July 20, 2020

Optometry in The News: Review of Clinical Perspectives on Patient Care, 24th edition - E1

Optometry in The News: Review of Clinical Perspectives on Patient Care, 24th edition - E1

My Review of Clinical Perspectives on Patient Care, 24th edition

Ok to start, I just have to get this off my chest, the first article annoys the crap out of me. “Warning: Major Changes Coming to Optometry… routine exams and dispensary income are going away forever”. Raise your hand if you have heard this before, oh really, all of you? I thought this was something new that we just learned in 2020.  

Let me be clear, I love our profession and I try to practice it to its fullest extent. However, I laugh at OD’s who look down on refractions, glasses, and contacts, like they are above such nominal things? I am not saying it is bad to practice medical optometry or have a passion for disease, but if you do not want anything to do with glasses or contacts, 1. Do not start your own office and 2. Why are you not an ophthalmologist? We all know optometry school was no joke, but neither is medical school, and their residency is way more demanding than anything we are required to do. Either you could not get in or you were not committed enough to go down that path. That's me, I want no part of that life. We got into school easier and put in less time, but we get to do pretty much the same things and people come to US for glasses and contacts. I feel like we come out ahead, so embrace it, rather than look down on it. That is all I am saying. Not to mention Thomas, Melton, and Vollmer tout 3d printing and 6.95 glasses as appealing. Judging from their practice management pearls and such, I am sure they are well versed in marketing, merchandising, and retail in general...or not.

Ok end rant, and let’s look at the nuts and bolts of what they wrote. I actually enjoyed what they had to say and found a few clinical pearls we could all benefit from, just do not try to take business advice from these 3 geniuses. They will have everyone in scrubs trying to sell glasses and such, just like you know Macy’s, Tiffany’s, and Pottery Barn does.

Things I feel like they missed the mark on: 

1. Their take on glasses and contacts (see above). 

2. Blue light filters. I get that there may not be peer reviewed evidence that these filters absolutely prevent damage to the retina. However, patients know about blue light from screens and devices and want an option. This is not the moment to “pull rank” and tell them “no, it’s not necessary”. At very least list the pros and cons, but when it is not a matter of actual damage to the eye, why not give them what they want? Additionally, when added with an anti-fatigue lens, such as the Eyezen, my patients notice less eye strain and less fatigue when doing near work and with devices. 

3.They are very big into lotemax and zylet.  I can barely get my patients to come back for a follow-up and not complain about another co-pay. “Well Mrs. Smith, your corneal ulcer may lead to permanent vision loss, but yea, save the $35 co-pay”. I have to look into the coupons they speak about, but otherwise, Prednisolone (and polytrim if antibiotic coverage) seems to be much more accepted by my patient population. 

4. Because they are “medical” optometrists, I doubt they have to deal with managed care vision plans, but I still haven't found a way to distinguish the dilated portion of a comprehensive vision exam from purely diabetic dilation. I understand the refraction is not covered under medical plans and we get reimbursed way more by medical insurance, but are people making a patient come back if they are diabetic to do the DFE so they can bill their medical insurance? That seems more shady than recommending a blue light filter in my opinion, and wait until you see how happy you make them if for some reason it goes towards their deductible and they have to pay for it.

Things I feel may work in my setting:

1. Now I know I made a big deal about embracing optometry, especially the glasses and contact lens aspect, but I treat disease and know with the aging baby boomer population we have a huge opportunity to provide care. They outlined the essentially flat supply of ophthalmologists over the next 10-20 years with increased demand. Umm yes please, of course we need to make sure we are set up to provide that care. We need to protect what we have, or at least not neglect it, and attack this opportunity.

2.When they lay out their treatment for dry eye, it is their belief that if you eliminate the inflammatory aspect of the condition, you do not need restasis or xiidra long term. They believe a 4 week course of loteprednol with a lipid based artificial tear and omega 3 fatty acid supplement (2,000 mg/day) will do the trick. I am game to try. People do not like long term medication or the cost. I think I can get my patients on board with their approach. 

3.Fornix sweep. They outlined a technique for a constant foreign body sensation as well as chronic blepharitis. I have been able to find those pesky CL’s and small debris the majority of the time by flipping their lids, but there may have been one or two times where their technique would have been useful. In addition, I have had a few of my older patients with deep set eyes that may have benefited from this technique and possibly reduced the irritation from their chronic blepharitis.

4. They discussed the toxic dosage for plaquenil and at what body weights the normal 400mg/day still becomes toxic. They tied this in with the desire to not be sued, so well, yeah, let's not get sued!

Anyways, if you do not have time to read it yourself, here are the highlights as seen by me. Let me know what you think!