ALERT: Florida optometrists gaining ground with recent bill

[peter2013]

I understand the opioid epidemic, but most states in our narcotic prescribing ability goes no further than a seven to ten day supply of typically schedule III narcotics. Been prescribing medications for 15 years, and of the times I needed to prescribe a narcotic it was never longer than a seven to ten day period with zero refills. As I said to the Orlando Sentinel reporter yesterday in the interview, we are not and cannot contribute to the opioid epidemic on seven to ten day supply that isn't refillable. The problem lies in the chronic pain clinics (i. e. lower back, post-traumatic accident, etc.). Those are the true and real causes of the opioid epidemic. Not modulating the pain with a tough corneal abrasion or post-operative PRK healing. In fact, even tough I could prescribe a narcotic post PRK I stick to an NSAID whenever possible. There are so many states we already prescribe narcotics in and we simply ARE NOT the cause of the epidemic and will not ever be. Our scripts are highly watched and if we ever prescribed multiple refills, which we are taught we do not do, then that would be a problem. But, the reality is that problem IS NOT present and will never be present. Respectfully, gotta run and teach the med 2's everything about the eye for their OSCI ICM clinical exam including some Grave's , Cushing's, glaucoma, you know all the things that are allegedly not in our curriculum or in our patient experience (smh)....

This post demonstrates your lack of understanding of the opioid epidemic. And I genuinely don't fault you. You'll learn this later in medical school and residency when you have clinical exposure to people who are hooked and observe (unfortunately) the prescription of narcotics to make patients happy. How do you think people get hooked? By getting prescribed narcotics when they don't need them and all it takes is one little high from the mildest of narcotics. I understand the temptation to make your patients happy, but giving them narcotics for a K abrasion hurts them in the long run. I would urge you to please reconsider this practice. The long-term effect you have on patient care doesn't end when you stop seeing them in your clinic.

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[OD/ MD student]

This was the results of the post house synapsis as this bill moves forward. The only thing thrown back at us was the JAMA 2016 study and that study being quoted EVERYONE knows is a classic correlation without causation effect from epidemiology. they are attached as attached files. The percentage of more surgeries does not, in fact, come from retreats but of the more conservative approach to optometric surgical procedures. Safety in these procedures is firmly and statistically on the side of the Doctor of Optometry

 

[LightBox]

I'll be curious to see how you've evolved 6 years from now.

Let's be realistic. No offense, but there is a very low chance that this person gets accepted to Ophthalmology residency in the United States. Besides every Program Director knowing his deed after a cursory Google search, there are several factors stacked against him. I forsee this lovely gentleman telling his patients that "yes, I am an Eye M.D. since I do have an M.D. and do treat eyes!" Just another way to blur the distinction between the two fields.

 

[OD/ MD student]

Let's be realistic. No offense, but there is a very low chance that this person gets accepted to Ophthalmology residency in the United States. Besides every Program Director knowing his deed after a cursory Google search, there are several factors stacked against him. I forsee this lovely gentleman telling his patients that "yes, I am an Eye M.D. since I do have an M.D. and do treat eyes!" Just another way to blur the distinction between the two fields.

I had no idea that testifying on behalf of the Florida Medicaid patients for greater access to high quality safe eye care by those trained to perform these laser procedures made me an "enemy" of the professsion. If it does then perhaps those people should find another profession, because the patient comes first not your inflated ego. It's not and us against them scenario, and you've seemingly forgotten that this bill is of importance to our patients.

 

[LightBox]

I had no idea that testifying on behalf of the Florida Medicaid patients for greater access to high quality safe eye care by those trained to perform these laser procedures made me an "enemy" of the professsion. If it does then perhaps those people should find another profession, because the patient comes first not your inflated ego. It's not and us against them scenario, and you've seemingly forgotten that this bill is of importance to our patients.

Here we go again. The massive "shortage of PRK providers" argument again. Lol.

 

[LightBox]

Proposed Optometry Bills for Scope of Practice Expansion

I guess ODs have "Jason K"... and now the medical field has "OD/MD student". Haha.

"Jason K's words still ring true for Optometry:

Proposed Optometry Bills for Scope of Practice Expansion

Optometry, as a field, needs to be worried about much bigger and important things than scope expansion.

 

[OD/ MD student]

Proposed Optometry Bills for Scope of Practice Expansion

I guess ODs have "Jason K"... and now the medical field has "OD/MD student". Haha.

 

[OD/ MD student]

You obviously didn't read the summary of the Florida legislative hearing committee and the Medicaid impact of this bill. Wouldn't expect you to . You probably are the kind of guy who only reads the studies that benefit your own opinion. Not surprised, medicine is full of manipulators. One more time in case you missed it the first time my brother.

 

[awftho]

I had no idea that testifying on behalf of the Florida Medicaid patients for greater access to high quality safe eye care by those trained to perform these laser procedures made me an "enemy" of the professsion. If it does then perhaps those people should find another profession, because the patient comes first not your inflated ego. It's not and us against them scenario, and you've seemingly forgotten that this bill is of importance to our patients.

Is there actually some data that shows that the residents of Flordia are in desperate need of more PRK and Narcotics or are you just saying that there is a need over and over until you can convince yourself and others that it is true?

