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Medical Forum / General / Vision / June 2006How do you select an eye surgeon for cataract surgery?
I'm a 40 year old male and need to have a cataract surgery in my right eye. My aunt, a pediatrician, recommended an eye surgeon in my area. He has a good reputation and 24 years of experience. I have high myopia, so he sent me to a retina specialist to make sure my retina is fine. The specialist, after examining my eye and doing OCT and FA, _convincingly_said to me, "You don't have to see like this. Have a surgery and you'll see much better." In contrast, my eye surgeon's take on my surgery is something like, "You MIGHT see better." I think he's very cautious. I know that at the end of the day it's the surgeon's skills that matter. I guess my question is, "Would you be more comfortable with a cautious surgeon or an assuring one?" > I'm a 40 year old male and need to have a cataract surgery in my right eye. > My aunt, a pediatrician, recommended an eye surgeon in my area. He has a [quoted text clipped - 8 lines] > guess my question is, "Would you be more comfortable with a cautious surgeon > or an assuring one?" I had cataract surgery a few years ago, and unfortunatley had *many* complications. The end result is that I have very thick glasses and still cannot see anywhere near 20/20, even in the one eye that still works. Unfortunately this means that when it comes time to renew my license it will be difficult. Please be sure to get a cautious doc, but one who has done a lot of these procedures. > I know that at the end of the day it's the surgeon's skills that matter. I > guess my question is, "Would you be more comfortable with a cautious surgeon > or an assuring one?" Neither. I would want (and sought out, in my case) the best I could find. You want someone who does lots of them (at least 10 per week), who uses all the latest techniques (stitchless, eyedrop alone anesthesia, etc), AND who won't try to talk you into a multifocal or "focusing" IOL. w.stacy, o.d. >> I know that at the end of the day it's the surgeon's skills that matter. >> I guess my question is, "Would you be more comfortable with a cautious [quoted text clipped - 4 lines] > all the latest techniques (stitchless, eyedrop alone anesthesia, etc), AND > who won't try to talk you into a multifocal or "focusing" IOL. There's one doctor in my area (New York) who was voted as one of the best eye surgeons. If I should go for him, should I go through the tests (OCT and FA) again? > There's one doctor in my area (New York) who was voted as one of the best > eye surgeons. If I should go for him, should I go through the tests (OCT and > FA) again? Voted by whom? If you go to him, let him decide what to do. He will likely be interested in what's already been done. w.stacy, o.d. > I'm a 40 year old male and need to have a cataract surgery in my right eye. > My aunt, a pediatrician, recommended an eye surgeon in my area. He has a [quoted text clipped - 8 lines] > guess my question is, "Would you be more comfortable with a cautious surgeon > or an assuring one?" That sucks to have cateract(s) at only 40! The biggest problem is you wont be able to tolerate glasses anymore due to anisometropia. Good thing you never had lasik because it would have been "wasted" cause cateract surgury also takes care of your myopia at the same time! How bad is your vision in the affected eye? >I'm a 40 year old male and need to have a cataract surgery in my right eye. >My aunt, a pediatrician, recommended an eye surgeon in my area. He has a >good reputation and 24 years of experience. I have high myopia, so he sent >me to a retina specialist to make sure my retina is fine. That was wise. >The specialist, after examining my eye and doing OCT and FA, >_convincingly_said to me, "You don't have to see like this. Have a >surgery and you'll see much better." In contrast, my eye surgeon's >take on my surgery is something like, "You MIGHT see better." I think >he's very cautious. I NEVER recommend elective surgeries, like most cataract surgeries, LASIK, etc. I inform patients of the risks/benefits, tell them the pros/cons and answer all their questions to the best of my ability. I tell them THIS is your problem and THESE are the options (including doing NOTHING). Then the patient makes their decision after being completely and fully informed. I never say, "You need to/should have (elective) cataract surgery", or "You should have refractive surgery"* That is IMHO asking for problem. If something bad happens, I do not want the patient to be able to say, "YOU TOLD ME TO HAVE THIS SURGERY!" However, if asked, I will answer the question, "Well, what would you do if you were me? Or what would you do if you were in the same situation as I was?" >I know that at the end of the day it's the surgeon's skills that >matter. I guess my question is, "Would you be more comfortable with a >cautious surgeon or an assuring one?" I'm not comfortable with ANY surgeon who RECOMMENDS a completely elective surgery. * (If a patient has a hypermature cataract, a cataract so dense that I cannot adequately visualize the fundus details, then I will suggest it. But that is like, maybe, <5% of the time.) That sucks to have cateract(s) at only 40! The biggest problem is you wont be able to tolerate glasses anymore due to anisometropia. Good thing you never had lasik because it would have been "wasted" cause cateract surgury also takes care of your myopia at the same time! How bad is your vision in the affected eye? I noticed you didnt see what I said but please look up anisometropia. I have seen people totally taken by supprise when they find they can no longer tolerate glasses! Wow. Since