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Medical Forum / General / Vision / July 2006dark / blindspots appearing in my vision...
Hello, I wanted to explain a situation I am experiencing and see if anyone had any ideas as to what may be taking place. About 10 weeks ago I was reading a book and first noticed that in the periphery of my vision in my right eye, when I blinked there was a dark spot. A split second later it was pretty much gone. At every blink. Higher up and still off center in my vision I saw three colored lines for a split second after I blinked as well - as if I had just looked at three bright lines of light and this was the after image. Shortly thereafter, I went to my optometrist and he examined my eyes having heard my story. Retina and all else looks fine. Now, 4-5 days ago I noticed a new dark spot - kind of a little slash shape that is JUST off center of my vision. Same eye. I started trying to evaluate what was going on and noticed that if I close my left eye and read a line w/ my right, a little blank spot could be shown as a letter one line down and a few over to the right was gone. So it is a blind spot that appears dark for a instant and then goes away somewhat. I have concluded that it is missing vision and after the instant of the dark spot after each blink, my mind fills in the missing info with the surrounding field color and so it "goes away." If this had been a fraction up and to the left, my right eye would be unable to see the letter it is looking at in a book. That small blindspot would make me rely on my left eye for reading. Obviously, this is disturbing so I went to the optometrist again. He did an exam and all looks fine. He is fitting me in for a field test where they use dots of light to determine just where you blind spots are. Depending on that he may want to issue an MRI, etc. He said could be an optic nerve issue - I asked what and he mentioned a few conditions like Lyme disease, etc. I should add that on and off for the past 5 years I've had little flashes of light appear - as if I am seeing the afterimage but not the causal flash of a bright light - then go away. Seen eye doc several times about it - again, all always looked ok. Never found out what was causing that. Also, I had an MRI for disiness about 4 years ago and nothing odd found. I am on meds for blood pressure (25mg atenolol) and cholesterol (zocor) and acid reflux (prevacid). I am a 34yo caucasian male. Anyone have any suggestions? I thought I may as well try to find something out as I wait for the next step (that field test), hoping no more spots appear. I assume these spots are permanent, whatever happens...? Thanks. bp I'd want a retinologist to take a look. Unless your o.d. is VERY good and used scleral indentation all the way around, not every part of your retina has been examined. Very few o.d.s and non-retinologist o.m.d.s do this type of exam regularly. Could be you've just had a little hemorrhage, but could also be a little peripheral retinal break (tear). w.stacy, o.d. Blake Patterson wrote: >Hello, > [quoted text clipped - 55 lines] > > It seems the couple of retinology practices I called just now only take doctor referrals. I have the field test on Thursday (7 days from now) and I don't think I talk to the doc (about results) until another apt, so likely the following week. I wonder if 12-14 days is too long to wait? Two docs did a "normal" retinal eval in the last 2 months. Years ago I did have an examl like the one I think you speak of - where they press the eyeball all the way around to get a better look at the retina. (All was fine) Hmm. bp > I'd want a retinologist to take a look. Unless your o.d. is VERY good > and used scleral indentation all the way around, not every part of your [quoted text clipped - 65 lines] > > > > On 6/30/06 11:22 AM, in article oZdpg.111324$H71.44985@newssvr13.news.prodigy.com, "William Stacy" <wstacy@obase.net> wrote: > I'd want a retinologist to take a look. Unless your o.d. is VERY good > and used scleral indentation all the way around, not every part of your [quoted text clipped - 3 lines] > > w.stacy, o.d. Interesting. I, as well as most of the general ophthalmologist colleagues in my Kaiser group, are adept at scleral depression. Not only do we see a lot of peripheral retinal tears, but most of us also laser them, including doing laser indirect ophthalmoscope treatment, or (old-fashioned) cryopexy if needed. If we sent all the flashes and floaters to our retina specialist, there would be not time left to do Mcugen/Avastin/Kenalog injections, pneumatic retinopexy, retinal/vitreous surgery, etc. We also treat, ourselves, A lot of diabetic retinopathy and diametic macular edema. I also do YAG laser