radiation oncology or chemo therapy or bradytherapy or hormonal therapy or careful observation can be effective options. To be completely correct I should have wrote ''can in some circumstances cut the tumor out".

 

[luckyfeet]

Is the only way an OD can see a tumor is if the eyes are dilated?

 

[Quaero]

If present somewhere in relation to the visual cortex, the tumor would also affect visual fields.

 

[syma]

Are we talking about a tumour in the brain, or melanoma on the retina?

It is not necessary to dilate the eyes to view papilloedema which is a sign of high ICP, which could be caused by a tumour.

 

[KHE]

I think this question is a bit misleading.

Can optometrists detect brain tumors? No. Not really.

Can optometrists detect signs that can possibly be FROM a brain tumor? Yes.
But those same signs can also mimic other conditions so I would certainly never tell a patient "hey....you have a brain tumor."

 

[PBEA]

I think this question is a bit misleading.

Can optometrists detect brain tumors? No. Not really.

Can optometrists detect signs that can possibly be FROM a brain tumor? Yes.
But those same signs can also mimic other conditions so I would certainly never tell a patient "hey....you have a brain tumor."

lol

 

[Tippytoe]

I think this question is a bit misleading.

Can optometrists detect brain tumors? No. Not really.

Can optometrists detect signs that can possibly be FROM a brain tumor? Yes.
But those same signs can also mimic other conditions so I would certainly never tell a patient "hey....you have a brain tumor."

I wouldn't necessarily agree with that. An OD can order a CT/MRI (based on findings) just as easily as any other clinician and get a report back from the radiologist that says/shows "brain tumor". From there you send to neuro for further care.

That said, an OD might "find" a brain tumor 2-3 times in his entire career depending on his work environment. It's not a routine thing and certainly no fun for anyone involved.

Too many ODs wimp out and send to an OMD at the first sign of any major problem (as if the OMD has some "magic" that he's gonna do that the OD can't).........further showing that most ODs are little more than opticians with an Rx pad.

 

[VA Hopeful Dr]

I think this question is a bit misleading.

Can optometrists detect brain tumors? No. Not really.

Can optometrists detect signs that can possibly be FROM a brain tumor? Yes.
But those same signs can also mimic other conditions so I would certainly never tell a patient "hey....you have a brain tumor."

Pansy 😛

 

[Shnurek]

Pansy 😛

lol

 

[luckyfeet]

I think the OP meant an actual brain tumor. That makes sense though, an OD can see a growth when the eyes are dilated but can't certainly say that it is a tumor.

 

[KHE]

I wouldn't necessarily agree with that. An OD can order a CT/MRI (based on findings) just as easily as any other clinician and get a report back from the radiologist that says/shows "brain tumor". From there you send to neuro for further care.

That said, an OD might "find" a brain tumor 2-3 times in his entire career depending on his work environment. It's not a routine thing and certainly no fun for anyone involved.

Too many ODs wimp out and send to an OMD at the first sign of any major problem (as if the OMD has some "magic" that he's gonna do that the OD can't).........further showing that most ODs are little more than opticians with an Rx pad.

There are times where I will order an MRI or CT scan but If I have a patient I"m suspecting a brain tumor on I refer to a neurologist and have them do the MRI.

The reason being is that if a patient actually has one, they are going to have questions. Questions that I probably can't answer. So while it's true that I can read the report as well as the neurologist it makes more sense to me to have the neurologist deliver that news so that any follow up questions can be answered.

 

[Tippytoe]

There are times where I will order an MRI or CT scan but If I have a patient I"m suspecting a brain tumor on I refer to a neurologist and have them do the MRI.

The reason being is that if a patient actually has one, they are going to have questions. Questions that I probably can't answer. So while it's true that I can read the report as well as the neurologist it makes more sense to me to have the neurologist deliver that news so that any follow up questions can be answered.

How do you know to send to a neurologist or neurosurgeon without confirmation of a problem? Are you saying if you see what appears to be edematous optic nerves, you would automactically send the patient to a neurologist? To me this would just delay the obvious. Might as well get the scan done so he has it sooner than later. It's going to be done regardless so I like to present the referring doctor with all the info I can. If I have a pt that got in a fight and has a supect orbital fracture I'm going to order an x-ray or CT myself. Why not? If it comes back negative, I just saved the patient time and money on another referrral. It's a win-win. If he's diplopic and one eye stuck outward and the scan shows a trapped EOM, I can intelligently made a referral without wasting time at a general OMD (or family doc or urgent care or whomever).