 

[eyeguy85]

Well if you understand how Doctors of Optometry have been treated like **** the last few years by ASCRS, the AAO and being band from their meetings you'll understand the hesitance to make it an open group. You could go on my facebook page which has a significant amount of both ophthalmology colleagues and OD colleagues and click on Dennis Golden or his brother Dixon Golden, they are the admins of the 200 strong group of optometric eye surgeons and if you wanted to POSITIVELY contribute I'm sure they would probably allow you to join the group . They are one of the chief providers of SLT, YAG, and PI, and other minor eyelid procedures for East Texas / Louisiana with their surgery center based out of Louisiana. Their partner John McCall will soon be introducing a new lens that is likely to replace the LUNA lens in the SLT procedure. He's marketing it as a four mirror lens. Imagine that a product innovation in laser eye surgery (gasp, insert polite sarcasm) that's coming from a SLT certified optometric physician. I would agree that the free flow of knowledge amongst professionals only leaves the patients out in the cold. But, lets not forget that the ban on OD's attending AAO meetings has been around the better part of a decade. I wonder if as a medical student I can attend these meetings with my medical school ID and apply the credits towards my continuing education for OD licensure. I'll have to check into that one. Technically as a med student shouldn't I get free attendance at Academy of Ophthalmology and / or ASCRS? Then I can hang out with Dr. Mendelson and Dr. Katz and tell them how great they are....

My understanding of the bill passed in Louisiana is that optometrists are barred from performing procedures that require suturing (see section section D-6-p http://weoassociation.com/documents/7/LSBOE-Optometry-Act-06122015.pdf).

Yet Dr. Golden's practice advertises performing peri-orbital surgery and has a fellowship program in "Ocular Disease and Optometric Surgery" that includes extensive exposure to entropion and "extropion" repair.

How on earth do they propose to correct lid malpositions without suturing?

 

[eyeguy85]

In fact, even tough I could prescribe a narcotic post PRK I stick to an NSAID whenever possible.

With few exceptions, narcotics should not be a routine part of any ophthalmic practice and definitely not a class of medications that optometrists need to be prescribing. I made it through ophthalmology residency only prescribing narcotics a handful of times (post-orbital fracture repair, enucleation, etc) and even then it was rare to prescribe something stronger than tylenol #3 and only after the patient had failed NSAID therapy.

A paper published just this week (Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017;66:265–269.) showed a significant increase in risk of long continued opioid use with only a 5-10 day prescription.

"The probability of long-term opioid use increases most sharply in the first days of therapy, particularly after 5 days or 1 month of opioids have been prescribed, and levels off after approximately 12 weeks of therapy. The rate of long-term use was relatively low (6.0% on opioids 1 year later) for persons with at least 1 day of opioid therapy, but increased to 13.5% for persons whose first episode of use was for ≥8 days and to 29.9% when the first episode of use was for ≥31 days."

 

[ojoseco]

You obviously didn't read the summary of the Florida legislative hearing committee and the Medicaid impact of this bill. Wouldn't expect you to . You probably are the kind of guy who only reads the studies that benefit your own opinion. Not surprised, medicine is full of manipulators. One more time in case you missed it the first time my brother.

"Such optometrists will experience increased revenues for performing such services."

Is this the "medicaid" impact your referring to?




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[akademix]

No offense to him, but if he really is an optom that is going to med school in the Caribbean, he has about no chance to match in ophthalmology residency...his terrible opinions on this thread clearly don't help his case either.

I second what Lightbox said. This is probably all marketing for him. He's not going to match ophtho in all likelihood, but he'll be an "MD that takes care of eyes" after he's done getting his Caribbean med school degree.

I cringe when I think of this type of legislation because I just think of the terribly managed patients that end up in our clinics after being mismanaged under optoms.

If air puff tonometry rather than applanating and crappy FDT fields on every patient (because everyone is a POAG suspect) isn't enough, it's ridiculous Optos imaging on every new patient.

I went to an optom who made me sign an against medical advice waiver because I told him I didn't want to get a random Optos fundus image as a new patient (prior to a DFE). I asked about a DFE before he knew I was in ophtho, and he said it's not standard of care... Lol. Seriously? These are ALL money grabs...

 

[ophthope]

...optometric surgical procedures. Safety in these procedures is firmly and statistically on the side of the Doctor of Optometry

So I expect your full backing when I introduce a bill to allow glasses dispensing rights to Ophthalmic Technicians after a 6 month certification course. There would be a regimented on-the-job and online course required for techs to prove competency in recognizing completely normal anterior segment and fundus exams compared to any possible abnormalities, and to prescribe glasses.

There are many rural areas where even ODs are not available, and technicians could be deployed to perform basic eye exams and prescribe glasses in those places. They would refer any pathology at all out to their supervising Ophthalmologist (which would be a requirement) and that Ophthalmologist would be available to immediately review fundus photos for any concerning pathology that needs to be triaged.

These technicians could provide an invaluable service by providing access and early detection of AMD, glaucoma, diabetic retinopathy, and a myriad of other conditions by being able to perform basic screening-only exams. Again, they would also prescribe to correct basic refractive errors as their ONLY method of treatment as this is basically a zero-risk intervention. At worst someone would be overminused and have mild eye strain. At best, screening by a technician would detect glaucoma in someone early and prevent blindness!

Again these technicians would be functioning purely to provide screening examinations - not to treat or diagnose any conditions except for 1. Myopia 2. Hyperopia 3. Astigmatism and 4. Presbyopia and only with glasses prescriptions. They would have an extremely limited scope of practice to ensure patient safety.

So "OD/ MD student" - do I have your support in this groundbreaking idea to increase access for patients' to eye care? Would your fellow Optometrists be willing to share the right to dispense glasses prescriptions in order to help patients' get better care?

Fellow MD and DO Ophthalmologists, would you support my new legislation in your State?

I started writing this to prove a point, but I honestly think that this could really be beneficial to patients. Most of my family resides deep in what would be considered 'rural' territory, and have no access to eye care outside of travelling an hour or more. But a technician located in a small office even a few days per month could provide great access to a large number of patients like this.

 

[hello lady!]