cyclodestruction if needed for recalcitrant glaucoma. Guess we seem to do more than a lot of other o.m.d's? David Robins, MD Board certified Ophthalmologist Pediatric ophthalmology and adult strabismus subspecialty > I, as well as most of the general ophthalmologist colleagues in my Kaiser > group, are adept at scleral depression. Not only do we see a lot of > peripheral retinal tears, but most of us also laser them, Wow. most omds I know refer such cases to the vitreoretinal group (in sacramento) which stays very busy indeed. Glad to hear that kaiser docs are so versatile. My own mother had a retinal tear during cataract surgery by a doc (not kaiser) who also had an "interest" in retina. Several attempts by him to repair it failed, and she's not quite blind enough in that eye to avoid constant diplopia without an opaque contact lens. I confess to a bias in favor of sub-specialists... w.stacy, o.d. >On 6/30/06 11:22 AM, in article >oZdpg.111324$H71.44985@newssvr13.news.prodigy.com, "William Stacy" [quoted text clipped - 12 lines] >I, as well as most of the general ophthalmologist colleagues in my Kaiser >group, are adept at scleral depression. I too, like Dr. Stacy, believe that you guys would definitely be in the minority. The vast majority of ODs I have spoken to are not comfortable and do not perform indirect ophthalmoscopy with scleral depression on patients who need it (i.e., patients with signs/symptoms of acute PVD/RD). Most are also clueless that it is the "standard of care" for such patients. (In my case, I found binocular indirect ophthalmoscopy with scleral depression to be the most technically difficult skill I ever had to learn in Optometry school by far. It took me months of performing it before I started to feel comfortable doing it.) This has likewise been the case with most of the general OMDs I have dealt with in private practice in SoCal. Especially the busier ones. >Not only do we see a lot of peripheral retinal tears, but most of us >also laser them, including doing laser indirect ophthalmoscope >treatment, or (old-fashioned) cryopexy if needed. If we sent all the >flashes and floaters to our retina specialist, there would be not time >left to do Mcugen/Avastin/Kenalog injections, pneumatic retinopexy, >retinal/vitreous surgery, etc. There are some OMDs around here that will do PRP or laser surgery for small retinal tears. I don't know of any who will do cryopexy (routinely). >We also treat, ourselves, A lot of diabetic retinopathy and diametic macular >edema. I also do YAG laser cyclodestruction if needed for recalcitrant >glaucoma. Don't know of any private practice OMDs around here that routinely do grid or focal laser for DME. Most OMDs around here will do a simple trabeculectomy, but for anything more than that -- say a Molteno or cyclodestructive procedures -- will be turfed off to a glaucoma sub-specialist. None do pediatrics either -- say even something as simple as congenital nasolacrimal duct obstruction surgery. Most aren't comfortable enough with a direct gonioscope and won't do something like a goniotomy for infantile glaucoma. >Guess we seem to do more than a lot of other o.m.d's? I bet it's just due to your mode of practice. OMDs with slower private practices may do more. Those general OMDs with busier practices seem to do less sub-specialty work. I have never dealt with you personally, but since you work at KAISER I was hoping you might be able to shed a little light on the following: In my experiences, I have noted that KAISER MDs are notoriously horrible at writing follow-up or progress reports. I have referred dozens of my patients back to their KAISER MDs for medical problems that came up during their "well vision" exams -- problems such as retinal detachments, diabetic retinopathy, papilledema, hypercholesterolemia, carotid bruits, basal cell carcinomas, cataracts, congenital nasolacrimal duct obstructions, strabismus, amblyopia, headaches, otitis media, HZO, hypertension, bacterial keratitis, etc. I typically write referral letters including their complaints, pertinent results of my examination, my recommendations and the recommended time frame for examination. I ask the patient the name of their KAISER MD and address it specifically to them. I have gotten ZERO follow-up reports from KAISER MDs -- not even one. So I end up chasing around patients asking them "Were you ever seen" for their problems to which they will say "No" or "Yes. Didn't you get a letter back from my KAISER doc?" Do you find this to be typical among your colleagues at KAISER there that they do not write reports back to their referring outside health care practitioners? In the private practice world, there is financial incentive to write follow-up letters. Doctors