I will get the report before I see the pt back. If there are problems, the pt will be referred to the appropriate specialist. If not, I deal with it myself. With a scan, it's easier to determine which specialist the patient will be referred (saving time and money hopefully)

My pet peave is the random OMD referral with "swollen disc". This is unsatisfactory in my opinion. And from my brief time working with an OMD, I saw silly stuff like that from local ODs far too often. Crap like "please evaluate for glaucoma" or "red eye not resolving with Zymar". DROVE ME FREAKING CRAZY!

Made me very embarrased to be an OD frankly when I found out this was more the norm than an exception. Many ODs won't bother with this. There is not much money in ordering scans and looking for medical problems. Most would just like to move this patient down the line as quickly as possible to look for the next high-dollar progressive purchaser in the exam room.

Of course, if an OD in Walmart or Costco tried to diagnose and manage my brain tumor, I'd laugh at them all the way to my OMD's office. This is what happens now and will certainly happen more in the future:

"I don't care about my swollen nerves *******. Just give my my glasses prescription before that 2 for $49 sale ends next door".

 

[luckyfeet]

Do you suspect a brain tumor if someone is complaining of blurred vision and vomiting? And then they have a swollen optic nerve?

 

[Meibomian SxN]

How do you know to send to a neurologist or neurosurgeon without confirmation of a problem? Are you saying if you see what appears to be edematous optic nerves, you would automactically send the patient to a neurologist? To me this would just delay the obvious. Might as well get the scan done so he has it sooner than later. It's going to be done regardless so I like to present the referring doctor with all the info I can. If I have a pt that got in a fight and has a supect orbital fracture I'm going to order an x-ray or CT myself. Why not? If it comes back negative, I just saved the patient time and money on another referrral. It's a win-win. If he's diplopic and one eye stuck outward and the scan shows a trapped EOM, I can intelligently made a referral without wasting time at a general OMD (or family doc or urgent care or whomever).

I will get the report before I see the pt back. If there are problems, the pt will be referred to the appropriate specialist. If not, I deal with it myself. With a scan, it's easier to determine which specialist the patient will be referred (saving time and money hopefully)

I am currently involved in litigation involving another OD missing a pituitary tumor. Thank goodness I am not named in the case, but I tell this story only to show why it is not worth getting involved in possible brain tumors.

Main reason is to save you from being involved in any type of litigation. The job of the OD in a case where there is a suspected tumor is to refer to the PCP or neurologist. Of course we can order a CT/MRI, but many OD staff are not trained to pre-certify scans. If the patient has to pay a couple more co-pays and go through the food chain line of doctors, then let them. Save yourself a headache.

I examined a patient who was seen by 'Dr. Negligence' on 2 annual visits prior. At this office they had an option where the patient could pay for an FDT test for an additional fee. On each visit, the patient had a unilateral mild macular and para-macular defect, that worsened to moderate on the second visit. Everything else with the exam was documented WNL and 20/20 vision OD/OS.

So on my visit encounter, the defect was dense in the macula and para-macula with BCVA 20/400. Fundus was wnl, no palor and intact nerve rim 360. The patient never noticed the vision being blurry in the 20/400 eye and just assumed it was dry eyes or a need for new glasses. I explained that something is wrong in the brain and imaging is the only way to see what's wrong. I took it upon myself to call in the CT/MRI etc, partially playing hero but also because I knew the staff was incompetent and I wanted things documented a certain way.

After 2-3 days of countless calls back and forth with patient's insurance, I finally got the scans approved. I also wrote the PCP a letter detailing everything. I never heard back from either of them.

Fast forward 2 yrs and 3 months ago, I receive a call from a lawyer representing the doctor who is involved in the case. He is being sued for negligence and I am being called in for a deposition. After discussing it with a good friend of mines, I found the patient's number and called to see what happened. They told me that they had to have 2 cranial surgeries and possibly a third later on and that the hormones are all out of whack now because of the tumor. It was so big that it pressed on the optic nerve and who knows what else! They obviously thanked me for getting so involved and is suing because the other doctor could have prevented the unilateral blindness and invasive brain surgery, had he caught it in time.