when is cataract surgery entirely elective? The end result of a cataract is loss of visual function. The only "elective" aspect is how much vision loss is tolerable to the patient. There are also common standards, such as requirements for the operation of a motor vehicle. LASIK, on the other hand, is elective in virtually all situations. Somehow, I believe that our patients expect us to be more than just spouting fountains of statistics. DrG > >I'm a 40 year old male and need to have a cataract surgery in my right eye. > >My aunt, a pediatrician, recommended an eye surgeon in my area. He has a [quoted text clipped - 39 lines] > cannot adequately visualize the fundus details, then I will suggest > it. But that is like, maybe, <5% of the time.) >Wow. Since when is cataract surgery entirely elective? When not having it does not result in significant risk of morbidity (hypermature cataract) or impair my ability to assess the status of the fundus. Other than that, it's elective. It's certainly not going to "hurt" the patient who choses NOT to have cataract surgery in most cases. What "bad" happens if they don't have the surgery? Nothing -- except they just don't see better. In a real sense, every surgery is elective. People can choose not to have retinal detachment surgery, not have malignant hypertension treated, not be treated for a corneal ucler, etc. In those cases I strongly recommend against not having those treated. I give them the reasons why they should and what will most likely happen if they do not. If they choose not to, I would do my best to insist they at least see another doctor for a second opinion and do I everything I could medicolegally to protect my rear. >The end result of a cataract is loss of visual function. The only >"elective" aspect is how much vision loss is tolerable to the patient. Exactly. It's up to the PATIENT to decide when the visual function has been degraded to the point where the patient DESIRES the surgery. I do not say, "Your vision is 20/50, you can't pass the DMV test, I recommend you have cataract surgery." I essentially say (this is paraphrased, I go into far more detail that this, but I hope you get the idea) "Your vision is 20/50, you can't pass the DMV test, if you want to be able to see better, then cataract surgery is required. What do you want to do?" >There are also common standards, such as requirements for the >operation of a motor vehicle. I, like you I am sure, have a few patients who have 20/80 cataracts that don't drive and their vision is adqeuate for their demands. IOW, they have no complaints. I don't recommend elective cataract surgery for those patients. >LASIK, on the other hand, is elective in virtually all situations. Yes. And for that very same reason, I never RECOMMEND refractive surgery. Our office has comanaged a few hundred patients, and I believe for the right patient, it is a great option. But I let the patient tell me this is what they want versus this is what I think they need. The last thing I would want a patient of mine who had a poor result from refractive surgery to have heard/be in their chart is that I recommended they have refractive surgery. >Somehow, I believe that our patients expect us to be more than just >spouting fountains of statistics. Certainly. Regardless, for medicolegal reasons, I don't *recommend* (IOW, "You should have") elective surgeries -- but that's just me. I say IF YOU WANT X, then you need to do Y. Or I might say, for you, I believe contact lenses would be the best option. It's a subtle, but important distinction -- at least for me. In fact, I don't recommend contact lenses either -- I examine their eyes and offer options. I might say that contact lenses offer advantages for you that spectacle and refractive surgery does not -- and if I were you, I would certainly go with contact lenses. It's all about giving my patients options and informed consent. I do make recommendations all the time though. I recommend people do not sleep in their contact lenses (sometimes I do more than recommend, other times I tell them). I recommend people with diabetes get at least yearly comprehensive eye examinations. I recommend people with significant glaucoma risk factors, such as elevated intraocular tensions or suspicious or characteristic optic nerve appearance, undergo a glaucoma workup. I tell my monocular or very young patients, "Your lenses NEED to be in polycarb or trivex. However, I recommend trivex." I strongly recommend nearly every patient who wears contact lenses have a backup pair of glasses. I recommend antireflective coatings for the vast majority of my patients. I recommend hi-index lenses for many. For patients that choose soft contact lenses, I almost always recommend a silicone hydrogel over a HEMA lens. Basically, I don't make recommendations that I feel, worse case *realistic* scenario, I would be uncomfortable defending my actions against in a court of law. Every doctor has their own comfort zone. If I "recommended" a patient had non-elective cataract surgery, and that person ended up having a horrible complication, say endophthalmitis, and I got sued, I would not feel comfortable defending a recommendation of cataract surgery. Lawyers, IMHO, are too nasty, heavy-handed and zealous in their clients interests. Read articles by Jerome Sherman -- I'm sure you know who he is. He's at Suny and does a lot of malpractice and expert witness stuff. You might be surprised at the stuff that people get sued for and lose in when it comes to Optometry malpractice. I'll give you one last example where I might differ: I haven't taken a poll, but from informal discussions with them, most of my colleagues feel that for a patient who presents with