new m.d.
A Comanagement Dilemma
Roxanne Woel, M.D.

As a resident, my only exposure to comanagement was sharing patients with optometrists at the Veterans Administration, where referring a patient was a surefire method to decrease the pile of charts awaiting you 3 months later. Understandably, I had concerns about how this would work in the real world.

Now, in my first year of practice, we have a network of optometrists referring patients with conditions from uveitis to glaucoma, ectropion, cataracts and dry eye. When I see these patients, my role in their management is relatively well defined.

Meeting Ms. Jones

Truth be told, the comanagement I find more challenging is managing patients with other ophthalmologists. Here, my role as a comprehensive practitioner is more nebulous. Take for instance, Ms. Jones. Eighty-three years old, she lost the central acuity in her right eye years ago from AMD and has mild-moderate glaucoma in her left eye with 20/25 acuity. She is followed regularly by our glaucoma specialist.

I first met Ms. Jones when she came in one day as a "squeeze in." For the past month, she had been seeing hallucinations of praying figures that disappeared when she covered her right eye. A recent CT scan had been normal and after a negative review of systems and an unrevealing eye exam, I reassured Ms. Jones her pious companions were likely the result of the vision loss in her right eye. Ms. Jones remained unsettled. Given her anxiety and monocular status, I referred her to a neuroophthalmologist, but the next appointment was 3 months away. I therefore arranged to see Ms. Jones in 1 month.

Four weeks later, when her hallucinations and exam were unchanged, I was able to focus on her general management. I noticed Ms. Jones had not had a visual field in 3 years and ordered one before her next appointment with the glaucoma specialist. Weeks later, I received a report from the neuroophthalmologist, who felt the hallucinations were phantom images resulting from the patient falling asleep in front of the television. While I found this diagnosis underwhelming, no further evaluation was recommended and I signed and filed the report. I was therefore surprised when I saw Ms. Jones again in clinic a mere 2 months later. She had seen the glaucoma specialist who felt she needed a work up for the hallucinations, which were not ocular in origin, and that the latest field showed "no clear progression." He continued her Timoptic and had referred Ms. Jones for a refraction.

A Diagnostic Dilemma

After a warm hello, Ms. Jones reported she was seeing the praying figures less frequently. Her vision was unchanged, and increasing the add on her glasses improved her near acuity several lines. But she also had marked punctuate keratopathy that might be alleviated by changing her glaucoma drop. Looking at the field, I agreed there was no clear progression. However, I wondered if we should repeat it as the indices were not very reliable and defects seemed markedly different from 3 years ago.

I found myself in a dilemma. I did not want to alter Ms. Jones' eye drops or repeat the visual field, since her glaucoma was being managed by another physician. But I was also following this monocular patient and it struck me as derelict to merely jot down "management per glaucoma." Three years between visual fields seemed like a long time.

Making a Decision

I resolved that in this case, less was more. I decided against ordering the visual field since to do so would forever embroil me in the management of her glaucoma, and I was not sure this was in either of our best interests. I proposed changing her drops in my assessment and then answered her questions, tactfully avoiding the "he-said she-said" quagmire.

I reassured Ms. Jones that even if everyone did not agree on the exact etiology of the hallucinations, the most worrisome causes had been ruled out. Then, I suggested it was best to discuss the fields with her glaucoma doctor. I made an appointment to see her in a year, with instructions to come sooner if she had any concerns. She accepted this with grace.

Ultimately in this case, it struck me that sharing patients can be much harder than sending them back to a referring provider.

Roxanne Woel, M.D., practices at Koch Eye Associates in Warwick, R.I.