Uniting Ophthalmology and Optometry

[rubensan]

Getting back to the heart of the thread...

Jenny, the problems I have with the way you presented your solution are that 1) the entire onus of improving relations between OMDs and ODs seems to be placed on the OMDs, and 2) as a matter of principle, regardless of whatever else happens between OMD and OD, for the protection of patients as everyone's first goal, OD's should not be pushing for surgical rights, and it shouldn't have anything to do with an 'exchange.' Protection of patients should never be subject to groups bartering.

Texas, thanx for redirecting this thread! I agree with you and draw the line at surgery. But, I think this thread is interesting because we are getting at the heart of why ODs are pushing for scope expansion. Yes, ODs should not be pushing for surgery, (and from what I am hearing, the majority of them don't want to do it). But should OD's be compensated less for similar services that an OMD provides? Should they be excluded from 3rd party plans for providing primary eye healthcare? If we rely on them to provide primary eye healthcare (as many OMDs do) and referrals for tertiary care, should OMDs be running ads like the ones run in Florida? Do OMDs have a professional responsibility to ensure that the OD profession that we rely on for such services and referrals be compensated fairly? I don't know the answers to these questions, they were posed to me by a couple of ophthalmologists and I've been thinking about them (rather than studying for my boards ) I do agree that improving relations between both fields should not fall squarely on the shoulders of OMDs, but both sides have some work to do.

Ruben

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[optometrist]

I'm an optometrist and do not want to do surgery - the problem is, what is considered surgery?. I do not consider punctal plugs, foreign body removal, epilation to be surgery. I'm practicing in CA where in order to treat POAG, i have to prove myself capable - by comanaging 50 patients over a period of two years with an OMD. This is not the case in Oregon, Washington, Nevada where optometrists can treat POAG w/o the comanagement. I feel the comanagement issue is a political move to create a barrier against optometrists treating glaucoma. Glaucoma diagnosis, treatment/management has been taught in optometry schools for over a decade and i simply want to practice at a level that i have been fully educated and trained for.

I have no desire to do cataract surgery, LASIK, scleral buckling or cryo, or ptosis surgery. I do feel that ALT or SLT is fully within the education/scope of optometry and should be allowed.

 

[CircleTheDrain]

Just my 2 cents!

..... But should OD's be compensated less for similar services that an OMD provides?

No they must be compensated at the same rate as an OMD. Why? because its only fair and besides the insurance companies will start authorizing procedures to be done only by an OD to save money.

Should they be excluded from 3rd party plans for providing primary eye healthcare?

I'm not sure how much input they should have, but they should have some input!

If we rely on them to provide primary eye healthcare (as many OMDs do) and referrals for tertiary care, should OMDs be running ads like the ones run in Florida?

Only when Surgery is on the table, otherwise they should be fully supported. The carrot and the stick method.

Do OMDs have a professional responsibility to ensure that the OD profession that we rely on for such services and referrals be compensated fairly?

Yes of course, they(ODs) are partners with OMDs.

 

[rubensan]

I have no desire to do cataract surgery, LASIK, scleral buckling or cryo, or ptosis surgery. I do feel that ALT or SLT is fully within the education/scope of optometry and should be allowed.

So you don't want to so surgery, but you want to do a lot. I agree, what is the definition of ophthalmic surgery? Where should lines be drawn?

Ruben

 

[Tx Guy]

So you don't want to so surgery, but you want to do a lot. I agree, what is the definition of ophthalmic surgery? Where should lines be drawn?

Ruben

This is also the question that I have. If OD's want recognition as primary eyecare providers by OMDs, do 'minor procedures' such as ALT or SLT qualify as primary care? I can see the point about punctal plugs, some FB removal, epilation, etc., but I can also see how this becomes a slippery slope...it would be easy for someone already doing these "minor procedures" to argue that a slightly more invasive procedure is also safe for them to do, and eventually you know where that leads to. Lasers, as common as they are, all have risks associated with their use. How qualified should a person be to use them?

Will some of the OD's comment on what types of laser procedures they are already performing, and what they feel they should also be able to do safely? What should be restricted to OMDs?

 

[optometrist]

As you all know this is a tough question.

Like i said before, punctal plugs, epilation, foreign body removal (corneal/conjunctival), and even ALT/SLT i would not call surgery.

Sugery constitutes cataract removal, LASIK, vitrectomy, scleral buckling, blepharoplasty, filtering blebs, etc, etc - i could keep going ang going but you get the point.

