Eager to move towards medical optometry and abandon refraction, etc?

[applegate]

Hi everyone,
While I have been lurking around this site for a while, this is my first post.

My question is that it seems as if many optometrists and pre-optometrists are so eager to move towards medical optometry, and some even want the majority of their work to be medical, rather than refraction, specialty CLs, etc...the stuff that makes optometrists unique. My question is WHY?

I've noticed that this can be a sensitive subject, so I'm not trying to start a flame war or anything, so let me state the reason why I ask.

I am a pre-opt student who had finished all my pre-reqs, got optometry experience, and got great scores on the OAT. I was all set to apply to optometry school, but right before application season started a couple years ago, I regrettedly underwent Lasik (w/ a renowned surgeon), which ruined my vision, and even worse, caused me extreme dry eye pain to the point that I could barely open my eyes. Dry eye pain might sound like nothing, and for most people, it is only mild-moderate and a mere inconvenience. But I (and like many patients I later met) were in extreme pain and many even people at this level of pain even committed suicide because there was no treatments available that helped, their docs were dismissive, and they lost their lives as they knew it. So of course, applying to optometry school was put on hold for me since I could barely even open my eyes to use the bathroom.

Ok, so of course I went to a ton of OMDs, and even some medical ODs for THREE YEARS, none were able to help me with my vision or pain problems. Until I discovered Boston Foundation for Sight which fits people with scleral contact lenses, a clinic run by OMDs. Unfortunately, the waitlist was long and cost was extreme. So, in while I was waiting, I did a search and found a handful of OMDs and ODs across the country who fit sclerals for people for various problems: post-Lasik disaster problems, severe keratonocus (sp?), burn patients, SJS patients, sjogrens, corneal neuralgia, etc...all people that did not benefit from standard medical treatment. I found a great OD in Texas, and decided to take a chance on him since I was desperate and didn't want to wait any longer, flew over there, got fitted with sclerals in 4 days, and now, I am pain-free, perfect vision, and finally getting my life back together. It was like a miracle. Along this journey, I have met a lot of ocular surface disease patients, all who have suffered for 3-20 years with nothing that helped, until they got fitted with sclerals, and it was like magic.

Since I am a pre-optometry student and I spent a considerable amount of time (~15 hours) with the optometrist that fitted me with sclerals, we got talking about the profession. He told me that he has tons of patients flying in across the country (its been steadily on the rise with the increase of post-lasik disaster patients) to try sclerals, many who have been suffering for years and willing to pay anything (like me!) and rejected or unwilling to wait for BFS (long list, since it is a nonprofit foundation and the only one that OMDs know about, so if they do refer, they end up referring there). He say that specialty CLs can have so much therapeutic value for so many ocular surface problems, that he feels so happy to be in this growing field and discovering what he can do with CLs. This is what optometry is about, and I completely agree. I don't understand why there aren't more optometrists getting into this niche...isn't this the heart of optometry? Why does it seem that optometrists are so intent on moving away from this area and moving into the territory of ophthalmologists instead of discovering the power of CLs and other optometric devices? In fact, I've found MORE OMDs than ODs (though the total is only a handful...like 1-2/state, if any at all) prescribing scleral lenses. Why are optometrists sitting around and letting OMDs take this over?

I for one, intend on filling this much needed niche, and becoming an expert on specialty CLs and researcihng all the therapeutic values of CLs....why aren't more optometrists interested? I've been told by my optometrist that he is making more money than ever doing this (plus money from collaborations with research companies, getting paid to speak, etc), so its probably not a financial reaons that are deterring optometrists. Can someone please explain why?

Thank you.

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[armstrong77]

Great post.

Will be interesting what people have to say about this.

Just curious - scleral or semi-scleral?

 

[362.04]

"...this is what optometry is about, and I completely agree. I don't understand why there aren't more optometrists getting into this niche...isn't this the heart of optometry? Why does it seem that optometrists are so intent on moving away from this area and moving into the territory of ophthalmologists instead of discovering the power of CLs and other optometric devices? In fact, I've found MORE OMDs than ODs (though the total is only a handful...like 1-2/state, if any at all) prescribing scleral lenses. Why are optometrists sitting around and letting OMDs take this over?..."