So I expect your full backing when I introduce a bill to allow glasses dispensing rights to Ophthalmic Technicians after a 6 month certification course. There would be a regimented on-the-job and online course required for techs to prove competency in recognizing completely normal anterior segment and fundus exams compared to any possible abnormalities, and to prescribe glasses.

There are many rural areas where even ODs are not available, and technicians could be deployed to perform basic eye exams and prescribe glasses in those places. They would refer any pathology at all out to their supervising Ophthalmologist (which would be a requirement) and that Ophthalmologist would be available to immediately review fundus photos for any concerning pathology that needs to be triaged.

These technicians could provide an invaluable service by providing access and early detection of AMD, glaucoma, diabetic retinopathy, and a myriad of other conditions by being able to perform basic screening-only exams. Again, they would also prescribe to correct basic refractive errors as their ONLY method of treatment as this is basically a zero-risk intervention. At worst someone would be overminused and have mild eye strain. At best, screening by a technician would detect glaucoma in someone early and prevent blindness!

Again these technicians would be functioning purely to provide screening examinations - not to treat or diagnose any conditions except for 1. Myopia 2. Hyperopia 3. Astigmatism and 4. Presbyopia and only with glasses prescriptions. They would have an extremely limited scope of practice to ensure patient safety.

So "OD/ MD student" - do I have your support in this groundbreaking idea to increase access for patients' to eye care? Would your fellow Optometrists be willing to share the right to dispense glasses prescriptions in order to help patients' get better care?

Fellow MD and DO Ophthalmologists, would you support my new legislation in your State?

I started writing this to prove a point, but I honestly think that this could really be beneficial to patients. Most of my family resides deep in what would be considered 'rural' territory, and have no access to eye care outside of travelling an hour or more. But a technician located in a small office even a few days per month could provide great access to a large number of patients like this.

Honestly I think if you had well-trained techs (maybe 2 years of training) optometrists could be made completely irrelevant.

 

[hello lady!]

No offense to him, but if he really is an optom that is going to med school in the Caribbean, he has about no chance to match in ophthalmology residency...his terrible opinions on this thread clearly don't help his case either.

I second what Lightbox said. This is probably all marketing for him. He's not going to match ophtho in all likelihood, but he'll be an "MD that takes care of eyes" after he's done getting his Caribbean med school degree.

I cringe when I think of this type of legislation because I just think of the terribly managed patients that end up in our clinics after being mismanaged under optoms.

If air puff tonometry rather than applanating and crappy FDT fields on every patient (because everyone is a POAG suspect) isn't enough, it's ridiculous Optos imaging on every new patient.

I went to an optom who made me sign an against medical advice waiver because I told him I didn't want to get a random Optos fundus image as a new patient (prior to a DFE). I asked about a DFE before he knew I was in ophtho, and he said it's not standard of care... Lol. Seriously? These are ALL money grabs...

Yup the fundus photos are "HD Retinal Imaging" and FDT fields are "brain tumor tests." Cash only, of course.

My other favorite thing is that glaucoma suspects come in q2-3 months for exams. I just had a patient today who I inherited from an optom in another state. C/D 0.6, 89 years old with pre-treatment IOP of 16. The treatment plan (which had been going on for years):

"f/u 2 months HVF
f/u 4 months OCT
f/u 6 months Photos
f/u 8 months glasses/comp" ... repeat repeat repeat

In all of the years of this testing had never been a documented HVF defect or thinning anywhere on OCT.

 

[eyeguy85]

Honestly I think if you had well-trained techs (maybe 2 years of training) optometrists could be made completely irrelevant.

In the future you won't even need a human component. Computer algorithm based image analysis can provide routine exam screening (see recent literature about the various supercomputers being trained to recognize skin cancer, etc).

Google or another company will build a kiosk that can provide many of the services currently offered by optometrists so of course they need to try to expand their scope of practice.

 

[Slide]

This was the results of the post house synapsis as this bill moves forward. The only thing thrown back at us was the JAMA 2016 study and that study being quoted EVERYONE knows is a classic correlation without causation effect from epidemiology. they are attached as attached files. The percentage of more surgeries does not, in fact, come from retreats but of the more conservative approach to optometric surgical procedures. Safety in these procedures is firmly and statistically on the side of the Doctor of Optometry

Since you don't seem to understand logical arguments and debate, maybe a picture would be easier for you to understand regarding "a more conservative approach"

 

[OD/ MD student]

Since you don't seem to understand logical arguments and debate, maybe a picture would be easier for you to understand regarding "a more conservative approach"

Sure thing, my brother it appears our definitions of "conservative approach" differ drastically. Your idea of conservative approach is for us not to utilize our training or education and not perform these laser procedures at all. Our idea of conservative approach in regards to SLT is to treat 180 degrees of the Trabecular Meshwork, wait to see if desired IOP lowering is present and then if necessary treat the remaining 180 degrees of the meshwork. The pro to getting all 360 degrees out of the way is that there may be less second procedures. Notice I am careful to say not repeat procedures over the primary procedures. But, rather a second primary procedure on the remaining 180 degrees of the meshwork. Less energy delivered to the eye obviously means less chance of post operative IOP spikes after the SLT procedure. That data quoted in the JAMA study is likely to change once optometry is encouraged in our education to treat the whole 360 degrees initially. As in every post operative complicaiton there's the double standard you are held to and the double standard we are held to. Meaning, if you have a post operative spike when you treat all 360 degrees it's just a "normal side effect." But, when we have the exact same post operative complication you and your brethren through out the "operator fault" or its because "OD's are doing the surgery." Same thing if, for example, we both did a PRK laser surgery and the patient developed post operative fibroblastic haze. When I worked with Dr. Michael Granberry (ophthalmologist) in Phoenix in 2001, who has subsequently died from a heart attack, he had several high myopes that he didn't lay down pre operative Mitomycin C on and they developed fibroblastic haze. No discipline for him, just a side effect of PRK. One of those patients by the way that developed that post op haze was my DO Dermatologist colleague who is testifying on our behalf on YAG laser usage up in Tallahassee. But, if the same patient developed fibroblastic haze under our watch then its alleged by your supposedly wise, fair and balanced colleagues that we either shouldn't be doing it or are not competent to be doing. See how that paradigm works? Adverse side effects get to happen to your patients as part of the normal process of the procedure but when we perform the same procedure they are not. Not exactly fair is it in that argument? The ONLY version of conservative you will ever be happy with is OD's not doing the procedures and that's unfortunately not going to happen.