The heads of our two professions need to sit down and come up with a mutually agreeable list of procedures. Every optometrist I know of has no desire to do cataract surgery or LASIK - we simply want to practice to the "full scope" of our education and training.

 

[rubensan]

The heads of our two professions need to sit down and come up with a mutually agreeable list of procedures. Every optometrist I know of has no desire to do cataract surgery or LASIK - we simply want to practice to the "full scope" of our education and training.

By heads, do you mean the AOA and the AAO? Jenny brought up a good point, not every OD is a member of the AOA. I know that OMDs are usually members of the AAO during their training. Can someone please explain if being a board certified ophthalmologist means that you are a member of the AAO for life? Are all community OMDs members of the AAO?

If not, then I think specific task forces need to be set up in each state with equal OD and OMD representation that lobby state legislatures to pass laws that mandate scope of practice with respect to ophthalmic care. Or can we, as Dr. Doan suggests, "self-police"?

And optometrist: I'd like you to answer the question that Texas posed re: if ALT and SLT constitute primary eye care?

Ruben

 

[optometrist]

Yes i do consider ALT and SLT primary eyecare

 

[JennyW]

Yes i do consider ALT and SLT primary eyecare

I do not. ALT and SLT are not difficult procedures to perform. Neither are YAGs and PIs. (And neither is learning when to do them and when not to do them) I have done about 40 YAGs and PIs myself. I have only done about 5 ALTs.

ALT and SLT procedures are surgical interventions for a progressive optic neuropathy. (glaucoma.) I don't consider that primary care. I also don't consider PRP or treatment of CSME primary care.

I also don't think it's a good idea for optometry as a profession to expend political energies trying to gain the rights to perform these procedures because unless an OD is working in a tertiary care center, it is highly unlikely that they will ever have the volume of patients needing these procedures to keep the skill level high, or justify the economics of having a laser in their office. Even if a group of ODs banded together and formed an ASC and shared a laser, the volume would still be too low.

Jenny

 

[JennyW]

Yes of course, they(ODs) are partners with OMDs.
__________________
"...And by that I mean Sex"

Do you really mean that?

Personally, I have never had sex with an OMD.

Jenny

 

[JennyW]

Getting back to the heart of the thread...

Jenny, the problems I have with the way you presented your solution are that 1) the entire onus of improving relations between OMDs and ODs seems to be placed on the OMDs, and 2) as a matter of principle, regardless of whatever else happens between OMD and OD, for the protection of patients as everyone's first goal, OD's should not be pushing for surgical rights, and it shouldn't have anything to do with an 'exchange.' Protection of patients should never be subject to groups bartering.

That being said, most of the points you mention probably should take place, anyway...I don't know enough about them to make much comment. My question is regarding your third point. Is is particularly common for OMDs to not return a pt back to the referring OD when the tertiary care need is done, or is it actually that the OMD thinks that the patient needs to continue to have tertiary care- level service by the OMD? If a primary care MD sends a patient to an OMD for any type of care, wouldn't that patient continue to be followed-up by the OMD for all of their eyecare? Is there a difference if that patient is sent to the OMD by an OD rather than an MD? Obviously, I don't know how it all works in the real world yet.

1) I do not see how the onus is placed entirely on OMDs. ODs are offering to give something up. We are willing to give that up in exchange for OMDs helping us with something else.

2) It is much more common than you think, sadly. I have seen it occur because I have worked for OMDs where this practice is employed. I have also experienced it as a referring provider. Yes, if a PCP referred to an OMD for eyecare, then it is likely that the OMD would perform most, if not all of the patients future eyecare. But if a PCP refers to an endocrinologist for treatment of diabetes, I don't think that means that the PCP never sees the patient again for any endocrine related problems.

Jenny

 

[rubensan]

Even if a group of ODs banded together and formed an ASC and shared a laser, the volume would still be too low.

Jenny

Why would this be? Is it because not enough tertiary eye care would be referred to them if a group of ODs banded together?

Ruben

 

[JennyW]

Why would this be? Is it because not enough tertiary eye care would be referred to them if a group of ODs banded together?

Ruben

An average person in the general population has a 6% chance of developing glaucoma. (IIRC)

Only a very small number of those people will need ALT and ALT can only be performed twice on each eye.

You can see that the percentage of people needing these procedures is extremely small. Therefore, there is not much point in ODs or even a group of ODs to have a laser that just sits there most of the time.