I think that some of the problems is that most dry eye patients can be effectively managed with topical medications. I have no doubt, though, that specialty contact lenses is a fertile specialty but one that requires significant experience. No, you don't have to have a residency (although it might help).

You do have to wonder that if there many patients who want to seek out a specialty contact lens person, then its likely that there is a significant obstacle to get the experience and the number of patients to be successful. In other words, I think if it was as easy to get into specialty contacts, then there would be lot of optometrists who want to do it. But i cannot confirm categorically why they don't.

For a long time, my specialty was rigid bifocal contacts and even now, I have patients who seek me out who I first saw 20 years ago and still want to follow me through three different office locations.

 

[stonegoat]

Honestly, the training that most ODs receive with regards to scleral CLs or even run-of-the-mill RGPS is minimal at best. I personally only fit about 2 patients with RGPs per year, and usually 1 has corneal ectasia. I could fit more RGPs, but with the plethora of soft lenses available, it almost always is easier (if not better) to go that route. Plus, I have a contact lens technician who deals with 99% of my CL practice. I practice in a rural area of BC, Canada, and I doubt I could ever become proficient at fitting specialty contact lenses with the few patients I see who would ever require them.

However, I do agree that ODs should embrace niche markets, if their patient demographic allows it.

 

[PBEA]

The fact is that, the use of scleral lenses is not that attractive because the VAST and OVERWHELMING majority of people either: do not need them, or do not want them. What people do have alot of is cataract, glaucoma, diabetes, etc. So from a "supply and demand" perspective it makes little sense to expect any OD to limit themselves to "specialty cl's", or even to offer it as a "niche".

 

[PBEA]

also ODs are not "moving away from refraction". Instead of the only way, refraction has become one of many ways, in which ODs can serve their pts.

 

[362.04]

Dear PBEA,

As you may probably know, a specialty lens practice includes more than just scleral lenses. It includes CRT (or Ortho k), bifocal, irregular corneas, reverse geometry lenses for post RK, damaged corneas from penetrating corneal injuries and even cosmetic iris lenses.

For a city of 1 million, probably there should be at least 20-30.

 

[PBEA]

Dear PBEA,

As you may probably know, a specialty lens practice includes more than just scleral lenses. It includes CRT (or Ortho k), bifocal, irregular corneas, reverse geometry lenses for post RK, damaged corneas from penetrating corneal injuries and even cosmetic iris lenses.

For a city of 1 million, probably there should be at least 20-30.

I agree, and I currently offer some of those options in my practice. However being in a rural setting I see maybe 10 or so per year that will benefit from these options. Hardly something most OD offices could make a living off of.

 

[applegate]

Thanks everyone for your always informational comments and thoughts.

Armstrong, I got sclerals. We did discuss mini-sclerals, macrolens, etc...but ultimately decided that sclerals would be the best option for me.

The fact is that, the use of scleral lenses is not that attractive because the VAST and OVERWHELMING majority of people either: do not need them, or do not want them. What people do have alot of is cataract, glaucoma, diabetes, etc. So from a "supply and demand" perspective it makes little sense to expect any OD to limit themselves to "specialty cl's", or even to offer it as a "niche".

I didn't intend to imply that optometrists should intend to limit themselves to specialty CLs; I agree that I don't think there would be a big enough market for many ODs to do something like that. I also did not intend to imply that ALL ODs should pick up specialty CLs, that would be completely unneccesary...I was wondering why there aren't more ODs than what we currently have to offer these types of services. And of course, it makes sense that ODs practicing in rural areas would have to pick up lots of medical optometry since eye docs there are scarce compared to metropolitan cities where i live where there is an eye doc about every 5 blocks or so (ok, i'm exaggerating a little bit, but you get the idea).