 

[MstaKing10]

Just curious, who covers optometrsists for malpractice insurance if they are doing these procedures?

 

[ophthope]

Not sure why your Derm friend who had post-op haze thinks he would have been better off having the procedure by someone with half of the professional degree level education as his Ophthalmologist. Ask him how he would feel if one of his post-punch biopsy patients that had post-procedure bleeding or secondary exuberant scar formation was testifying that NPs/DNPs should be able to do absolutely everything that a Dermatologist can do. That's about the same difference in years of training comparing OD to MD/DO. Would be curious to see his comments directly here, if he would be willing to get on the forum.

But more importantly - OD/ MD Student, you may not have seen my post above but I would like your support and opinion on my new bill proposal. I think it will drastically improve patient care in rural areas.

 

[ophthope]

Just curious, who covers optometrsists for malpractice insurance if they are doing these procedures?

Not OMIC, the insurer who probably covers most of our practices. Last paragraph contains pertinent information. Post is from some years ago but their policy has not changed AFAIK.

 

[hello lady!]

Sure thing, my brother it appears our definitions of "conservative approach" differ drastically. Your idea of conservative approach is for us not to utilize our training or education and not perform these laser procedures at all. Our idea of conservative approach in regards to SLT is to treat 180 degrees of the Trabecular Meshwork, wait to see if desired IOP lowering is present and then if necessary treat the remaining 180 degrees of the meshwork. The pro to getting all 360 degrees out of the way is that there may be less second procedures. Notice I am careful to say not repeat procedures over the primary procedures. But, rather a second primary procedure on the remaining 180 degrees of the meshwork. Less energy delivered to the eye obviously means less chance of post operative IOP spikes after the SLT procedure.

SLT can take up to 6 weeks for full effect. If your theory is true, why are so many optoms doing the second laser right outside of the 10 day global period?

 

[OD/ MD student]

SLT can take up to 6 weeks for full effect. If your theory is true, why are so many optoms doing the second laser right outside of the 10 day global period?

No where in our training manual for laser surgery for the anterior segment procedure does it say to do slt on the second 180 degrees within 10 days of the first procedure. Since the mechanism of slt is the laser stimulating the macrophages 10 days would technically not give the macrophages time to do their job. Who do you know thats doing the two 180 degree procedures 10 days apart??

 

[OD/ MD student]

Not OMIC, the insurer who probably covers most of our practices. Last paragraph contains pertinent information. Post is from some years ago but their policy has not changed AFAIK.

I am covered under the optometric protector plan but also under Mercer insurance. Maguines and associates out of chicago is a third carrier. Our carrier rates have not gone up for the 20 ++ years of performing laer ey surgery

Just curious, who covers optometrsists for malpractice insurance if they are doing these procedures?

 

[Doctor.Mario]

..it's ridiculous Optos imaging on every new patient.

I went to an optom who made me sign an against medical advice waiver because I told him I didn't want to get a random Optos fundus image as a new patient (prior to a DFE). I asked about a DFE before he knew I was in ophtho, and he said it's not standard of care... Lol. Seriously? These are ALL money grabs...

This was one of my pet peeves when I was an optom tech before starting med school. The OD I worked for bought one of these things and immediately subbed it in for DFEs to increase the clinic's throughput, even incentivized the techs with a $3 bonus per patient that got it. Of course, that led to other techs telling patients less-than-true or scary phrases to get that extra $40 out of them. I would get yelled at monthly for "not filling my 50% patient-optos quota and slowing down the practice with DFEs". I never approached the other techs' numbers or that "quota", so I'm still not sure why I was never fired from that job.

To be on topic though, I'd like to make sure I'm understanding these bills (this one + the NC bill) correctly. This one seems to grant FL ODs the ability to do cataract surgery + most types of laser surgery, whereas the NC bill looks like it's restricted to certain laser surgeries only? The NC bill concerns me, as someone who came to medical school specifically for ophthalmology, but the FL bill looks worse by a large margin.

To be honest, if this becomes a widespread thing and ODs get more surgical privileges, I'm not sure why people like me (who come in knowing they want to be an eye surgeon) would go to medical school at all. Why risk it when there's a very real chance of not matching ophthalmology at the end? Especially when med school requires that extra 4 years of residency when "optometrist certified in ophthalmic surgery" needs, what, an extra year at most?

 

[ojoseco]

Dr Mario, dont forget about their advanced, hands-on training courses---

"Oklahoma requires passage of the Laser Therapy for the Anterior Segment Course offered by Northeastern State University to become a licensed optometrist. 10 The course consists of 9 hours of lectures and 4 hours of laboratory sessions with hands-on training."

--per the summary document about the FL bill that OD/MD posted


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[OD/ MD student]

Dr Mario, dont forget about their advanced, hands-on training courses---

"Oklahoma requires passage of the Laser Therapy for the Anterior Segment Course offered by Northeastern State University to become a licensed optometrist. 10 The course consists of 9 hours of lectures and 4 hours of laboratory sessions with hands-on training."