that don't write back follow-up letters to patients referred to them for problems find themselves not getting my referrals anymore, but KAISER patients are essentially a captive audience. However, there is also something called professional courtesy also that states that when a doctor refers you a patient you respond back with a thank you and you state the results of your exam and what was done. Are my experiences with KAISER MDs/OMDs in these cases also atypical? On 7/1/06 8:56 AM, in article l83da213l20u83fkeit25igrq949rfpeg5@4ax.com, >> On 6/30/06 11:22 AM, in article >> oZdpg.111324$H71.44985@newssvr13.news.prodigy.com, "William Stacy" [quoted text clipped - 95 lines] > > Are my experiences with KAISER MDs/OMDs in these cases also atypical? Most of the Kaiser docs I know do most of the procedures I discussed. Although I don't, many do office blepharoplasties and other lid procedures for ectropion or entropion, minor basal cell excisions, puntoplasties, pterygium surgery, etc. This reduces the load on the subspecialist oculoplastics people. The retina work we do keeps the retianl person able to handle real retina work. Argon laser trabeculoplasty, and now SLT is done by the generalist. Some real comprehensive ophthalmologists also do horzontal strabismus surgery in older children trhoug adults. All depends what their interests and skill sets are. No, I think that except for a short occasional note back, most do not send notes back. The problem is, we have very little support staff. I have 1 medical assistant, who is really working hard to keep the rooms filled, schedule followups, check on failed appointments, schedule surgery, handle patient messages, etc. I'm also rather busy - besides the patients, and now going into electronic charting (which adds a lot of time) I read diabetic screening photos and fill out patient cards and record the info electronically, do IOL calculations, read fluoresceins and fields. Guess when I get to do that? After patients end, until I leave about 7:30 pm or later. Doesn't leave a lot of time to dictate a formal letter back. For that I have to apologize. As you rightly point out, it is a captive audience, and no real financial incentive to write letters to get more patients. The occasional pt I get from outside, if it is something interesting, or misdiagnosed, I do try to get back. Sometimes I call if the diagnosis really was out of line. I get perhaps one outside referral every few months. Even getting information back to the referrring general ophthalmologist or pediatrician regarding strabismus cases they have sent me used to be a problem. However, I developed a strabismus database that I now use in real-time when seeing patients, as the electronci medical record customized for strabismus. I can generate a "form" letter which exctracts a lot of information from the exam and history I did, and formats it in letter form. By touching one button, and then print, I get the letter to the front desk, sign it, and it can be sent. BTW, although I am a pediatric ophthalmologist, I don't do direct gonios or glaucoma/Molteno surgery on infants. That IS best left to the few pediatric glaucoma specialists. Most general glaucoma specialists won't touch them either. [snip] >I'm also rather busy - besides the patients, and now going into electronic >charting (which adds a lot of time) I read diabetic screening photos Thanks... I had a couple more questions/comments if you don't mind: 1. Recently, I have had quite a few KAISER patients who have been diabetics (mostly type II) for many years tell me that their annual "diabetic eye exam" now consists of a non-mydriatic posterior pole fundus photograph. These photographs are then sent to an OMD for evaluation and diabetics are now only seen for physical examinations by an OMD if these photographs demonstrate retinopathy. IOW, yearly routine dilated fundus examinations by an eye doctor are apparently not the standard of care at KAISER. Is that true? 2. Do you think, in the long run, that electronic charting will end up taking less time for you personally than paper charting? [snip] On 7/1/06 11:05 PM, in article 7onea2dhpeh6k693rkq7gpilru5bhgp3mm@4ax.com, > [snip] > [quoted text clipped - 11 lines] > routine dilated fundus examinations by an eye doctor are apparently > not the standard of care at KAISER. Is that true? YES. This means of screening (screening for disease) has been shown to be effective. Better than not getting any screening, which was was happening when the only means was a dilated exam, which was inconvenience and hard to schedule for some. In addition, the load of diabetics is so large that the majority were not getting screened regularly. We now screen (between photos and dilated exam) at