Help! I need somebody. Help - not just anybody. Help ?-

[jack2357]

Please excuse the random title, I come from a technical background - medical engineering, and am not at all familiar with ophthalmology, and would be incredibly indebted if someone could help me understand the purpose of retinal photography in primary/secondary/tertiary level healthcare.

In recent years am I right in saying we've seen an explosion in retinal photography? Do you think this is because it actually serves a purpose or is because firms like Optos have been encouring Optometrists to do the hard sell and there's little medical insight provided by these devices? Or do you think they serve a purpose, and this shall only grow?

Thank you all so much, sorry for invading your forum.

J

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[MstaKing10]

Don't know where to start on this one, but will give it a try...

First of all, you are posting on an ophthalmology forum. Although optometrists do use these devices as well, it is important to recognize the distinction as many on this forum can become quite sensitive about this topic (see many, many prior posts).

Secondly, you must recognize that there is a difference between photography (external, slit lamp, fundus etc), flourescein or ICG angiography, and optical coherence tomography (OCT). The former two have been around for a long time, and I'm pretty sure this is not the "boom" that you are refering to. OCT has become more and more useful in daily practice and has certainly become a much more commonly ordered test over the past few years.

While companies do try to influence practitioners to purchase their device, I don't believe it is the companies that are "brain washing" and driving their increased use, rather, it is their very utility which has actually motivated companies to develop, fine tune, and then distribute these devices. OCT technology has come a long way over the past few years, and its ability to help discern pathology, monitor patients, and help us better treat eyes has driven the market in my opinion.

So in short...yes there is INCREDIBLE clinical insight provided by these machines and their use is not just a brain washing by companies such as Optos, Zeiss or others. Although I do admit that they likely influence the market to some degree, I'd like to think that I use the technology based on its clinical utility (of which there is tons), and not the company selling the device.

 

[Dusn]

We could probably help you more if you tell us what your purpose in asking the question is. But yes, retinal photography is pretty important, especially if you're talking about OCT, IVFA. ICG is becoming more important. Just taking a straight up fundus photo though probably isn't that much more useful now than it was in the past and most ophthalmologists I know don't take photos unless there's a reason for it (such as to document the changing characteristics of a retinal lesion).

I don't want to turn this into another opto vs ophthalmology thread but since you brought it up, I have seen some optometrist get fundus photos on everyone who walks in and that probably isn't a very useful practice.

 

[jack2357]

I'm doing some research into Optos, and have been amazed by its success of late, given what I believe is an inferior product and just trying to fully understand how they've managed to successed vis-à-vis their competition.

Anyone have any thoughts?

J

 

[Visionary]

I'm doing some research into Optos, and have been amazed by its success of late, given what I believe is an inferior product and just trying to fully understand how they've managed to successed vis-à-vis their competition.

Anyone have any thoughts?

J

Optos does something the other imaging devices can't: widefield imaging. With other imaging devices, you need to pan around to view the periphery. Optos allows single shot pan-fundus imaging, which is particularly useful if combined with angiography. As a non-mydriatic fundus camera, I don't think it's particularly useful, unless you want to charge patients a fee for revenue purposes (a bit distasteful, IMO). It doesn't beat a dilated fundus exam for evaluation. I used Optos in fellowship predominantly for wide-field angiography and documentation of peripheral retinal lesions. In private practice, it's cost-prohibitive, quite honestly.

 

[jack2357]

Wow, thanks all for your feedback. I've decided to develop a little questionare, should anyone have too much time on their hands, please feel free to answer on here or PM me.

I'm very grateful for your feedback:

Following on from calls/conversations I have made with other ophthalmologists and optometrists. Would you agree with the following points:
• The Ultra-Wide imagery Optos offers has tremendous value, however, this value is yet to be realised by Optometrists as research into enhanced diagnostic capabilities is in its infancy and yet to receive full recognition by Ophthalmologists/the general medical community?
• Do you think it will eventually be recognised by the optometrist community or will it take considerable time?
• Would you say the image quality is somewhat sacrificed because of the enhanced wideness and hence the quality of the image is not so good? Do you think a traditional fundus camera could better capture the macular region? I think this point is summarised here by a professional: http://drjoeross.com/optos_vs_dri_.htm
• Out of these diseases which do you think the Optos captures better: macular degeneration, Diabetic retinopathy, Glaucoma, Retinal detachment, Melanoma?

Following on from this:
• Given the enhanced diagnostic capabilities of the Optos machine (which seems given by the Ophthalmologist community) I need to work out how long this will take to filter down into the optometric community. Who would you advise speaking to if you were in my position? Ideally someone who acts as link between the two fields.......

 

[Shnurek]

We have an optos at SUNY Optometry and some guy walks around probably a representative of the optos company asking patients if they want to be photographed and they almost always agree. I'm just taking a shot here because I don't know how expensive an optos is but I think a lot more ophthalmologists would use it because they are more pathology oriented. Usually secondary or tertiary care. Optometrists are more primary care and many do mostly optical care. Some optometrists are fully medical and some only partly. The bigger the institution/hospital/college/doctor group the more likely they would be to have an optos. Small optometrist private practices would not have it usually unless they were really disease oriented (more in a rural setting) . I'm just a first year however so there is still much I do not know.