Jenny

 

[JennyW]

So you don't want to so surgery, but you want to do a lot. I agree, what is the definition of ophthalmic surgery? Where should lines be drawn?

Ruben

If it were that simple, then these debates would probably not be needed.

But since they are raging, let me throw out a statement and you can all feel free to comment. (politely.)

I know you are not supposed to define something based on what it's not, but when defining ophthalmic surgery with respect to the issue of optometrists performing it, perhaps it can be defined along these lines.

"Procedures performed in office at a slit lamp are NOT surgery."

Comments?

Jenny

 

[rubensan]

"Procedures performed in office at a slit lamp are NOT surgery."

Comments?

Jenny

I've only had a couple of months of clinical ophthalmology, so I am the first to admit that I lack some knowledge here. Are lasers not surgery? The couple of times i've seen YAG, it looked like it was a laser connected to a slitlamp device, is YAG not surgery? What about PRP?

Don't I always comment politely?

Ruben

 

[Tx Guy]

If it were that simple, then these debates would probably not be needed.

But since they are raging, let me throw out a statement and you can all feel free to comment. (politely.)

I know you are not supposed to define something based on what it's not, but when defining ophthalmic surgery with respect to the issue of optometrists performing it, perhaps it can be defined along these lines.

"Procedures performed in office at a slit lamp are NOT surgery."

Comments?

Jenny

Your definition may suffice now, but what about in the future? Who knows what we'll be able to do at the slit limp in the coming years? In my opinion, when you use devices or instruments that directly cause irreversible tissue damage or otherwise change the tissues, I think you are performing a surgical procedure. It may not be major surgery, but it's not just medically altering cellular function, either.

At the same time, as mentioned before, there are procedures that are so minor that they can fit nicely in a 'primary eyecare' practice.

I don't know what everyone thinks, but maybe we should work to define what fits into primary eyecare and what doesn't, rather than try to fit all procedures neatly into surgical or not surgical categories. Thoughts?

I'm sure we'll never all agree exactly on what is and isn't surgery, but I'm glad we can cordially discuss it and try to reach compromises on this forum. There's hope for us yet!

 

[futuredoctorOD]

Okay, hun, I'll do that. And when I'm a REAL doctor, not just some Wal-mart hack, I'll let your experience and wisdom and 2.5 GPA guide me into a nice pair of lenses. Sheesh, must have hit a nerve with this glorified technician.

Shouldn't you be going to a 10 keg party tonight and pimp some chicks with your frat buddies? You obviously have aboslutely NO chance of ever getting into an MD or DO program with the childish attitude you display on here! You live in LA LA land-------and will never ever be a medical doctor. Your comments are so ridiculous that I don't know why anybody is even acknowledging them! Please go back to your fraternity house and hit on some Tri-Delts---I heard they put out!

Are you like 19yrs old?

 

[rubensan]

"Procedures performed in office at a slit lamp are NOT surgery."
Jenny

Dear Jenny,

To answer your question, it's easier for me to think about what surgery IS first.

So how about this? eehmmm (clearing throat)

Ophthalmic Surgery is....

The branch of medicine that treats diseases, injuries, deformities and cosmetic appearance by manual operative methods or localized application of laser energy to repair, remove, disrupt, coagulate, or otherwise physically alter biological tissue for the intended treatment of disease, injury, deformity or cosmetic problems.

http://www.aao.org/member/policy/glossary.cfm


Therefore, procedures performed in office at a slit lamp that do not meet the above criteria are NOT surgery. That's where state task forces with equal OD and OMD representation come in and say. In the state of [fill in your state here], exceptions to the above include:

1. punctal plugs,
2. epilation
3. foreign body removal (corneal/conjunctival)
4.
5.

I'm getting out of my league pretty quickly here, but I wanted to reply to your question because I really like where this thread is going.

Ruben

 

[smiegal]

"Procedures performed in office at a slit lamp are NOT surgery."

Jenny

An anterior chamber tap would fit in that category

 

[shredhog65]

why would an optometrist perform an AC tap? I would think by the time a patient needs this proceedure they should have already been refered to an ophthalmologist. AC taps are nearly always perfromed on severly diseased eyes or post-ops.

i think i see the point you are trying to make though (or maybe i don't)

 

[Ben Chudner]

why would an optometrist perform an AC tap? I would think by the time a patient needs this proceedure they should have already been refered to an ophthalmologist. AC taps are nearly always perfromed on severly diseased eyes or post-ops.

i think i see the point you are trying to make though (or maybe i don't)

I think the point was that you cannot make a blanket statement that any procedure performed at the slit lamp is not surgery. A point that was very well made, by the way.