least 80% of the diabetics, a large step up from before. Almost all diabetics will show disease in the range of the photos well before they need care. Whether or not there are some microaneuryms peripheral to the field of the photos is almost a not issue, since they are not treatable. In addition, it has been shown in studies that if there is no retinopathy, and the pt is is reasonable control, two years can elapse between screenings, as it is very rare to have treatable disease by that time. In this way, most people get adequate screening. Once any background disease is seen, screening is stepped up to at least once a year. I am amazing how much more I can see more on a photo than during an indirect exam supplemented by a 90D exam in selected areas. We used to use Polaroid photos, now digital photos on our computers. I can blow up and maniplulate photos as needed, and is is less common to overlook early disease on a photo than on an office exam these days. If it is more severe, then they stop having photos and get office dilated exams. It has greatly reduced seeing pts coming in with a surprise of advanced background or proliferative disease that had gone undetected. Some pts still manage avoid screening by either not responding to appt requests, or cancelling and not rescheduling. This coupled with the internists getting a better ahndle on our pts labs electronically has also reduced the numbers of pts who were out of control, and had fallen through the cracks by not following up with their doctor. The system helps find these pts. > 2. Do you think, in the long run, that electronic charting will end > up taking less time for you personally than paper charting? I'm not sure it will take less time. It will make records accessible (no lost charts or charts out to someone else) and certainly legible. I'm told that long-term there is still about a 10% time penalty involved in EMR over paper charts. The other thing is, it is easy to hand-draw (retina, corneal lesions, etc) in a paper chart, a lot harder in an electronic chart. It is still a feat to get fields, photos, etc into the electronic record, and be able to access them easily. The Fed is pushing for EMR's for everyone soon. Aside from some smaller offices that have systems. I believe Kaiser is the first to have such a huge system. It has been many years in the making, since it is on such a grand scale. We have had some pieces of it for years - I have instant electronic access to labs, x-rays, ekg's, and a list of diagnoses since 1995, as well as the preventive health prompts (when due for diabetic testing, labs and tests of other types). This means I can look at a long-term trend easily. It also means that if the chart is not available, I still have something to go by. Ut, pretty soon, it will all be electronic, mandated from our CEO who feels that electronic records are part of the key technology for the future success of good medical care. The only way electronic charting can be faster is by customization of form records, and the use of shortcuts, which each doctor does according to their style. Trouble is, these are not yet customizable down to the subspecialty level, but will be getting there. My particular database for strabismus that I described is not part of the Kaiser system (yet). >On 7/1/06 11:05 PM, in article 7onea2dhpeh6k693rkq7gpilru5bhgp3mm@4ax.com, > [quoted text clipped - 18 lines] >when the only means was a dilated exam, which was inconvenience and hard to >schedule for some. I certainly agree with the *last* statement. The one prior to that does not reflect what I have been told by local retinal specialists, endocrinologists and what I have read in the literature. I will have to investigate that. [snip] >Almost all diabetics will show disease in the range of the photos well >before they need care. [...] >In addition, it has been shown in studies that if there is no >retinopathy, and the pt is is reasonable control, two years can elapse >between screenings, as it is very rare to have treatable disease by >that time. In this way, most people get adequate screening. I would imagine these arguments and policy were debated by some at KAISER. They certainly don't reflect the recommendations of the AAO's PPP for DR. >I am amazing how much more I can see more on a photo than during an >indirect exam supplemented by a 90D exam in selected areas. We used to >use Polaroid photos, now digital photos on our computers. I can blow >up and maniplulate photos as needed, and is is less common to overlook >early disease on a photo than on an office exam these days. This is certainly true. I have picked up things in fundus photos that I missed during fundus examinations and visa versa. I wouldn't want to manage