the chief complaint of a symptomatic PVD, that an unremarkable standard binocular indirect examination (BIO) is adequate from a medicolegal standpoint. It's not. I don't think it's even debateable. There are NO reliable symptoms that can rule out a symptomatic PVD from a retinal tear. And to rule out a retinal break, one needs to perform careful and meticulous BIO *with scleral depression 360 degrees* in both eyes. And acceptable alternative is to use a Goldmann-type 3-mirror lens. Standard BIO alone is failure to meet the standard of care. And if a small retinal tear was missed because of failure to perform scleral depression which then progressed to RD which causes permanent vision dysfunction, I would be unable to defend such a doctor's actions. If a doctor DID perform BIO with scleral depression and missed it, then I would find no fault because that doctor met the standard of care. That would however need to be documented in the chart. An eye doctor needs to perform BIO with scleral depression (or careful Goldmann 3-mirror examination of the periphery) for every patient that presents with a symptomatic PVD, or refer that patient to a doctor that can or that is malpractice if something goes bad as a result. Do most Optometrists do this on every patient that presents with a PVD? In my experience, no. Do most Ophthalmologists do this? No, in my experience. They play an odds-game. Do most retinal surgeons do this? In my experience, they do. IMHO, you would be on stronger legal grounds recommending cataract surgery to someone who obviously "needed it," than by co-managing a patient whom you "non-recommended" having LASIK and the patient didn't like the outcome, or suffered ectasia. Whether you recommend a treatment or not has nothing to do with negligence. But, your points are well-taken for the most part. DrG > >Wow. Since when is cataract surgery entirely elective? > [quoted text clipped - 132 lines] > my experience. They play an odds-game. Do most retinal surgeons do > this? In my experience, they do. > IMHO, you would be on stronger legal grounds recommending cataract > surgery to someone who obviously "needed it," than by co-managing a [quoted text clipped - 142 lines] > > my experience. They play an odds-game. Do most retinal surgeons do > > this? In my experience, they do. Cateract surgury is both elective and a neccessary. Someone who doesnt drive and spends most of his time home eating, reading, watching TV, sleeping may not bother with the surgury. Same for someone with risks of other problems including retina detachment. People with only one good eye because the other has diseases, retina detachment or amblyopia are much more reluctant because if theres a complication in the good eye they dont have the other eye to fall back. You can have complications from cateract surgury that can make your vision WORSE than it was with cateracts. I know one guy who ended up overcorrected and induced astigmastim and other disortions in his vision. He said his new vision wasnt any better than his old vision so he was unhappy. He also couldnt wear glasses anymore due to anisometropia. Lasik is generally reguarded as completely elective >Cateract surgury is both elective and a neccessary. Someone who doesnt >drive and spends most of his time home eating, reading, watching TV, [quoted text clipped - 9 lines] >also couldnt wear glasses anymore due to anisometropia. >Lasik is generally reguarded as completely elective As always, I don't know what the eye doctors would do without you coming along to clarify things. >Lasik is generally reguarded as completely elective Not completely, but I'm sure even this is up to debate. Here's an example: 7 year old girl with the following prescription: OD plano DS OS -8.00 +4.00 x 090 or OD plano DS OS -7.00 DS Cannot tolerate spectacles (e.g., due to anisekonia) and is contact lens intolerant. Without proper intervention, the possibilty of amblyopia, poor/non-existant stereopsis, etc. is high. Someone like this I could consider *recommending* refractive surgery, depending on the rest of the story (e.g., OrbScan, keratometry, pachymetry, etc.) and examination results (e.g., BCVA, retinal status). If it was my eye, I would prefer the relative risk of refractive surgery over almost certain amblyopia and astereopsis. But for the vast, vast majority of patients, LASIK surgery is completely elective. > >Lasik is generally reguarded as completely elective > [quoted text clipped - 26 lines] > But for the vast, vast majority of patients, LASIK surgery is > completely elective. I think I mentioned somewhere about lasik being a good option for anisometropia. However lasik is illegal if you are under 18. Thats because your eye(s) are not stable, still growing and changing and also you are a minor and can not consent. She will just either have to deal with contacts as best as she can or wear glasses and patch the good eye to exercise the weak eye so it wont go amblyopic. I'm sorry, but if the 7 year/old doesn't already have amblyopia, she won't get it with that script. Now assuming your scenario for the sake of discussion, what makes you think that providing a spectacle RX of -4.00 -4.00 x 180 and patching won't work on this patient as it has on countless other patients with this kind of script? Still elective, although there is considerable justification. The percentage of the population having such amblyogenic prescriptions is about 3-5%. Anyway, we're straying off the original argument, which is whether or not any surgery is not elective. DrG > >Lasik is generally reguarded as completely elective > [quoted text clipped - 26 lines] > But for the vast, vast majority of patients, LASIK surgery is > completely