Laser Procedures Performed by O.D.'s at VA Stopped

[Andrew_Doan]

---

Members do not see this ad.

This is recent news from the aao (www.aao.org)

May 22, 2003
Volume IX, Issue 9



Academy and Allies Stop Precedent Setting O.D. Laser Surgery at the VA
Under pressure from the Academy, the AMA, and the American College of Surgeons (ACS), Department of Veterans Affairs Undersecretary for Health Robert A. Roswell, M.D. has suspended indefinitely the laser surgery activities of an optometrist at the Robert J. Dole Veterans Affairs Medical Center in Wichita. In a May 19, meeting with Academy Secretary for State Affairs Michael W. Brennan, M.D. and State Affairs Secretary-Elect Cynthia Bradford, M.D., Roswell confirmed the order but also raised concerns about ways to resolve the situation over the long run. Academy, AMA, and ACS representatives will work with Dr. Roswell over the next few weeks to ensure veterans receive high-quality surgical eye care within the VA system, both now and into the future.

The controversy in Wichita surrounds an Oklahoma licensed optometrist who, with the approval of the director of surgical services at the Wichita VA, purchased a laser for both conducting anterior segment and lid lesion procedures, as well as with the intent of setting up a laser surgery instruction activity within the medical center. After learning of this unprecedented threat to patient safety, the Academy, ACS, and AMA contacted VA Secretary Anthony Principi on May 2, and Undersecretary Roswell issued his stop order on optometric surgery on May 9. To date, Oklahoma is the only state to pass legislation allowing optometrists to perform laser eye surgery, though the exact nature of the training program and its methods of certification have yet to be fully vetted through regulation.

The Academy reminds members who work in the VA system?even part time?that any information on optometric scope-of-practice incursions or related patient safety issues should be reported immediately to the Academy?s VA staff liaison Patrick Eddington.

 

[Richard_Hom]

Dr. Doan,

Interesting post. What are your thoughts on this? I also know that you will be working with optometrists when you complete your residency and would like your thoughts on how you will work with optometrists. (PS. I'm a retired LTCOL, USAR having spent time on the USS Carl Vinson and USS Abraham Lincoln, USAF airbases and community hospital clinics.)

 

[TomOD]

It appears that this OD was licensed in OK, where he probably was trained and had been using laser therapy for many years........would it make any difference if he had been performing PI's and YAG capsulotomies for 5 years, treated a 1000 patients and had no adverse "incidences"?

By the way Richard, I spend 2 years on the USS John F. Kennedy......not as an OD.......simply as a Marine "grunt"😉

 

[Richard_Hom]

Tom,

Having an primary care optometrist on board a carrier on deployments makes great sense. You can both refract the flights for their annual recerts and take care all of the corneal foreign bodies and ulcers.

My first mission on board the Lincoln was the first to have women. On the first night, I had 3 corneal foreign bodies and ulcers.

Pursuant to my initial stay (it was a pilot program), the Navy now deploys Navy optometrists on several of their attack carriers as a matter of course.

 

[Andrew_Doan]

Originally posted by Richard_Hom
Dr. Doan,

Interesting post. What are your thoughts on this? I also know that you will be working with optometrists when you complete your residency and would like your thoughts on how you will work with optometrists. (PS. I'm a retired LTCOL, USAR having spent time on the USS Carl Vinson and USS Abraham Lincoln, USAF airbases and community hospital clinics.)

Retired LTCOL Hom,

It's great having you post on these forums. I'm interested to hear more about your experiences with military optometry and what was your scope of practice while in the USAF.

I work with optometrists now at both the University and VA. The optometrists here are very good, and they do an outstanding job running a primary eye care clinic. Their scope of practice include fitting hard and soft contact lenses, refractions, low vision, and basic eye care (management of early diabetic retinopathy, glaucoma monitoring, and diagnosing other ocular diseases). However, the ODs here don't work with lasers.

In regards to how I will work with Naval optometrists will be determined by what ODs are allowed to do in the NAVY. I'm not completely familar with the scope of practice of Naval optometrists, but the scope of practice of military optometrists is similar to their civilian counterparts. At larger facilities like San Diego, Portsmouth, and Bethesda, I think laser procedures are primarily performed by ophthalmologists. Currently, the Navy has enough ophthalmologists to fill all billets, and I think there is not much of a need for optometrists to perform laser procedures.

 

[Richard_Hom]

Dear Dr. Doan,

Aside from the laser controversy, I can only say what I did in the US Army since that is my service.