 

[Visionary]

Jack-

Not sure what your angle is here, but here's my take:

Optos is great for widefield imaging, but does not have the quality of many other cameras. It is limited by the fact that it's not a true camera, but a laser imaging device. There is a false color aspect and distortion potential that makes interpretation of standard shots difficult, in some cases. That's why I'm against using it as a non-mydriatic screening tool. I think it's great for documenting peripheral pathology, such as choroidal nevi/melanoma, as well as for widefield angiography--IN A DILATED EYE. For all other purposes, it's inferior, IMO. Of course, there is still no substitute for a careful dilated fundus exam. Fact is, Optos is currently too expensive, for the added utility, to become widely adopted either by the ophthalmology or optometry community.

Wow, thanks all for your feedback. I've decided to develop a little questionare, should anyone have too much time on their hands, please feel free to answer on here or PM me.

I'm very grateful for your feedback:

Following on from calls/conversations I have made with other ophthalmologists and optometrists. Would you agree with the following points:
• The Ultra-Wide imagery Optos offers has tremendous value, however, this value is yet to be realised by Optometrists as research into enhanced diagnostic capabilities is in its infancy and yet to receive full recognition by Ophthalmologists/the general medical community?
• Do you think it will eventually be recognised by the optometrist community or will it take considerable time?
• Would you say the image quality is somewhat sacrificed because of the enhanced wideness and hence the quality of the image is not so good? Do you think a traditional fundus camera could better capture the macular region? I think this point is summarised here by a professional: http://drjoeross.com/optos_vs_dri_.htm
• Out of these diseases which do you think the Optos captures better: macular degeneration, Diabetic retinopathy, Glaucoma, Retinal detachment, Melanoma?

Following on from this:
• Given the enhanced diagnostic capabilities of the Optos machine (which seems given by the Ophthalmologist community) I need to work out how long this will take to filter down into the optometric community. Who would you advise speaking to if you were in my position? Ideally someone who acts as link between the two fields.......

 

[texaseyegeek]

Please excuse the random title, I come from a technical background - medical engineering, and am not at all familiar with ophthalmology, and would be incredibly indebted if someone could help me understand the purpose of retinal photography in primary/secondary/tertiary level healthcare.

In recent years am I right in saying we've seen an explosion in retinal photography? Do you think this is because it actually serves a purpose or is because firms like Optos have been encouring Optometrists to do the hard sell and there's little medical insight provided by these devices? Or do you think they serve a purpose, and this shall only grow?

Thank you all so much, sorry for invading your forum.

J

Optos Optomap is a magnificent instrument enabling early detection of diseases that are non symptomatic. Diabetes, Cholesterol, Retinal diseases, Glaucoma, Macular Diseases and early detection of HIV. The first Optos I used, we were able detect an abormality not commoly seen on other images. The OD suggested the young man be tested for HIV for precautionary reasons. As it turns out, he was, in fact, in early stages of HIV. Early detection and early treatment has allowed him to live a full,lively and healthy life to this day,8 years later. All Thanks to Optos.

 

[Visionary]

Optos Optomap is a magnificent instrument enabling early detection of diseases that are non symptomatic. Diabetes, Cholesterol, Retinal diseases, Glaucoma, Macular Diseases and early detection of HIV. The first Optos I used, we were able detect an abormality not commoly seen on other images. The OD suggested the young man be tested for HIV for precautionary reasons. As it turns out, he was, in fact, in early stages of HIV. Early detection and early treatment has allowed him to live a full,lively and healthy life to this day,8 years later. All Thanks to Optos.

Nice anecdote, but unless you are using it for advanced imaging (e.g., angiography, autofluorescence), there is nothing an Optomap image will pick up that a thorough dilated fundus exam won't. There is nothing magical about Optos, and it is not a substitute for a dilated exam.

 

[odieoh]

Optos Optomap is a magnificent instrument enabling early detection of diseases that are non symptomatic. Diabetes, Cholesterol, Retinal diseases, Glaucoma, Macular Diseases and early detection of HIV. The first Optos I used, we were able detect an abormality not commoly seen on other images. The OD suggested the young man be tested for HIV for precautionary reasons. As it turns out, he was, in fact, in early stages of HIV. Early detection and early treatment has allowed him to live a full,lively and healthy life to this day,8 years later. All Thanks to Optos.

Eh, always suspicious of a new member whose first posts sound like a commercial for whatever product is being discussed. . .

That being said, my practice does have an optos and it is actually quite useful. As others have stated it shouldn't be used to replace a dilated exam. It can be very useful to document pathology, and actually very very useful for getting a good look at the peripheral retina in younger kids. Its pretty easy for them to sit at the machine and have the picture taken, and for a younger kid who is in for a routine exam, its much much easier to do that than fight with them.

