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Here’s another example of why everyone should consider getting a yearly eye exam despite what Canadian studies say. A college student came in for a routine eye exam to get more contacts since the last doctor made her contact prescription expire only after a year. Everything seemed normal except that this year she didn’t pass the FDT screening field with one eye and that same eye had 20/30 vision. The ONH looked a little pale and both were elevated.

If I was still in Indian Health Service, I could have handled this myself- ordering all kinds of fun tests. But what I’ve learned out in the private sector is that insurance companies HATE it when optometrists order tests. Patients get denial letters on labs. Forget about imaging. Besides, I was having a train wreck day, so I just punted to the ophthalmologist.

Turns out that an MRI ordered by the OMD diagnosed a brain tumor that would have killed her if allowed to fester. I know that because she stopped by last week on a day that I wasn’t there to say thank you. When I heard that, I felt ashamed. I should have been the one to piece together the information and order the scans and have the burden to tell her the bad news.

But regardless of my personal shame, the patient is now okay. She is yet another shining example of why Utah state law should not mandate to me that I have to make prescriptions good for two years. I saw her chart from previous years. No VF defects, 20/20 vision in both eyes- no indication that the next year she would be diagnosed with brain cancer.

Hey 1-800 and your lobbiests! Who knows how many people you will kill or blind because you force by law that every eye doctor in the state of Utah has to make their Rx’s for 2 years.

So everyone: check yearly, see clearly, live longer.

At my round of golf after some CE a couple weeks ago, the topic of conversation drifted to what practice management software was everyone using. Of course, for years we have been inundated with PIM/EHR software ads in industry magazines and booths at conferences and conventions. I still haven’t seen an appreciable improvement in the EHR part of the package. Sure, the PIM helps me track the money, but the EHR still slows me done. It would be faster to draft a paper chart and then scan it under the patient’s name in the PIM.

The whole reason to utilize a database for EHR would be to track numbers over time. For example, OfficeMate has this feature in the fields of IOP and C/D ratio. BUT THE WHOLE CHART SHOULD BE THIS WAY! And it would be great to have the functionality to analyze binocular testing data according to OEP, graphical, and normative analysis.

Anyway, if your EMR is just basically storing text for you instead of inserting data into searchable/analyzable database fields, I think it’s faster to scan your paper copy and link it into the PIM instead. Plus it will save you money on buying a separate EMR module.

Here were EHR wants number one and two.

[Edit: For some reason, this is the most popular page on my site thanks to people searching the internet for mentions of Biofinity. Please be sure to read my other article entitled There is No Biofinity Conspiracy.]
Also, be sure to read my Full Review of the Biofinity Lens!

I posted an entry on my practice website about the Biofinity lens. Within less than 2 hours, I got the following comment in the comment moderation cue:

Author : John Bird (IP: ***.**.**.** , [URL removed to protect the innocent])
E-mail : jbird@aol.com
URL :
Whois : http://ws.arin.net/cgi-bin/whois.pl?queryinput=***.**.**.**
Comment:
I have tried Biofinity and quickly went back to Oasys. Oasys is a more comfortable lens, and it doesn’t have the problems with protein build up that Biofinity does.

Before approving the comment, I sent the following e-mail to “John Bird”:

Mr. Bird,
I’m skeptical of your comment. Tell me who you are, how you know the
phrase “protein build up” and how you happened upon my article shortly
after it was posted, and then I’ll think about approving it for my
patients to see.

Then I recieved word from AOL that the message couldn’t be delivered:

This is an automatically generated Delivery Status Notification

Delivery to the following recipient failed permanently:

jbird@aol.com

Technical details of permanent failure:
PERM_FAILURE: SMTP Error (state 13): 550 MAILBOX NOT FOUND

So, someone made up a fake name and e-mail address and tried to push people away from Biofinity to Acuvue Oasys. The IP address links the poster to a company named ************, a “***** ******* *** ****** ******* firm.” He could be just a random employee of a big company in New York who happens to subscribe to content from the website of a small optometrist office in Utah.

Or…what do you think?