On the carriers and in small community hospitals (where the nearest ophthalmologist was 50 miles away) the chief of surgery or the on board chief medical officer gave me great latititude as would every supervisor dependant upon the skills and experience of the individual.

My scope was above most civilian practitioners. I didn't want to do any type of surgery (no lasers aboard a carrier or in a small 200 bed hospital with on ophthalmologist). I could order any test, prescribe a broad range of analgesics, BCP's., cold medications, oral antihistamines and sometimes did some "general medicine" triaging.

I believe that large facilities would limit the scope of most optometrists and I, for one, chose smaller facilities avoid those artificial constraints.

In my opinion, the degree of leeway you should give an optometrits should be constrained by motivation, competency, and experience. I also believe that there was a lot of trauma and surgery to go around and frequently I was better equipped to handle the eye stuff than a PA, NP, or GMO.

I hope that your naval career will not be encumbered by any unrestrained biases that you may have been given by your mentors towards optometrists. As a team, it will make your tour of duty really exciting and easy.

Originally posted by Ophtho_MudPhud
Retired LTCOL Hom,

It's great having you post on these forums. I'm interested to hear more about your experiences with military optometry and what was your scope of practice while in the USAF.

Regards,

 

[Andrew_Doan]

Originally posted by Richard_Hom

In my opinion, the degree of leeway you should give an optometrits should be constrained by motivation, competency, and experience.

I hope that your naval career will not be encumbered by any unrestrained biases that you may have been given by your mentors towards optometrists. As a team, it will make your tour of duty really exciting and easy.

Dr. Hom,

I completely agree with you. As long as people are properly trained, there should be no constraints. Military medicine is wonderful in regards to training people and pushing them to be at their best. If you're able to handle the ocular complications, then there shouldn't be any limitations.

I'm not encumbered by unrestrained biases. I work well with people and try to keep an open mind. I'm confident my Naval career will be rewarding and exciting; however, I didn't join the Navy because I wanted an 'easy' career. 🙂

Best regards,

 

[TomOD]

Came across this article. It's slightly dated (1999) but possibly informative.
--------------

http://jrs.slackinc.com/vol154/news.pdf

 

[droliver]

Tom,
thanks for the link to that article. I think you can see the clear endpoint of the optomatrists in that article. They are being conservative in their position thru most of the interview in that article, but clearly they have their target on the lucrative LASIK market (the guy pretty much admits it near the end as he hedges about what were formaly more adamant declarations that OD's had no interests in it)

 

[Richard_Hom]

Dear droliver,

I believe the "conflict" or "adverserial" relationship between most ophthalmologists and optometrists would subside significantly, if each side weren't so adamant or emotional in their positions. In most cases, it's like "...cannot live together...but need each other..."

I don't see optometry and ophthalmology being anywhere near close to being bedfellows in the near future. Both sides are producing graduates in significant numbers to overcome each other's competitive position. Both sides are firmly entrenched in their viewpoints with no possibility of compromise.

It's fortunate that the cost of healthcare and the public's ability to pay for it will really be the judge of how this relationship will evolve.

Regards,
Richard

 

[JDENTHOPEFULL]

bump

 

[angelic02]

Dr. Hom and/or Dr. Doan as well as any other MD/DO (opthalmology) and/or OD,

How do you perceive the future of optometry as regards to eye trauma and ocular diseases (w/o laser [in civilian life])?

Do you believe that OD's will be utilized more in hospitals (trauma centers, etc.) in order to diagnose and treat these ailments?
For clarity, do you believe that there will be OD's serving in a similar capacity as MD/DO specialists when an emergency arises?

I know that there is already another thread that deals with similar issues, but I am interested in a specific question, as above.

I am only an undergrad premed, but I am interested in the relations between physicians and other health care practitioners.

Thanks.

 

[Andrew_Doan]

Originally posted by angelic02

How do you perceive the future of optometry as regards to eye trauma and ocular diseases (w/o laser [in civilian life])?

Do you believe that OD's will be utilized more in hospitals (trauma centers, etc.) in order to diagnose and treat these ailments?
For clarity, do you believe that there will be OD's serving in a similar capacity as MD/DO specialists when an emergency arises?

This is only my opinion.

I think traumas should be consulted with the surgeons who will evaluate the extent of injury and decide if surgical intervention is needed. Optometrists are not trained for severe ocular trauma, and it would be very inefficient for trauma centers/ERs to consult with an optometrist and then have the optometrist call an ophthalmologist. This delay in evaluation by a trained surgeon is not cost effective nor is it good delivery of care.

