Scope of practice question

[Shnurek]

Can ODs place amniotic grafts on patients eyes that have a corneal ulcer to help the healing process in all states?

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[Jason K]

Can ODs place amniotic grafts on patients eyes that have a corneal ulcer to help the healing process in all states?

This is something that's going to be appropriate for neuro-trophic ulcers and others on the far right end of the spectrum. You're not likely to be anywhere near a patient who would be a good candidate for something like this. Who knows, though, maybe in a few years, you'll be able to pick up an amniotic graft on 1800AminioticTissues.com for a $50. They might even do a BOGO offer if they really take off.

The moral of the story is, even if an OD were within scope to place this sort of graft, it would be something you would rarely see in your chair. Also, by the time you graduate, medicare will probably reimburse about $12 for the procedure.

 

[Visionary]

There are amniotic membrane contact lenses that are easily placed. They are very expensive, and reimbursement can be an issue. True amniotic membrane grafts are technically difficult to suture in (very friable) and are unlikely to be utilized by optometrists. Fact is, amniotic membrane is rarely used by anyone other than a fellowship-trained corneal specialist.

 

[mclem222]

Just because someone is "allowed by law" to do something doesn't mean they should do it. Usually only cornea specialists use amniotic grafts. Patients are not lab rats to hone skills on..This is the same line of thinking I see in new grads constantly. "What can I legally do, I am going to go for it...who cares if I f()_( up someones eye..my scope of practice is expanded...yay!" Not saying you think that Shrunek because you could be asking an innocent question but a lot of your peers have that what I call "Shopkeeper mentally to treating patients". Just like 5 and dime stores who sold contacts just cos it was legal. Who cares a whole bunch of kids got corneal ulcers and went blind.

 

[Shnurek]

I am only asking because the comprehensive ophthalmologist I worked for placed one in a patient's eye that had a corneal ulcer. He kept the graft in the refrigerator for a while beforehand. No sutures were needed. He's also the same ophtho that did intravitreal injections, FAs, SLT, LPI, LASIK/PRK and a lot of cataract surgery. He did graduate from a Caribbean school which I thought was interesting. Said he had to do better on the USMLE than US MD students and had to take a clinical skills assessment to prove he wasn't ******ed lol. Overall a really cool guy that knew what he was doing and had great bedside manner.

There are amniotic membrane contact lenses that are easily placed. They are very expensive, and reimbursement can be an issue. True amniotic membrane grafts are technically difficult to suture in (very friable) and are unlikely to be utilized by optometrists. Fact is, amniotic membrane is rarely used by anyone other than a fellowship-trained corneal specialist.

Thank you for a succinct and informative post.

 

[Visionary]

I am only asking because the comprehensive ophthalmologist I worked for placed one in a patient's eye that had a corneal ulcer. He kept the graft in the refrigerator for a while beforehand. No sutures were needed. He's also the same ophtho that did intravitreal injections, FAs, SLT, LPI, LASIK/PRK and a lot of cataract surgery. He did graduate from a Caribbean school which I thought was interesting. Said he had to do better on the USMLE than US MD students and had to take a clinical skills assessment to prove he wasn't ******ed lol. Overall a really cool guy that knew what he was doing and had great bedside manner.



Thank you for a succinct and informative post.

Must have been an amniotic contact lens. Easy-peasy, but reimbursement, as I said, can be an issue.

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[CMM83]

A corneal ulcer that necessitates this type of treatment represents a severe case and should be in the hands of a corneal specialist.

 

[thiaeyemd]

I am only asking because the comprehensive ophthalmologist I worked for placed one in a patient's eye that had a corneal ulcer. He kept the graft in the refrigerator for a while beforehand. No sutures were needed. He's also the same ophtho that did intravitreal injections, FAs, SLT, LPI, LASIK/PRK and a lot of cataract surgery. He did graduate from a Caribbean school which I thought was interesting. Said he had to do better on the USMLE than US MD students and had to take a clinical skills assessment to prove he wasn't ******ed lol. Overall a really cool guy that knew what he was doing and had great bedside manner.



Thank you for a succinct and informative post.

