happy customer of optometrist

[Dude2011]

I started a thread yesterday asking whether I should see an optometrist or ophthalmologist for my increased number of floaters. My thread was banned for "asking for advice."

I am happy to report that I chose to see an optometrist today at a well-known eyeglass chain. I was very impressed.

I got a comprehensive eye exam with dilation for just $80. The optometrist was very competent. She is a graduate of Berkeley School of Optometry.

My retinas are totally fine. As a bonus, I learned that I will need reading glasses soon. I was told to postpone getting them as long as possible because I will become dependent on them.

I was given a choice between Optomap for an additional $40, or a dilated manual exam. I chose the latter because I am a cheapskate, and because Optomap look likes a gimmick to me. Of course, I could be wrong, because I am not an optometrist.

Lesson that I learned: Always go to an optometrist first for any eye problem unless it is obvious that I will need surgery.

---

Members don't see this ad.

 

[KHE]

I started a thread yesterday asking whether I should see an optometrist or ophthalmologist for my increased number of floaters. My thread was banned for "asking for advice."

I am happy to report that I chose to see an optometrist today at a well-known eyeglass chain. I was very impressed.

I got a comprehensive eye exam with dilation for just $80. The optometrist was very competent. She is a graduate of Berkeley School of Optometry.

My retinas are totally fine. As a bonus, I learned that I will need reading glasses soon. I was told to postpone getting them as long as possible because I will become dependent on them.

I was given a choice between Optomap for an additional $40, or a dilated manual exam. I chose the latter because I am a cheapskate, and because Optomap look likes a gimmick to me. Of course, I could be wrong, because I am not an optometrist.

Lesson that I learned: Always go to an optometrist first for any eye problem unless it is obvious that I will need surgery.

I'm skeptical of this post for so many reasons but just for kicks, I'll assume it's true and point out that even if you chose the "optomap" you should still have been dilated anyways because the standard test for a complaint like that. In fact, I would respectfully submit that offering an optomap to someone coming in for the reason you did is just ripping them off.

 

[Visionary]

I'm skeptical of this post for so many reasons but just for kicks, I'll assume it's true and point out that even if you chose the "optomap" you should still have been dilated anyways because the standard test for a complaint like that. In fact, I would respectfully submit that offering an optomap to someone coming in for the reason you did is just ripping them off.

Not only ripping them off, but doing them a disservice. Any new onset floaters eval needs a dilated exam with scleral depression to look for retinal tears. An Optomap is completely insufficient.

To the OP, think what you want about this wonderful optometrist you saw, but feel lucky you chose to be a "cheapskate" and got a dilated exam. Was scleral depression even performed? That's when the doctor looks at you with the head lamp and presses on your eyeball with a Q-tip or similar instrument to evaluate the anterior retina (where most tears occur). If not, you still were not properly examined.

 

[Dude2011]

To the OP, think what you want about this wonderful optometrist you saw, but feel lucky you chose to be a "cheapskate" and got a dilated exam. Was scleral depression even performed? That's when the doctor looks at you with the head lamp and presses on your eyeball with a Q-tip or similar instrument to evaluate the anterior retina (where most tears occur). If not, you still were not properly examined.

After dilation, she looked at me with a scope that attached to her head, while telling me to look in different directions, but she never touched my eyes during the exam with a q tip or any other object. The only thing that touched my eyes was puffs of air from a machine to check eye pressure.

 

[Dude2011]

I'm skeptical of this post for so many reasons but just for kicks, I'll assume it's true and point out that even if you chose the "optomap" you should still have been dilated anyways because the standard test for a complaint like that. In fact, I would respectfully submit that offering an optomap to someone coming in for the reason you did is just ripping them off.

I am pretty sure they offer the optomap to every customer having an eye exam. The receptionist was the first person to offer me an optomap. I told her I will discuss it with the optometrist before deciding. When I told the optometrist I choose the dilated manual exam, she seemed pleased by my choice.

 

[IndianaOD]

I bet the chain staff offer everyone the optomap. They probably weren't even aware of the chief complaint. The optomap is a gimmick as far as I'm concerned. Nothing takes the place of a well performed dilated retinal exam.