Besides all that, as someone else mentioned, it is a nice tool to generate revenue. It can be done without having to resort to sales tactics. The basic "wellness screening" is something patients can pay for out of pocket, which adds some revenue, but I think in my practice we generate a lot more from things we can bill as fundus photography (nevi, diabetic retinopathy, any pathology really.) I think 60% or so of our patients end up having it done for either the wellness or fundus photos.

The machine is expensive so I think you would need a multi-doc practice to make it work. We have 2 MDs/2 ODs.

 

[Visionary]

Eh, always suspicious of a new member whose first posts sound like a commercial for whatever product is being discussed. . .

That being said, my practice does have an optos and it is actually quite useful. As others have stated it shouldn't be used to replace a dilated exam. It can be very useful to document pathology, and actually very very useful for getting a good look at the peripheral retina in younger kids. Its pretty easy for them to sit at the machine and have the picture taken, and for a younger kid who is in for a routine exam, its much much easier to do that than fight with them.

Besides all that, as someone else mentioned, it is a nice tool to generate revenue. It can be done without having to resort to sales tactics. The basic "wellness screening" is something patients can pay for out of pocket, which adds some revenue, but I think in my practice we generate a lot more from things we can bill as fundus photography (nevi, diabetic retinopathy, any pathology really.) I think 60% or so of our patients end up having it done for either the wellness or fundus photos.

The machine is expensive so I think you would need a multi-doc practice to make it work. We have 2 MDs/2 ODs.

How much did it set you back, if you don't mind me asking? I'm in an 8 doc practice, so if the ROI is decent, it may be a consideration. We need to update our fundus camera eventually, anyway.

Sent from my Droid Incredible on SDN Mobile

 

[PBEA]

There may be some minor advantages in certain pts when using an Optos but IMO Optos is an overpriced low grade fundus camera. Having the wierd colors and other spatial type distortions might be tolerable but considering that DFE is still providing better views and a fundus camera still provides better images, the high cost makes it a total dealbreaker. Wouldnt touch it with a 10 foot pole.

 

[odieoh]

I'll double check, its been a while since we bought it and I don't remember off the top of my head. We got the one that is capable of doing FA's which is the more expensive model, but it is our only way to do FA's so worth the extra IMO.

For an 8 doc practice I am certain it would be worth the investment, at least 8 general ophthalmologists/optometrists. If I remember you are retina? I don't really know how it would affect a retina practice.

Honestly with 8 doctors, depending on how many are in the office at a time, the problem you could run into is it being a bottleneck for patient flow, at least the way we do it. We run almost every patient through it as part of the workup, the tech tells them about it as they are doing it, and then they are left with some information about it while they wait for their doctor. They can then choose for us to look at it with them (in which case they're billed), or not. This is all for the wellness screening thing.

You can choose to only have those who choose to have it be run through it, but in our experience it took more time to do that running people back and forth in and out of their exam rooms. But that would make flow a little easier for a large practice.

We charge $29 for the wellness screening, which is a lot less than some places. You can pick whatever price you want and do the math, but with that many docs it would easily pay for itself, probably even if only 30%% of your patients choose to have it. Add on to that what you get for fundus photography, which again is we probably use as much or more than the wellness, and it becomes quite worthwhile.

Also people are talking about weird colors and so on. I haven't had a problem with this. Certainly if there is significant cataract or other opacity, the image can be poor. But if done right (and its not very hard for the techs to learn) the images can actually be really really good. You wouldn't know you arent looking at an actual photo.

And again, so useful for kids. I have one three year old ROP kid who I saw and her pupils barely dilated. I couldn't get much of a view posteriorly, partly because of her cooperation, partly her pupils, but we did manage to sit her at the optos and get photos (not all 3 year olds would be able.) I got really good pictures. I had her see retina in follow up, and emailed the photos to the retina doc. The retina doc had a hard time seeing as well but used the photos. She ended up wanting to see the girl back in 6 months but she asked to have the girl come by and get an optos first and have it emailed to her before her exam. Take it for what its worth.

 

[odieoh]

How much did it set you back, if you don't mind me asking? I'm in an 8 doc practice, so if the ROI is decent, it may be a consideration. We need to update our fundus camera eventually, anyway.

Sent from my Droid Incredible on SDN Mobile

It ended up being in the neighborhood of 120k. There was some negotiation after the fact and we may have brought the price down a bit, I don't remember the exact figure. They have several options, including one where you don't actually buy the machine but pay a yearly lease. Looking at the math, it made more sense to buy for the long run.

A couple other things I should mention. We have had ours for almost 2 years now. In that time it has broken down 3 times. 2 times were very minor things where they overnighted us a new cable or other part and it was back in business the next day. The one time it broke down, they tried to fix it but couldn't, so sent a whole new machine.