And is there any truth to Biofinity getting deposit build up? From what I’ve read the Aquaform material is supposed to resist deposits.

I was listening to an ophthalmology update podcast number 7:

# Program Title: Deciding when to treat glaucoma, and what to tell patients.
Description: A conversation with George L. Spaeth, MD, Professor of Ophthalmology and Chief of Glaucoma Service at Wills Eye Hospital in Philadelphia. He has a special interest in the quality of life of patients with glaucoma, and insight on deciding when to treat.
Speaker: George L. Spaeth, MD

Dr. Spaeth’s premise is that when you tell someone that they have glaucoma, you lower their quality of life. At one point in the conversation he states that even if someone has visual field loss, you still may opt not to treat, again citing quality of life concerns.

Okay, let’s step back. The mere fact that you are running all these extra tests like visual fields, fundus photography, HRT2/OCT/GDx, and checking their IOP every 3-4 months is going to cause some worry. Am I going to look them in the face and say, “No, you don’t have glaucoma even though, as I just showed you on your visual field printout, you have some areas of decrease vision. And disregard these big, red X’s on the HRT2 printout.”

So, I’m not going to treat someone because I don’t want to hurt their feelings? I suppose that would go over really well in a malpractice suit.

What if I simply said something like, “Yes, you have glaucoma, but odds are you won’t go blind if we start these drops as soon as possible and make sure you take them everyday and see us back for regular follow-up to maintain our target eye pressure goal.” Would that approach be enough to soften the blow to their quality of life?

And while we’re on the subject of glaucoma, I think it’s preposterous that the American Academy of Ophthalmology stopped admitting optometrists to their annual convention with CE. The public health is at stake. Already someone over in the UK did a study and smeared optometrists by saying that optometrists were more likely to miss glaucoma than ophthalmologists (listen to As Seen From Here podcast episode #48, start listening around minute 26:00).

This whole glaucoma topic just makes me shiver when I think that there is such thing as a glaucoma specialist. I know I’ve already gone over this before, but ALL eye doctors must be glaucoma specialists for the sake of our patients. I foresee in the future that maybe every complete exam will include stereo photos given to the patient in case they switch doctors, HRT2/OCT/GDx testing, and using one of those new fangled ways of testing eye pressure thingies that I don’t quite understand yet because I can’t afford yet another expensive instrument in my practice.

Yes, the expense will be enormous to implement these tactics. Maybe those who don’t include such things in every exam should just call their routine eye exam an eye screening. But doing that is one step away from having the ophthalmology establishment legislate out of existence the optometry profession since we would be ignoring the public health by only providing eye screenings and not full eye care.

Dr. Epstein elucidates the ramifications of the staining grid in the latest Optometric Physician e-journal.

I think the real reason there is any controversy is because Renu, which has a huge market share thanks to lower cost, has so much to loose. Of course Alcon/Optifree and Ciba/ClearCare are jumping all over it since it makes them look good. I guarantee Renu would embrace the Staining Grid studies if it would have shown favorable results.

We saw the same thing when Renu Moisture-Loc was recalled. Optifree and Complete sent e-mails out to optometrists gloating that their products were safe. Then we saw Complete get recalled.

There are even studies trying to show that the Staining Grid study design is flawed; however, noticeably absent from inclusion in the study is Renu. All I have to say is, make a better product and you’ll get better results. If Bausch & Lomb is so concerned that Renu doesn’t do so well with most contacts in the Staining Grid tests, then maybe they should re-tool and make a better solution. Don’t try to tell me that, awe shucks, corneal staining really doesn’t matter.

Meanwhile, Biofinity, Acuvue2, and Acuvue Oasys are also capitalizing on the staining grid by sending to my office pamphlets and copies of studies saying (in effect), “Look at us. It doesn’t matter what MPS your patients use if you fit them in our lens.”

I’ve actually posted on my practice website a little ditty about the staining grid.

It looks like doctors are at the bottom of the totem pole. We are in the wrong profession if we’re trying to make tons of money. I’ve recently had a few undergrad students want to shadow me at work. I tell them all the same thing, “Don’t become an optometrist because you think you’ll have an easy lifestyle and comfortable living. I work six 10-hour days a week, and I don’t even have a house. Only become an optometrist because you love it.”