 

[7ontheline]

why would an optometrist perform an AC tap? I would think by the time a patient needs this proceedure they should have already been refered to an ophthalmologist. AC taps are nearly always perfromed on severly diseased eyes or post-ops.

i think i see the point you are trying to make though (or maybe i don't)

Um. . .CRAOs don't have a lot of time to be referred to anybody. Of course, AC taps aren't proven to work, but nothing reallly is I suppose.

Don't take this to mean that I support OD surgery, because I do not. There are certainly areas that need to be discussed and better defined to both sides' satisfaction though.

 

[Tom_Stickel]

Although I have no financial interest in any of these companies, I am an optometrist who is not particularly pro-surgery.

As far as what is surgery and what's a 'minor non-surgical procedure', here goes:

Minor procedures:
1. Non-corneal anterior seg lasers, i.e. SLT/YAG
2. Lash epilation
3. FB removal - conj. and cornea
4. Incisional surgery not requiring local anesthetic injection. In other words, I don't consider incising and draining an conj. serous cyst "surgery"
5. Dilation and irrigation of the lacrimal system
6. Lash electrocautery

Surgery
1. Invasive anterior and posterior segment procedures, e.g. A/C tap, cataract surgery
2. Lid procedures requiring anesthetic injection
3. LASIK/PRK
4. Posterior seg. lasers (which general OMDs don't do routinely anyway)

????
1. Limbal relaxing incisions
2. Papilloma/other benign lesion removal
3. Anterior stromal puncture for recurrent erosion

I come at my list, as do the OMDs, from the standpoint of patient safety. As I've asked before, I'd like someone to tell me when they last ran into a serious complication post-YAG that they didn't refer in the same way an OD would do. Ditto for any report of a post-YAG complication in OK. Same goes for the above minor procedures on my list.

The surgeries, IMHO, have potential complications beyond the scope of what an OD should be dealing with in any capacity. If that CRAO patient gets a tap and then endophthalmitis, I think any OD would have a difficult time defending themselves.

All that said, I don't really see the point in widespread optometric laser use. I don't particularly see an overwhelming patient benefit that justifies it.

The problem with any discussion, as has been pointed out here, is that our technological capabilities keep increasing. I don't think we can just make a rule that will apply to all situations. Level-headed people on both sides need t o try to reach some form of consensus on what's best for patients, and realistically, what's best for the health of each profession.

Tom Stickel
Indiana U. 2001

 

[scott McGregor]

I've thought about this issue at length. This is my take.

1) Only a few optometrists want to do surgery, i.e., real surgery and not the FB removal or punctal plugs we hear about.

2) Optometrists are primary care eye doctors who want to be respected and want to be trained well to do this task.

Here are my professional goals:

1) Try to identify the "bad apples" on both sides of the fence, and encourage the profession to self-police itself. There are bad ophthalmologists, and there are bad optometrists.

2) Help optometrists have access to medical information that will make them better primary care eye doctors. For goodness sake, we live in the information age, and people are trying to lock down medical information, i.e., "patent the gene". However, I will draw the line at surgery, which should be defined by surgeons - the ophthalmologists.

3) Perhaps ophthalmology should allow optometrists who want to do surgery to enter medical school after they pass the USMLE Step 1. If the first two years of optometry schools are similar to medical schools as stated by numerous optometry students and optometrists, then these students should have no problem passing the USMLE Step 1. These optometrists then complete years 3 and 4 of clinical training, and then go on to complete a medical/surgical internship and ophthalmology residency. An MD is awarded before doing residency.

I don't know the answers, and these are just my opinions.

