Diagnostic Assistance from an Unlikely Source: O.D.s

A healthy working relationship is possible by following a few key guidelines.

BY RENÉ LUTHE, SENIOR ASSOCIATE EDITOR

It is a truth universally (or at least nationally) acknowledged that the relationship between ophthalmologists and optometrists can often be a tense one. Periodic tussles over turf demonstrate that tension hasn't gone away. The key to a harmonious, productive relationship, according to those who have learned to live together, is a clear, mutually understood division of labor and respect for each other's areas of specialization. Some ophthalmologists may even find that the preponderance of routine eye exams performed by optometrists can yield a few insights into primary care that the M.D. may not have time to catch.

The bottom line: Comanagement relationships that allow each practitioner to thrive in their respective areas of expertise are better for everyone. Below, some O.D.s and M.D.s discuss the finer points of making it work.

The M.D.'s View

Michael Korenfeld, M.D., of Comprehensive Eye Care in Washington, Mo., employs an optometrist in his solo practice. While he involves that optometrist in all the tasks and responsibilities "that are allowed under the law," he is also mindful of just what responsibilities he assigns him.

There are particular eye care issues, he says, where optometrists are very skilled. "I think optometrists are generally pretty good with the oculomotor system," he explains. "Specifically, oculomotor balance, things like strabismus and accommodation. I think they do a pretty good job of measuring those problems. Not specifically nystagmus — everybody has a hard time with nystagmus. But as far as things like misaligned eyes, I think optometrists are very good at that."

Dr. Korenfeld says that while he is quite able to take care of something like strabismus himself, it is helpful to have someone on staff who can handle it as well. "A lot of ophthalmologists are not so comfortable, I think, with matters of ocular motility and would be happy to have an assistant who has a special interest in that," he says.

Dr. Korenfeld feels similarly about contact lens-related issues. While he can handle them, he would rather not. "I frankly don't like contact lenses," he explains. "I find them frustrating and don't think they're such a good thing for the eye. The fact that someone knows how to deal with them clinically and gets good results fitting them makes me feel especially good about having him handle this facet of our practice."

Steven C. Schallhorn, M.D., chief medical director of Optical Express and in private practice in San Diego, agrees that thoughtful delineation of roles for both the ophthalmologist and optometrist is crucial to making the partnership work.

"Comanaging patients with optometrists was essential to the way we delivered care in the U.S. Navy, in my previous position as the Director of Refractive Surgery, and is essential to delivering excellent patient care at Optical Express, the largest provider of laser vision correction in Europe," says Dr. Schallhorn.

For the comanagement relationship to work, certain important conditions need to be in place, Dr. Schallhorn says:

• clearly defined roles and responsibilities for each

• open lines of communication between the surgeon and the optometrist

Dr. Schallhorn describes the role of the optometrist in his model as preparing patients for surgery "by careful examination," and evaluating many of the clinical factors related to a possible procedure.

"This includes a patient's eligibility for a procedure, and then managing routine postoperative follow-ups from a clinical perspective," he explains. His optometrists also perform tasks such as refraction and checking intraocular pressure. "And when I say ‘checks intraocular pressure’ or ‘does a refraction’, that doesn't simply mean as a technician," Dr. Schallhorn says. "That means contemplating whether the refraction is stable and the acuity make sense. In other words, thinking about it, applying their clinical acumen to those results."

And in the comanagement model in which he works, the optometrist is the one who tends to spend more time with the patient, and thus develops in-depth knowledge about the patient, such as their lifestyle and visual needs.

"Visual needs at near, middle and distance and the relative importance of those visual needs — for hobbies, professional needs, low-light vision for driving at night — this is what the optometrist must convey to the surgeon to get the best possible result for the patient," Dr. Schallhorn says.

Moreover, Dr. Schallhorn says that with proper training, optometrists can be very adept at interpreting the results of diagnostic equipment, such as aberrometers and topography devices. Their ability to assist performing and evaluating diagnostic tests can enhance patient care and free up surgeon time. As Dr. Korenfeld points out, "You can only do so many things in your day."

The O.D.'s View

The optometrists interviewed for this article tended to see their roles much as their M.D. counterparts did. According to Cory J. Bosanko, O.D., in practice at Eye Centers of Tennessee, located in Crossville, he frequently helps patients with oculomotor issues, including low vision, and believes his experiences give him an understanding that ophthalmologists may lack.

"What many M.D.s think of low vision needs is a 20/70 or 20/80 patient who absolutely has to have magnifiers, telescopes or other nonoptical aides to read, or something like that," he explains. "But I've actually helped a lot of 20/25 or 20/30 patients who can't see tiny print, through the use of either a magnifier or telescope or another non-optical aid that helps to improve and increase their lifestyle. And that's something patients have been looking for, too."

Dr. Bosanko reports that he is excited about all that optometrists can do in the contact lens field now. Specialized contact lens fittings for cases such as post-refractive surgery for those with corneal irregularities, postoperative ectasia and lenses for keratoconus are becoming popular, he says.

