Question for an optometrist

[ReMD]

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This question is in response to a reply from Jenny on the "optometrists are a joke, not a threat" discussion forums. I wanted to start a new thread b/c my question is totatlly different from the title of that thread.

Jenny, I don't know the full extent of optometry training in pharmacology but I do know one thing for sure. Since completing an internship in internal medicine, I realize now how important clinical training is in dealing with multiple systemic effects of topical and oral meds.

By merely completing my pharmacology class in med school, I would definitely not be prepared to identify complications/adverse effects of meds, let alone manage them in the correct way.

Many of the side effects/complications are very subtle but can have a detrimental effect on pts if not identified. Some things, like a typical rash or upset stomach, can usually be managed by stopping the med.

But more subtle things such as fatigue, weight gain, small nose bleed, mild confusion, patechiae, etc can all mean potentially sever systemic reactions that may be missed by clinicians without experience dealing with them.

When would you refer someone to a physician when they c/o fatigue? It may be b/c they have depression or walked a while that day but it also could be the first stages of liver or renal failure (etc) from the abx given.

Correct me if I'm wrong but would an optometrist know what other signs and sx there are with liver or renal failure so that they could differentiate btw something benign or malignant? People with renal failure can have plenty of urine output so that question would not be enough.

People with liver toxicity have very specific problems that can be fairly easily determined with a few questions and physical exam, then lab work.

I understand that you could refer these people but if it's a very subtle finding, do optometrists have the clinical training to know when to do so. You probably wouldn't refer everyone for some mild fatigue, would you?

I'm not trying to start a forum war here. I really just would like to know what you think.

 

[JennyW]

This question is in response to a reply from Jenny on the "optometrists are a joke, not a threat" discussion forums. I wanted to start a new thread b/c my question is totatlly different from the title of that thread.

Jenny, I don't know the full extent of optometry training in pharmacology but I do know one thing for sure. Since completing an internship in internal medicine, I realize now how important clinical training is in dealing with multiple systemic effects of topical and oral meds.

By merely completing my pharmacology class in med school, I would definitely not be prepared to identify complications/adverse effects of meds, let alone manage them in the correct way.

Many of the side effects/complications are very subtle but can have a detrimental effect on pts if not identified. Some things, like a typical rash or upset stomach, can usually be managed by stopping the med.

But more subtle things such as fatigue, weight gain, small nose bleed, mild confusion, patechiae, etc can all mean potentially sever systemic reactions that may be missed by clinicians without experience dealing with them.

When would you refer someone to a physician when they c/o fatigue? It may be b/c they have depression or walked a while that day but it also could be the first stages of liver or renal failure (etc) from the abx given.

Correct me if I'm wrong but would an optometrist know what other signs and sx there are with liver or renal failure so that they could differentiate btw something benign or malignant? People with renal failure can have plenty of urine output so that question would not be enough.

People with liver toxicity have very specific problems that can be fairly easily determined with a few questions and physical exam, then lab work.

I understand that you could refer these people but if it's a very subtle finding, do optometrists have the clinical training to know when to do so. You probably wouldn't refer everyone for some mild fatigue, would you?

I'm not trying to start a forum war here. I really just would like to know what you think.

I'm not really sure what your question is here and I'm not sure what other thread you are referring to but I'll say this.

Optometrists are trained in the side effects of the medications that they are licensed to prescribe as well as to recognize the sign and symptoms of those entities you mentioned.

Eye doctors (ODs and OMDs) are in a unique position. Some people never see an eye doctor in their lives. But for some people, we are the only doctor that they ever see. So ODs are also trained to recognize signs and symptoms of systemic disease so appropriate referals can be made, but not always their management.

Fatigue from depression or exhaustion can usually be ilicited with a good history. But no, I am not trained to manage liver or kidney failure, if that's what you're asking.

Jenny

 

[vanelo]

I'm not really sure what your question is here and I'm not sure what other thread you are referring to but I'll say this.

Optometrists are trained in the side effects of the medications that they are licensed to prescribe as well as to recognize the sign and symptoms of those entities you mentioned.

Eye doctors (ODs and OMDs) are in a unique position. Some people never see an eye doctor in their lives. But for some people, we are the only doctor that they ever see. So ODs are also trained to recognize signs and symptoms of systemic disease so appropriate referals can be made, but not always their management.

I am starting to think Jenny's previous reply is the best thing OD school teaches

 

[EYESURG]

I am starting to think Jenny's previous reply is the best thing OD school teaches

😀

 

[Richard_Hom]

"...I understand that you could refer these people but if it's a very subtle finding, do optometrists have the clinical training to know when to do so. You probably wouldn't refer everyone for some mild fatigue, would you?

I'm not trying to start a forum war here. I really just would like to know what you think.

Dear ReMD,

I believe that the optometric training does provide a foundation for most of the occasions whereby systemic medical problems and side or adverse effects might be encountered in general practice.