Most emergencies that come in at night or during the weekends require the expertise of a physician or surgeon. For instance, in the last month on call, I've evaluated and treated patients with: intraorbital lymphoma misdiagnosed as "red eye", TTP-HUS which was overlooked until the patient developed cotton wool spots bilaterally and developed VF scotomas, several MAC-ON retinal detachments, endophthalmitis, orbital cellulitis, numerous orbital traumas requiring surgical intervention, several open globes, traumatic hyphema, and acute angle closure glaucoma requiring immediated medical and surgical intervention.

All these cases are best managed by an ophthalmologist. Furthermore, I don't know any optometrist who would really want to evaluate patients with the above problems. These patients require imaging studies of the head, surgical intervention, hospitilization, and blood tests, which are definitely beyond the scope of practice for optometrists.

 

[TomOD]

Andrew,

I can't argue much with you on this one. But..........I do remember seeing a study a number of years ago (5-7 maybe-I'll try to find it), documenting that "most" eye visits to emergency rooms nationwide were not major trauma. I believe it said that 90% of ER eye visits could be handled by OD's.

Many of the ER visits that I happen to catch in the hind-end are corneal F.B's, abrasions, pre-septal cellulitis (and orbital cell.), and uveitis (usually misdiagnosed by the E.R. doc at "conjunctivitis).

All of these are easily handled by OD's (with the exception of orbital cellulitis). As a matter of fact, I visited with a local Ophthalmologist recently that voiced his dismay at a local E.R. for constantly calling him in the middle of the night telling him that they would be sending him over a patient with a corneal abrasion the next day. After this happen 4-5 times, he finally put an end to it and just told them to send them to the office but don't wake him up in the middle of the night for no reason.

I think your scenerio would be typical of a large city trauma center but medium to small town E.R.'s typically don't see that much major eye trauma, I don't think.

So, I'm not necessarily disagreeing with you..........but you have to admit that just about any OD would be in a better position to treat ER eye problems than an Emergency medicine doctor. I've seen them make quite a few messes in the past.

 

[TomOD]

Originally posted by Ophtho_MudPhud
.
For instance, in the last month on call, I've evaluated and treated patients with: intraorbital lymphoma misdiagnosed as "red eye", TTP-HUS which was overlooked until the patient developed cotton wool spots bilaterally and developed VF scotomas, several MAC-ON retinal detachments, endophthalmitis, orbital cellulitis, numerous orbital traumas requiring surgical intervention, several open globes, traumatic hyphema, and acute angle closure glaucoma requiring immediated medical and surgical intervention.

All these cases are best managed by an ophthalmologist. Furthermore, I don't know any optometrist who would really want to evaluate patients with the above problems. These patients require imaging studies of the head, surgical intervention, hospitilization, and blood tests, which are definitely beyond the scope of practice for optometrists.

Huh,

I can (and do regularly) order imaging studies and blood work. I can't admit to a hospital but some OD's can (I've never applied).

Surgical intervention...........you got me there (at least for now😀 😉 )

I can diagnose and evaluate a retinal detachment and get ahold of a retinal surgeon (just like any sensible ophthalmologist should do), I can diagnose orbital cellulitis, I can diagnose and, in many cases, mangage traumatic hyphemas, and certainly angle-closure glaucoma (although I am not yet able to use a laser here in NC). The other conditions such as the endopthalmitis is certainly more in your realm.

I'm just afraid you might be giving OD's just a little too little credit.

Anything "medically eye" is within my realm. Hey, I'd never try to fight an Ophthalmologist for ER duty..........but if the circumstance came about where there was no Ophthalmologist available, I think I'd be able to do a decent job.

I believe Richard Hom is on the "front line" in a community hospital center. I'm sure he may have another opinion.

 

[Richard_Hom]

Dear Dr. Doan,

Thanks for your opinion and in some respects, you're partly correct.

On the other hand, I've personally also taken ER call (night) for a 200 bed rural hospital in Georgia 3-4 days/nights of every week for 7 months and can say that whatever trauma (including 8-ball hyphema) was adequatedly care for by me.

In all of the circumstances that you have described of mistaken or missed diagnoses a surgeon isn't required to diagnose. I think any untrained or uncaring practitioner whether they be optometrist or ophthalmologist may miss the diagnosis. I do agree, however, that a surgeon may be needed to treat.

In addition, an optometrist that has been properly trained and evaluated by the medical staff (as I was) can do first call. I did this for 7 months at a GA hospital and when appropriate referred them to an ophthalmologist 50 miles away.