Over a 2 year period thats really not too bad, with their quick response for the first 2 incidents I didn't even realize it had broken. Fortunately its use is optional for people doing the wellness screening, so not a huge deal if its down. For fundus photos if it happens to be down for a day, anyone needing fundus photography can just come back another day and have it done and let the doctor review it whenever is convenient. Thats slightly inconvenient for the patient, but for us its been so infrequent that I don't feel like its been a problem.

If your practice is thinking of getting one there is definitely a transition period of getting the techs used to it. I've mentioned that we do it on roughly 60% of our patients (it may even be higher), but it took some time to build up to that. I was a little uncomfortable with it at first because it felt like we were "selling" things to patients and I don't like that. But it can really be presented in a no-pressure fashion and a good number of people want it. Getting the techs used to presenting it takes time, and they all eventually develop their little dialogue, and as they get used to it more and more people choose to have it.

I try to go out of my way to make sure patients know they DON"T have to have it and its optional, and if they do get it once I let them know they don't have to have it done every year but can if they want. We're at the point where people who had it the first time around are coming back for their yearly exams, and a lot of them who got it the first time end up getting it again.

It also has a certain "cool factor" for patients, being able to look at stuff inside their eye. It has a little animation you can run where it places their retinal image inside a picture of an eye, and you can start outside and zoom in through the pupil and look at their retina.

Anyway, I'm not trying to sell this thing, but for my practice it has been a positive thing, and if you have the patient volume it is VERY viable financially.

 

[Visionary]

odieoh, thanks for the info. I'm med ret, but the rest in the group are comprehensive. We have a Heidelberg Spectralis 6-mode that I use for FA, ICGA, AF, and OCT. The main reason to get the Optos would be to replace our dated non-digital fundus camera. Of course, the widefield angiography of Optos is superior to the composite function of the Spectralis. Would be nice to have that. Not sure if we would use the wellness screening aspect, and as such, ROI might not be justified. We'll see.

 

[Light]

Just to add a little to the discussion, i've worked with Optos extensively and know it well. If you are looking at getting the current version with Photos/FA/Autoflourescence it runs $147k (retail). There is no lease option or per use option for that version.

The reason the 'color' photos on the Optos don't look quite right is because it uses only 2 of the 3 primary colors (i forgot which of the three it lacks) when it takes 'photos' which are really mathematical extrapolations from SLO scans.

For macular imaging/FA it has a feature called ResMax which is approximately 1/2 the resolution of the Heidelberg FA, adequate in most cases.

ICG is not available for Optos yet, but is anticipated to be released sometime in the next year or so. The problem is for this feature it won't be an upgrade and a new machine purchase will be required.

Finally, for optometric photos, i believe the photo only unit can be lease or consigned on a per-use cost.

 

[odieoh]

Just to add a little to the discussion, i've worked with Optos extensively and know it well. If you are looking at getting the current version with Photos/FA/Autoflourescence it runs $147k (retail). There is no lease option or per use option for that version.

The reason the 'color' photos on the Optos don't look quite right is because it uses only 2 of the 3 primary colors (i forgot which of the three it lacks) when it takes 'photos' which are really mathematical extrapolations from SLO scans.

For macular imaging/FA it has a feature called ResMax which is approximately 1/2 the resolution of the Heidelberg FA, adequate in most cases.

ICG is not available for Optos yet, but is anticipated to be released sometime in the next year or so. The problem is for this feature it won't be an upgrade and a new machine purchase will be required.

Finally, for optometric photos, i believe the photo only unit can be lease or consigned on a per-use cost.

I don't really like the resmax thing. To me it always looks like they just took the original image and turned up the contrast way too high.

 

[PBEA]

I don't really like the resmax thing. To me it always looks like they just took the original image and turned up the contrast way too high.

on another thread there is some discussion about how performing fundus photos/optos scans on normals serves no purpose (other then to inflate the fees). How do the MDs and ODs in your office rationalize this?

 

[OphthoQuestions]

on another thread there is some discussion about how performing fundus photos/optos scans on normals serves no purpose (other then to inflate the fees). How do the MDs and ODs in your office rationalize this?

They lie.

No seriously, I have seen doctors who document b.s. diagnoses so that they can bill out more diagnostics. The shady sign of medicine...

 

[bucknut101]

They lie.

No seriously, I have seen doctors who document b.s. diagnoses so that they can bill out more diagnostics. The shady sign of medicine...

Yep totally agree. Just like some ophthalmologists tell patients they have to have cataract surgery even though the patient is happy with their vision. Or my favorite, ophthalmologists telling patients that they have glaucoma and need to have a SLT done. Despite the fact the patient has a borderline large c/d ratio, normal IOP, normal OCT, and normal visual fields.

 

[odieoh]

on another thread there is some discussion about how performing fundus photos/optos scans on normals serves no purpose (other then to inflate the fees). How do the MDs and ODs in your office rationalize this?

You imply that my fellow docs and I are doing something shady, which I resent and disagree with. . .that being said let me try to address what I believe you are asking.