elective. >I'm sorry, but if the 7 year/old doesn't already have amblyopia, she >won't get it with that script. Correct. Assume she already has it. She is still at an age where amblyopia therapy can work (although I prefer to intervene much earlier than this, the earlier the better). >Now assuming your scenario for the sake of discussion, what makes you >think that providing a spectacle RX of -4.00 -4.00 x 180 and patching >won't work on this patient as it has on countless other patients with >this kind of script? It may work for amblyopia therapy, but prescribing spectacles doesn't address the problem of giving this girl comfortable binocular vision once the therapy is complete. >Still elective, although there is considerable justification. The >percentage of the population having such amblyogenic prescriptions is >about 3-5%. > >Anyway, we're straying off the original argument, which is whether or >not any surgery is not elective. Fine. All sugery is ultimately elective. In the United States, a patient has the absolute right (in nearly every case) to refuse medical care. My argument is there are surgeries that I am comfortable recommending and those that I am not. Medically necessary or mandatory ones -- ones that if they are not done incur relatively high odds of morbidity/mortality -- such as retinal detachments, coronary artery bypass, acute appendicitis, etc. would be ones I recommend. Medically unnecessary or non-mandatory ones -- ones such as most catarct/refractive/capsulotomy surgery, breast augmentation, cosmetic rhinoplasty -- are ones I don't recommend. Recommend means that I tell a patient "You should have this done" or "Have this surgery." I don't instruct patients to have non-mandatory surgeries. Even ones I don't recommend, such as nearly all cases of refractive surgery, I may say (after the patient decides after being explained the pros and the cons), "that's exactly what I would do if I were in your shoes". I am a big believer in refractive surgery for the right patient -- our office has comanaged at least 300 such patients. > >I'm sorry, but if the 7 year/old doesn't already have amblyopia, she > >won't get it with that script. [quoted text clipped - 11 lines] > address the problem of giving this girl comfortable binocular vision > once the therapy is complete. Agreed. I can see this as one of the few areas where LASIK would be considered medically advisable. > >Still elective, although there is considerable justification. The > >percentage of the population having such amblyogenic prescriptions is [quoted text clipped - 15 lines] > retinal detachments, coronary artery bypass, acute appendicitis, etc. > would be ones I recommend. Cataract surgery should be easy to lump into that category, since a cataract ultimately causes visual morbidity. As I said, only the timing is elective, and some patients do not outlive their cataracts. I feel like you have really stretched the definition of 'elective' and 'medically necessary' beyond their common usage. > Even ones I don't recommend, such as nearly all cases of refractive > surgery, I may say (after the patient decides after being explained > the pros and the cons), "that's exactly what I would do if I were in > your shoes". I am a big believer in refractive surgery for the right > patient -- our office has comanaged at least 300 such patients. Hmmm. That would seem to be a significant business for your office. Is this a national trend for optometry do you think? DrG >> Medically necessary or mandatory ones -- ones that if they are not >> done incur relatively high odds of morbidity/mortality -- such as [quoted text clipped - 4 lines] >cataract ultimately causes visual morbidity. As I said, only the >timing is elective, and some patients do not outlive their cataracts. Visual morbidity, like pain, can be very subjective in its impact on an individual patient although visual acuity is objective. Two people who have the same visual acuity can have vastly different subjective impact -- one of these people can have no complaints, the other can be suffering tremendously. Sure, I can look at the two different patients after a careful and detailed history and think I would "recommend" person A get cataract surgery and patient B shouldn't. I really don't come across to my patients this "cold" and objective like I appear here. I empathize and I make it pretty clear which way I think they should go, but I am careful not to give them anything that would appear to not give them ultimately the choice of whether to have an elective surgical procedure. Perhaps a good analogy would be how an OB/GYN manages labor pain. From my limited experience, they don't say, for the most part, "I recommend you have an epidural or spinal block". They say, "Do you want an epidural?" They allow the patient to decide what their pain tolerance is and ultimately let the patient choose whether they want the pain medication. I'm sure if the patient is screaming in agony, then they will up it from an offering to a recommendation. If I had a patient with cataracts who was terrified of surgery but was bumping into walls because he couldn't see, I would tell that person I "recommended" cataract surgery. Or if I had a person who absolutely refused to give up driving, had 20/80 vision, and was hesistant to have cataract surgery, that they "needed" or I "recommended" cataract sugery. I would also be careful to fully document in the chart the reasons why in great detail. >I feel like you have really stretched the definition of 'elective' and >'medically necessary' beyond their common usage. Point taken. >> Even ones I don't recommend, such as nearly all cases of refractive >> surgery, I may say (after the patient decides