In my present circumstance, an ophthalmologist is only available 3 half days per week and I take the ER referrals for 5 half days. The ER staff knows that a catastrophic eye problem will require an ophthalmologic consultation but in most cases, I stabilize with the ophthalmologist on the phone and will follow up accordingly when their half day arrives.

I will tell you that in addition, there is ample ocular disease to go around but with the way reimbursement is going, I feel that a vacuum will be created as ophthalmologists pursue the high-reimbursement or private patient populations. It's in this circumstance that optometists can and are able to provide the definitive eyecare.

Dr. Doan, I believe that most ophthalmologists have a "knee-jerk" reaction to an optometrist even venturing into this category. But I can say that the power for medical care dynamics will no longer be in each of our hands but in individuals who seek to care for a population or constituency with an ever dwindling budget.

Would you therefore leave segements of the population untreated or undiagnosed? Would you wait until they come into ER. I also believe that a large segment of the population do not have jobs, cannot qualify for Medicaid and see eye medical care until it's too late (usually via the ER).

Thanks again, Dr. Doan for expressing your thoughts and I welcome your insight going forth,

Richard Hom, O.D.,F.A.A.O.
San Mateo, CA

Originally posted by Ophtho_MudPhud
This is only my opinion.

I think traumas should be consulted with the surgeons who will evaluate the extent of injury and decide if surgical intervention is needed. Optometrists are not trained for severe ocular trauma, and it would be very inefficient for trauma centers/ERs to consult with an optometrist and then have the optometrist call an ophthalmologist.

 

[Andrew_Doan]

Originally posted by TomOD
Huh,

I can (and do regularly) order imaging studies and blood work. I can't admit to a hospital but some OD's can (I've never applied).

Thanks for your opinion.

I'm sure you do order blood work and imaging studies; however, whether or not you're qualified to interpret these studies is up to much debate. I would say that an optometrist's training is inadequate to interpret radiological studies and blood tests. These skills can only be gained with a proper medical background AND proper residency training. I would not let a new medical graduate interpret these studies without residency training; thus, why would I want an optometrist without medical training interpreting blood work, CT scans, and MRI scans of the head. This is simply beyond the scope of an optometrist's practice.

Furthermore, some medical conditions may turn out to be non-surgical, but they should still be evaluated by a surgeon/physician. For instance, a traumatic hyphema with subconj. heme can easily be an open globe, but difficult to tell. This will require surgical exploration in the OR. Why have two non-surgical health care providers (ER physician and optometrist) evaluate the patient and delay care? If you're not a surgeon, then you won't be thinking of surgical issues. It's best to leave the traumas to the surgeons who have seen thousands of cases more than the optometrist.

Additionally, some corneal abrasions turn out to be open globes. I saw a self-sealing open globe from a metal foreign body at the beginning of this year. The ER doc said it was a "corneal abrasion" and patched the eye (NEVER patch an open globe). The patient was sent home without an ophthalmology consult. We saw the patient the next morning, and he had a FB in the globe.

The point is that if you're not used to seeing numerous ocular traumas, then you should not be evaluating them on call. Also, if you're not able to surgically repair the problem, then you should not be in the ER seeing patients with ocular trauma. Finally, if you're not medically qualified to interpret blood tests and head scans, then don't. You wouldn't want to be on the stand testifying why you think you're qualified when the lawyer will simply make it clear that optometrists lack the medical training to make this call. Without the training, I wouldn't want to make this call.

 

[Andrew_Doan]

Originally posted by Richard_Hom
Dear Dr. Doan,

I will tell you that in addition, there is ample ocular disease to go around...

Would you therefore leave segements of the population untreated or undiagnosed? Would you wait until they come into ER. I also believe that a large segment of the population do not have jobs, cannot qualify for Medicaid and see eye medical care until it's too late (usually via the ER).

Dr. Hom,

Thank you for your insight. Your military background is unique and your training is not typical of the average optometrists. I have a few points to make, however.

1) Very few people are being untreated, at least when there is a University hospital around. For example, if they come to the ER in the state of Iowa, then they will be forwarded to the University for treatment regardless of the ability to pay. Additionally, if people are unable to pay, then I can assure you that a private practice optometrist will unlikely want to treat that patient in fear of not being reimbursed. Your arguement about lack of care for the indigent does not support your call for optometry to have more medical scope of practice.

