Ocular Injections

[cpw]

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Hey guys

today in lab we did ocular injections. It was so damn cool !! 😎 We did an intralesional injection and a sub-conj injection. Both were done with sterile saline on our lab partners. It was so much easier than we'd all hyped it up to be.

Just thought y'all would want to hear all about it. 🙂

have a great weekend at TOA Simisn! Wish I could go !
🙁

 

[Andrew_Doan]

Just curious. Do you know which states allow optometrists to perform intralesional and periocular injections?

 

[cpw]

I know there are 5. The only ones I know off the top of my head are NC and TN. Texas is working on it for this upcoming years legislation.

 

[Richard_Hom]

Originally posted by Andrew_Doan
Just curious. Do you know which states allow optometrists to perform intralesional and periocular injections?

Dr. Doan,

How many actual injections would you feel that a person needs to do to be comfortable and competent to do this procedure?

Regards,
Richard_Hom

 

[Andrew_Doan]

Originally posted by Richard_Hom
Dr. Doan,

How many actual injections would you feel that a person needs to do to be comfortable and competent to do this procedure?

Regards,
Richard_Hom

Dr. Hom,

It's not the procedure (which is easy to do), but rather the medical experience with the diseases one is treating that concerns me the most.

Periocular injections of antibiotics is routinely done immediately post-operatively. There's no need for optometrists to use sub-conj antibiotic injections for anything that walks into a general eye clinic. If there is a serious endophthalmitis, then we perform an intravitreal injection or vitrectomy.

Periocular and intraocular injections of steroids are usually performed for serious retinal and inflammatory diseases, which should be performed by a physician with experience in these diseases. For instance, AMD CNVM, idiopathic CNVM, POHS CNVM, JRA, severe uveitis, etc... All of these diseases should be treated by an ophthalmologist. Also, periocular injection may not be enough, and therefore should be treated by a physician who has other treatment modalities, e.g. retinal lasers, PDT, and intravitreal kenalog injections. Otherwise, delay of adequate treatment may result in poor visual outcomes.

Dr. Hom, what role does periocular injections of steroids or antibiotics play in your daily practice? How often do you use these treatment modalities?

 

[Richard_Hom]

Originally posted by Andrew_Doan
"...Dr. Hom, what role does periocular injections of steroids or antibiotics play in your daily practice? How often do you use these treatment modalities?..

Dr. Doan,

Thanks for your question and I believe your answer does hit the spot of why do the procedure. I believe it may be appropriate to learn the procedure, but I doubt it has relevance in 99.99% of the circumstances of optometry practice.

In reference to my practice, I'll gladly refer difficult medical cases with ophthalmic complications to our 5 ophthalmologists including he above procedure. However, I object to ophthalmology delineating all ophthalmic manifestations or cases of systemic disease as outside the optometric realm . I believe that each optometrist should be observed (or proctored) for a period of time as would a new ophthalmic surgeon applying for surgical privileges at a hospital and based upon this evaluation, a set of procedures or conditions could be created which describes the "scope of practice" of the optometrist. In this scenario, the optometrist shouldn't be summarily and arbitrarily limited in scope of practice but should have the scope as wide as the skill and experience level permits.

Regards,
Richard Hom, OD,FAAO
San Mateo, CA

 

[Andrew_Doan]

Originally posted by Richard_Hom
Dr. Doan,

Thanks for your question and I believe your answer does hit the spot of why do the procedure. I believe it may be appropriate to learn the procedure, but I doubt it has relevance in 99.99% of the circumstances of optometry practice.

In reference to my practice, I'll gladly refer difficult medical cases with ophthalmic complications to our 5 ophthalmologists including he above procedure. However, I object to ophthalmology delineating all ophthalmic manifestations or cases of systemic disease as outside the optometric realm . I believe that each optometrist should be observed (or proctored) for a period of time as would a new ophthalmic surgeon applying for surgical privileges at a hospital and based upon this evaluation, a set of procedures or conditions could be created which describes the "scope of practice" of the optometrist. In this scenario, the optometrist shouldn't be summarily and arbitrarily limited in scope of practice but should have the scope as wide as the skill and experience level permits.