Of course, I believe that optmetrists, like physicians, who encounter and deal with certain classes of patients will be more likely to better patients just by experience. Those optometrists who are "partners" in the care of their patients are more likely, therefore, to be aware of the more subtle symptoms that you suggest.

Something that obstructs optometrists in a more detailed examination, and something even ophthalmologists may have, is the extent of examination. Most patients would not expect to disrobe and have chest sounds examined in an eye examination and I doubt would do so even in the context of an ophthalmologic examination. In the many ophthalmologic office, I rarely(!) saw this happen.

In fact, in some cases, optometrists have even been criticized for doing "other" procedures even though they are qualified to do them.

Richard

 

[JR]

Dear Richard,


I think you have missed OP's point. He was referring to the fact that side effects of certain systemic and even topical medication may be overt and one would need certain level of expertise and clinical suspicion to catch early signs of problems. I agree with the OP that by no means one can acquire such skills just by taking pharmacology classes.

I am not trying to imply that Optometrists shouldn't have prescription privileges. I am just genuinely curious- how do you deal with occasional metabolic acidosis from Diamox or occasional renal failure or TTP/HUS from acyclovir? Do you just refer them to a PMD or do you stop/switch the drug yourself?

 

[Richard_Hom]

Dear Richard,


I think you have missed OP's point. He was referring to the fact that side effects of certain systemic and even topical medication may be overt and one would need certain level of expertise and clinical suspicion to catch early signs of problems. I agree with the OP that by no means one can acquire such skills just by taking pharmacology classes.

I am not trying to imply that Optometrists shouldn't have prescription privileges. I am just genuinely curious- how do you deal with occasional metabolic acidosis from Diamox or occasional renal failure or TTP/HUS from acyclovir? Do you just refer them to a PMD or do you stop/switch the drug yourself?

I restated the point because this issue has been overstated or misstated so many times.

In my care, I do prescribe orals and check for side effects on follow up examination. Fortunately, most oral medications for eye problems are short term (less than 2 weeks usually) and side effects or adverse reactions are statistically minimal but by no means absent.

In my setting, I work closely with the treating internist or family medicine practitioner. In many cases, I advise that doctor of the potential side effects and they are following them up closely. They refer to me only for the specific eye problem.

Richard

 

[ReMD]

I restated the point because this issue has been overstated or misstated so many times.

In my care, I do prescribe orals and check for side effects on follow up examination. Fortunately, most oral medications for eye problems are short term (less than 2 weeks usually) and side effects or adverse reactions are statistically minimal but by no means absent.

In my setting, I work closely with the treating internist or family medicine practitioner. In many cases, I advise that doctor of the potential side effects and they are following them up closely. They refer to me only for the specific eye problem.

Richard

Dr. Hom, do you ever refer to an OMD instead, prior to starting certain oral/topical meds that have potential for multiple adverse effects or drug interactions in those pts with multiple medical problems and/or on multiple meds?

I know an internist may be more suitable to treat these problems but I'm just curious; do any OMDs treat/manage adverse effects or drug/drug interactions with meds they prescribe.

Would you refer to them if they did?

Some examples would be refering a pt to an OMD prior to starting a med that interacts with coumadin metabolism, immunosuppressives in transplant pts, starting a potentially nephrotoxic med in a pt with CRI, or a topical betablocker in a pt with sick sinus syndrome.

During my clinical experiences, I have come to realize how dangerous it can be to rx even the most perceived benign drugs. Like NSAIDs; I have seen numerous cases of NSAID induced renal insufficiency in the elderly, esp those on ACE-I.

 

[Richard_Hom]

Dr. Hom, do you ever refer to an OMD instead, prior to starting certain oral/topical meds that have potential for multiple adverse effects or drug interactions in those pts with multiple medical problems and/or on multiple meds?

In my circumstance, I have access to the complete medical file of my patients. I frequently do confer with my ophthalmologic or primary care colleagues prior to prescribing an oral, but they don't necessarily see the patient unless I feel that tertiary care is warranted or that the condition is more intractable than at first presentation.

I believe that office-based providers that do not have access to the complete patient file are at a disadvantage whether they be optometrist or ophthalmologist or even FM physician. Most of the problems that doctors or providers encounter are related to incomplete or unknown historical facts which have significant impact on the care of patients. Thus an unseen reaction or side effect.

IMHO,
Richard

 

[futurist]

It is true that it takes more than a pharm class to understand the impact of meds on pt management. It doesn't matter if it was pharm in med school or optometry school, the truth is that it takes clinical experience.
Different clinicians have different comfort levels in managing pts and I think it is based on both education and experience. I think most optometrists manage their pts within their comfort level and in the best interest of their pts. Any optometrist who specializes in treating pts with complicated medical histories has a responsibility to recognize any potential problems. I don't know anyone who wouldn't refer or co-manage difficult cases.