2) Additionally, just because there is ample disease to go around, does not justify having optometrists without the proper medical and surgical background treating ocular traumas on call. This makes no sense to me. Ophthalmologists take call now in private practice. 90% of my consults on call are from Ophthalmologists who take call from their small, rural towns. Therefore, even in a rural state like Iowa, we have plenty of ophthalmologists taking call and covering the state, regardless of the patient's ability to pay.

 

[Richard_Hom]

Dr. Doan,

Well said.

I hope our different view points will not blind each of us to "knee jerk reactions which you and I know both of our sides are more than capable of.

One question, though. What is your best guess of the percentage or proportion or incidence of eye-related ER visits that are related to significant surgical intervention such as lacerated corneas, penetrating and retained metallic/non-metallic corneal or scleral foreign bodies, ruptured globes, orbital fractures causing herniation of the globe,etc versus non-surgical cases?

Would you say there is a difference in the proportion or incidence between an urban vs rural.

BTW, I agree about compensation / reimbursement issues for the optometrists regarding ocular trauma. In circumstances where there is no reimbursement issues, would you feel the same about optometrists taking first ER call? or treating medical or minor surgical eye problems?

Thanks,
Richard Hom, OD,FAAO
LTCOL, USAR (Ret)

 

[Andrew_Doan]

In regards to the percentage of ER visits due to open globe traumas, this depends on the population. In a city where there is a knife and gun club, I think the incidence is higher. However, I'm not sure of the exact numbers in Iowa because the ERs here only send us the obvious traumas. Most of my ER consults have been open globes. Furthermore, most have already been screened by outside ophthalmologists/ER physicians in rural Iowa.

I think TomODs quote of 10-15% of all ER visits for eye problems are ocular traumas is likely correct.

Regardless of compensation status, I still believe that traumas and medical emergencies should be handled by those who have the proper medical and surgical background. Optometry in the US is not known for it's preparation of broad medical and surgical background. Numerous medical emergencies and medical diagnoses emerge first in the eye. It's even tough for physicians to make these diagnoses some times. I just don't see how optometrists can make these diagnoses without the proper medical and residency training. Like I said before, if I didn't have the residency and medical training, then I wouldn't want to make the call. This is not good, safe patient care.

When I hear TomOD speak his opinions, it sounds like he should have attended medical school and residency. It appears that he would like to expand the scope of practice that is typically handled by ophthalmologists. It's not too late to attend medical school. Some ODs are applying to medical school and residency. 🙂

At the present moment, there isn't a shortage of ophthalmologists. Most areas have access to an ophthalmologist within 30 miles. In major cities, there are plenty of ophthalmologists to take call. Thus, I just don't see how patient care can be improved by having non-medical, non-surgical optometrists taking first call in trauma centers and ERs when ophthalmologists already do the job. This may be a mute point because I think most ODs enjoy their clinic hours and would rather not take call. Am I wrong? No one really enjoys taking call.

 

[Richard_Hom]

Dr. Doan,

It's likely that you may be correct in regards to the training of optometrists who may have graduated several years ago and who function in private practice in communities all over the US.

However, in the past 5 years, many optometrists have had additional training and experience which have shortened the gap that you may perceive that exists. I think your future affiliation with optometrists with these kinds of credentials might broaden your view.

It's true that the surgical area of eye care will long remain the exclusive domain of ophthalmology and I don't feel that is something I personally want to take on.

As always, yours truly,
Richard Hom, OD,FAAO
LTCOL, USAR (Ret)

Originally posted by Ophtho_MudPhud
Optometry in the US is not known for it's preparation of broad medical and surgical background. Numerous medical emergencies and medical diagnoses emerge first in the eye. It's even tough for physicians to make these diagnoses some times. I just don't see how optometrists can make these diagnoses without the proper medical and residency training. Like I said before, if I didn't have the residency and medical training, then I wouldn't want to make the call. This is not good, safe patient care.

 

[TomOD]

Originally posted by Ophtho_MudPhud
Thanks for your opinion.

I'm sure you do order blood work and imaging studies; however, whether or not you're qualified to interpret these studies is up to much debate. I would say that an optometrist's training is inadequate to interpret radiological studies and blood tests.

What interpretation? I get a report back from the radiologist at the diagnosistic center. HE interprets it, I read it. HE tells ME if there is a problem in most cases.

Blood work comes back with a report HIGHLIGHTING normal vs abnormal. References are available in a number of cases.