--per the summary document about the FL bill that OD/MD posted


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[OD/ MD student]

As opposed to all four or five SLT cases that ophthalmology needs in their residency for graduation, included in the Florida legislatives sessions report enclsed as the attached file...

 

[ojoseco]

OD/MD---I would encourage you to actually read the entirety of the document you have reposted multiple times...specifically the part that lists the average number of procedures actually performed by ophthalmology residents during their training as opposed to regurgitating the minimum requirements.


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[KHE]

You're missing the point again. And you can't speak for optometrists at large and say no one does more than 7-10 days and that they know what they are doing. You can't speak for the endless amount of optometrists who have no idea about the narcotic epidemic and have never treated a pain patient. In this climate we need to be restricting who can give narcotics, not broadening scope to those who are under educated about them.

If you really believe that optometrists should be granted the power to prescribe narcotics then I'm afraid you're totally lost on the conversation. And furthermore it shows you don't understand the opioid epidemic as I've actually spoken to multiple patients first hand that indeed we're hooked on shorter than a 10 day course. And the smug remark and the end was anything but respectful, so don't say respectfully. We disagree, so be it, but man, I'll be curious to see how you've evolved 6 years from now.

Optometrists are already prescribing narcotics safely and judiciously in several states.

 

[kid Icarus 3]

Optometrists are already prescribing narcotics safely and judiciously in several states.

Thanks for the unsupported blanket statement. The fact is they aren't qualified to do so and there is NO NEED for them to have the ability to prescribe them. If the pain is truly that severe (rare) refer to ophthalmology. Also, you can't persuade me that narcotic prescribing power is an optometric necessity due to limited access to eye care, lol.

 

[hello lady!]

No where in our training manual for laser surgery for the anterior segment procedure does it say to do slt on the second 180 degrees within 10 days of the first procedure. Since the mechanism of slt is the laser stimulating the macrophages 10 days would technically not give the macrophages time to do their job. Who do you know thats doing the two 180 degree procedures 10 days apart??

From the "hit-piece" article

We also studied the timing of the additional LTPs by the 2 eye care professional groups relative to the 10-day global period (ie, the immediate post-LTP period, when charges for normal postoperative care are included in the global surgical procedure fee). For patients first treated by ophthalmologists, no additional procedures occurred during the global period, and the probability of a subsequent LTP between 11 and 30 days was 1.1% (95% CI, 0.7%-1.9%). For patients first treated by optometrists, the probability of subsequent LTPs in the global period was 0.4% (95% CI, 0.1%-3.0%) and between days 11 and 30 was 10.3% (7.0%-15.0%).

Optoms are 10x more likely to retreat before the one month mark, which is earlier than the time it takes for full efficacy of SLT to occur.

 

[Slide]

No where in our training manual for laser surgery for the anterior segment procedure does it say to do slt on the second 180 degrees within 10 days of the first procedure. Since the mechanism of slt is the laser stimulating the macrophages 10 days would technically not give the macrophages time to do their job. Who do you know thats doing the two 180 degree procedures 10 days apart??

Again, did you even read the article and the results? It was clearly stated in the results section of the paper. In the paper, over 3 years the rate of repeat SLT was double over time. If you're being conservative with your procedures, the rate should be lower, not higher. Thus, your argument about being conservative with treatment is completely INCORRECT.

Sure thing, my brother it appears our definitions of "conservative approach" differ drastically. Your idea of conservative approach is for us not to utilize our training or education and not perform these laser procedures at all. Our idea of conservative approach in regards to SLT is to treat 180 degrees of the Trabecular Meshwork, wait to see if desired IOP lowering is present and then if necessary treat the remaining 180 degrees of the meshwork. The pro to getting all 360 degrees out of the way is that there may be less second procedures. Notice I am careful to say not repeat procedures over the primary procedures. But, rather a second primary procedure on the remaining 180 degrees of the meshwork. Less energy delivered to the eye obviously means less chance of post operative IOP spikes after the SLT procedure. That data quoted in the JAMA study is likely to change once optometry is encouraged in our education to treat the whole 360 degrees initially. As in every post operative complicaiton there's the double standard you are held to and the double standard we are held to. Meaning, if you have a post operative spike when you treat all 360 degrees it's just a "normal side effect." But, when we have the exact same post operative complication you and your brethren through out the "operator fault" or its because "OD's are doing the surgery." Same thing if, for example, we both did a PRK laser surgery and the patient developed post operative fibroblastic haze. When I worked with Dr. Michael Granberry (ophthalmologist) in Phoenix in 2001, who has subsequently died from a heart attack, he had several high myopes that he didn't lay down pre operative Mitomycin C on and they developed fibroblastic haze. No discipline for him, just a side effect of PRK. One of those patients by the way that developed that post op haze was my DO Dermatologist colleague who is testifying on our behalf on YAG laser usage up in Tallahassee. But, if the same patient developed fibroblastic haze under our watch then its alleged by your supposedly wise, fair and balanced colleagues that we either shouldn't be doing it or are not competent to be doing. See how that paradigm works? Adverse side effects get to happen to your patients as part of the normal process of the procedure but when we perform the same procedure they are not. Not exactly fair is it in that argument? The ONLY version of conservative you will ever be happy with is OD's not doing the procedures and that's unfortunately not going to happen.

Are you daft? Again, you definitely did not read the paper. A conservative approach by definition medically means being less aggressive with treatment, especially if its invasive in any way. Discussion of how you do the procedure does not mean anything. You do realize that the approach you discuss is the STANDARD OF CARE for ophthalmologists as well? You are making fallacious and incorrect conclusions from the data. The paper clearly states in the 11 to 30 day post-op period and beyond, the rate of repeat SLT by optometrists was higher.