Regards,
Richard Hom, OD,FAAO
San Mateo, CA

I agree with you Dr. Hom.

However, a huge difference is that a young ophthalmic surgeon/physician has already been "observed" & "proctored" during four years of post-graduate training. During this time, the resident physician has seen and treated dozens of rare diseases (i.e., diseases that private practice clinicians may only see once in a life time) and hundreds of less common diseases (i.e., diseases that private practice clinicians may see once or twice a year). This is the advantage of training in a University setting. In contrast, optometrists usually do not reach a high level of expertise with these rare and uncommon diseases without a residency. Even with a one year post-graduate residency, an optometrist may not see enough pathology to be familiar with these rare and uncommon entities.

My point is: if a clinician is not familiar with a particular disease and the possible treatment modalities (e.g. retinal lasers, PDT, or intravitreal kenalog injections), then why even learn a fraction of the treatment? Even general ophthalmologists who have experience with intraocular injections, often consult with the retina specialists or an ophthalmologist who has more experience.

When optometry schools teach students to perform periocular injections, which conditions and disease processes are being taught that require these injections?

 

[Richard_Hom]

Originally posted by Andrew_Doan
When optometry schools teach students to perform periocular injections, which conditions and disease processes are being taught that require these injections?

Dr.Doan,

I will defer to the student(s) who took the class.

I believe,though, it is appropriate to be familiar with future modalities of drug deliviries other than topical or IV/IM.

BTW, I think that a "fellowship" of 1 year within a busy practice might also work. I spent two yearss elbow to elbow with a UCSF clinical retinal professor and a Harvard clinical corneal faculty in assisting the treatment of common and not-so-common eye problems.Since these two fellows had to serve 41,000 folks, I assisted in calls when there were too many emergent or urgent cases occuring at the same time. In this circumstance, an optometric education might meet your condition.

Regards,
Richard Hom,OD
San Mateo,CA

 

[Andrew_Doan]

Originally posted by Richard_Hom


BTW, I think that a "fellowship" of 1 year within a busy practice might also work. I spent two yearss elbow to elbow with a UCSF clinical retinal professor and a Harvard clinical corneal faculty in assisting the treatment of common and not-so-common eye problems.Since these two fellows had to serve 41,000 folks, I assisted in calls when there were too many emergent or urgent cases occuring at the same time. In this circumstance, an optometric education might meet your condition.

Dr. Hom,

You know that I respect your training. Without a doubt, your training was awesome, but unfortunately, your pathway is not the norm. There are only a few with your military optometry background and two years of experience as a clinical fellow.

Regards,
Andrew

 

[Richard_Hom]

Originally posted by Andrew_Doan
"...There are only a few with your military optometry background and two years of experience as a clinical fellow..."

I think that therein lies the problem with optometric education. It will come a time that the pre-doctoral portion of the education might not be sufficient to provide the type and number of patients necessary to be confident and knowledgeable about your skills,interests and limits.

I believe that there should be more efforts for academic institutions to embrace optometrists. In this way, the two disciplines may work more closer together rather than continue to "spend" huge dollars on legislative and lobbying efforts.

What are your thoughts?

Richard_Hom

 

[Andrew_Doan]

Originally posted by Richard_Hom
I think that therein lies the problem with optometric education. It will come a time that the pre-doctoral portion of the education might not be sufficient to provide the type and number of patients necessary to be confident and knowledgeable about your skills,interests and limits.

I believe that there should be more efforts for academic institutions to embrace optometrists. In this way, the two disciplines may work more closer together rather than continue to "spend" huge dollars on legislative and lobbying efforts.

What are your thoughts?