Dr. Bosanko agrees that his greater familiarity with patients' lifestyles means he can provide valuable information to surgeons. His presence in the practice can also help create premium sales opportunities in the dispensary.

"You can't really do that if you don't understand what the patient does on a day-to-day basis. You could have an avid golfer who can't play golf because you put him into a progressive bifocal and when he looks down to see the ball, his focal distance is set for about 16 inches." When spectacle options address specific facets of the patient's lifestyle, he says, they're more receptive and consider it a service rather than a hard sell. "Understanding how they use their eyes is a huge amount of what I spend my exam on," Dr. Bosanko says, "because I want to prescribe the best functional glasses for them."

Medical Optometry

Optometrists' familiarity with patients' lifestyle and their role in providing routine exams to patients leads them to develop their own insights about eye care, and even an emphasis on monitoring aspects of a patient's health that may not seem closely related to the eyes.

Smitesh J. Patel, O.D., in private practice in Columbus, Ga., recently presented a study investigating early warning signs in patients who may be at risk for developing diabetes and how it affects their vision and lifestyle. Subjects were overweight and a high body mass index (BMI) was one of the criteria, as well as waist-height ratio. "When it came to the eye exam itself, we were trying to find out those who also had corneal arcus, which is a sign of possible high cholesterol in the body, as well as hypertensive changes or diabetic retinopathy changes associated with a possible condition," he explains. "And I don't think probably a lot of clinicians are aware of that correlation."

Dr. Patel says that one of his most significant findings was a high correlation of patients who had corneal arcus and who were also ultimately found to have "diabetic-type symptoms," such as high blood sugar levels.

"I think it's important for even general ophthalmologists who have patients with corneal arcus to possibly have them checked not only for cholesterol levels, but also for blood sugar levels and diabetes as well," he says, noting that is what is typically done in a routine eye exam. "We measure their weight, their waist size and figure out their BMI according to age, gender, and other factors."

Such things are most likely not being checked in general ophthalmologists' offices, Dr. Patel says, where visits tend to be problem-focused. "But the bread-and-butter of a primary care optometrist is an entire vision exam done routinely once a year, and probably even more frequently for some people."

Cincinnati's Paul Karpecki, O.D., who specializes in dry eye, says that he has always worked closely with ophthalmologists and believes the two groups can learn from each other. One issue that he sees in his practice, and that he hopes becomes more widely known, is the debilitating nature of dry eye and its impact, both on patient quality of life and surgical outcomes.

"The surgeons do a fantastic job in their area of expertise," Dr. Karpecki says, citing as an example implantation of premium IOLs. "But some patients come back and their overall satisfaction with the procedure isn't quite as good as it should be." Often it is because ocular surface disease such as dry eye has been overlooked, he says.

Dr. Karpecki also reports that many of the dry eye patients he sees have not had their problem taken very seriously prior to seeing him. "In the course of a busy day, I think sometimes these ocular surface disease patients are thought of as less of a priority than a surgical patient, for example. I get many referred to my clinic who have seen many ophthalmologists and optometrists, and they tell me no one took their disease as seriously in terms of the effect it's had on their quality of life."

While such patients typically do require a greater investment in time, helping them is sure to generate referrals. "There's a lot of growth opportunity when patients find someone who is going to take the time to take this condition seriously and realize the impact it has on their lives," says Dr. Karpecki. "In fact, I think this is why we've seen success in the integrated eyecare delivery practices I've worked in as I can focus on these types of patients and allow the ophthalmologist to focus on surgery."

Dr. Bosanko also reports that medical optometry can help an ophthalmic practice thrive. When he first joined the Eye Centers of Tennessee, he initiated a personal meeting with the local endocrinologist and neurologist in an effort to build up a patient base. It quickly began expanding as the endocrinologist began referring his diabetic patients for eye examinations.

"It was the best thing I had done," Dr. Bosanko says. "Now, we've modified something out of the Minnesota Ophthalmology Association — a diabetes letter that we send back to all our primary care physicians after every diabetic eye exam." After the practice began to distribute that, they started to garner more referrals even from primary care physicians. "I'd say that 25% to 30% of all patients I see now are diabetic. That helps fill my schedule so much, all because of 10 minutes with my local endocrinologist."

A Peaceful and Productive Coexistence

With their complementary skills and areas of expertise, ophthalmologists and optometrists seem destined to continue sharing patients' eye care, tensions or not.

"When cost containment is important in a practice — delivering high quality eye care with cost as a factor — the optometrist's role is critical," Dr. Schallhorn says. "If there were two million surgeons in the United States, there wouldn't be much need for the work load of the optometrist — but there aren't! So there clearly is a role; certainly there is in refractive surgery."

Further, a positive optometric experience holds benefits for the ophthalmologist, according to Dr. Karpecki. "The clinical experience for a patient has to be, in the patient's mind, equal to the entire surgical experience. If a patient gets 20/20 results after cataract or refractive surgery, but their clinical experience with the optometrist is not a great experience, or they're waiting a long time in the reception area or even the staff isn't treating them or listening to them properly, the entire surgical outcome is negated." OM