If he went to a Caribean school for med school and matched in ophtho there is something big he is leaving out. I have found very very few foreign trained residents in ophthalmology who did not have a major connection (parent, family member etc..) who was on the inside who helped to get them into an ophthalmology residency. Without one, most FMGs can pretty much forget it. There are always exceptions but it would be only that..an exception. Most american grads who match in ophtho are getting above 240 on step I which is 99% percentile. If he is getting 270 or something kudos but not sure how he could say he had to do "better". It doesn't get any better than what US grads are getting right now to match into ophtho. At Georgetown the average Step I for ophtho this year was above 250. Thats like saying someone had to do better that US grads to match into derm. Basically he had to get a perfect score...or have a family connection.

 

[Shnurek]

He took a year off for research. Also scored higher than the average American MDs on the USMLE that matched into ophtho. His dad was a plastic surgeon so maybe he had a connect somehow.
He really takes his scope of practice to the max. I mean aren't FA's and intravitreal injections by comprehensive ophthos looked down upon?

 

[thiaeyemd]

Some comprehensive ophthalmologists do FAs and intravitreal injections if they are in their 60s and were trained in it. In the 80s ophthalmology residents graduated with almost as many vitrectomies as a retinal fellow does now so if they were trained at that time might be totally in their armamentorium. Its hard to keep up with all the subspecialties at the cutting edge so a lot of people over time drops things they don;t like to do. He might have an interest in retina and still keeps doing it. Kudos to him.

 

[Shnurek]

Ya, he's an awesome guy. Late 30's. Taught me a lot actually. Caught a bunch of APD's for him after he taught me how to spot em well :O

 

[odieoh]

Some comprehensive ophthalmologists do FAs and intravitreal injections if they are in their 60s and were trained in it. In the 80s ophthalmology residents graduated with almost as many vitrectomies as a retinal fellow does now so if they were trained at that time might be totally in their armamentorium. Its hard to keep up with all the subspecialties at the cutting edge so a lot of people over time drops things they don;t like to do. He might have an interest in retina and still keeps doing it. Kudos to him.

I think its actually becoming more common for general ophthalmologists to do intravitreal anti-VEGF. I'm only 3 years out of my residency and I did a ton during my residency and I do it fairly routinely in practice now. Granted, I'm in a rural area and its often hard for people to travel to a retina specialist. Whenever we have a patient with a new dx of wet AMD or CRVO with ME or Diabetic retinopathy with ME, we give them the option of going to a Retina doc. Some of them go to retina and just continue with the retina doc. Some go to retina, get treatment initiated, then come to us for their subsequent injections. Some decline a retina consult and start treatment with us from the get-go.

I routinely do 1-2 injections a day, and have done up to 4-5 in a day.

I'm not sure what general ophthos do in bigger cities where a retina doc is more readily available. I believe some still do injections, but it seems like it would be less common.

 

[Tippytoe]

Ya Caught a bunch of APD's for him after he taught me how to spot em well :O

Shnurek, you caught a bunch of APD's. Really!? You do know that they are a relatively rare finding (unless you are working in a university study on IONs or maybe in a VERY BUSY neuro/retina clinic). So sorry, I've gotta bust you on this one. Just doesn't happen routinely in a private practice. Your only 23 years old so you couldn't have worked with him long unless you started in middle school.
Are you saying you are his primary tech that works up every patient he sees.............all the way to looking for APD's?? Or do you just run around with a pen-light and shine it into the eyes of every patient in the reception area.? Wait, do they call you "The Flashlight Boy"?

That's a FAIL on many levels.Try again.

What you meant to say was, "I was there bugging him one day and a patient was referred in with loss of vision and the doc called me over and showed me how one pupil wasn't reactive like the other". And then he sent you to get him some coffee. Isn't that really how it went?

Sorry to be a smartass. But DAMN, Shnurek, you just never stop the hyperbole, do you? Your man-crush with this mythical Caribbean doctor does have the makings of a good romance novel though.

 

[Shnurek]

Yes, I caught 3 actually in 1 month of screening patients for him. Every time he told me good job and said its not easy to find them. I found about 5-6 suspected APDs that he double checked but they weren't true APDs just early release or something of that sort. Your writing style is so low class and belligerent. You are a very knowledgeable practitioner but you don't show it with this most recent post.

 

[Shnurek]

I should add he sees about 30 patients a day for 5 days a week.

 

[KHE]

Yes, I caught 3 actually in 1 month of screening patients for him. Every time he told me good job and said its not easy to find them. I found about 5-6 suspected APDs that he double checked but they weren't true APDs just early release or something of that sort. Your writing style is so low class and belligerent. You are a very knowledgeable practitioner but you don't show it with this most recent post.