So long story short, refer to the one with the bigger staff and larger malpractice insurance. Play hero on video games 😎

 

[luckyfeet]

Amazing story thank you!

 

[xanthomondo]

My local Pearle Vision advertises the visual field study as a "brain-tumor screen." That's how they get people to pay extra every year during their annual exam..

 

[thiaeyemd]

I think this question is a bit misleading.

Can optometrists detect brain tumors? No. Not really.

Can optometrists detect signs that can possibly be FROM a brain tumor? Yes.
But those same signs can also mimic other conditions so I would certainly never tell a patient "hey....you have a brain tumor."

Great and true post...someone who sees nerve swelling and says "you have a brain tumor" is saying something untrue. The incidence of pseudotumor cerebri or AION, NAION is much higher than brain tumor causing optic nerve swelling.... When you see optic nerve swelling, it is most likely in fact not a brain tumor....

 

[Visionary]

My local Pearle Vision advertises the visual field study as a "brain-tumor screen." That's how they get people to pay extra every year during their annual exam..

Wow. "The Little Clinic" in my neighborhood Kroger now advertises that they "specialize in corneal abrasions." They aren't even eye care professionals.

 

[KHE]

How do you know to send to a neurologist or neurosurgeon without confirmation of a problem? Are you saying if you see what appears to be edematous optic nerves, you would automactically send the patient to a neurologist? To me this would just delay the obvious. Might as well get the scan done so he has it sooner than later. It's going to be done regardless so I like to present the referring doctor with all the info I can. If I have a pt that got in a fight and has a supect orbital fracture I'm going to order an x-ray or CT myself. Why not? If it comes back negative, I just saved the patient time and money on another referrral. It's a win-win. If he's diplopic and one eye stuck outward and the scan shows a trapped EOM, I can intelligently made a referral without wasting time at a general OMD (or family doc or urgent care or whomever).

Separate issues.

If a patient has a suspected fracture and a scan comes back that they do and they need surgery, I can have a reasonable discussion with the patient about what to expect and I can answer most questions. In the case of a brain tumor, I can not.

In the case of edematous optic nerves, if an MRI comes back normal the next step is usually a lumbar puncture which is going to be done by the neurologist. So either way, they end up at the neurology office.

You're also ranting against inappropriate ophthalmology referrals which I don't think is the point of this thread.

 

[namams]

Wow. "The Little Clinic" in my neighborhood Kroger now advertises that they "specialize in corneal abrasions." They aren't even eye care professionals.

That's funny. They charge $79 for their 'specialty' (quoted from the website):

Corneal Abrasion is a scratch on the surface of the eye ball. The Little Clinic provider will do the following for this service:
1) Evaluate visual activity
2) Evaluate seriousness of the scratch
3) Evaluate for other possible conditions
4) Provide appropriate treatment or referral

WTF is 'visual activity'? Haha, losers...
I never knew the cornea covered the entire surface of the eyeball either; guess I'm reading the wrong textbooks.

 

[Zorro12]

I examined a patient who was seen by 'Dr. Negligence' on 2 annual visits prior. At this office they had an option where the patient could pay for an FDT test for an additional fee. On each visit, the patient had a unilateral mild macular and para-macular defect, that worsened to moderate on the second visit. Everything else with the exam was documented WNL and 20/20 vision OD/OS.

So on my visit encounter, the defect was dense in the macula and para-macula with BCVA 20/400. Fundus was wnl, no palor and intact nerve rim 360. The patient never noticed the vision being blurry in the 20/400 eye and just assumed it was dry eyes or a need for new glasses. I explained that something is wrong in the brain and imaging is the only way to see what's wrong. I took it upon myself to call in the CT/MRI etc, partially playing hero but also because I knew the staff was incompetent and I wanted things documented a certain way.

They told me that they had to have 2 cranial surgeries and possibly a third later on and that the hormones are all out of whack now because of the tumor. It was so big that it pressed on the optic nerve and who knows what else! They obviously thanked me for getting so involved and is suing because the other doctor could have prevented the unilateral blindness and invasive brain surgery, had he caught it in time.