Dr Doan
This is a wonderful thread. Open-minded suggestions toward cooperation. Although I worry that there is no need for more surgeons. Primary care by ODs is a reality. Surgery should never be attempted by ODs, the entire process from decisions pre to post op complications are outside the realm of OD training. I have a 2005 grad from oklahoma optometry school in my group. She said she never performed one single laser procedure, nor ever touched a scapel, and only put sutures in other students, never a real patient. NOW this is OKLAHOMA grad 2005!!
Now, if we are going to discuss training, and what is best for the patient, why are OMDs allowed to fit rigid gas permeable contact lenses on patients? Why are OMDs issuing scripts on plus cylinder phoroters when only minus cylinder can be manufactured in 2005? Why are OMDs opening dispensaries and advising patients on best progressive add to purchase and best high index materials to make high myopic lenses for cosmetic and abberation reduction? OMDs get upset that ODs treat conjunctivitis, but they form the Contact lens Association of Ophthalmologists. OMDs won't let ODs prescribe viroptic for viral "pink-eye" but they form Association of Dispensing Ophthalmologists. Does this mean that an OMD can get training outside the standard med school and residency to make them capable in these areas not or barely touched in residency? If so, why can ODs not also get outside abilities (NOT to include surgery) to Rx a bottle of Viroptic? Please don't tell me an OMD is a degree in all 3 "O"s. I have a degree with honors in opticianry and also optometry. Yet I won't fit glasses anymore, I've lost touch with current products. I can prescribe narcotics, but not Viroptic. I can prescribe topical but not oral steroids. I don't want to touch a laser or a scapel, but I want to practice primary care without limitations. The law in my state says I'm capable of Rxing meds for only for certain number of days. What is that about? ODs don't push for laws that say OMDs can only prescribe soft contacts, but id extended wear, you must involve an OD. See my point?? OMDs have blurred the lines as badly as OD are accused.

 

[Andrew_Doan]

Actually, I agree. I think ophthalmologists should NOT dispense glasses or contact lenses. I do diagnostic refractions, but will refer patients to see their local optometrist. Several faculty I've worked with do the same.

 

[scott McGregor]

Your definition may suffice now, but what about in the future? Who knows what we'll be able to do at the slit limp in the coming years? In my opinion, when you use devices or instruments that directly cause irreversible tissue damage or otherwise change the tissues, I think you are performing a surgical procedure. It may not be major surgery, but it's not just medically altering cellular function, either.

At the same time, as mentioned before, there are procedures that are so minor that they can fit nicely in a 'primary eyecare' practice.

I don't know what everyone thinks, but maybe we should work to define what fits into primary eyecare and what doesn't, rather than try to fit all procedures neatly into surgical or not surgical categories. Thoughts?

I'm sure we'll never all agree exactly on what is and isn't surgery, but I'm glad we can cordially discuss it and try to reach compromises on this forum. There's hope for us yet!

TX_GUY--I think a major stumbling block comes from Medicare and Insurance coding. These entities consider pulling an eyelash or plugging a puncta as"SURGERY". So when ODs say we want surgery, we think the above. Of course a 2-3rd year OMD resident thinks....you must be kidding, ODs in surgery" Part of the problem is not cooperation but semantic between ICDM Coding/Insurance Regs/Government Definitions/etc. The average honest OD knows they don't belong in surgery, while the average honest OMD knows it doesn't take a surgeon/residency to treat conjunctivitis or pull a lash.

 

[rubensan]

Why are OMDs issuing scripts on plus cylinder phoroters when only minus cylinder can be manufactured in 2005?

I agree with you scott, but maybe you can answer a question i have had for awhile. why does is matter if you write cylinder as plus or minus? I asked someone one time and they said OMDs usually use plus, ODs and OMDs on the "East Coast" generally write scripts in minus cylinder.

+1.00 -2.00 x 45 is the same thing as -1.00 + 2.00 x 135, correct? I know my question sounds naive, but I'm still working on basic refracting skills and feel lucky if i can straddle the damn axes of the Conoid of Sturm when I refract.

 

[Ben Chudner]

I agree with you scott, but maybe you can answer a question i have had for awhile. why does is matter if you write cylinder as plus or minus? I asked someone one time and they said OMDs usually use plus, ODs and OMDs on the "East Coast" generally write scripts in minus cylinder.

+1.00 -2.00 x 45 is the same thing as -1.00 + 2.00 x 135, correct? I know my question sounds naive, but I'm still working on basic refracting skills and feel lucky if i can straddle the damn axes of the Conoid of Sturm when I refract.

It doesn't matter. I am not sure what Scott is referring to about only minus cyl being able to be manufactured in 2005. I am not sure why OD's use minus and OMD's use plus. I can tell you that plus cyl is actually more convenient as it matches with how we read K's off the keratometer without having to make an axis conversion. And just so you know, lens blanks that come from the lab actually print the rx ilabel in both plus and minus cyl to be sure there is no mistake made in the conversion by opticians.

 

[JennyW]

I agree with you scott, but maybe you can answer a question i have had for awhile. why does is matter if you write cylinder as plus or minus? I asked someone one time and they said OMDs usually use plus, ODs and OMDs on the "East Coast" generally write scripts in minus cylinder.