my glaucoma patients without both periodic optic nerve (stereoscopic)/retinal nerve fiber layer photographs and actual fundus examinations. [snip] Once again, thanks for taking the time to respond. On 7/2/06 7:50 AM, in article fvlfa2dhkp971k2r01ru7m941pftrvstg3@4ax.com, >> On 7/1/06 11:05 PM, in article 7onea2dhpeh6k693rkq7gpilru5bhgp3mm@4ax.com, >> [quoted text clipped - 57 lines] > > Once again, thanks for taking the time to respond. A lot of the AAO recommendations are based on historical opinion of ophthalmologists, rather than evidence based medicine (the new catchphrase). It is also based on traditional practice patterns (once a year ...). My understanding is that there is sufficient evidience in the literature to support a q2 years screening protocol (a large study in Britain??) I believe Kaiser also reviewed a huge number of records and did its own study. The capture of medical information in the system makes research projects like that easier than in other venues. We have been doing this for a number o years now, and even I must say I am impressed with the success. Retinologists always want patients back in 1 year - it is traditional. For example, even after a long-healed retinal tear, they recommend a yearly exam with them eve IN THE ABSENCE OF ANY NEW SYMTPOMS. Yield is close to zero, and eats up a lot of time that could be better used serving those who need it. Medicine is not a bottomless well. There is only so much manpower to go around, and needs to be put to use where it will do the most good for the greatest number of people. Or else the system fails (lots of HMO's have folded over the years). I just found out that these spots are almost certainly hypertensive retinopathy. I have been on 25mg/day of Atenolol to control bp. It's been doing its job for a few years - home and office readings in range. But I've gained 15-20lbs and stopped execising (new baby) for past few months and took bp a few days ago - it was 143/95. I've taken readings for last 48hrs and the diastolic has been averaging around 90 and just now I got a 151/107. Clearly I need to get under control with adjusted meds - and then longer term exercise, sodium control, etc. Will see doc tomorrow. On phone he suggested 2x 25mg/day to start. Hopefully - if this was the cause of these spots - new spots will not appear once bp under control again. bp > On 7/2/06 7:50 AM, in article fvlfa2dhkp971k2r01ru7m941pftrvstg3@4ax.com, > [quoted text clipped - 79 lines] > greatest number of people. Or else the system fails (lots of HMO's have > folded over the years). Folllowing to my last post... Opthalmologists out there - tell me, if these spots ARE hypertensive retinopathy, would that have been visible in a standard retinal exam? Thanks. bp > I just found out that these spots are almost certainly hypertensive > retinopathy. [quoted text clipped - 99 lines] > > greatest number of people. Or else the system fails (lots of HMO's have > > folded over the years). >tell me, if these spots ARE hypertensive retinopathy, would that have >been visible in a standard retinal exam? If the retinal exam was thru a dilated pupil and using indirect ophthalmoscopy (via a binocular head-mounted *and* slit-lamp fundus lenses), hypertensive retinopathy that would cause visual complaints (e.g., retinal hemorrhages, nerve fiber layer infarcts) is typically quite obvious. Through an undilated pupil, these can be easily missed. <rant> Every eye doctor should check blood pressure routinely and make it an intregal part of every eye examination, as much as checking visual acuities, intraocular tensions and pupils. Undiagnosed hypertension is a huge public health problem and I routinely find people with elevated blood pressure readings who I refer to their internist and get put on hypertensive medications. Optometrists could learn a lot from the medical model where one looks at the patient as a whole, but specializes on the eyes rather than merely thinking of a patient as a pair of eyes. </rant> > Optometrists could learn a lot from the medical model where one looks > at the patient as a whole, but specializes on the eyes rather than > merely thinking of a patient as a pair of eyes. And many of us do. We recently had an interesting discussion on our private forum about this very issue. I, for example, check BP on many patients---targeting those whose medical or family history, presenting complaints, or my observations indicate a possible risk. An example from my office: Two weeks ago patients comes in for "routine" contact lens check up. History indicates previous hypertension. He has a few sub-conja hems and states he hasn't taken his meds for a year or so because he feels fine. BP was something like 180/120. Off to the MD for