As far as your anecdote about PRK (which I'm not sure has much relevance towards your SLT anecdote), you do realize that during the 2000s, Mitomycin C was just being used off-label and lots of studies and research was being done to see it if the toxicity at certain doses did not outweigh the benefits of corneal haze? It's not unreasonable for ophthalmologists in the late 1990s and early 2000s to have not used MMC because there wasn't enough information and experience then to determine if it should be widely used for high myopes (which by the way, PRK/LASIK is also FDA off-label). If anything, the ophthalmologist you were working with was being conservative in treating high myopes. So I'm not sure what argument you're trying to present because it doesn't make any sense, "brother".

As opposed to all four or five SLT cases that ophthalmology needs in their residency for graduation, included in the Florida legislatives sessions report enclsed as the attached file...

You need to be using the average number, not the minimum number. Even then, the minimum number is much more training than a weekend course and a few hours to play around.

Since you're all about lecturing attendings about the lessons you've learned about med school, let me lecture you on something about what happens when you've graduated and now have increased responsibility. If you're going to make assertive claims, you better know your stuff, because based on your points you clearly do not, and you better bet attendings and lawyers will tear you to shreds during questioning. If you're going to be taking care of patients and doing procedures, if you fake it until you make it, you're going to be causing irreparable damage to people.

 

[ophthope]

So I expect your full backing when I introduce a bill to allow glasses dispensing rights to Ophthalmic Technicians after a 6 month certification course. There would be a regimented on-the-job and online course required for techs to prove competency in recognizing completely normal anterior segment and fundus exams compared to any possible abnormalities, and to prescribe glasses.

There are many rural areas where even ODs are not available, and technicians could be deployed to perform basic eye exams and prescribe glasses in those places. They would refer any pathology at all out to their supervising Ophthalmologist (which would be a requirement) and that Ophthalmologist would be available to immediately review fundus photos for any concerning pathology that needs to be triaged.

These technicians could provide an invaluable service by providing access and early detection of AMD, glaucoma, diabetic retinopathy, and a myriad of other conditions by being able to perform basic screening-only exams. Again, they would also prescribe to correct basic refractive errors as their ONLY method of treatment as this is basically a zero-risk intervention. At worst someone would be overminused and have mild eye strain. At best, screening by a technician would detect glaucoma in someone early and prevent blindness!

Again these technicians would be functioning purely to provide screening examinations - not to treat or diagnose any conditions except for 1. Myopia 2. Hyperopia 3. Astigmatism and 4. Presbyopia and only with glasses prescriptions. They would have an extremely limited scope of practice to ensure patient safety.

So "OD/ MD student" - do I have your support in this groundbreaking idea to increase access for patients' to eye care? Would your fellow Optometrists be willing to share the right to dispense glasses prescriptions in order to help patients' get better care?

Fellow MD and DO Ophthalmologists, would you support my new legislation in your State?

I started writing this to prove a point, but I honestly think that this could really be beneficial to patients. Most of my family resides deep in what would be considered 'rural' territory, and have no access to eye care outside of travelling an hour or more. But a technician located in a small office even a few days per month could provide great access to a large number of patients like this.

Hey I just wanted to quote myself because OD/MD Student seems to keep missing this point and I'm just sweating in anticipation of his/her approval! As someone active in the State legislatures, your backing could really help me get my bill off of the ground!

 

[OD/ MD student]

OD/MD---I would encourage you to actually read the entirety of the document you have reposted multiple times...specifically the part that lists the average number of procedures actually performed by ophthalmology residents during their training as opposed to regurgitating the minimum requirements.


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Where in the world do

This was one of my pet peeves when I was an optom tech before starting med school. The OD I worked for bought one of these things and immediately subbed it in for DFEs to increase the clinic's throughput, even incentivized the techs with a $3 bonus per patient that got it. Of course, that led to other techs telling patients less-than-true or scary phrases to get that extra $40 out of them. I would get yelled at monthly for "not filling my 50% patient-optos quota and slowing down the practice with DFEs". I never approached the other techs' numbers or that "quota", so I'm still not sure why I was never fired from that job.

To be on topic though, I'd like to make sure I'm understanding these bills (this one + the NC bill) correctly. This one seems to grant FL ODs the ability to do cataract surgery + most types of laser surgery, whereas the NC bill looks like it's restricted to certain laser surgeries only? The NC bill concerns me, as someone who came to medical school specifically for ophthalmology, but the FL bill looks worse by a large margin.

To be honest, if this becomes a widespread thing and ODs get more surgical privileges, I'm not sure why people like me (who come in knowing they want to be an eye surgeon) would go to medical school at all. Why risk it when there's a very real chance of not matching ophthalmology at the end? Especially when med school requires that extra 4 years of residency when "optometrist certified in ophthalmic surgery" needs, what, an extra year at most?

No ! Please read the bill that I have attached several times. It does not give Ods the right to do cataract surgery . With all due respect simply read the bill and youll see all the surgeries excluded. Our profession has two decades of doing these laser procedues safely. Do you need me to upload a copy of the bill one more time?

 

[ophthope]

No ! Please read the bill that I have attached several times. It does not give Ods the right to do cataract surgery . With all due respect simply read the bill and youll see all the surgeries excluded. Our profession has two decades of doing these laser procedues safely. Do you need me to upload a copy of the bill one more time?

And Ophthalmic Assistants and Ophthalmic Technicians have a decades-long history of performing refractions safely and accurately! Give them the rights that they have proven time and time again they deserve! Patients are dying without accurate manifest refractions because they have to drive half an hour to get to an Optometrist even though a tech lives down the street!!