 

[TomOD]

Originally posted by Ophtho_MudPhud

Optometry in the US is not known for it's preparation of broad medical and surgical background. Numerous medical emergencies and medical diagnoses emerge first in the eye. It's even tough for physicians to make these diagnoses some times. I just don't see how optometrists can make these diagnoses without the proper medical and residency training. Like I said before, if I didn't have the residency and medical training, then I wouldn't want to make the call. This is not good, safe patient care.

Yep, I believe most of the problems with erroneous perception of OD's is the fact that there is a wide variety of practice patterns among today's OD's.

Some are, in my opinion, simply lazy and only want to do refractions and sell eyeglasses..............others, a growing segment, realize the need to go more.

Andrew, I like our conversations, but I just don't understand how you could truely know about the training of Optometrists and say it is inadequate to do what I do.

There is no doubt that you will be/are much more highly trained surgically. But to say that you are much more competent to diganose medical eye conditions or systemic problems via eye conditions is possibly a stretch.

Perhaps, your view is a bit distored working in a University environment. You probably see the worst of the worst. Most of us OD's and Ophthalmologists will never see the severity or bulk of serious eye problems that you do. But hey, that's what your there for, right. Why would you even want to waste your time treating minor corneal abrasions and minor lid infections when you could be using you surgical skills that is much needed?

 

[Andrew_Doan]

Originally posted by TomOD
What interpretation? I get a report back from the radiologist at the diagnosistic center. HE interprets it, I read it. HE tells ME if there is a problem in most cases.

Blood work comes back with a report HIGHLIGHTING normal vs abnormal. References are available in a number of cases.

Your point above highlights why you should not be ordering imaging studies and blood work.

Just because the lab value is abnormal does not mean there is a problem. In addition, what you do with this information is equally as important, for instance, as knowing that there is hypernatremia or acidosis. In addition, all therapeutic modalities come with risks. To treat a patient who does not have disease may be just as bad as not treating one who does have disease. I've been taught again and again: "Don't treat the lab, treat the patient..."; you would have little idea behind this concept because your background doesn't cover this extent of medical training. You even said it yourself, "What interpretation?... "

Ophthalmology is more than just eyes... it's also knowing about the systemic pathology they may manifest in the eyes. Ordering and interpreting imaging studies and blood work are way beyond your scope of practice and training as an optometrist. This would be hard to defend in a court of law if you happen to mis-treat or mis-diagnose a major medical problem. It's true when you say that 90% of patients are not complicated. But I'm not willing, nor is the public willing to risk a 1 out of 10 chance for you to mis-diagnose or mis-treat a medical emergency or trauma.

Furthermore, radiologists often report things and then refer to the clinician for "clinical correlation". This is where the medical training is important. If you only rely on the radiology report, then that is very poor management of an emergency patient. In addition, it's also important to know what imaging scans to order for certain ophthalmological emergencies... are you going to order all of them, i.e. CT, MRI, ECHO, plain films? Optometry training does not teach you these things.

I am confident that I know what is taught at optometry school. I have numerous friends in optometry, and I also work with academic optometrists. We discuss the issue of optometry education, and optometrists are not trained to the extent that would allow them to workup emergency trauma and emergency medical problems in the ER. Until optometrists attend a MEDICAL residency, they should stay out of the ER and remain in the optometric clinic.

Finally, I don't buy your argument that only University physicians see the complicated cases. We may see a higher incidence, but at least 1-5% of the patients in a general ophthalmology practice may be a complicated medical problem. This is 1:100 and 1:20. Just because the incidence is low, does not give someone without the proper medical training to work in ERs to evaluate and treat ocular/medical emergencies. This is dangerous.

 

[TomOD]

For the record, I have absolutely no desire to work in an ER as I very much enjoy my private practice setting. I also like sleeping alot.

The only lab work I have ever had the need to order is a sed rate, C-reactive protein and CBC for suspected giant cell arteritis and a few other problems. Most other suspected conditions from rheumatoid artheritis to AIDS, I consult with the patients internist/PCP or appropriate specialist and let them order and intrepret tests and treat.

The only imaging I have ever had to order have be MRI of the brain and orbits and CT scans for unexplained vision loss and/or nerve edema. And once or twice for orbital fractures.

In my non-academic world, that is basically all that is relevant. I do have a chart in my private office of people I refer to Ophthalmologist's. Right now, there are 12 people on the list. 4 to the retinal guy for surgery, 4 to the glaucoma guy for sx, 2 for cataract sx and 2 for YAG capsulotomies. The only time I order neuroimaging is for vision loss or nerve edema that defies explanation. I have caught (or actually, the radiologist described), a pituitary adenoma, and an aneurysm that both required surgery last year. Last week, I ordered a sed rate and a CBC for a suspected NAION. With the great importance in differentiating Ischemic from non-ischemic neuropathy, why wouldn't I order this test.