after being explained [quoted text clipped - 3 lines] > >Hmmm. That would seem to be a significant business for your office. It is. It is just another option for my patients. Most of the time, choice is good. With the advent of great refractive surgery procedures, in particular PRK and LASIK, I think it is a disservice to not offer these procedures to potential candidates in the same way it would be a disservice to not offer contact lenses as an option to my spectacle lens patients. I tell my patients that 15 years ago if you came into my practice and you were a -5.00D myope, you had 3 options: (1) Do nothing, (2) spectacles, or (3) contact lenses. [Although there was RK, I never recommended it (note: although I don't "recommend" elective refractive surgery, there are many times I strongly "DO NOT RECOMMEND" refractive surgery), and I tell them why.] Now, I tell them they have one more option, "refractive surgery". I discuss the pros/cons, risks/benefits, and potential complications of all of their options and ultimately let them decide as long as they are a good candidate. >Is this a national trend for optometry do you think? I would think so. And in my area, anecdotally other ODs tell me the option of refractive surgery options has been a win:win situation for their office and patients. It definitely has been a win:win situation for my office and patients. > Now, I tell them they have one more option, "refractive surgery". I > discuss the pros/cons, risks/benefits, and potential complications of > all of their options and ultimately let them decide as long as they > are a good candidate. Does this imply that a refractive surgeon is employed within the practice? Or do you offer the patient a choice from a menu of outside surgeons? Or do you let the patient choose from the yellow pages? DrG >> Now, I tell them they have one more option, "refractive surgery". I >> discuss the pros/cons, risks/benefits, and potential complications of [quoted text clipped - 3 lines] >Does this imply that a refractive surgeon is employed within the >practice? No, there is not. >Or do you offer the patient a choice from a menu of outside >surgeons? It never really comes up that way. It typically goes like this (this is a very condensed synopsis -- a lot of details are left out, I can go into more depth if desired): The patient states he is interested in refractive surgerym and some ask me if I personally do that here. I tell them, no I am not a surgeon, but I have been referring to a particular refractive surgeon since 1995 and I have nothing but the utmost confidence in skills and ability. I then tell the patient that this surgeon did my father (also an OD), my sister (office manager in the practice), my uncle and brother-in-law. They then state they would like to obtain a refracticve surgery consultation at this surgeon's office. > Or do you let the patient choose from the yellow pages? I have never had that come up -- where my patient chose a refractive surgeon on his own and then wanted me to comanage with him. I don't know if I would be comfortable doing that. > Now, I tell them they have one more option, "refractive surgery". I > discuss the pros/cons, risks/benefits, and potential complications of > all of their options and ultimately let them decide as long as they > are a good candidate. When you say "good" candidate, does this imply that all are candidates, but that there are varying degrees, such as bad, good, and excellent? I assume that you do pachymetry and infrared pupillometry. But, do you also have an Orbscan so that you can detect forme fruste keratoconus? DrG >> Now, I tell them they have one more option, "refractive surgery". I >> discuss the pros/cons, risks/benefits, and potential complications of >> all of their options and ultimately let them decide as long as they >> are a good candidate. > >When you say "good" candidate, does this imply that all are candidates, No. I have quite a few patients who want (or think they want) refractive surgery, but are poor candidates. Others still are definitely NOT candidates period. >but that there are varying degrees, such as bad, good, and excellent? Some candidates are good, while others are excellent. >I assume that you do pachymetry and infrared pupillometry. No I do not. They are done at the refractive surgeon's office at that consultation appointment. >But, do you also have an Orbscan so that you can detect forme fruste >keratoconus? No I do not. That, along with standard corneal topography, is done at the refractive surgeon's office at the consultation appointment. FWIW, I have had only one patient out of the two-to-three hundred patients I have comanaged be rejected because of suspicious Orbscan results. I have had only two patients that have been rejected because of thin corneas -- and I warned them prior to going down there that was a distinct possibility. And I have had one or two patients that the procedure was changed from LASIK to PRK because of suspicious topography. > >> Now, I tell them they have one more option, "refractive surgery". I > >> discuss the pros/cons, risks/benefits, and potential complications of [quoted text clipped - 32 lines] > And I have had one or two patients that the procedure was changed from > LASIK to PRK because of suspicious topography. Well, then -- and I am sure you saw this coming -- on what basis do you advise your patient that s/he is a "good" candidate if you don't perform the required tests? DrG [snip] >Well, then -- and I am sure you saw this coming -- on what basis do you >advise your patient that s/he is a "good" candidate if you don't >perform the required tests? When I tell a patient they are a good candidate, it is based on the