I am highly skeptical of this claim.

3 APDs in a month in a practice that sees about 600 patients is an incidence of .5% which seems enormously high for general practice and it would also suppose that you personally screened every patient. If you screened only half of them which also seems unlikely then it would mean an incidence of 1% or greater in your population alone which is absurd.

C'mon Schnurek, don't pee on our legs and tell us it's raining.

 

[Tippytoe]

Yes, I caught 3 actually in 1 month of screening patients for him. Every time he told me good job and said its not easy to find them. I found about 5-6 suspected APDs that he double checked but they weren't true APDs just early release or something of that sort. Your writing style is so low class and belligerent. You are a very knowledgeable practitioner but you don't show it with this most recent post.

Dude, people on this forum, the OMD forum, and who knows how many other fourms (neuro?) have been calling you out for months. Don't you think it's time to stop? Really.

I'm not the only one calling your bluff.

 

[Tippytoe]

I am highly skeptical of this claim.

3 APDs in a month in a practice that sees about 600 patients is an incidence of .5% which seems enormously high for general practice and it would also suppose that you personally screened every patient. If you screened only half of them which also seems unlikely then it would mean an incidence of 1% or greater in your population alone which is absurd.

C'mon Schnurek, don't pee on our legs and tell us it's raining.

Trying my best to give Shnurek the benefit of the doubt, perhaps it's possible that he and his caribbean trained OMD are mistaking other pupillary abnormalities as APDs?

 

[Meibomian SxN]

Trying my best to give Shnurek the benefit of the doubt, perhaps it's possible that he and his caribbean trained OMD are mistaking other pupillary abnormalities as APDs?

I do have to admit that APDs are rare, even in a high volume oMD practice. But to answer the original question, in theory it may seem intellectually stimulating to treat such a sever ulcer, but in practice you would refer this patient to a corneal specialist (not even to a comprehensive oMD).

Reason being is they have the resources to culture, biopsy and most importantly, have a deeper malpractice pocket to handle it. You certainly do not want the patient to pursue an erroneous lawsuit and the OD expert witness testifying against you that it was medical negligence not to refer to a specialist.

 

[CL Doc]

This thread makes me very suspicious. I'm not sure what he or she really is, but I don't think we're dealing with an optometry student.

 

[Shnurek]

This thread makes me very suspicious. I'm not sure what he or she really is, but I don't think we're dealing with an optometry student.

Yes I'm an ophtho spy Why do you say that?

 

[odieoh]

I should add he sees about 30 patients a day for 5 days a week.

So he doesn't have an OR day?

 

[Shnurek]

So he doesn't have an OR day?

One OR day every 2 weeks.

 

[Tippytoe]

One OR day every 2 weeks.

That's not many surgery days for a good OMD.

 

[blazenmadison]

One OR day every 2 weeks.

That's not a lot.

So basically he's a medical optometrist. :-D

 

[Shnurek]

That's not a lot.

So basically he's a medical optometrist. :-D

Ya he just started out (5-6 years) and yeah basically. However, however, he does intravitreal injections, SLT, ALT, chalazion excision, at least one a day almost in-office. Basically, he'll do anything he can get his hands on and barely refers out.

 

[FunnyCurrent]

Shnurek, you caught a bunch of APD's. Really!? You do know that they are a relatively rare finding (unless you are working in a university study on IONs or maybe in a VERY BUSY neuro/retina clinic). So sorry, I've gotta bust you on this one. Just doesn't happen routinely in a private practice. Your only 23 years old so you couldn't have worked with him long unless you started in middle school.
Are you saying you are his primary tech that works up every patient he sees.............all the way to looking for APD's?? Or do you just run around with a pen-light and shine it into the eyes of every patient in the reception area.? Wait, do they call you "The Flashlight Boy"?

That's a FAIL on many levels.Try again.

What you meant to say was, "I was there bugging him one day and a patient was referred in with loss of vision and the doc called me over and showed me how one pupil wasn't reactive like the other". And then he sent you to get him some coffee. Isn't that really how it went?

Sorry to be a smartass. But DAMN, Shnurek, you just never stop the hyperbole, do you? Your man-crush with this mythical Caribbean doctor does have the makings of a good romance novel though.

If you are working in a screening setting, you will see APD's. I have seen 3 in the last month (between 97 patients).