Honestly, a lot of the time I don't feel scleral depression adds a lot to a good BIO exam with a maximally dilated pupil. I would definitely do it if there was a + shaffer's sign or saw a suspicious area but otherwise I don't think its a major advantage. It is more usefull to help differentiate an area of concern than find one.

 

[Dude2011]

I bet the chain staff offer everyone the optomap. They probably weren't even aware of the chief complaint. The optomap is a gimmick as far as I'm concerned. Nothing takes the place of a well performed dilated retinal exam.

Then I was right about it being a gimmick. Not bad for a layman.

Honestly, a lot of the time I don't feel scleral depression adds a lot to a good BIO exam with a maximally dilated pupil. I would definitely do it if there was a + shaffer's sign or saw a suspicious area but otherwise I don't think its a major advantage. It is more usefull to help differentiate an area of concern than find one.

That's comforting to hear. I was considering returning and asking for a scleral depression.

I asked the optometrist if my floaters were unusually numerous. She said no.

 

[Visionary]

I bet the chain staff offer everyone the optomap. They probably weren't even aware of the chief complaint. The optomap is a gimmick as far as I'm concerned. Nothing takes the place of a well performed dilated retinal exam.

Honestly, a lot of the time I don't feel scleral depression adds a lot to a good BIO exam with a maximally dilated pupil. I would definitely do it if there was a + shaffer's sign or saw a suspicious area but otherwise I don't think its a major advantage. It is more usefull to help differentiate an area of concern than find one.

Agreed that it usually doesn't add, particularly if you use a 2.2 Panretinal. That said, I've found two tears in the past year or so that could not be seen without scleral depression, even with a 2.2. Oh, and neither had significant vitreous debris. I consider scleral depression to be standard of care for new onset floaters/flashes, but I am a retina specialist.

 

[cvod]

Agreed that it usually doesn't add, particularly if you use a 2.2 Panretinal. That said, I've found two tears in the past year or so that could not be seen without scleral depression, even with a 2.2. Oh, and neither had significant vitreous debris. I consider scleral depression to be standard of care for new onset floaters/flashes, but I am a retina specialist.

Just curious what treatment did you give your patients with these tears?

 

[Retinopathy]

I would be pro-optomap just because it gives better documentation. I would recommend BOTH the optomap + dilation. Maybe optomap every other year or something. Not bad, $40 bucks!

 

[Dude2011]

I would be pro-optomap just because it gives better documentation. I would recommend BOTH the optomap + dilation. Maybe optomap every other year or something. Not bad, $40 bucks!

I just wanted the cheapest way to make sure that my eyes are okay.

 

[Visionary]

Just curious what treatment did you give your patients with these tears?

Laser retinopexy. I'm not a cryotherapy guy.

 

[KHE]

Agreed that it usually doesn't add, particularly if you use a 2.2 Panretinal. That said, I've found two tears in the past year or so that could not be seen without scleral depression, even with a 2.2. Oh, and neither had significant vitreous debris. I consider scleral depression to be standard of care for new onset floaters/flashes, but I am a retina specialist.

Leaving the discussion of what is or isn't standard of care aside for a second because that's always debateable, what percentage of patients that you see do you find things with sclearal depression that you would not otherwise find (assuming a reasonably dilated pupil?

You said two in the last year. I'm assuming you see about 30 patients a day (please correct me if I'm wrong) which would be about 7500 per year.

That would imply then that on only 0.02% of patients did the scleral depression actually uncover anything that may have otherwise gone undetected.

Is that an efficient use of your time and resources?

Now....I know the response will be that those two patients thought so. But there certainly is no guarantee that those patients would have had a less than optimal outcome anyways. Either the break would have healed itself or it would have gotten more symptomatic at which case the likelihood of a positive visual outcome would still be very high.

I'm not trying to discount the value of scleral depression. I wonder though as to it's value on a routine basis.