+1.00 -2.00 x 45 is the same thing as -1.00 + 2.00 x 135, correct? I know my question sounds naive, but I'm still working on basic refracting skills and feel lucky if i can straddle the damn axes of the Conoid of Sturm when I refract.

For pre-presbyopic patients, and even for early presbyopes refracting in minus cylinder is ideal because it gives you much better control of their accommodation.

Jenny

 

[scott McGregor]

I agree with you scott, but maybe you can answer a question i have had for awhile. why does is matter if you write cylinder as plus or minus? I asked someone one time and they said OMDs usually use plus, ODs and OMDs on the "East Coast" generally write scripts in minus cylinder.

+1.00 -2.00 x 45 is the same thing as -1.00 + 2.00 x 135, correct? I know my question sounds naive, but I'm still working on basic refracting skills and feel lucky if i can straddle the damn axes of the Conoid of Sturm when I refract.

Dear Ruben
Your question is quite valid. Yes, on an "optical cross" the resultant powers are the same in either cylinder form. In plus cylider the assumption is that the lens will be manufactured with the cylinder correction on the front of the lens. In minus cylinder, the cylinder correction is placed on the back of the lens. The difference is small until you get into higher powers. Then vertex optics finds that focal points are in different locations due to placement of the cylinder correction. For over 50 years now all ophthalmic lenses are manufactured in minus cylinder. An Rx issued from a plus cylinder refraction may not, in fact, be the prescription received by the eye in the finished pair of glasses. This is why ODs use minus cylinder, to determine a "more perfect" refraction. It is my understanding that OMDs have retained the plus cylinder because of tradition, as no optical reason could ever be justified. Or perhaps OMDs acknowledge that refracting is not their function, its not important enough to be absolutely accurate.

 

[scott McGregor]

It doesn't matter. I am not sure what Scott is referring to about only minus cyl being able to be manufactured in 2005. And just so you know, lens blanks that come from the lab actually print the rx ilabel in both plus and minus cyl to be sure there is no mistake made in the conversion by opticians.

Dear Ben
You are correct that lens packages are labelled with both plus and minus cylinder forms and it is done to prevent transposition errors by opticians. However:
From textbook: Practical Aspects of Ophthalmic Optics" pp182-83 (Quote)
"Manufacturers phased out plus-cylinders and the definition of base curve is no longer the weakest curve on a lens. Almost without exception the preferred for a minus cylinder is that the base curve is the front spherical surface of the lens. Optical experts prefer minus cylinder because meridional magnification is kept to a minimum. All contemporary lenses manufactured in the United States (glass and plastic) are made in minus cylinder form.""(end Quote)
Additionally if we apply the Effective Power Formulas to this discussion, we note that in a lens with 3-4-5 mm thickness the placement of the cylinder effects the prescription that emerges from the back surface. Effective Power=Diopters/1-DioptersXdistance in meters. Thus a 4.00 cylinder refracted at one plane but supplied in a lens in a plane 4 mm different, that power would no longer be 4.00. Since only minus cylinder (cylinder located on back of the lens) can be obtained, ODs use phoropters with minus cylinder to more accurately refract their patients. Agreed this is "nit-picking", but we are all in a profession that works in microns, let alone many millimeters of induced error.

 

[Ben Chudner]

Dear Ben
You are correct that lens packages are labelled with both plus and minus cylinder forms and it is done to prevent transposition errors by opticians. However:
From textbook: Practical Aspects of Ophthalmic Optics" pp182-83 (Quote)
"Manufacturers phased out plus-cylinders and the definition of base curve is no longer the weakest curve on a lens. Almost without exception the preferred for a minus cylinder is that the base curve is the front spherical surface of the lens. Optical experts prefer minus cylinder because meridional magnification is kept to a minimum. All contemporary lenses manufactured in the United States (glass and plastic) are made in minus cylinder form.""(end Quote)
Additionally if we apply the Effective Power Formulas to this discussion, we note that in a lens with 3-4-5 mm thickness the placement of the cylinder effects the prescription that emerges from the back surface. Effective Power=Diopters/1-DioptersXdistance in meters. Thus a 4.00 cylinder refracted at one plane but supplied in a lens in a plane 4 mm different, that power would no longer be 4.00. Since only minus cylinder (cylinder located on back of the lens) can be obtained, ODs use phoropters with minus cylinder to more accurately refract their patients. Agreed this is "nit-picking", but we are all in a profession that works in microns, let alone many millimeters of induced error.