him. Another: Woman with recent history of repeated sub-conja hems concerned about it. My questioning turns up headaches, ringing in the ears, dizziness. BP was around 220/160 or higher. Stopped exam and had her driver take her to the ER (faster than 911/paramedics from my office) where she was admitted to ICU on the verge of a stroke. She's well now. </rant> LB, O.D. >> Optometrists could learn a lot from the medical model where one looks >> at the patient as a whole, but specializes on the eyes rather than >> merely thinking of a patient as a pair of eyes. > >And many of us do. I realize some do. And I was writing as a fellow OD myself. I just don't think the majority of us do. >We recently had an interesting discussion on our private forum about >this very issue. I, for example, check BP on many patients--- >targeting those whose medical or family history, presenting >complaints, or my observations indicate a possible risk. Why don't you check blood pressure routinely as part of your eye examinations? Lots of articles in the literature argue that all health care practitioners should routinely screen blood pressure, not merely based on family/patient history, complaints, signs or symptomology. >An example from my office: Two weeks ago patients comes in for >"routine" contact lens check up. History indicates previous [quoted text clipped - 7 lines] >driver take her to the ER (faster than 911/paramedics from my office) >where she was admitted to ICU on the verge of a stroke. She's well now. ***A real life example from my office: On 06/01/2006, patient D.R., a 29 year old Caucasian gentleman was seen in our office with the chief complaint of it being hard to see with his current RGPs. Patient felt fine, medical history was unremarkable and he was not taking any medications. Corrected visual acuities with the contacts were OD 20/30 and OS 20/30. Blood pressure was 230/150 in the right arm, seated, @ 16:14. Repeat blood pressure reading was 230/140 in the left arm, seated, @ 16:16. Indirect ophthalmoscopy with a non-contact fundus lens was completely normal. A diagnosis of hypertensive urgency was made. Patient's MD was called, patient was admitted to ER and blood pressure was slowly lowered over the course of a few hours to prevent organ ischemia/hypoperfusion. There was absolutely no symptoms or signs to indicate this hypertensive urgency; it was only picked up as a result of making BP measurement a routine part of every eye examination I do. This patient hadn't been to his family practice MD in years, and it is likely IMHO that if the hypertensive urgency wasn't picked up by me, it would be not been picked up until it progressed to malignant hypertension, which brings me to the next example who was not so lucky... ***Another real life example from my office: On 3/16/2006, patient PT, a 49 year old Caucasian lady presented to my office with the chief complaint of gradually decreasing vision. Symptoms were vague and she was a poor historian. Patient claimed to feel fine edical history was unremarkable and she was not taking any medications. Uncorrected visual acuities were OD CF @ 4' -> PHNI and OS 20/200 -> PHNI. Blood pressure was 220/140 in the right arm, seated, @ 11:18am. Confrontation visual fields revealed a inferior nasal quadrantopia OD. Pupils revealed a grade 1 afferent pupillary defect. Slit-lamp examination was unremarkable. Dilated fundus examination revealed obvious and severe papilledema with diffuse hard exudates, macular stars and retinal hemorrhages. Examination of the fundus periphery revealed Elschnig's spots of choroidal non-perfusion. Patient's internist called and patient admitted to hospital for 2 days to control the blood pressure. Patient came back 04/10/2006 with blood pressure down to 142/88. Visual acuities unchanged, APD still present, but visual field defect no longer present. Fundus appearance essentially unchanged. Pateint returned on 05/25/2006 with blood pressure down to 110/84. Corrected visual acuities now OD 7/400 and OS 20/70. Fundus appearance unchanged. A retinal consult was obtained on 06/01/2006 and retinal specialist diagnosed of subfoveal lipid migration OD, hypertensive retinopathy and hypertensive choroidopathy. IVFA and OCT confirm diagnosis and there is absolutely nothing that can be done medically or surgically to improve her vision. ***Final real-life example: This story was related to me by a fellow OD and it happened a few years ago. Patient came into office with chief complaint of red eye started this AM. Diagnosis of subconj heme made. Slit-lamp and IOPs normal. Undilated fundus exam normal. OD considered checking BP and asked patient when saw Dr. last. Said was there less than 1 week ago and the MD checked BP at that