 

[Visionary]

Leaving the discussion of what is or isn't standard of care aside for a second because that's always debateable, what percentage of patients that you see do you find things with sclearal depression that you would not otherwise find (assuming a reasonably dilated pupil?

You said two in the last year. I'm assuming you see about 30 patients a day (please correct me if I'm wrong) which would be about 7500 per year.

That would imply then that on only 0.02% of patients did the scleral depression actually uncover anything that may have otherwise gone undetected.

Is that an efficient use of your time and resources?

Now....I know the response will be that those two patients thought so. But there certainly is no guarantee that those patients would have had a less than optimal outcome anyways. Either the break would have healed itself or it would have gotten more symptomatic at which case the likelihood of a positive visual outcome would still be very high.

I'm not trying to discount the value of scleral depression. I wonder though as to it's value on a routine basis.

Sorry if I wasn't clear, but I only perform scleral depression on symptomatic patients (e.g., new floaters/flashes)--not as part of a routine exam. I usually see at least 2 of those per day, so that's probably fewer than 500 patients per year, still only making it about 0.4% that I wouldn't see without a depressed exam. Agreed that, at least with a 2.2 (which has a greater field of view than a 20D), most pathology can be seen without scleral depression. I just don't want to miss those cases, however few, and it doesn't really add that much time to the overall exam. I also don't want to wait until symptoms worsen. Yes, they may still be fine, but they also could have developed a retinal detachment. If I can confine the break early with laser, I think that's better for the patient. I guess, alternatively, you could do a 3-mirror exam to scrutinize the anterior retina. I just prefer a BIO exam with scleral depression (no icky goniosol).

 

[Dude2011]

Very educational.

 

[odieoh]

Sorry if I wasn't clear, but I only perform scleral depression on symptomatic patients (e.g., new floaters/flashes)--not as part of a routine exam. I usually see at least 2 of those per day, so that's probably fewer than 500 patients per year, still only making it about 0.4% that I wouldn't see without a depressed exam. Agreed that, at least with a 2.2 (which has a greater field of view than a 20D), most pathology can be seen without scleral depression. I just don't want to miss those cases, however few, and it doesn't really add that much time to the overall exam. I also don't want to wait until symptoms worsen. Yes, they may still be fine, but they also could have developed a retinal detachment. If I can confine the break early with laser, I think that's better for the patient. I guess, alternatively, you could do a 3-mirror exam to scrutinize the anterior retina. I just prefer a BIO exam with scleral depression (no icky goniosol).

How far out do you think you can get with a 90 or a 78 at the slitlamp, having patient look in the direction of interest? I always examine with the indirect and 20 as well, and depression in symptomatic patients, but I feel like I can see sooo much clearer at the slitlamp with good positioning.

 

[Visionary]

How far out do you think you can get with a 90 or a 78 at the slitlamp, having patient look in the direction of interest? I always examine with the indirect and 20 as well, and depression in symptomatic patients, but I feel like I can see sooo much clearer at the slitlamp with good positioning.

I use a digital wide field, and I can see pretty far with directed gaze, though still not all the way. I often check questionable pathology like that, but it's not practical as a screening method. If I can't get to it with the DWF, I move to the 3-mirror, usually at the laser (with consent signed), so I can treat, if needed. Depending on the view, I sometimes use BIO laser. Just not as much control of the eye that way.

 

[ABaverage]

Do most ODs perform scleral depression on their symptomatic patients?

 

[JMU07]

How far out do you think you can get with a 90 or a 78 at the slitlamp, having patient look in the direction of interest? I always examine with the indirect and 20 as well, and depression in symptomatic patients, but I feel like I can see sooo much clearer at the slitlamp with good positioning.

I get much better views of my patients with that technique than with the BIO, although I know that I can't get out quite as far. I always do BIO anyway with a new patient but if it's an established patient with no concerning symptoms or past hx I'll do peripheral views with the 90. Of course it depends on my staff doc too, but most of them are okay with that.

 

[optsuker]

Do most ODs perform scleral depression on their symptomatic patients?