Interesting point. The problem with your arguement is that even at 8 diopters, the difference in rx is only 0.25 and that's at 4mm. I don't know about your office, but my 8D myopes are in high index lenses with a center thickness of about 2mm. True, in the periphery the thickness increases, but we are really splitting hairs with a 0.25D difference in the periphery. Furthermore, the refraction is performed with separate lenses for sphere and cyl rather than the back surface toric lens found in glasses. I believe the toric lens is further from the patient in my phoropters, but I don't believe these lenses are very thick, therefore the power cross is virtually identical for the same patient refracted on a plus cyl phoropter and a minus cyl. Once the rx is obtained and ordered the manufacturer ensures the back surface is toric.

To further make the point, my office still has a Greens phoropter (max 2.50 cyl) I have rarely had to reach for the additional cyl lens (which by the way is further way from the patient). Even at 8mm thickness we are talking about 0.05D difference in power for 2.5D of cyl in your example. I just don't believe it really matters.

 

[scott McGregor]

Interesting point. The problem with your arguement is that even at 8 diopters, the difference in rx is only 0.25 and that's at 4mm. I don't know about your office, but my 8D myopes are in high index lenses with a center thickness of about 2mm. True, in the periphery the thickness increases, but we are really splitting hairs with a 0.25D difference in the periphery. Furthermore, the refraction is performed with separate lenses for sphere and cyl rather than the back surface toric lens found in glasses. I believe the toric lens is further from the patient in my phoropters, but I don't believe these lenses are very thick, therefore the power cross is virtually identical for the same patient refracted on a plus cyl phoropter and a minus cyl. Once the rx is obtained and ordered the manufacturer ensures the back surface is toric.

To further make the point, my office still has a Greens phoropter (max 2.50 cyl) I have rarely had to reach for the additional cyl lens (which by the way is further way from the patient). Even at 8mm thickness we are talking about 0.05D difference in power for 2.5D of cyl in your example. I just don't believe it really matters.

Dear Ben
My purpose was not to argue millimeters, nor fractions of diopters. I did not invent the "system". Despite degrees in opticianry and optometry, I don't hold myself out as one of the "Optical Experts" cited in the text in my post. My intent was to state that plus cylinder lenses are no longer manufactured, and they are not. The mathmatical calculations, abbe numbers, effective powers, abberation controls, etc I will defer to others that have determined such things. To argue them is fruitless, as experts have already determined what is best...and why. The only real question is why do we have two systems if the plus cylinder of yester-year was flawless? Personally I've used minus cylinder for 15 years and plus cylinder for 10 years and I never noticed hoardes of remakes with either. But if the finished lens on the patients face is a minus cylinder, logic says that a refraction with a minus cylinder phoropter, or corrected curve trial lenses (minus cylinder) will more closely match.

 

[Ben Chudner]

Dear Ben
My purpose was not to argue millimeters, nor fractions of diopters. I did not invent the "system". Despite degrees in opticianry and optometry, I don't hold myself out as one of the "Optical Experts" cited in the text in my post. My intent was to state that plus cylinder lenses are no longer manufactured, and they are not. The mathmatical calculations, abbe numbers, effective powers, abberation controls, etc I will defer to others that have determined such things. To argue them is fruitless, as experts have already determined what is best...and why. The only real question is why do we have two systems if the plus cylinder of yester-year was flawless? Personally I've used minus cylinder for 15 years and plus cylinder for 10 years and I never noticed hoardes of remakes with either. But if the finished lens on the patients face is a minus cylinder, logic says that a refraction with a minus cylinder phoropter, or corrected curve trial lenses (minus cylinder) will more closely match.

You are right, it is useless to argue this point. Since the OMD's are not as concerned with refraction as we are, there is no reason for them to change to minus cyl.

 

[Caffeinated]

If phoropters had a shelf life of only a few years, then plus cylinder probably would have died out years ago. But since most phoropters are built to withstand a nuclear expolsion, it doesn't make sense to throw out a perfectly good plus cyl phoropter. Furthermore, most optical dispensaries are smart enough to know how to transpose between minus cyl and plus cyl. Given this, most people in the plus cyl camp are perfectly content to stick with what they know.

While I was in optometry school I worked as a technician in an ophthalmology office. I would do some exams in the morning in minus cyl, then do some in plus cyl later than afternoon. It was not difficult to go back and forth. Chasing red dots, chasing white dots, it's all the same game.