examination and tests I am able to perform at most office. I tell them something along the lines of, "Everything looks like you would be an excellent candidate for refractive surgery. We can set up an appointment for you down there where they have to do a few extra tests to make sure your corneas aren't too thin, and your corneas don't have an unusual appearance." I do things like make sure the patient has realistic expectations, a stable refraction, no obvious ocular contraindications, is within the range for refractive surgery, determine final result goals (distance vision OU or monovision), perform the cycloplegic refraction and dilated fundus examination, etc. This arrangement seems to work out well for our office and our patients. Financially, an Orbscan doesn't make good business sense for our office. We wouldn't use it enough to cover the lease payment -- so when it is needed to be performed, it is done elsewhere. The same thing goes for fundus photography, objective optic nerve imaging (e.g., HRT), objective retinal nerve-fiber layer imaging (e.g., Stratus OCT, GDx VCC) and pachymetry. For my glaucoma patients/suspects (I am one of the few ODs in the state of CA who have their glaucoma certification), I have those tests perfomed elsewhere and have the results sent back to me where I do the interpretation. (Well, I suppose we could afford a pachymeter, but when they are having stereo optic nerve photographs, HRT, and GDx VCC performed, it is no big deal to have CCT measured at the same time.) > [snip] > [quoted text clipped - 6 lines] > tests to make sure your corneas aren't too thin, and your corneas > don't have an unusual appearance." It would appear then that your co-management fee is earned primarily for the post-op visits? I find it really amazing that you are one of the few OD's in California with glaucoma certification. What's the problem out there? Let me guess: HMO's. DrG >> [snip] >> [quoted text clipped - 9 lines] >It would appear then that your co-management fee is earned primarily >for the post-op visits? Yes. We charge a standard eye exam fee for a pre-op examination. If the person is wearing contact lenses, there may be more pre-op visits to make sure the cornea and the refraction is stable. We then perform, at a minimum, the following post-op examinations: 1 day, 1 week, 1 month, 3 month and 6 month follow-ups. Any other follow-ups either the patient or I require (up until 1 year) is included in the post-op surgical fees. This does not, however, pay for visits unrelated to the surgery -- for example, if the patient come in 3 months after surgery with a subconjunctival heme or a PVD, that would be billed to insurance or fee-for-service. >I find it really amazing that you are one of the few OD's in California >with glaucoma certification. What's the problem out there? The unrealistic glaucoma certification law/requirements that ODs are required to treat. TPA certified ODs have to comanage (with an ophthalmologist) 50 glaucoma/glaucoma suspect patients within the course of two-years. After that is completed, then as an OD you are permitted by law to treat POAG only in people >18 years of age with a maximum of two topical medications. This ends up being overly burdensome for the vast majority of California ODs for the following reasons: Finding 50 glaucoma patients/suspects within 2 years in the context of HMOs, finding cooperative ophthalmologists, and the logistical burden of going back and forth between two doctors offices. Also factor in the fact that some patients might not like to be comanaged by someone who is not yet glaucoma certified. When I got my glaucoma certification back in October, there were, depending on who I talked to (pharmacetical rep vs instructor at SCCO) there was anywhere between a handful and 40 of us. Other problems: o Brand new graduating ODs are not immune from this requirement. They too must go through this. o Glaucoma certified ODs are not permitted to comanage with non-glaucoma certified ODs. IMHO, what it came down to is this: Ophthalmology realized they had to give us a glaucoma law. Too many other states have it and their excuses for not giving it to us would have been seen for what it was -- political rather than real concern for public health. If they would have flat-out refused, I believe the legislators would have given us a blank piece of paper and said "Go ahead and write up your law." So Opthalmology wrote up the most restrictive law they could that would still look like they were making a "good faith effort". If Optometrists would have complained the law was too difficult, I believe the legislators would have said "Forget it then. You get no law." Although the law is clearly overly burdensome for the vast majority of ODs in the State, I had to "suck it up" and "jump through the hoops". The reasons I felt this way were: 1. As a VA-residency trained OD, I feel I must be leading the way in Optometry. I am not content to be an average or mediocre Optometrist. 2. I believe my patients expect me, and I owe it to them, to be the best-trained and able to practice Optometry to the full-extent of the law, to differentiate me from Joe Blow, OD down the street. 