If your office is not equipped with the necessary technology, consider referring ocular disease patients to other ODs.
Optometrists provide the overwhelming majority of routine comprehensive eye examinations in the U.S. In contrast, ophthalmic surgeons have splintered into subspecialties, where they are highly trained to treat and manage specific end-stage ocular disease. Their contact with the front line in diagnosis has become distant from their reach. It is evident that we, as ODs, are charged with the responsibility of acting as the front line of diagnosis and management of ocular diseases such as glaucoma, diabetic retinopathy and age-related macular degeneration. It follows that if we accept the common sense understanding of how timely diagnosis and accepted preventive measures clearly affect the severity and outcome of these diseases, we must be at the top of our game with regard to the current standard of care.
It is our responsibility as optometrists to detect glaucoma suspects during routine eye examinations. During the exam, suspicion of glaucoma usually arises from elevated intraocular pressure, questionable appearance of the optic nerve or some combination of the two. At this point, patients should be scheduled for a glaucoma work-up to determine whether they should be prescribed appropriate treatment or followed on a regular basis.
When is referral necessary, and to whom?
When optometrists suspect glaucoma, the decision must be made regarding the venue of the ongoing follow-up. Is there sufficient technology and skill at hand to appropriately follow this patient? If not, should the glaucoma suspect be referred to an OD who does have that skill set and technology or to a glaucoma surgeon?
My personal bias is that patients with nonsurgical glaucoma, diabetic retinopathy and AMD are better managed by non-surgeons (ODs). This sentiment is, in no way, an attempt to discount the amazing skill set of our valued surgical specialists. It is rather a reflection of the fact that, exceptions aside, optometrists have schedules, interests and patient management skills that are clearly better suited to manage chronic disease. We are more accessible and can spend more time with our patients, and these attributes clearly affect outcome.
Role of technology
Beyond having interest in nonsurgical chronic disease, treating ODs and MDs must be in tune with the technical state of the art.
Catching a disease early is like catching a snowball when it is not as far down the hill. We used to call “early glaucoma” the time when we identified three repeatable defective points of loss in the white-on-white threshold visual field. Now, because of our better understanding of the structure-function relationship in glaucoma, we call that condition “moderate glaucoma,” because we can see tissue changes with optical coherence tomography (OCT) quite earlier than the visual field of defect even starts to appear.
Another example of technology aiding earlier diagnosis is fundus photography with autofluorescence, which allows us to view changes in dry AMD earlier than with direct observation or even OCT. Additionally, the newest ultrasound biomicroscopic (UBM) devices provide a valuable perspective on the anatomy of the anterior segment, especially when opaque media is present. With access to more information, doctors treating glaucoma can achieve a better understanding of the anterior chamber’s role in individual glaucoma cases.
Elliot M. Kirstein
Our office protocol includes a complete series of OCT and UBM scans for each glaucoma suspect. After initial evaluation, suspects are rescanned at least once per year. Those who have been diagnosed with and are being treated for glaucoma receive OCT scans two times per year and UBM annually. Our practice cares for approximately 1,000 patients who either have glaucoma or are suspects.
A closer relationship with patients
Optometrists’ strength in the dynamics of chronic disease also results from our willingness and ability to see patients more often and establish a closer verbal relationship with them. An age-old joke is that surgeons “heal with steel.” Optometrists, however, are the health care professionals that have more face-to-face time with patients pre- and postoperatively in the context of chronic disease. Patients have more access to the optometrist in the early stages of glaucoma, AMD and diabetes compared to glaucoma and retinal surgeons who are less accessible for nonsurgical patients.
When considering whether to refer patients to surgeons or to another optometrist, ask yourself a few questions. If I send this patient to another doctor, will this clinician do something I cannot do? Does the patient need testing or therapy that I cannot provide? Is a surgical intervention indicated for this patient that would better serve him or her than the medicinal therapy I can provide?
If another doctor can offer the patient treatment or tests that would better serve them, then the answer is yes. If there is any suspicion of early glaucoma, AMD or diabetic retinopathy, patients must be referred onto an optometric or ophthalmologic facility where the experience and technology is suited to meet their needs.
All of us need to objectively and constantly assess where we sit and where we aspire to be on the technology and knowledge spectrum. If we are not happy with where we are, it is incumbent upon us, as individual doctors, to take the measures necessary to change. In doing so, we will best serve our patients by delivering the level of service that best fits their needs. We have an implied contract with our patients to provide a level of care consistent with the time in which we are practicing, not the year we graduated from school, stopped investing in technology or stopped reading books. Looking forward, we must thoughtfully provide care that is consistent with or excels the evolving community standard.
For more information:
Elliot M. Kirstein, OD, FAAO,
practices at Harper’s Point Eye Associates in Montgomery, Ohio. He can be reached at firstname.lastname@example.org
No products or companies were mentioned that would require financial disclosure.