First of all, we need to separate fundus photos from the "wellness screening" thing. Fundus photos are done to document pathology, and ethically its no different if they are done with an optos or any other camera/device capable of doing fundus photos. Fundus photos are billed to insurance, and I'm sure there are docs who abuse this system no matter what device is taking their pictures. You really can't do fundus photos on "normals," at least no insurance would pay you for them. Whether you SHOULD do a fundus photo on every little choroidal nevus or background diabetic retinopathy is a question everyone has to answer for themself.

So I believe what you are asking is how do I "rationalize" doing the wellness screening on "normals." When you use the word rationalize you imply wrongdoing. I don't believe offering (but not requiring or pressuring anyone into) an additional service is wrong. So what does the wellness add? Quite a bit actually, mainly from an educational standpoint. When someone elects to have it then at the end of the exam I pull up their scan and show them the pictures of their eyes. I explain to them the various important anatomical parts, namely the optic nerve, the macula, and their blood vessels. In explaining the nerve I mention that glaucoma is a disease that can damage the nerve, usually painlessley/asymptomatically, and thus part of the reason regular eye exams are important. Likewise showing them their macula I explain it is the part that can be affected by macular degeneration. If they have high blood pressure, or diabetes without retinopathy I show them the blood vessels and explain how they can be affected by their disease.

So for someone with normal findings I believe it has some good educational value. Of even more educational value is for patients who come for a routine exam, elect to have the wellness screening, and DO end up having some finding that is important, but that you wouldn't necessarily routinely do fundus photos for, whether they have a somewhat large c/d ratio, some fine drusen, mild diabetic retinopathy, whatever. It makes educating them a LOT easier by being able to point to the picture and show them rather than trying to explain verbally.

All in all I think it adds a lot more to a practice than other optional things like latisse or botox. Yes, to some extent it is also a tool to increase revenue. But as long as people aren't pressuring patients into getting it, I don't think its something I need to "rationalize."

 

[Shnurek]

Yep totally agree. Just like some ophthalmologists tell patients they have to have cataract surgery even though the patient is happy with their vision.

O this is a great example. Pt. had a VA of 20/25 in one eye. One comprehensive ophtho recommended cataract surgery and it was performed. Day later, VA of HM. Had the patient come to the retina doc I worked for after the cataract sx. Scleral buckle procedure done to try and save retina because of massive retinal detachment. VA of HM after procedure. Comprehensive ophtho gives phone number to patient. Calls patient every night to see if she is doing OK. Retina doc says "hes probably doing that so you don't sue him." I just shake my head.

 

[OphthoQuestions]

O this is a great example. Pt. had a VA of 20/25 in one eye. One comprehensive ophtho recommended cataract surgery and it was performed. Day later, VA of HM. Had the patient come to the retina doc I worked for after the cataract sx. Scleral buckle procedure done to try and save retina because of massive retinal detachment. VA of HM after procedure. Comprehensive ophtho gives phone number to patient. Calls patient every night to see if she is doing OK. Retina doc says "hes probably doing that so you don't sue him." I just shake my head.

1) You don't know whether this patient's vision decreased significantly on glare testing. I have seen plenty of "20/25" eyes that have 3-4+ cortical spoking and BAT down to 20/400. These patients complain bitterly about their vision despite having "20/25".

2) Sure, there are cataract surgeons that are too aggressive or mismanage cases. Just like there are some people that hold onto glaucoma or AMD patients until they are half-blind before referring them to someone who can actually do something about it.

3) Every surgeon is human including the one you mentioned. Do you think he wanted a "massive retinal detachment" for his cataract surgery patient? Those cases keep any surgeon up at night. At least the guy is making sure the patient is being taken care of and not hiding the fact that there was a complication.

4) There are only two types of people who have no complications: (1) Liars and (2) Non-Surgeons.

 

[odieoh]

1) You don't know whether this patient's vision decreased significantly on glare testing. I have seen plenty of "20/25" eyes that have 3-4+ cortical spoking and BAT down to 20/400. These patients complain bitterly about their vision despite having "20/25".

2) Sure, there are cataract surgeons that are too aggressive or mismanage cases. Just like there are some people that hold onto glaucoma or AMD patients until they are half-blind before referring them to someone who can actually do something about it.

3) Every surgeon is human including the one you mentioned. Do you think he wanted a "massive retinal detachment" for his cataract surgery patient? Those cases keep any surgeon up at night. At least the guy is making sure the patient is being taken care of and not hiding the fact that there was a complication.

4) There are only two types of people who have no complications: (1) Liars and (2) Non-Surgeons.

I agree. Also Shnurek, was the retina doc talking to you when he made the comment about suing or was he/she talking to the patient? Pretty unprofessional thing to say to a patient.

 

[PBEA]

You imply that my fellow docs and I are doing something shady, which I resent and disagree with. . .that being said let me try to address what I believe you are asking.