time and it was normal. Because of this OD decided not to check BP and patient was discharged by OD* and told of normal natural course of resolution. Patient didn't feel 100% and was in local pharmacy later that evening and decided to check BP with automated machine. BP was 180/120. Patient told OD a few weeks later that MD was changing asthma medications and as a result of that a hypertensive urgency was iatrogenically created by MD. OD felt like an idiot, patient was lucky and OD was lucky. OD now checks BP on everyone as part of eye exam, even if patient saw MD for physical earlier that day and it was normal. > Why don't you check blood pressure routinely as part of your eye > examinations? Hey, better check for STDs as well. For instance, the clap, you know, can have serious ocular consequences. (Is there anybody doing refractions anymore?) -- Dicky > Why don't you check blood pressure routinely as part of your eye > examinations? You guys don't routinely check blood glucose, but find plenty of pathologies pointing to diabetes. Why don't you routinely do a finger stick for glucose? As a patient, I would say check my blood pressure if a retinal pathology requires hypertension to be ruled out. Otherwise, I would frankly consider it an invasion of privacy. If an OD came at me with a blood pressure cuff, I would ask why, and if I weren't satisfied with the answer, I would not consent. A diagnosis of hypertension can carry some pretty significant insurance ramifications. While MD's take elevated BPs very seriously, they actually think pretty hard before they write down that diagnosis. In my (nonprofessional) opinion, it's not a diagnosis that should appear on an OD's chart, except as a patient-provided history, or when a pathology requires elevated BP to be ruled out.  SignatureScott Reverse name to reply > > Why don't you check blood pressure routinely as part of your eye > > examinations? If a patient has not been to his/her primary care physician within recent memory I certainly do offer to take BP. Routinely. > You guys don't routinely check blood glucose, but find plenty of > pathologies pointing to diabetes. Why don't you routinely do a finger > stick for glucose? If a patient has ocular signs of diabetes and *is not* aware of having the disorder, he/she is immediately referred to a MD for diagnosis and treatment. That is a very rare occurrence. If he/she *is* aware, a report is immediately faxed to the MD. Not to mention a *finger stick* glucose test at the moment is not appropriate for diagnosing diabetes. > As a patient, I would say check my blood pressure if a retinal pathology > requires hypertension to be ruled out. Otherwise, I would frankly consider > it an invasion of privacy. If an OD came at me with a blood pressure cuff, > I would ask why, and if I weren't satisfied with the answer, I would not > consent. Try the other way around. I ask if the patient has had BP checked recently and if not would he/she like to have it done. No invasion there, eh? > A diagnosis of hypertension can carry some pretty significant insurance > ramifications. A diagnosis of untreated, uncontrolled HT can carry some pretty significant ramifications like stroke, heart attack and death. >While MD's take elevated BPs very seriously, they actually > think pretty hard before they write down that diagnosis. In my > (nonprofessional) opinion, it's not a diagnosis that should appear on an > OD's chart, except as a patient-provided history, or when a pathology > requires elevated BP to be ruled out. ODs take elevated BP very seriously. We write down the findings simply as BP readings. We don't diagnosis HT. We refer the person to the MD who has the responsibility for the medical diagnosis and treatment for HT. Most of the time, we look at healthy, normal eyes that need a few diopters of optical correction. LB, O.D. >>While MD's take elevated BPs very seriously, they actually >> think pretty hard before they write down that diagnosis. In my [quoted text clipped - 6 lines] > the MD who has the responsibility for the medical diagnosis and > treatment for HT. What would you write down as the reason for the referral to the PC? SignatureScott Reverse name to reply > >>While MD's take elevated BPs very seriously, they actually > >> think pretty hard before they write down that diagnosis. In my [quoted text clipped - 8 lines] > > What would you write down as the reason for the referral to the PC? A simple report. It would look like this: BP xxx/xxx, date, time, which arm, sitting. Report to: name of MD. If there were ocular signs, those would be noted. LB, O.D. >You guys don't routinely check blood glucose, but find plenty of >pathologies pointing to diabetes. Why don't you routinely do a finger >stick for glucose? I think your question would be more apppropriately worded, "Why don't you routinely screen for diabetes via a blood test?" Short answer: Because the medical community does not recommend all health care practitioners routinely screen for diabetes mellitus, but does recommend all health care practitioners screen for hypertension via measuring blood pressure. >As a patient, I would say check my blood pressure if a retinal pathology >requires hypertension to be ruled out. Otherwise, I would frankly consider >it an invasion of privacy. You are free to feel however you want and free to reject any tests you want. It is just your eye doctor's responsibility to inform you why he wants to perform any test and the risks of your refusal. However, the next chance you get, why not ask your internist, family practice doctor or any other health care practitioner you like if they think it's a good idea for their optometrist (or any other health care practitioner) to screen for hypertension via taking blood pressure measurements on a routine basis? >If an OD came at me with a blood pressure cuff, I would ask why, and >if I weren't satisfied with the answer, I would not consent. Would you do the same if a dermatologist, ophthalmologist, neurologist or nurse practitioner did the same on a routine basis? (BTW, a doctor should always be able to explain why he wants to perform any test.) >A diagnosis of hypertension can carry some pretty significant insurance >ramifications. While MD's take elevated BPs very seriously, they actually >think pretty hard before they write down that diagnosis. In my >(nonprofessional) opinion, it's not a diagnosis that should appear on an >OD's chart, except as a patient-provided history, or when a pathology >requires elevated BP to be ruled out. As an OD, I have never diagnosed anyone with primary or essential "hypertension", however I have diagnosed the following related to blood pressure: Malignant hypertension Hypertensive retinopathy Hypertensive choroidopathy Hypertensive urgency Isolated elevated blood pressure reading For example, with the last diagnosis, I typically will write a letter to the patient's internist or family practice doctor informing them of the blood pressure reading and the results of their eye examination. IOW, I screen for (don't diagnose) primary hypertension as part of a routine comprehensive eye examination, but when the readings are elevated then refer to the proper health care practitioner as appropriate based on the recommendations of the medical community as a whole. Hope that helps! On 6/30/06 10:51 AM, in article 1151689873.345390.138990@d56g2000cwd.googlegroups.com, "Blake Patterson" <blakespot@gmail.com> wrote: > I wanted to explain a situation I am experiencing and see if anyone had > any ideas as to what may be taking place. [quoted text clipped - 5 lines] > for a split second after I blinked as well - as if I had just looked at > three bright lines of light and this was the after image. When I first started reading this, I thought ocular migraine, but from the verbal description it is very difficult to tell what someone else sees. Moreover, I am not a medical person, so anything I say should not be given much weight anyway. If I were you, I would run to a good ophthalmologist as quickly as possible, Based upon his posts, I respect William Stacey but I think you want a medical specialist. It would not hurt to mention ocular migraine. From what I know, that is not an eye problem per se but a neurological problem occurring between the retina and the brain. In any event, get medical attention for piece of mind. Bill -- Ferme le Bush Thanks for the advice. I did just visit an opthalmologist and he examined my eyes and has set a field test to be done next week. (I've got to go in at 7am or so to get squeezed in that week) and if all is fine there he may want to go down the neuro / MRI route. Hopefully no more progression between then and now. bp > On 6/30/06 10:51 AM, in article > 1151689873.345390.138990@d56g2000cwd.googlegroups.com, "Blake Patterson" [quoted text clipped - 24 lines] > Bill > -- Ferme le Bush >If I were you, I would run to a good ophthalmologist as quickly as possible, >Based upon his posts, I respect William Stacey but I think you want a >medical specialist. > I appreciate that, but not only did I recommend ophthalmology consultation, I was more specific and specified retinologist (aka vitreo-retinal sub-specialist). I've witnessed quite a few general ophthalmology exams and not one of them included scleral depression. I hope his o.m.d. does it, unless he/she is able to spot the trouble without going the extra mile... w.stacy, o.d. |
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