It just doesn't take a rocket scientist to understand that the ESR is within normal limits (age/2 for men and age +10/2 for women). I am smart enough to intrepret that. Also, this NAION along with normal blood work, along with a relatively healthy patient is simple to follow. I can watch it or I can let the retinal guy watch it.

I don't know who brought up the OD in the ER thread but is surely wasn't me. Like I said, I have no desire. I'm too busy and having too much fun. AND I haven't killed or blinded anyone yet.

Lighten up Andrew. You are going to be a highly-trained surgeon and physician. OD's are not your competition. All we're doing is the bread and butter minor medical stuff. You should want to make everyone around you the best they can be. Just as I am not worried about Opticians (and I think they should be refracting, by the way), I don't worry too much about what Ophthalmologists think.

I have already been around long enough to see terrible ones and great ones. (saw a 67 y.o. lady a few months ago diagnosed with glaucoma by not one but two Ophthalmologists without ever having a visual field. I did a work up and field and it was obvious that she didn't have glaucoma..........0.20 cupping, no FmHx, IOP's 22/22, thick pacys, normal HRT, AND a very congruous, homonymous, hemianopsia . It's OBVIOUS that this women has a stoke in the past........obvious to me and to her based on her symptoms and a confirmation call to the Internist that verfied that she did, indeed suffer a stroke a few years back........ but apparantly not very obvious to the 2 Ophthalmologists that she saw for 6 years, not to mention the wasted money on meds over that time. ) I have other cases. I don't make a big deal over it and always try to talk good about the other doctors. But it does make me wonder.

What you learn in training and what you find in the real world may be different. I see mistakes from both sides. Your painting a broad stroke to say Ophthalmologists can do everything because they are all-knowing and OD's can only prescribe glasses and contacts because that's all they are trained to do.

I work with some great Ophthalmologists and respect them highly for what they can do. But I rarely need their expertise except for surgery cases. I also see how the Anti-OD mediocre Ophthalmologists are. I'd be scared if I was one of the mediocre Ophthalmologists. But if your good, and I know you are Andrew, you have absolutely nothing to worry about from us lowly OD's. 😀

Your arguments would be valid if not for the fact that your speaking to 2 OD's that treat alot of ocular disease and do it well, if I must say 🙂. But I feel like we are talking about 2 different things. You talking about serious eye trauma (open globes) and I am talking about relatively "minor" but troublesome eye conditions and "surgeries" like lid infections, chalazion injections/removals etc. We might be comparing apples to oranges.

Take care. We've probably beat this this topic to death and people are probably getting board. I guess we can agree to disagree. But I always like hearing another viewpoint. 🙂

 

[Andrew_Doan]

Originally posted by TomOD

It just doesn't take a rocket scientist to understand that the ESR is within normal limits (age/2 for men and age +10/2 for women). I am smart enough to intrepret that.

TomOD,

I enjoy these discussions we have, and I look forward to your responses because each time you respond, you give me one more reason why I think optometrists should not manage medical problems. I'm not criticizing your intelligence. I just don't think optometrists have enough medical background to manage systemic diseases such as GCA.

You're correct that it doesn't take a rocket scientist to look at the ESR and see that it's high. However, a high ESR or CRP does not mean that the patient has giant cell arteritis. Both the ESR and CRP are acute phase reactants and can be high for numerous reasons; thus, these lab tests can be falsely elevated in several clinical scenarios. Starting high dose prednisone on elderly patients who don't have GCA can be dangerous. The most definitive way to diagnose GCA is a collection of several things: clinical exam, history, lab tests, and a temporal artery biopsy, which will require the expertise of an ophthalmologist. The management of GCA is also lifelong and requires close monitoring of patients. This is best done by an ophthalmologist who can also monitor for medical complications related to steroids.

In addition, 10% of GCA may have a negative ESR/CRP. The patient then needs a biopsy. This is also complicated by the fact that 10% of patients with GCA may also have a negative temporal artery biopsy.

Therefore, I agree with you that it does not take a rocket scientist to recognize that a lab value may be elevated. On the other hand, it does require an experienced, medically trained physician to diagnose and manage a complicated disease like GCA. Diseases are not always black and white, yet you seem to respond with only black and white answers. This concerns me.