First of all, we need to separate fundus photos from the "wellness screening" thing. Fundus photos are done to document pathology, and ethically its no different if they are done with an optos or any other camera/device capable of doing fundus photos. Fundus photos are billed to insurance, and I'm sure there are docs who abuse this system no matter what device is taking their pictures. You really can't do fundus photos on "normals," at least no insurance would pay you for them. Whether you SHOULD do a fundus photo on every little choroidal nevus or background diabetic retinopathy is a question everyone has to answer for themself.

So I believe what you are asking is how do I "rationalize" doing the wellness screening on "normals." When you use the word rationalize you imply wrongdoing. I don't believe offering (but not requiring or pressuring anyone into) an additional service is wrong. So what does the wellness add? Quite a bit actually, mainly from an educational standpoint. When someone elects to have it then at the end of the exam I pull up their scan and show them the pictures of their eyes. I explain to them the various important anatomical parts, namely the optic nerve, the macula, and their blood vessels. In explaining the nerve I mention that glaucoma is a disease that can damage the nerve, usually painlessley/asymptomatically, and thus part of the reason regular eye exams are important. Likewise showing them their macula I explain it is the part that can be affected by macular degeneration. If they have high blood pressure, or diabetes without retinopathy I show them the blood vessels and explain how they can be affected by their disease.

So for someone with normal findings I believe it has some good educational value. Of even more educational value is for patients who come for a routine exam, elect to have the wellness screening, and DO end up having some finding that is important, but that you wouldn't necessarily routinely do fundus photos for, whether they have a somewhat large c/d ratio, some fine drusen, mild diabetic retinopathy, whatever. It makes educating them a LOT easier by being able to point to the picture and show them rather than trying to explain verbally.

All in all I think it adds a lot more to a practice than other optional things like latisse or botox. Yes, to some extent it is also a tool to increase revenue. But as long as people aren't pressuring patients into getting it, I don't think its something I need to "rationalize."

yes I was asking about the "wellness photo" aspect, and not about the billing of fundus photos for legitimate reasons. I do realize many ODs and MDs do this extra "wellness" testing thing and I do think it is an unecessary clinical test serving no real purpose. I disagree with your argument that it "helps educate". If there is nothing wrong with the pt then there is nothing to "educate" them on. I've always limited my exam to that which I felt was necessary given the case presentation. That I might perform a certain test might be met with some different opinions, and thats ok, but the regular use of non-indicated tests is unjustified. If a doctor were to bundle that test in with their regualr exam fee and perform it on all pts it would still be below the standard of care, but that it is added for an additional fee makes it particularly unsavory, IMHO.

donning flame ******ant gear

 

[odieoh]

Eh, I understand where you are coming from, and to some extent I agree. There's a lot of weasly ways to make money in ophthalmology/optometry. We have a local optom who tells all his patients they need prescription reading glasses and sells them $300 +2.00s. We recently had one of the lens reps come try to get us to "increase our conversion rate" on premium IOL's. While I think its important to let patients know what their options are, I never want to feel like a salesman. She went in the room with the techs on a couple pre-op visits to help them "educate." She came out of one room and told me she had "sold" the pt on Restor. I went in and talked to the patient and the pt. said she had decided on the Restor. I talked to her a little more and it turns out she really didn't mind wearing reading glasses and in fact thought she was so used to wearing glasses she would find it strange to not have them. Additionally the extra money would have been burdensome on her financially. We went with the standard lens and she is very happy.

When we were considering getting the optos, I shared your same concerns, mainly again I did not want to be a salesman or put pressure on anyone to spend more than they could afford. However, as I"ve stated before, you can do it in a fashion that there is no pressure and make sure they know it is completely optional.

I do take issue with your verbage-- the optos wellness is not a" test", and I am not "doing it" or "ordering" it. It is never "indicated" nor "nonindicated" and mentioning standard of care when discussing it is ridiculous. It is a service that is 100% optional and the patient has complete control over it.

I would liken patients spending money on it to patients who are willing to spend $1200 on a pair of frames. Its their money and if thats what they want to spend it on, I'm happy to give it to them. I wouldn't ever tell anyone they NEED a $1200 pair of frames. Likewise I would never tell an optical shop that their $1200 frames aren't "indicated" since the patient could get by with $100 frames, and therefore if they offer $1200 frames their optical care is "below the standard of care."

 

[bucknut101]

O this is a great example. Pt. had a VA of 20/25 in one eye. One comprehensive ophtho recommended cataract surgery and it was performed. Day later, VA of HM. Had the patient come to the retina doc I worked for after the cataract sx. Scleral buckle procedure done to try and save retina because of massive retinal detachment. VA of HM after procedure. Comprehensive ophtho gives phone number to patient. Calls patient every night to see if she is doing OK. Retina doc says "hes probably doing that so you don't sue him." I just shake my head.

1) You don't know whether this patient's vision decreased significantly on glare testing. I have seen plenty of "20/25" eyes that have 3-4+ cortical spoking and BAT down to 20/400. These patients complain bitterly about their vision despite having "20/25".