Will you stand with us and fight or will you fall to the wayside, a shameless greedy husk that needlessly guards the right to provide refractions just to pad their pockets while the public suffers? Are you an Optometric Surgeon of the future, or an Optometric Surgeon of the past!? Can I count on your support, Senator OD/MD!?!!?

 

[Doctor.Mario]

I see it now, line 367 specifies exclusion of "surgical extraction of the crystalline lens" from approved surgeries, which I missed on the first read through. Just to clarify that for other interested med students lurking the thread.

 

[LightBox]

One of the problems I see with ODs doing more and more SLTs is that there is definitely a delay in referral to someone who actually can offer the breadth of glaucoma treatments. SLT is pretty wimpy stuff, but many ODs will view it as the "end all be all" of glaucoma treatments just because they have the ability to do it if this legislation passes.

A great example of delay of referral to me today:

New patient: "I've been losing vision for the past 3 months in my left eye."

Me: "Your eye pressure is 45 mmHg and you have 0.9 cupping with double arcuate visual field defects."

New patient: "But I've seen three eye doctors over that time period that said everything was normal and that I just needed a pair of glasses!"

Me: "Ummmm"

New patient's wife: "They were optometrists dear..."

New patient: "Maybe the eye pressure just went up suddenly over the past week or two?"

Me: "Ummmm"

I never disparage or criticize any health care provider to patients since that breeds patient distrust in the entire field. However, this patient should really bring a lawsuit to any one of these eye care providers if they had any sense in them. I'm sure I could use this as ammunition to our state legislature to demonstrate the disparity in training between the two fields. This guy would testify in a heartbeat if I pressed him. This type of situation of delayed referral has happened A LOT in my experience and it is not limited to one geographic locale. Poor training and ego for fear of "losing a patient" really hurts patients.

Again, I'm not trying to bash anyone, but the training that Optometrists get in recognizing and managing ocular disease is not comparable to any Ophthalmology residency. I consistently remember some Optometry students would rotate through for a week at a training program I was at. These were 4th year Optometry students during their final months of a well-regarded school. They would constantly say stuff like "wow, I've never seen a hyphema before! Cool!".

Scary.

 

[Eyefixer]

Do.Not.Feed.The.Troll


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[KHE]

Thanks for the unsupported blanket statement. The fact is they aren't qualified to do so and there is NO NEED for them to have the ability to prescribe them.

Well isn't that a bit of an unsupported blanket statement?

If the pain is truly that severe (rare) refer to ophthalmology. Also, you can't persuade me that narcotic prescribing power is an optometric necessity due to limited access to eye care, lol.

Why? So the patient can pay another $180 and get the exact same Rx I would have given them?

 

[KHE]

One of the problems I see with ODs doing more and more SLTs is that there is definitely a delay in referral to someone who actually can offer the breadth of glaucoma treatments. SLT is pretty wimpy stuff, but many ODs will view it as the "end all be all" of glaucoma treatments just because they have the ability to do it if this legislation passes.

A great example of delay of referral to me today:

New patient: "I've been losing vision for the past 3 months in my left eye."

Me: "Your eye pressure is 45 mmHg and you have 0.9 cupping with double arcuate visual field defects."

New patient: "But I've seen three eye doctors over that time period that said everything was normal and that I just needed a pair of glasses!"

Me: "Ummmm"

New patient's wife: "They were optometrists dear..."

New patient: "Maybe the eye pressure just went up suddenly over the past week or two?"

Me: "Ummmm"

I never disparage or criticize any health care provider to patients since that breeds patient distrust in the entire field. However, this patient should really bring a lawsuit to any one of these eye care providers if they had any sense in them. I'm sure I could use this as ammunition to our state legislature to demonstrate the disparity in training between the two fields. This guy would testify in a heartbeat if I pressed him. This type of situation of delayed referral has happened A LOT in my experience and it is not limited to one geographic locale. Poor training and ego for fear of "losing a patient" really hurts patients.

Again, I'm not trying to bash anyone, but the training that Optometrists get in recognizing and managing ocular disease is not comparable to any Ophthalmology residency. I consistently remember some Optometry students would rotate through for a week at a training program I was at. These were 4th year Optometry students during their final months of a well-regarded school. They would constantly say stuff like "wow, I've never seen a hyphema before! Cool!".

Scary.

Calling BS. The notion that three optometrists would all miss pressures of 45 along with 0.9 cupping and a chief complaint of "losing vision for the past three months" is ridiculous.

It's funny how every time someone is trying to make a point in one of these discussions, they always have the most absurd example of incompetence that they saw "just today." It's ALWAYS "just today." And the second statement will always be "yea! I see cases like that EVERY day."

Now, there's no point in arguing it because the standard response will always be "well, I don't care what you say! I'm telling the truth" and there's obviously no way to refute it because this is the internet so we'll just have to let that absurd claim stand on it's own absurd merits.

 

[OD/ MD student]

No

Again, did you even read the article and the results? It was clearly stated in the results section of the paper. In the paper, over 3 years the rate of repeat SLT was double over time. If you're being conservative with your procedures, the rate should be lower, not higher. Thus, your argument about being conservative with treatment is completely INCORRECT.



Are you daft? Again, you definitely did not read the paper. A conservative approach by definition medically means being less aggressive with treatment, especially if its invasive in any way. Discussion of how you do the procedure does not mean anything. You do realize that the approach you discuss is the STANDARD OF CARE for ophthalmologists as well? You are making fallacious and incorrect conclusions from the data. The paper clearly states in the 11 to 30 day post-op period and beyond, the rate of repeat SLT by optometrists was higher.