 

[TomOD]

Ophtho_

I don't treat GCA typically. But I do help diagnose it. My retinal guy appreciates that I have the blood work available (saves him from having to do it). And he typically has an ENT doc do the temporal artery biopsy.

The retinal guy does not do a temporal artery bioposy at random unless it is highly suspect for GCA. For more obvious, NAION, he monitors.............and I monitor.

This guy is good...............having been doing retinal work for 25 years.

I am not an island. I "co-manage" many cases. You make it sound like I'm out here alone treating HIV and doing surgery.

I work closely with both Ophthalmologists and Family practioners in a way, that I feel, is best for my patients. I'm sorry if you feel otherwise.

 

[Richard_Hom]

Dr. Doan,

I think it would be a "stretch" to believe that any clinician would diagnose and treat absolutely insulated from other sources such as text books, journals, personal experience, other clinicians nearby. Any prudent optometrist, likewise, who steps into this type of clinical situation as Tom and I might be or am in, would prepare themselves much more intensely than the average "academic" or "resident" optometrist might even be.

Not knowing Tom personally, but I'm guessing the he and I aren't cavalier about our situations. An old mentor once told me that the "know your limits"

BTW, my "fellowship" was as follows: 2 years of experience with an associate clinical professor of ophthalmology (retinology), 2 years of experience with a clinical professor of ophthalmology (anterior segment) and 1 year side-by-side with a assistant clinical professor of internal medicine. In each case, they scratched their heads when they first met me, but discovered I was the "real deal" when I demonstrated my clinical skills in caring and management the patient.

Do I want to be an ophthalmologist. No! I've been asked this for the past 20 years and have been invited to join medical school entering classes. I'll still say no.

I like the "medical" aspect of ophthalmology rather than the surgery and I feel in many circumstances, an optometrist may have the breadth of clinical skill and experience to function as a primary care eye care provider that can complement the ophthalmologist.

As I said before, the cookie cutter or knee jerk response of most ophthalmologist is something I encounter daily.

Back to the other question of dispersal of ophthalmologists. In the Navy, I spent a rotation on the USS Abraham Lincoln and the USS Carl Vinson. As you may know, deployments at sea do not include an ophthalmologist and the usual complement is a General Surgeon, a flight surgeon, internist, 1 PA and 1 RN and 4-10 HM's. Or the US Army where a small military hospital where there isn't an ophthalmologist (civilian or military) within 50 miles.

I think it would be a disservice to paint and color the uneventful and helpful instances where optometrists has successfully provided the only type of eyecare for these types of situations durng the last 15 years

Thanks again, Dr. Doan, for expressing yourself openly. I'm sure that both my comments won't change your mind, but may someday prevent you from giving that "knee jerk" response to any other situation you might face,

Richard Hom, OD,FAAO
LTCOL, USAR (ret)

Originally posted by Ophtho_MudPhud
This concerns me.

 

[Andrew_Doan]

Originally posted by TomOD
I am not an island. I "co-manage" many cases. You make it sound like I'm out here alone treating HIV and doing surgery.

TomOD,

I'm sorry if I offended you, but your posts at first seem to imply that you do diagnose, order tests, and manage major medical problems by yourself.

I strongly believe in team work. I have no problems with optomestrists, ophthalmologists, and other physicians working together. Having a good team of the above will result in excellent delivery of care. As long as people stay within their scope of training and expertise, patients will receive good health care.

From previous posts, it seems that your comments were more in line with the voice of optometrists in NJ and OK where they don't want to "co-manage". They want full medical privileges similar to physicians and surgeons. This is where I have a problem.

In regards to Dr. Hom's comments, as stated previously, your experiences in the military clearly places your experiences above the average optometrist. With you on the health care team, I would have no reservations because you seem to know what you're good at and what your limitations are. I can't really say the same for many health care providers in our field.

This will be a continual struggle between optometry and medicine. The knee-jerk responses are inevitable, but at least we can listen to the other side and have a decent discussion. 🙂 Thanks for both of your inputs, and I always appreciate hearing your point of views.

Best regards,

 

[cpw]

This thread is fun. I like watching y'all go back and forth. 😉 At least in this scenario no ones calling someone else names like often happens in the OD forum. (where I normally dwell)

It's interesting that y'all brought up GCA and ESR. We just had a huge lecture last week on this and how many ESR tests and even biopsies come back negative. And never ONCE was it suggested we handle something like this ourselves. It was all about getting the blood work started and handing the biopsy and treatment over to the OMD.

OKay, enough procrastinating..back to studying for boards. T-minus two weeks and couting! 😳