So long story short, refer to the one with the bigger staff and larger malpractice insurance. Play hero on video games 😎

So, I am not a neuro-ophthalmologist, but this doesn't make sense. How can you have a unilateral, optic nerve lesion only involving the central vision with a normal nerve? You did not mention pupils, but was an APD documented? I am unclear what the original OD did wrong. If the nerve looks good, there is no APD, no proptosis and only a unilateral central finding that would localize to the macula, not to the nerve or an intracranial lesion, why image? An occiptial infarct could give loss of central vision, but it would be bilateral. Furthermore, "hormone problems" would suggest a pituitary resection, but I cannot figure out how a lesion would hit only the central fibers of one eye near the chiasm. I would be interested to hear what the "experts" from each side had to say. Enjoy your deposition.

 

[Tippytoe]

Separate issues.

If a patient has a suspected fracture and a scan comes back that they do and they need surgery, I can have a reasonable discussion with the patient about what to expect and I can answer most questions. In the case of a brain tumor, I can not.

In the case of edematous optic nerves, if an MRI comes back normal the next step is usually a lumbar puncture which is going to be done by the neurologist. So either way, they end up at the neurology office.

You're also ranting against inappropriate ophthalmology referrals which I don't think is the point of this thread.

Frequently (as you know, students might not) the nerve swelling is either optic nerve drusen or pseudtumor cerebri, in which case of the later, the neuro would definately be involved. But he's gonna want to know if there is a brain mass too. So, again, it's just a matter of timing on who's ordering the imaging. Why not send the pt for a scan on the way to the neuro? No right or wrong answer. I happen to think ODs should order them when needed. If I was the patient, I wouldn't want to wait weeks to know if I had a big fat tumor growing back there. I'd want to know TODAY!

I also have no idea what the other poster meant when he said, "Of course we can order a CT/MRI, but many OD staff are not trained to pre-certify scans". Pre-certify scans???? I assuming he's talking about insurance issues. That's a whole 'nother story. But I've never had a problem. I write out the order on an Rx pad or letterhead and it get's done. I get a friendly call from the radiologist and a note the next day. Never a problem with 'pre-certifying' except recently with Medicaid. When that happens, I get on the phone and get the person's name and degree (don't have one) and explain to them that I need it for the patient's attorney if they happen to die from something undiagnosed from the lack of the scan. That works about every time.🙂

But in my opinion, you can go through life afraid and wondering where a lawsuit will come from. What happens if you refer to a neurologist and he doesn't bother with a scan and there IS a problem. Don't you think the OD would be sued in this case too?

If it's gonna happen, it's gonna happen. Another poster seems to basically be saying, "why bother, refer it up the food chain from the get go". I suppose there is nothing wrong with that. But I think many times, the willingness to go the extra mile is worth it. It's one of the things that seperates a 'doctor' from a technician.

But by all means, I do encourage ODs to only work within their comfort level. My comfort level seems to be higher........but I enjoy the challenging cases and have always worked beyond the little OD programs to educate myself. It's a shame organized ophthalmology moved to BAN ODs from their continuing educational programs in the early 2000's. But knowledge is everywhere. Fortunately no one group has a monopoly on it.

 

[Meibomian SxN]

So, I am not a neuro-ophthalmologist, but this doesn't make sense. How can you have a unilateral, optic nerve lesion only involving the central vision with a normal nerve? You did not mention pupils, but was an APD documented? I am unclear what the original OD did wrong. If the nerve looks good, there is no APD, no proptosis and only a unilateral central finding that would localize to the macula, not to the nerve or an intracranial lesion, why image? An occiptial infarct could give loss of central vision, but it would be bilateral. Furthermore, "hormone problems" would suggest a pituitary resection, but I cannot figure out how a lesion would hit only the central fibers of one eye near the chiasm. I would be interested to hear what the "experts" from each side had to say. Enjoy your deposition.

No APD either. What the original OD did wrong was not document or inquiry as to why the patient had field defects. If a patient has field defects it has to be attributed to something, cataracts, retinal scar, poor test taker, etc. The patient had a documented, progressively worsening field defect that warranted either a referral or a work-up.

Trying to figure out why a tumor is not following a classic text book pattern is not worth thinking about. They are not bound to follow the rules. But yes, I'm interested also. I meet with the doctor's lawyer tomorrow so I'll finally see the CT/MRI that I ordered. Stay tuned...