2) Sure, there are cataract surgeons that are too aggressive or mismanage cases. Just like there are some people that hold onto glaucoma or AMD patients until they are half-blind before referring them to someone who can actually do something about it.

3) Every surgeon is human including the one you mentioned. Do you think he wanted a "massive retinal detachment" for his cataract surgery patient? Those cases keep any surgeon up at night. At least the guy is making sure the patient is being taken care of and not hiding the fact that there was a complication.

4) There are only two types of people who have no complications: (1) Liars and (2) Non-Surgeons.

Actually Shnurek that is not a great example of what I was getting at. I completely agree with what OphthoQuestions is saying. Sometimes 20/25 vision does significantly bother people and they want their cataracts removed. And there is nothing wrong doing cataract surgery on these folks as long as they are complaining of visual difficulties. I've removed 20/25 cararacts before but I make darn sure these patients understand there are risks involved.

What I am referring to is when people go in to see their eye doctor, are perfectly happy with their vision, have no visual complaints and the doctor says "Mrs X you really should get those cataracts removed" Mrs X replies "Oh my I didnt realize that they needed to come out, but your the doctor so whatever you say". Mrs X has surgery done, something goes wrong, and ends up worse vision than before surgery. Cataract surgery in nearly all cases is an elective procedure and some unfortunate folks are told that need to have it done and they dont' know any better.

I have seen several patients in my practice that come in with with problems after cataract surgery (in my case usually peristent corneal edema) and I hear how that they though their vision was just fine before surgery but were told that they had to have cataract surgery. And yes it is possible that they weren't told they "had" to have surgery and are just bitter and trying to place the blame on the surgeon for their situation.

Schnurek you example case is very unfortunate and sad but as OpthoQuestions said that doesn't mean the cataract surgeon did anything wrong. Retinal detachment is a well known complication of cataract surgery. Even when a surgeon does a perfect case there is still the possibility of complications developing. And every surgeon that operates is going to have complications. It's just a fact of life.

And as far at the cataract surgeon calling the patient to make sure they are doing ok.....That's pretty standard for that type of situation. It means that the cataract surgeon really cares about what happened to his patient. That's exactly what I would do in the same situation. If the retina doc did really say "well he's just calling you so you won't sue him" that is completely unprofessional on his part. The second I found a doc said something like that about a patient I referred you could count on the fact I would never send them a patient again.

As a corneal specialist I see referals all the time because of things gone wrong. Mismanaged ulcers, perforated ulcers, disclocated IOLs, corneal edema after cataract surgery. And not once have I ever spoke of a referring doc in a negative way. All doctors make mistakes, including myself.

 

[Shnurek]

I agree. Also Shnurek, was the retina doc talking to you when he made the comment about suing or was he/she talking to the patient? Pretty unprofessional thing to say to a patient.

Unfortunately, she said it to the patient in a slightly less audible tone of voice. She was always a little "off" and the medical biller used to catch misdiagnosis every now and then. I felt sad for the patient and I mentioned to her about the case of a VA ophtho resident that exploded an eye ball because instead of doing a proper retrobulbar block she injected directly into the globe and the patient got an insane amount of compensation for that. Online she is known as Dr. Eyesplosion lol but she does have an MD and a PhD. Na but back to the point I understand that if the cataract surgeon provided adequate informed consent then it was fair but the only people that know if it was adequate that are the doc and the maybe the patient. My opinions have changed a bit since then and I believe in tort reform and getting money hungry scumbags out of healthcare too but those are much broader issues.

 

[odieoh]

Unfortunately, she said it to the patient in a slightly less audible tone of voice. She was always a little "off" and the medical biller used to catch misdiagnosis every now and then. I felt sad for the patient and I mentioned to her about the case of a VA ophtho resident that exploded an eye ball because instead of doing a proper retrobulbar block she injected directly into the globe and the patient got an insane amount of compensation for that. Online she is known as Dr. Eyesplosion lol but she does have an MD and a PhD. Na but back to the point I understand that if the cataract surgeon provided adequate informed consent then it was fair but the only people that know if it was adequate that are the doc and the maybe the patient. My opinions have changed a bit since then and I believe in tort reform and getting money hungry scumbags out of healthcare too but those are much broader issues.

You have some serious flight of thought going on there.

Also. . .wtf. This patient just had a retinal detachment after cataract surgery and you decide that might be a good time to tell a story about an exploding eye? What exactly was your thought process there? "At least your eye didn't explode" might make her feel better?

 

[Visionary]

Unfortunately, she said it to the patient in a slightly less audible tone of voice. She was always a little "off" and the medical biller used to catch misdiagnosis every now and then. I felt sad for the patient and I mentioned to her about the case of a VA ophtho resident that exploded an eye ball because instead of doing a proper retrobulbar block she injected directly into the globe and the patient got an insane amount of compensation for that. Online she is known as Dr. Eyesplosion lol but she does have an MD and a PhD. Na but back to the point I understand that if the cataract surgeon provided adequate informed consent then it was fair but the only people that know if it was adequate that are the doc and the maybe the patient. My opinions have changed a bit since then and I believe in tort reform and getting money hungry scumbags out of healthcare too but those are much broader issues.