Richard_Hom

I feel that we have a system that works well. Optometry programs are training competent primary eye care providers. Medical schools and ophthalmology residency training programs are training competent physicians and surgeons. I don't see a need to combine the two disciplines.

 

[Richard_Hom]

Originally posted by Andrew_Doan
I feel that we have a system that works well. Optometry programs are training competent primary eye care providers. Medical schools and ophthalmology residency training programs are training competent physicians and surgeons. I don't see a need to combine the two disciplines.

Dr. Doan,

My apologies for lack of eloquence. I had not intended "combining programs", but provide some exposure at the "primary care" level. I find that the best exposure for "primary care" optometry is to see a high density of acute and chronic eye problems. I fear that most optometric environments won't provide that kind of exposure.

Regards,
Richard_Hom

 

[TomOD]

There are primarily 4 occasions where I will do injections. Kenalog (I use 40mg/ml) for intralesional chalazions (they work beautifully).

I will, on occasion, do a subconjunctival steroid injection in a difficult inflammatory ocular condition (recently for a chronic uveitis pt. secondary to sarcoidosis). But this in not the norm. If it gets too serious, I will certainly refer out to a specialty OMD.

Third situation: I inject licocaine/epi when I remove superficial lesions such as verruca and 'other lumps and bumps'. Again, if it is suspicious, I will have an oculoplastic OMD look at it. As a matter of fact, I have 2 such pt.s going to him this week.

The forth reason: For FA's, which I am not currently doing because I don't have a camera yet. But I was trained and feel it is an outstanding diagnostic test that will help me help the retinal OMD (poor guy is constantly backlogged for 3 months). Either his "certified ophthalmic photographer" will do it, or I will. Probably both.

These are the 4 situations I can think of off the top of my head.

All are very minor procedures that can be performed by OD's and ARE performed all over the country and world by LPN, RN, PA's, IV drug users, people in their bathroom removing a splinter, etc.........😉

 

[Andrew_Doan]

Originally posted by TomOD
There are primarily 4 occasions where I will do injections. Kenalog (I use 40mg/ml) for intralesional chalazions (they work beautifully).

My question is not any injection, but specifically periocular sub-conj injections.

 

[TomOD]

Originally posted by Andrew_Doan
My question is not any injection, but specifically periocular sub-conj injections.

Oh.........then I'm with you there🙂

 

[Andrew_Doan]

Originally posted by TomOD
Oh.........then I'm with you there🙂

That's why I'm curious about optometry schools teaching students to perform periocular sub-conj. injections. I would really like to know what diseases they're also being taught that indicates performing a sub-conj. injection.

 

[TomOD]

Originally posted by Andrew_Doan
That's why I'm curious about optometry schools teaching students to perform periocular sub-conj. injections. I would really like to know what diseases they're also being taught that indicates performing a sub-conj. injection.

http://www.revoptom.com/osc/nov02/lesson_1102.htm

http://www.revoptom.com/index.asp?page=2_258.htm

 

[HighlyFanatic]

TomOD, thx for those resources! Very helpful.

 

[Tony.]

I may look silly, but Im gonna ask anyway b/c Im not in opometry school yet ( i start this year, in Boston if anyone is interested):

what is the difference between a periocular injection, intralesional injection and subconj injection. And is this another "grey area" between ODs and MDs?
and also; how much "experience" does one need to become an expert with these procedures...?

 

[boston bound]

I will also be attending NEWENCO next fall.

 

[Tony.]

boston Bound...

I guess I'll see you this fall at NEWENCO !! I have mad love for the city....( and the school, and the people ) but not the weather...

 

[Andrew_Doan]

Originally posted by anothertony

what is the difference between a periocular injection, intralesional injection and subconj injection. And is this another "grey area" between ODs and MDs?
and also; how much "experience" does one need to become an expert with these procedures...?

The procedure is simple.