 

[Meibomian SxN]

I also have no idea what the other poster meant when he said, "Of course we can order a CT/MRI, but many OD staff are not trained to pre-certify scans". Pre-certify scans???? I assuming he's talking about insurance issues. That's a whole 'nother story. But I've never had a problem. I write out the order on an Rx pad or letterhead and it get's done. I get a friendly call from the radiologist and a note the next day. Never a problem with 'pre-certifying' except recently with Medicaid. When that happens, I get on the phone and get the person's name and degree (don't have one) and explain to them that I need it for the patient's attorney if they happen to die from something undiagnosed from the lack of the scan. That works about every time.🙂

But in my opinion, you can go through life afraid and wondering where a lawsuit will come from. What happens if you refer to a neurologist and he doesn't bother with a scan and there IS a problem. Don't you think the OD would be sued in this case too?

If it's gonna happen, it's gonna happen. Another poster seems to basically be saying, "why bother, refer it up the food chain from the get go". I suppose there is nothing wrong with that. But I think many times, the willingness to go the extra mile is worth it. It's one of the things that seperates a 'doctor' from a technician.

But by all means, I do encourage ODs to only work within their comfort level. My comfort level seems to be higher........but I enjoy the challenging cases and have always worked beyond the little OD programs to educate myself. It's a shame organized ophthalmology moved to BAN ODs from their continuing educational programs in the early 2000's. But knowledge is everywhere. Fortunately no one group has a monopoly on it.

Yes, I was talking about insurance issues. When I did a residency at an oMD office, I've ordered CTs and MRIs and sometimes the staff had to get pre-certifications and sometimes they did not. In this case, I knew that the "$2/hr staff" were not qualified to handle something like that.

I agree with you, I don't regret my willingness to 'go the extra mile'. But you and I both know that's rare for an OD. Heck, for that matter many oMDs would have referred out also, I know this for a fact. Its a shame that many of our colleagues would rather limit themselves to refracting. 🙁

 

[Mon2012]

I'm not in optometry school, but I'm currently in the process of applying 🙂 What's the best advice as a prospective student for surviving optometry school? I've been browsing the curricular of most optometry schools and I see that students have to take almost 8 to 9 classes per semester, which I know is manageable, yet it seems a bit overwhelming🙂 Any helpful feedback is greatly appreciated!🙂

 

[Meibomian SxN]

So, I am not a neuro-ophthalmologist, but this doesn't make sense. How can you have a unilateral, optic nerve lesion only involving the central vision with a normal nerve? You did not mention pupils, but was an APD documented? I am unclear what the original OD did wrong. If the nerve looks good, there is no APD, no proptosis and only a unilateral central finding that would localize to the macula, not to the nerve or an intracranial lesion, why image? An occiptial infarct could give loss of central vision, but it would be bilateral. Furthermore, "hormone problems" would suggest a pituitary resection, but I cannot figure out how a lesion would hit only the central fibers of one eye near the chiasm. I would be interested to hear what the "experts" from each side had to say. Enjoy your deposition.

So, after seeing the chart after 2 yrs I was mistaken on some things. Firstly, you're right in that the during the original doc's encounter, the FDT only had 1 moderate para-macular defect. And the doc only seen the patient on one encounter.
Vision was recorded as OD: 20/25+, OS: 20/20. Nothing alarming. 1yr later I see the patient: FDT defect was unilateral homonymous hemifield. So you're right, doc actually did not do anything wrong except be in the wrong place at wrong time 🙁

Problem is that the doc actually wrote on a sticky note: 'Retake FDT at dispense of Rx'. The docs staff never repeated the FDT, which I felt still would not have warranted any further tests or referrals. The plaintiff lawyer asked why this note was not recorded in the assessment/plan and are sticky notes part of AOA protocol? He pulls out the AOA guidelines and tries to get me to admit that sticky pads have no place in a chart. Smh.

So after seeing everything again, I felt that it could've happened to anyone. Sad part is that they'll probably end up having to settle big time because no one wants a brain tumor patient going to trial; jury would more than likely side with the patient.