While the vast majority of people may not need specialty CL services, I wonder if the actual number of people in the minority who may need or want them are actually higher than what you may think. The caveat is that I say this based completely on anedoctal and personal experience. Throughout the first couple years after my lasik disaster (ugh!), I visited a great many a docs (both OMDs and ODs)...some in private practice, some very renowned clinical faculty, and not a single one of them mentioned that I might benefit from CLs. Many told me to learn to live with it because I've exhausted all possible options. I had even asked some docs about sclerals, but many told me that would make me feel worse, so I dropped the idea. It wasn't until I got in touch with a woman who ran a support group for people with difficult to manage ocular surface disorders, where she spends 40+ hrs a week for the past 7 years or so talking to people and helping to connect to docs that may be able to finally help them. It was she who got me in contact with my current OMD and the BFS. She, my current OMD, and my OD (all w/ extensive experience with various DE related disorders) pretty much implied that they would be insanely rich if they had a dollar for every person they met that benefited from specialty CLs when they were previously told by docs that they wouldnt or docs didn't even bother to mention this option to them (I have also met a good number of these people). So it seems to me that there may be a bigger number of people than you think that may benefit from specialty CLs, but many docs simply miss that. But what do I know, I'm not a doc, and all this comes from a patient's perspective (and pre-opt student 😀). And also, no patient likes to be out of options just because he/she didn't fit into a textbook example of a medical condition. Just a thought though.

362.04, it's interesting that you say you've gained some big patient loyalty due to rigid bifocal contact speciality. I for one, intend to follow my OD for as long as he is in practice, even though he is out of state for me. In fact, he has patients from out of the country and continent who seek his help and continues to come by for their yearly visits (and trust me, he doesn't live in area where you would want to vacation). Now, that is some patient loyalty!

 

[applegate]

Oops...I apologize for my long posts. Its just been a long while since I've been able to use a computer without crawling into fetal position from the pain, and I can't help it but to spend a little extra time. 😳

 

[stonegoat]

Oops...I apologize for my long posts. Its just been a long while since I've been able to use a computer without crawling into fetal position from the pain, and I can't help it but to spend a little extra time. 😳

I'm glad you found someone who could help you and didn't give-up. Sometimes that's what it takes, as many health care practitioners can be dismissive.

 

[PBEA]

While the vast majority of people may not need specialty CL services, I wonder if the actual number of people in the minority who may need or want them are actually higher than what you may think. The caveat is that I say this based completely on anedoctal and personal experience.

The combined prevalence of conditions that might benefit from a scleral lens is very low. You can argue that they may be underreported, but your anecdote (while personally rewarding) is not very convincing evidence that there is a larger untapped market. Scleral lens, btw, are not w/o their fair share of complications, and may add to the list of reasons they are not commonly used (other reasons would include cost, comfort, accessability, as well as other, less invasive CL options). In any case, a "specialty lens" clinic would be comprised mainly of ocular disease pts, so the suggestion that OD's are "moving into medical and away from refraction" is innaccurate. The two (medical and refraction) are intertwined, with refractive error often being on the roster of sequelae from many disease conditions of the eye. Also, I'm not really surprised that an ophtho might not mention cl's as part of a treatment plan, as they might not be comfortable with this aspect, or as you have pointed out, do not know where to send them. The same can be said for many ODs.

Good luck in school, it seems you already have some "flesh" in the game, so I imagine you might do well.

 

[KHE]

Oops...I apologize for my long posts. Its just been a long while since I've been able to use a computer without crawling into fetal position from the pain, and I can't help it but to spend a little extra time. 😳

You make some interesting points. This is my $0.02.

If we put aside the issue of optometric access to medical insurance plans, the reason many ODs are moving "towards medical" is multi-fold:

a) Third party payers cover it, whereas they generally don't cover vision.
b) it allows ODs to take better care of their patients without having to refer them out
c) I guess it's slightly "sexier."
d) you generally don't have to compete with the various commercial outlets when working in this area
e) from a liability standpoint, ODs are held to the same standards as ophthalmologists in courts of law. An OD can incur significant liability for missing something "medical" but they aren't going to incur any for "failure to refer for scleral lenses." As such, more attention gets paid to "medical."


As far as scleral lenses go and why more ODs don't do them, I would say that most ODs are not adequately trained for those types of fittings while in school and the opportunities to gain experience in them once out of school are somewhat limited.

Lastly, people in need of scleral lenses are usually very recalcitrant cases and it takes a very special personality type to deal with a patient population like that. Most doctors simply don't have that personality type.

 

[Meibomian SxN]

...I regrettedly underwent Lasik (w/ a renowned surgeon), which ruined my vision, and even worse, caused me extreme dry eye pain to the point that I could barely open my eyes.....

Sounds like you should have sought out a good malpractice lawyer the same way you sought out a eye practitioner with your eye problem. Hope things get better for you.