It's the understanding of when to use the treatments and under which conditions is the most difficult part. There are not many diseases that we routinely use a periocular sub-conjunctival injection. I think these types of periocular injections are running into a "grey area" between ODs and MDs.

If ODs are going to do a sub-conjunctival injection, then they may push to do sub-Tenon injections (why not... it's only another layer of tissue below the conjunctiva??? or some clinicians may inadvertantly inject into the sub-Tenon space). If clinicians are willing to perform certain procedures, then they should also be able to manage the complications. One of the most feared complications from a periocular sub-Tenon injection, for instance, is retrobulbar hemorrhage. This requires immediate surgical intervention (i.e., canthotomy and cantholysis) if the patient is to have any hope of preserving vision. Therefore, I feel that if periocular injections are not a routine treatment in the optometric clinical setting, then ODs should consult with MDs if patients require these types of treatments. Also, I don't know of any ODs that know how to do a canthotomy/cantholysis, which definitely is not within the scope of optometric practice.

Here is a case report where retrobulbar hemorrhage occured after sub-Tenon injection of Triamcinolone for uveitic cystoid macula edema.

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=12095826&dopt=Abstract

This is not an anti-optometry reply. I respect ODs and truly believe that we can work together. This issue is really about what's best for the patient.

 

[TomOD]

A couple of other interesting links:

http://www.ncbi.nlm.nih.gov/entrez/...ve&db=PubMed&list_uids=11973246&dopt=Abstract

http://www.omic.com/resources/risk_man/deskref/clinical/25.cfm

No doubt there is a limit to what a non-surgical doctor should do.

What I don't understand is the hyped up freenzy some folks get in when discussing the scope of practice topic (speaking of no one here).

What I don't think most people understand is that this is a self-regulating situation that really doesn't require all the hoopla.

If I were to do any procedure, whether I was licensed to do it or not, and did it poorly, I wouldn't be doing it for long.

There are salivating attorneys that would be all over OD's or anyone else, for that matter, if we began to hurt people.

If there are just a few complaints against OD's, that would be the end of it. Every group from organized Ophthalmology, Medicine, Attorneys.........hell, probably Dentists and Podiatry, would be on the bad-wagon demanded OD's stop blinding/killing people.

This is the problem with so much anti-OD legislature. The body bags and blind eyes just are not available for show.

Of course, there is a limit. The real question is, what is the limit? Everyone has their own opinion.

For the record, I have no desire or need to perform sub-tenons or intravitreal (all the rage with retinal OMD's) injections.

 

[Andrew_Doan]

The sub-Tenon injection was given under the supervision of a surgeon who is able to perform the necessary canthotomy/cantholysis in the situation of a severe retrobulbar hemorrhage. If one performs enough procedures, then there will be complications. Even if the rate of RB hemorrhage is low, these types of injections should not be given by clinicians who are not able to take care of the complications.

 

[cpw]

Originally posted by Andrew_Doan
The sub-Tenon injection was given under the supervision of a surgeon who is able to perform the necessary canthotomy/cantholysis in the situation of a severe retrobulbar hemorrhage. If one performs enough procedures, then there will be complications. Even if the rate or RB hemorrhage is low, these types of injections should not be given by clinicians who are not able to take care of the complications.

as far as I know.. even if ODs get injection rights.. Sub-Tenon's is not on the list. Tom is right too in that there would be self-regulation. Many ODs out in practice right now would opt not to get licensed to perform injections, while many others would get licensed and then not perform them. I think chalazion is the only situation I can think of where it would be useful in primary care. Anything nasty enough to need a sub-conj injection I'm going to refer to the corneal specialist or anterior seg OMD.

 

[Tony.]

thank you all for posting replys...
I have NO CLUE what the *&%$ you guys are talking about ...something sub tendon injection , chalazion; but it sounds interesting....I'm looking forward to learning about it in opt. school this year in Boston!

hay...Andrew Doan (or for anyone actually)
can you recommend an optometry magazine I can subscribe to? something I can read and understand with limited optometric technical stuff. I've been reading the online magazine "Review of Optometry", but is there anything else out there that I should be reading before I begin school?