 

[Zorro12]

So, after seeing the chart after 2 yrs I was mistaken on some things. Firstly, you're right in that the during the original doc's encounter, the FDT only had 1 moderate para-macular defect. And the doc only seen the patient on one encounter.
Vision was recorded as OD: 20/25+, OS: 20/20. Nothing alarming. 1yr later I see the patient: FDT defect was unilateral homonymous hemifield. So you're right, doc actually did not do anything wrong except be in the wrong place at wrong time 🙁

Problem is that the doc actually wrote on a sticky note: 'Retake FDT at dispense of Rx'. The docs staff never repeated the FDT, which I felt still would not have warranted any further tests or referrals. The plaintiff lawyer asked why this note was not recorded in the assessment/plan and are sticky notes part of AOA protocol? He pulls out the AOA guidelines and tries to get me to admit that sticky pads have no place in a chart. Smh.

So after seeing everything again, I felt that it could've happened to anyone. Sad part is that they'll probably end up having to settle big time because no one wants a brain tumor patient going to trial; jury would more than likely side with the patient.

That, is unfortunate. I don't know about a settlement, as there was a huge change in the field a good lawyer may do OK in court and say there was no way to predict the new field defect. However, you are right there was alot of wrong place wrong time. The good news is no matter what happens alot of lawyers are going to make some $$, and of course that is all that matters.

 

[PBEA]

So, after seeing the chart after 2 yrs I was mistaken on some things. Firstly, you're right in that the during the original doc's encounter, the FDT only had 1 moderate para-macular defect. And the doc only seen the patient on one encounter.
Vision was recorded as OD: 20/25+, OS: 20/20. Nothing alarming. 1yr later I see the patient: FDT defect was unilateral homonymous hemifield. So you're right, doc actually did not do anything wrong except be in the wrong place at wrong time 🙁

Problem is that the doc actually wrote on a sticky note: 'Retake FDT at dispense of Rx'. The docs staff never repeated the FDT, which I felt still would not have warranted any further tests or referrals. The plaintiff lawyer asked why this note was not recorded in the assessment/plan and are sticky notes part of AOA protocol? He pulls out the AOA guidelines and tries to get me to admit that sticky pads have no place in a chart. Smh.

So after seeing everything again, I felt that it could've happened to anyone. Sad part is that they'll probably end up having to settle big time because no one wants a brain tumor patient going to trial; jury would more than likely side with the patient.

how can a unilateral hemianopsia be homonomyous?

also reduced bcva due to visual field defect would at least warrant closer f/u, if not further testing immediately. I'd probably repeat the VF in 1-3 months (although I'm not a fan of FDT). If the reduced vision was not from the VF defect I'd be looking for something else.

 

[Meibomian SxN]

how can a unilateral hemianopsia be homonomyous?

also reduced bcva due to visual field defect would at least warrant closer f/u, if not further testing immediately. I'd probably repeat the VF in 1-3 months (although I'm not a fan of FDT). If the reduced vision was not from the VF defect I'd be looking for something else.

So how would you classify it then? I assumed that's what it was called, even if unilateral?

Her BCVA was recorded as 20/25+ in that eye. You would consider that reduced? And remember, the FDT defect was 1 square, grade moderate, although it was para-central. Honestly speaking, I highly doubt I would have watched it sooner. Especially with no other symptoms to go along with it.

 

[thiaeyemd]

This is at interesting case because a unilateral hemianopic field defect for a pituitary mass is unusual. Not sure if the first OD would be considered to be deviating from standard of care if he didn't see an APD, or nerve changes. A junctional scotoma wouldve shown a central defect in the other eye with a temporal defect in the eye in question. All in all, unusual case...If he had missed a bitemporal then he would have little defense...

 

[PBEA]

So how would you classify it then? I assumed that's what it was called, even if unilateral?

Her BCVA was recorded as 20/25+ in that eye. You would consider that reduced? And remember, the FDT defect was 1 square, grade moderate, although it was para-central. Honestly speaking, I highly doubt I would have watched it sooner. Especially with no other symptoms to go along with it.

unilateral hemianopsia

20/25 is reduced, and IMO should always be investigated. If the defect was felt not to be causing the reduced vision then I'd look for a reason. If it was felt to cause the reduction then other testing was indicated. In either case close f/u and or additional testing is warranted IMO.

 

[Meibomian SxN]

unilateral hemianopsia

20/25 is reduced, and IMO should always be investigated. If the defect was felt not to be causing the reduced vision then I'd look for a reason. If it was felt to cause the reduction then other testing was indicated. In either case close f/u and or additional testing is warranted IMO.