3. In order to give credibility when California Optometry attempts their next scope-of-practice expansion. If CA ODs go to the legislators for a new scope of expansion and no ODs are glaucoma-certified because it is "overly burdensome", organized Ophthalmology will be right in there saying, "They don't need another scope-of-expansion bill. They can't even get what we already gave them." For more details on the law, see <http://www.optometry.ca.gov/laws_regs/2006lawbook.pdf>; in particular, p.182-184. >Let me guess: HMO's. HMOs are a huge barrier to ODs doing anything in the state of CA besides routine comprehensive eye examinations. I would guess easily 50% of my patients have HMOs for their medical insurance. > I find it really amazing that you are one of the few OD's in California > with glaucoma certification. What's the problem out there? Let me > guess: HMO's. No, the o.m.d.s lobbied to make the requirements so tough as to be almost impossible for the average o.d. (50 glaucoma patients managed "under" an o.m.d. for 2 years, plus the normal c.e. stuff. w.stacy, o.d. > (Well, I suppose we could afford a pachymeter, but when they are > having stereo optic nerve photographs, HRT, and GDx VCC performed, it > is no big deal to have CCT measured at the same time.) Any optometrist who claims to be able to detect or manage glaucoma should have a pachymeter. You just have no clue what your IOP readings mean if you don't know the corneal thickness. w.stacy, o.d. >> (Well, I suppose we could afford a pachymeter, but when they are >> having stereo optic nerve photographs, HRT, and GDx VCC performed, it >> is no big deal to have CCT measured at the same time.) > >Any optometrist who claims to be able to detect or manage glaucoma >should have a pachymeter. "Should" is subjective and debatable. What does "should" mean? Any optometrists who claims to be able to detect or manage glaucoma does not need to own an pachymeter. Any doctor who claims to be able to detect or manage glaucoma needs to know a patient's central corneal thickness. And, in 6/2006, I need to know that exactly ONE time. And as I wrote above, and in the earlier post (look up there -- it's still there and you even quored it), I have CCT measured on all my glaucoma patients/suspects at the same time I have optic nerve/retinal nerve fiber layer photographs, optic nerve and retinal nerve fiber layer imaging/analysis done offsite. Pachymeters cost around $2K I recall. Insurance reimburses about $20 for CPT code 92154. Financially, a pachmeter doesn't make fiscal sense to our office, so when we need it done, it is done offsite. >You just have no clue what your IOP readings mean if you don't know >the corneal thickness. Where in the world did you get the idea that I am unaware of that? And even so, as a "blanket statement", that is false. I know that a patient with useful vision and IOPs of 45 is too high, regardless of their CCT. Certainly one also needs to know if their form of tonometry is impacted by varying CCTs -- Goldmann is, Pascal dynamic contour is not. CCT is, according to the OHTS study, an *independent* risk factor for glaucoma even after adjusting for its impact, on say, Goldmann tonometry. Nevertheless, every glaucoma patient or suspect that I work up has CCT meausured and I use that risk factor in their diagnosis and management. >CCT is, according to the OHTS study, an *independent* risk >factor for glaucoma even after adjusting for its impact, on say, [quoted text clipped - 4 lines] >management. > You agree thin corneas are a risk factor, but you don't measure it. The only people getting pachymetry are your glaucoma patients or "suspects". But you have lots of patients with thin corneas that you will never know are "suspects" because you chose not to invest in what has become standard of care in optometry. I think pachymetry is perhaps more important than tonometry for early glaucoma detection. w.stacy, o.d. Also, a lot of "borderline" glaucoma suspicions can be eliminated by pachymetry. Very often I get an eyebrow-raising Goldmann tonometry of 22 but then measure 620 mu corneas. The eyebrow relaxes. But I also see a lot of people with 16 mm Goldmann and around 440 mu corneas. Up go the eyebrows again... w.stacy, o.d. >>CCT is, according to the OHTS study, an *independent* risk >>factor for glaucoma even after adjusting for its impact, on say, [quoted text clipped - 5 lines] >> >You agree thin corneas are a risk factor, but you don't measure it. Yes I do, but not on every patient. >The only people getting pachymetry are your glaucoma patients or >"suspects". Correct. And refractive surgery candidates. >But you have lots of patients with thin corneas that you will never >know are "suspects" Thin corneas, in and of themselves, are a risk factor, and do not, in and of themselves, make a patient a glaucoma suspect. IOW, I do not have any patients where I look at that patient and think, "If this person has thin corneas, they would be a glaucoma suspect, but if they had thick corneas, they would not be a glaucoma suspect" that does not get a glaucoma workup. According to the OHTS, PSD is a risk factor for glaucoma. Do you perform threshold perimetry on every patient? >because you chose not to invest in what has become standard of care in >optometry. Pachymetry is not (yet) the standard of care in routine comprehensive eye examinations for eyecare practitioners in 6/2006. See <http://www.aao.org/education/library/ppp/upload/Comprehensive_Adult_Medical_Eye_ Exam.pdf>. In particular, from page 7 (emphasis mine): Based on the patient's history and findings, addiitonal tests or evaluations might be indicated to evaluate a particular structure of function. There are *not routinely part of the comprehensive medical eye evaluation* and include the following: [...] Measurement of corneal thickness Likewise, feel free to see what MediCare, VSP, Medical Eye Services, etc. consider and require to be part of a comprehensive eye examination. You won't find pachymetry there. You are holding Optometry to a higher standard-of-care than Ophthalmology holds itself. >I think pachymetry is perhaps more important than tonometry for early >glaucoma detection. It may very well be, but (attempting) tonometry *is* the