 

[Andrew_Doan]

Thanks for the OMIC site TomOD.

What's your cap for malpractice awards under your current insurance company, i.e. how much (max) does your insurance pay out if you're sued?

I think the average OD pays less than $1000/year in malpractice insurance premium. Is this true?

 

[TomOD]

Originally posted by Andrew_Doan
Thanks for the OMIC site TomOD.

What's your cap for malpractice awards under your current insurance company, i.e. how much (max) does your insurance pay out if you're sued?

I think the average OD pays less than $1000/year in malpractice insurance premium. Is this true?

I am required to carry $1 million/$3 million and it cost me about $800/year. The carrier stopped doing malpractice so I went with another and voluntarily upped my limits to $2 million and $4 million (mostly because I'm paranoid). For that, I pay around $1,200/year.

It's a bargin from what I've read recently. I hear some refractive surgeons are paying a ransom of $60,000 per year. I'm sure you've seen the article but will post it here for those that haven't read this months Ophthalmology Management.

http://www.ophthalmologymanagement.com/archive_results.asp?article=86003

We've recently had an Ob/Gyn stop practicing here mostly because of rediculous malpractice premiums.

 

[Andrew_Doan]

Malpractice premiums for physicians who perform surgeries or deal with babies are extremely high. It's crazy.

It seems like you're an awesome clinician, and I hope you don't have problems with litigation in the future
(*knock on wood*). 😉

 

[Tony.]

We love you TomOD !
for all your ideas, posts and web links; keep em' comin'


🙂

 

[drbizzaro]

Hey guys

today in lab we did ocular injections. It was so damn cool !! 😎 We did an intralesional injection and a sub-conj injection. Both were done with sterile saline on our lab partners. It was so much easier than we'd all hyped it up to be.

Just thought y'all would want to hear all about it. 🙂

have a great weekend at TOA Simisn! Wish I could go !
🙁

i know i wont be doing injections any time soon... that's not something that i've ever wanted to do... topicals and orals are fine with me

 

[cpw]

We can't do them here in Florida. Although, there has been only one instance in the last two years I would have needed to. I sent the chalazion to my OMD friend to decide between injection vs removal.

 

[VA Hopeful Dr]

I just want to point out that, though 3 years old, this thread has 2 ODs, one OD student, and one (at the time) MD resident participating in a civil, polite discussion. We could learn from this.

 

[PBEA]

I just want to point out that, though 3 years old, this thread has 2 ODs, one OD student, and one (at the time) MD resident participating in a civil, polite discussion. We could learn from this.

Thats funny, because I was thinking the same thing. Although, my post was going to be something like "Holy cow, is this a factual/logical discussion between ODs and OMDs? " I am as bewildered as you for sure

 

[Shnurek]

I just want to point out that, though 3 years old, this thread has 2 ODs, one OD student, and one (at the time) MD resident participating in a civil, polite discussion. We could learn from this.

Its because they have volunteered to not be anonymous and their professional reputations are at stake.

 

[Tippytoe]

Its because they have volunteered to not be anonymous and their professional reputations are at stake.

Seriously, bringing back a FIVE (really 8) year old thread with totally useless blather!

One word: Girlfriend.

 

[Shnurek]

I have 1

 

[Jason K]

I have 1

If she has a valve on her, she doesn't count.

 

[luvely]

Hi, just to bump this thread-- my school is offering the injections elective. I'm just wondering which states currently allow ocular injections? Thanks! 🙂

 

[jimi luv]

Just curious. Do you know which states allow optometrists to perform intralesional and periocular injections?

Dr.Doan , What are your thoughts on optometrists doing BOTOX injections. The following are a list of people that I know that do Botox INJECTIONS.
My wifes OB, my dentist, my internest and his PA. There are but I think you get the picture .