Oh ok, uni hemi. Because it was a FDT screening test and not full threshold, there was only 1 square with a moderate defect. I'm sure if it was a HVF or even full threshold FDT, the defect may have been a bit more pronounced.

His literal recording for VA was '20/25+'; which can also mean '20/20-'. So I can not imagine someone going through with a full workup over 3 letters missed on the 20/20 line.

The messed up part is that the doctor actually wrote on a sticky note 'please retest OD on dispense'; yet no staff or optician repeated it. For me it was a lesson learned: NEVER trust the staff to follow up on anything. Smh.

I've already seen the defense's expert MD witness testify that there was nothing alarming about her FDT or exam results; and that the 1 defect could be interpreted as a false positive. But in my opinion, if the case goes to trial, a jury will probably sympathize with the widowed patient.

 

[JBurns]

I am sure the plaintiff lawyer will spin things saying that FDT is the most reliable visual field test in the world, and that any idiot eye doc should have picked up on this. I personally do not think that the plaintiffs have a case.

 

[itek2OD]

My local Pearle Vision advertises the visual field study as a "brain-tumor screen." That's how they get people to pay extra every year during their annual exam..

How do they advertise OCTs then?

 

[itek2OD]

Oh ok, uni hemi. Because it was a FDT screening test and not full threshold, there was only 1 square with a moderate defect. I'm sure if it was a HVF or even full threshold FDT, the defect may have been a bit more pronounced.

His literal recording for VA was '20/25+'; which can also mean '20/20-'. So I can not imagine someone going through with a full workup over 3 letters missed on the 20/20 line.

The messed up part is that the doctor actually wrote on a sticky note 'please retest OD on dispense'; yet no staff or optician repeated it. For me it was a lesson learned: NEVER trust the staff to follow up on anything. Smh.

I've already seen the defense's expert MD witness testify that there was nothing alarming about her FDT or exam results; and that the 1 defect could be interpreted as a false positive. But in my opinion, if the case goes to trial, a jury will probably sympathize with the widowed patient.

About the retest part:

i) If that note was documented in an EMR, and the pt did another FDT with a similar result, would the optom have a better defense for his/her actions?
ii) I've always considered the FDT, even on full threshold, as a screening VF. Is a followup sita-standard a better f/u test?
iii) VF's are no fun. What if the pt refused to do another VF until the HMO will pay for it [ ie 1 more year?]

 

[Meibomian SxN]

About the retest part:

i) If that note was documented in an EMR, and the pt did another FDT with a similar result, would the optom have a better defense for his/her actions?
ii) I've always considered the FDT, even on full threshold, as a screening VF. Is a followup sita-standard a better f/u test?
iii) VF's are no fun. What if the pt refused to do another VF until the HMO will pay for it [ ie 1 more year?]

Good questions.:

1) I feel that the note is what has this doctor in trouble. By having a note to retest the 1 defect, it shows that the abnormal results were worth following up on. Had there been no note, he could've argued that it wasn't significant enough to retest.
But the plaintiff is going to argue 'had the doctor retested and seen a repeatable defect then the patient would still have vision in that eye.'

2) I actually prefer the FDT at full threshold over a sita-standard but that's just my opinion and preference. If the defect was repeatable in screening and the eye was healthy, then I would say yes, a full threshold test should be done; whether FDT or SITA .

3) At this practice they charge out of pocket for VFs so a repeat was free. But given the scenario you mentioned, I would think as long as its documented that the patient refused, then the doctor would not be at fault.

 

[itek2OD]

😎Thanks a bunch for answering.

 

[rph3664]

When I worked in retail pharmacy, I had a customer whose brain tumor was detected, although not diagnosed, by an optometrist. He was having some vision problems and thought maybe he needed glasses (he was in his 20s) and the optometrist knew something was terribly wrong as soon as s/he looked into his eyes. He was sent straight over to the hospital for an MRI, which detected a very large benign brain tumor. This was successfully removed, although at least by the time I left that job, he was not back to where he was before the surgery, health-wise. Among other things, he used those short arm stick crutches like the kind some polio survivors used to use.

 

[Commando303]

I think this question is a bit misleading.

Can optometrists detect brain tumors? No. Not really.

Can optometrists detect signs that can possibly be FROM a brain tumor? Yes.
But those same signs can also mimic other conditions so I would certainly never tell a patient "hey....you have a brain tumor."

I completely agree.