 

[scott McGregor]

If phoropters had a shelf life of only a few years, then plus cylinder probably would have died out years ago. But since most phoropters are built to withstand a nuclear expolsion, it doesn't make sense to throw out a perfectly good plus cyl phoropter. Furthermore, most optical dispensaries are smart enough to know how to transpose between minus cyl and plus cyl. Given this, most people in the plus cyl camp are perfectly content to stick with what they know.

While I was in optometry school I worked as a technician in an ophthalmology office. I would do some exams in the morning in minus cyl, then do some in plus cyl later than afternoon. It was not difficult to go back and forth. Chasing red dots, chasing white dots, it's all the same game.

Ben and Caffeinated
Forgive me for taking this previously wonderful thread down a path only an "engineer" could love. Type of phoropter doesn't matter--in reality.

 

[Caffeinated]

Ben and Caffeinated
Forgive me for taking this previously wonderful thread down a path only an "engineer" could love. Type of phoropter doesn't matter--in reality.

Scott,

No apology necessary. I am originally a physicist by training, so I can relate.

Caff

 

[lvmopt]

If i refer a patient to an OMD - i do not expect the patient back. A referral is sending a patient to someone else for all their future care. If i send a patient to an OMD for a consult (regarding cataracts surgery, etc) i expect the patient back. The wording is important. The problem is in my experience, even if i send a patient out for a consult for cataract surgery, you tend to not get the patients back. Its not right, but it does happen - I keep track of which OMDs don't send patients back, and those OMDs simply don't get any more consults/referrals from me at all.

This is so true, I have practiced Optometry since 1984, and the OMDs rarely send patients back. They keep them, AND they send them to their own opticals.

 

[cme2c]

This is so true, I have practiced Optometry since 1984, and the OMDs rarely send patients back. They keep them, AND they send them to their own opticals.

Obviously patient choice doesn't matter to some here. Maybe those who complain about OMDs keeping their patients need to look in the mirror.

 

[orbitsurgMD]

This is so true, I have practiced Optometry since 1984, and the OMDs rarely send patients back. They keep them, AND they send them to their own opticals.

Not where i work.

And can't we let the dead rest in peace? Like this thread, for example.

 

[ABaverage]

If only all OMDs had similar logic to Dr. Doan, the OD/OMD world would be a better place.

I think it's important to note that he is right about the low percentage of ODs actually wanting to perform "surgery", and that a mutual respect for each others profession would work in everyone's favor.

I can't stand the high and mighty attitude of OMDs. They seem to outnumber the ODs that are trying to expand their scope of practice to include surgery. I have yet to meet an OD that was very pro-surgery but I have spoken with OMDs that think ODs don't know what the hell they are doing in general.

 

[KHE]

Obviously patient choice doesn't matter to some here. Maybe those who complain about OMDs keeping their patients need to look in the mirror.

Yea, but let's also be honest with ourselves here.

Any patient is free to choose whichever doctor they wish to see. Some may in fact be comfortable staying with the opthalmologist and truth be told, sometimes as an optometrist we're happy to see the patient gone. But many ophthalmologists make no effort whatsoever to encourage patients to return to their referring provider.

Any OD out there has lost patients over the years to some shady ophthalmologist who tells patients that the ophthalmologist should see their whole family because the patients have *insert strange disease here*

Examples I've personally experienced in my 11 years.......

"unusual astigmatism." (-0.75 axis 90 OU)
"child is blind in one eye" (20/40 amblyope)
"peripheral damage that could blind you" (lattice degeneration)
"very high prescription that you need a specialist for" (+3.00 OU)
"high eye pressure" (18 OU - yes...this is the ophthalmologist's reading, not mine)

Thankfully it hasn't happened to me in years because you learn who the dickheads are very quickly and you simply don't refer to them.

 

[socal2014]

This is a wet dream.


We can sit here and talk about this and that and how OD's should be doing this while the OMD's should be doing that. But the fact of the matter is, our leaders, those in charge of our associations, have special interests which will prevent any mutual agreements between OMD's and OD's from taking place.

Until the AMA/AOA are not cleansed, the gap between OMD's and OD's will continue to only increase. While OMD's and OD's are fighting for rights, reimbursement from vision plans, and how to keep each other away from profitable gains, the respective associations are making huge amounts of money off of each respective professional. If you wanna get scientific, I would have to say that the entire OMD vs OD turf war emulates a postive feedback mechanism.