unquestionably the standard of care in routine comprehensive eye examinations. And, it should be obvious from this discussion, that *I* do care more about knowing tonometry on every patient than knowing their CCT. I rely on my optic neve and retinal nerve fiber layer examination for ruling out glaucoma (suspects) far more than I do tonometry. >>You agree thin corneas are a risk factor, but you don't measure it. > > Yes I do, but not on every patient. I thought you didn't own a pachymeter. >>The only people getting pachymetry are your glaucoma patients or >>"suspects". [quoted text clipped - 6 lines] > Thin corneas, in and of themselves, are a risk factor, and do not, in > and of themselves, make a patient a glaucoma suspect. I think they do. Anyone with less than 500 mu corneas is a glaucoma suspect, in my book. > According to the OHTS, PSD is a risk factor for glaucoma. Do you > perform threshold perimetry on every patient? I used to, but it became tiresome with very low returns and of course is quite subjective. But pachymetry is a 30 second, completely objective test that only needs to be done once unless the patient has lasik. >>because you chose not to invest in what has become standard of care in >>optometry. > > Pachymetry is not (yet) the standard of care in routine comprehensive > eye examinations for eyecare practitioners in 6/2006. Maybe, but it will be, and very soon. Why don't you cough up the 3 grand or whatever and get on with it? > You are holding Optometry to a higher standard-of-care than > Ophthalmology holds itself. Duh. Always have. Always will. It's a bar that's set pretty low... > I rely on my optic neve and retinal nerve fiber layer examination for > ruling out glaucoma (suspects) far more than I do tonometry. That's a good first step, whoever you are. w.stacy, o.d. > The same > thing goes for fundus photography, objective optic nerve imaging [quoted text clipped - 3 lines] > their glaucoma certification), I have those tests perfomed elsewhere > and have the results sent back to me where I do the interpretation. Very interesting. My OD does fundus photography and VF testing, and I can't help having the feeling that I ended up as in the "rule out glaucoma" category than I would have if he didn't have that equipment. Once, I actually could have argued a bit. The office scheduled a second appointment for me for VF testing and fundus photos, as I have lare cups. I resisted a bit, not thinking it necessary--I came in to the original appointment with a decade-old fundus photo, and the doc observed no change in his direct exam, and my IOP was fine, but the doc insisted it was necessary, so I did it. On the way out the door of the second exam, they receptionist told me I needed to contact my PC for approval. I didn't like the idea of requesting approval for a procedure already done. As it occurred in a second visit, real preapproval certainly could have been arranged. In addition, when a specialist in my area does a test or procedure that requires preapproval, my experience is that the office handles all the paperwork and approval solicitations, and I don't see a reason why the OD's office should dump the paperwork on the patient. Push came to shove, I never called my PC, figuring that the office would call me if it were necessary, or they could absorb the added administrative cost of calling on their own. Also, I really dislike the way the OD walks me right from the exam chair to his optical shop. I prefer using a shop that I have access to for extended hours and on weekends, and I was placed in a situation where I would have felt guilty not having my work handled by his business-hours only internal shop. Also, from the deal my wife just got at Pearle (recommended by her ophth!), it seems they get a better deal from my insurance company than my OD shop does-- $60 off the top, and %50 off the lenses! Come to think of it, maybe I should consider changing my OD!  SignatureScott Reverse name to reply > 7 year old girl with the following prescription: > [quoted text clipped - 9 lines] > lens intolerant. Without proper intervention, the possibilty of > amblyopia, poor/non-existant stereopsis, etc. is high. Some years back, the guy down the hall from me had cataract surgery. I talked to him, and he said if contacts didn't work, then the HMO would do refractive surgery without cost to him, as a medical necessity. SignatureDan Abel dabel@sonic.net Petaluma, California, USA > Wow. Since when is cataract surgery entirely elective? The end result > of a cataract is loss of visual function. I agree. Blindness is not an acceptable condition. Having said that, I knew a woman who didn't want the knife. She couldn't see the signs on the freeway, but she was going to wait until they had a "laser" surgery to fix her cataract. I suggested that it wasn't going to happen, but she chose not to hear about it. I suspect that she didn't pass her next DMV exam, but she retired so I don't know what happened. SignatureDan Abel dabel@sonic.net Petaluma, California, USA >> Wow. Since when is cataract surgery entirely elective? The end result >> of a cataract is loss of visual function. > >I agree. Blindness is not an acceptable condition. Acceptable to whom? >Having said that, I knew a woman who didn't want the knife. She >couldn't see the signs on the freeway, but she was going to wait until >they had a "laser" surgery to fix her cataract. I suggested that it >wasn't going to happen, but she chose not to hear about it. I suspect >that she didn't pass her next DMV exam, but she retired so I don't know >what happened. So to her, blindness was an option. Thank you for making my point for me. |
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