Sounds like you learned professionalism from her.

 

[Shnurek]

Also. . .wtf. This patient just had a retinal detachment after cataract surgery and you decide that might be a good time to tell a story about an exploding eye? What exactly was your thought process there? "At least your eye didn't explode" might make her feel better?

No, I emphasized the compensation the person received and I didn't go into details about what happened. At that point I thought she was treated unjustly and should sue the surgeon. Now looking back, I probably should have asked her if the surgeon gave proper informed consent. And if not, then I would make the remark about the malpractice case. She decided not to sue anyway.

 

[odieoh]

No, I emphasized the compensation the person received and I didn't go into details about what happened. At that point I thought she was treated unjustly and should sue the surgeon. Now looking back, I probably should have asked her if the surgeon gave proper informed consent. And if not, then I would make the remark about the malpractice case. She decided not to sue anyway.

Or, as an observing optometry student, maybe you should have realized that it is not your role to be giving her legal advice at all. Your explanations keep making this interaction seem worse and worse. . .seriously, "I thought she should sue so I emphasized the compensation from another lawsuit???" wow.

 

[guttata]

No, I emphasized the compensation the person received and I didn't go into details about what happened. At that point I thought she was treated unjustly and should sue the surgeon. Now looking back, I probably should have asked her if the surgeon gave proper informed consent. And if not, then I would make the remark about the malpractice case. She decided not to sue anyway.

Incredible. That is completely, absolutely, unprofessional. You only know half of the story and you are pushing for malpractice? You are not a surgeon but profess to know when malpractice occurs from cataract surgery? As others have mentioned, a vision of 20/25 means nothing. She could have been symptomatic from glare or had decrease contrast sensitivity.

Malpractice did not occur just because the patient suffered a retinal detachment and poor outcome. I am not saying that it did not occur, but I (and you) do not have enough information to make that determination. Retinal detachment is a known risk after cataract surgery, EVEN if the surgery goes perfectly.

Also, it's pretty standard to call the patient regularly after a complication.

You could have been empathetic to the patient without discussing other cases or accusing the cataract surgeon of malpractice. I hope you learn something from this experience.

Go ahead and joke about the poor outcome from the retrobulbar injection. I am 100% sure no one feels worse (outside of the patient) than the surgeon who did the injection. You better not go into clinical practice, because I am 100% confident that some day, some time, you will miss a diagnosis (just like everyone else).

 

[OphthoQuestions]

No, I emphasized the compensation the person received and I didn't go into details about what happened. At that point I thought she was treated unjustly and should sue the surgeon. Now looking back, I probably should have asked her if the surgeon gave proper informed consent. And if not, then I would make the remark about the malpractice case. She decided not to sue anyway.

It is ridiculous that you made any comments at all. If I were the precepting Ophthalmologist, I would have kicked you out of my clinic immediately.

You need to learn to keep your uninformed opinions to yourself while observing patients that are NOT yours.

 

[odieoh]

No, I emphasized the compensation the person received and I didn't go into details about what happened. At that point I thought she was treated unjustly and should sue the surgeon. Now looking back, I probably should have asked her if the surgeon gave proper informed consent. And if not, then I would make the remark about the malpractice case. She decided not to sue anyway.

This has me a bit riled up, and shnurek I feel like you are a person who has to have things spelled out for them, so I will attempt to do so. Even now "looking back," and backpedaling you still don't get it. Why would you have asked her if the surgeon gave proper informed consent? How would you even ask her that, would you say "did he give you proper informed consent?" She would have no idea what that meant.

You need to learn what your role is, and in no way am I trying to start and ophtho/optom flame war. RIght now you are a student. Your job is to observe, learn, and STFU.

When you are done with school and out in practice (heaven forbid), your job is to fix the eye problems that come to you to the best of your ability, and no more. If someone comes to you and has a past history of a complication with another doc, it is not your job to assess their legal situation. You do what you can to help with whatever problem you are capable of treating, you reassure them the best that you can, and thats it.

Even if a patient outright asks you if you think they should sue, your response should be "Its really hard for me to make that determination since I wasn't there and I don't have all the information about your case." If you think there really was malpractice involved, you can follow that with "I'm not a lawyer but if you think you were wronged maybe you should speak with one."

Learning to shut your mouth (or keyboard in some cases) is the most valuable skill you can learn at this point.

 

[Shnurek]

At that point I didn't know anything. I was just entering the health field as a tech. (you know how dumb techs can be) The surgeon I worked for was really chill and she let me do almost anything. Just letting you know what people outside of the medical profession think. They usually think, bad doctor, gimme money. That is why I am for tort reform nowadays. Almost all docs don't wish bad things to happen upon their patients but people, including my past self, don't really understand that.