I do.
With definite symptoms, you have to look with every tool in the bag until you see something. Helps to have big hands for this test & I prefer the "thimble" depressor myself. It's a procedure we all learned, but if you can't master it, you owe it to your patient to refer on to someone who can.

There are also times where you just have to go with your gut feeling & refer. I'm always surprised over the years how many times I've seen a PVD with traction or a funny-looking patch of lattice/atophic holes that I turf to the retinologist on a hunch & it winds up tearing/detaching by the time they see the OMD.

It's not just the technical skill, it's the knowledge that comes with looking at thousands of retinas to know when something isn't normal.

 

[mclem222]

I usually send those to the retinologist. My partner missed a tear a couple years ago and it taught me a good lesson. We work in a corporate situation and it wasn't worth the time. Sometimes you have to understand that the corporate places may indirectly push you to have an optomap or do a field on everyone because they raise their rates etc...Just being honest

 

[IndianaOD]

I usually send those to the retinologist. My partner missed a tear a couple years ago and it taught me a good lesson. We work in a corporate situation and it wasn't worth the time. Sometimes you have to understand that the corporate places may indirectly push you to have an optomap or do a field on everyone because they raise their rates etc...Just being honest

Not trying to be rude but this is one of the reasons I HATE commercial optometry. Referring out everything makes us ODs that practice full scope medical eye care look like nothing more that a glasses and contact lens peddler. It creates a bad professional image for all optometrists and devalues our training and education.

I feel an OD should ONLY refer out surgical cases and extremely rare and complicated ocular disease. I only use general OMDs for cataract and the very rare LASIK. (Well I have their techs do OCTs for me on referral) When my diabetic and AMD patients are ready (and not before) they go to a retinal surgeon for laser/injections. It is rare I have to send out a glaucoma case to a glaucoma specialist but I will if the patient it progressing on maximum therapy.

Lets practice how we are trained fellow ODs. Please!

 

[imemily]

Not trying to be rude but this is one of the reasons I HATE commercial optometry. Referring out everything makes us ODs that practice full scope medical eye care look like nothing more that a glasses and contact lens peddler. It creates a bad professional image for all optometrists and devalues our training and education.

I feel an OD should ONLY refer out surgical cases and extremely rare and complicated ocular disease. I only use general OMDs for cataract and the very rare LASIK. (Well I have their techs do OCTs for me on referral) When my diabetic and AMD patients are ready (and not before) they go to a retinal surgeon for laser/injections. It is rare I have to send out a glaucoma case to a glaucoma specialist but I will if the patient it progressing on maximum therapy.

Lets practice how we are trained fellow ODs. Please!

I think some OD's might refer out cases because there is very little money to be made in further examining the patient. Isn't this true, or are most ODs who refer out simple cases, incompetent?

 

[KHE]

I think some OD's might refer out cases because there is very little money to be made in further examining the patient. Isn't this true, or are most ODs who refer out simple cases, incompetent?

In most cases, that's where the money actually is.

 

[mclem222]

IndianaOD...I hear what you are saying but if I am specialized doing my thing why waste time with a patient who could get a more thorough exam with a specialist? My brother who is a corneal specialist sees only corneal and general patients. If he has a patient with glaucoma or a retinal problem he sends it out. It isn't worth his time. If I choose to specialize doing refractions and lasik comanagement that is my business not yours. Sorry that it isnt coinciding with your goals for our profession but I am happy in my world. In terms of the glaucoma referral comment, I recently had a chance to do a chart review at our practice of the previous doc who did all the glaucoma himself. The patients he sent out were all highly advanced glaucoma patients who should have (in my opinion) had surgery years prior. He didn't want to "lose" the patient and held on to them until their optic nerve was completely cupped out. Some OMDs I am friends with feel that this practice is not uncommon...no different than an OMD who doesn't operate any more. They also tend to not refer out patients until things are markedly advanced. When I send out a patient with a problem I am trying to do what is best for them and not bog myself down in stuff I don't do frequently. It is better for me and more importantly the patient! Oh and by the way...that was rude when you say you HATE a type of optometry being practiced..

 

[Shnurek]

I see good arguments on both sides. Mclem and IndianaOD.