As far as your anecdote about PRK (which I'm not sure has much relevance towards your SLT anecdote), you do realize that during the 2000s, Mitomycin C was just being used off-label and lots of studies and research was being done to see it if the toxicity at certain doses did not outweigh the benefits of corneal haze? It's not unreasonable for ophthalmologists in the late 1990s and early 2000s to have not used MMC because there wasn't enough information and experience then to determine if it should be widely used for high myopes (which by the way, PRK/LASIK is also FDA off-label). If anything, the ophthalmologist you were working with was being conservative in treating high myopes. So I'm not sure what argument you're trying to present because it doesn't make any sense, "brother".



You need to be using the average number, not the minimum number. Even then, the minimum number is much more training than a weekend course and a few hours to play around.

Since you're all about lecturing attendings about the lessons you've learned about med school, let me lecture you on something about what happens when you've graduated and now have increased responsibility. If you're going to make assertive claims, you better know your stuff, because based on your points you clearly do not, and you better bet attendings and lawyers will tear you to shreds during questioning. If you're going to be taking care of patients and doing procedures, if you fake it until you make it, you're going to be causing irreparable damage to people.

Your argument is incorrect because the 2016 jama article paper does not distinguish the second time procedures as being slt procedures done over the initial slt procedures or rte second slt procedure as being the remaining 180 degrees. This is far from an accurate study if the author is making a leap of faith and assumption strictly by using medicare data on patients that have multiple procedures by an OD. This was further substanriated by the Murray Fingeret paper reaffirming that most ODs preferring to treat 180 degrees and wait to see if desired Iop lowering is achieved. The very obvious benefit to this conservative application of 180 degrees at a time is less IOP increase post operatively because less thermal energy delivered to the eye. So , the claim that ods are doing more "repeat " procedures is false, misleading and simply downright disingenuous. Performing slt on the remaining untouched 180 degrees does NOT constitute a repeat procedure as that remaining trabecular meshwork was never touched in the first place.

 

[OD/ MD student]

Do.Not.Feed.The.Troll


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he troll being my medical colleagues? Sure that sounds about right

 

[OD/ MD student]

W

Hey I just wanted to quote myself because OD/MD Student seems to keep missing this point and I'm just sweating in anticipation of his/her approval! As someone active in the State legislatures, your backing could really help me get my bill off of the ground!

Who put the sarcastic quarter in you.. so looking forward to sitting next to a "professional" like you in the future

 

[ophtholife12345]

I also want to make the point that these expansion bills apply to ALL optometrists who do the extra certification. In reality, there are optometrists who may have trained in a large tertiary referral center and seen complex pathology who would do an outstanding job, but a large group likely trained in a private practice optometry setting and could theoretically have never seen endophthalmitis during their training.

MD/OD and KHE - you guys may be great and know how to quickly recognize these complications, but if you're honest with yourself, do you think that bottom 25% of your optometry class could do this effectively (not because they are not smart people, but because they never saw enough pathology to recognize complications)? I saw your own famous JasonK on your board talk about how poorly trained many optometrist students are because of the oversupply of optometry students compared to quality training sites.

The problem isn't a practitioner shortage. The problem we should be fighting is expensive drug costs and reducing health care costs throughout the entire system so that people have access to cheaper health care.

 

[OD/ MD student]

W

From the "hit-piece" article



Optoms are 10x more likely to retreat before the one month mark, which is earlier than the time it takes for full efficacy of SLT to occur.

We do not treat the next 180 degrees until its been evaluated that the first slt procedure is working or not working . For many ods this is waiting up to six months to perform the remaining 180 degrees. I call bs in this ten day claim.

 

[VA Hopeful Dr]

Thanks for the unsupported blanket statement. The fact is they aren't qualified to do so and there is NO NEED for them to have the ability to prescribe them. If the pain is truly that severe (rare) refer to ophthalmology. Also, you can't persuade me that narcotic prescribing power is an optometric necessity due to limited access to eye care, lol.

I don't see why everyone gets so up in arms over narcotic prescribing. Its just not that big a deal. There are way WAY more dangerous medications that aren't controlled. I'm much more worried about stuff like prednisone than I am about norco.

 

[kid Icarus 3]

Well isn't that a bit of an unsupported blanket statement?


Why? So the patient can pay another $180 and get the exact same Rx I would have given them?

1 - Logically the burden of proof falls onto the person with no real experience or training in prescribing narcotics. Harmful until proven otherwise.

2 - No. So the ophthalmologist can make the correct diagnosis and offer the appropriate treatment, lol.

Seriously though, I think it would only be wise to have a qualified physician further investigate a patient with severe eye pain before a narcotic is dealt and you'd be careless to disagree.

I'm really not trying to be rude or condescending but it's crazy that optometrists can prescribe narcotics. Furthermore no one can offer a great or even reasonable reason why they should be allowed to. I have the feeling this is falling on blind eyes (pun intended) so I'm just stopping before you find something else to haggle about.

 

[VA Hopeful Dr]

1 - Logically the burden of proof falls onto the person with no real experience or training in prescribing narcotics. Harmful until proven otherwise.

2 - No. So the ophthalmologist can make the correct diagnosis and offer the appropriate treatment, lol.

Seriously though, I think it would only be wise to have a qualified physician further investigate a patient with severe eye pain before a narcotic is dealt and you'd be careless to disagree.

I'm really not trying to be rude or condescending but it's crazy that optometrists can prescribe narcotics. Furthermore no one can offer a great or even reasonable reason why they should be allowed to. I have the feeling this is falling on blind eyes (pun intended) so I'm just stopping before you find something else to haggle about.

No, its really not. Repeat after me: "narcotics are not all that dangerous. They are not even in the top 10 commonly used drugs if ordered by how dangerous they are"