They all give me that same look of trying to hide their befuddlement. I know they’re thinking, “Yah, but it’ll be different for me. You must be a bad optometrist because statistics say I’ll make over $100 grand a year.”

And I’m thinking, how could anyone possibly love to be an optometrist unless you already work as an optometrist? It’s a Catch 22. By time you are one, it’s too late to back out of all those school loans if you decide it’s not for you. Maybe a good check about whether being an optometrist for you is to go out everyday and explain to ten people, all over the age of 40, what presbyopia and astigmatism are and why all the sudden they can’t see up close anymore even though they used to see just fine until about two months ago. If you enjoy that, then maybe optometry is for you.

The Independent Urologist’s post makes me think maybe we should just start buying products directly from those who make them, not necessary those who distribute/market/resell them. Insurance has done nothing to help optometry, and I wish people realized they would be better off paying doctors directly for eyecare instead of adding a middleman who takes money from both of us.

The AOA News reports that the FTC sent letters to a few eye doctors saying they were in trouble for not releasing the contact lens prescription.

This isn’t a problem for me. As soon as the contact lens prescription is finalized, I give them their copy. I even make it good for 2 years since that is what Utah law requires (unless there is a medical reason to make it one).

My problem is that almost every day, I receive a request for another copy of a patient’s CL Rx-and I know for darn well sure that I gave them their copy already. Patients are apparently losing/misplacing their CL Rx, but why do I have to waste time, paper, and toner to fill out another one?

I think I should be allowed to charge money for extra CL Rx copies. The first one is free, but additional ones will cost you. That is in a perfect, fair world. But life isn’t fair. As it stands, I’m not allowed to charge for additional copies. You know that one lady who comes into your dispensary at least once a week to get her glasses adjusted? What if you had some perverse person who enjoyed making you fill out a CL Rx every day or weekly? Do we have a recourse for that?

P.S. Normally you can’t access the AOA News site unless you have a user name and password, which requires membership in the AOA. This is also a big hassle because it should just be able to go publish an RSS feed so I can reed the content in Bloglines or Google Reader. Do they really expect me to open a web-browser, type in the URL, then type in my user name and password everyday just to see if they have updated content?

I think it’s funny that Ciba and VisionWeb pay for advertisements that only a small portion of the optometrists even see. The WSJ is going free because exposure of ads outweighs revenue from paid subscription. The AOANews should do the same. Hey Ciba and VisionWeb, tell the AOANews to go free and publish a site feed!!

By the way, you can circumvent AOANews’ username and password requirement by simply pasting “?AOAMember” at the end of each URL. Again, another reason to go free and offer RSS, AOANews.

I had a great round of Golf with area O.D.s yesterday. Mount Ogden Eye Center sponsors a lunch, one hour of CE, and then a round of Golf for any northern Utah optometrist that is interested in taking the day off.

It was really cool to get together with local O.D.s who share the same concerns that I do about business aspects of practicing optometry in Utah.

I recently talked about a local HMO/Insurance Plan, IHC-SelectHealth, that discriminates against optometry. A lawsuit was brought against them by a group of individual optometrists which they later lost and now there can be no more appeals. My question was why wouldn’t the Utah Optometric Association or even the American Optometric Association get involved and sponsor the suit. The answer was not enough money and that there would be serious repercussions. The thinking is that IHC won’t counter-suit a bunch of individual optometrists, but they would the UOA, which could go bankrupt in such a scenario. Apparently a lot of optometrists were upset that there was a lawsuit in the first place because they thought there should be more diplomatic means.

I say the only diplomacy we need is with our state legislatures to enact an Any Willing Provider law so that IHC/SelectHealth’s discrimination would be illegal.

Another thing, this Insurance sponsored discrimination fosters an Us vs. Them attitude with ophthalmologists. The areas where both ODs and OMDs are all paneled is usually because early on, the OMDs went to bat for the ODs and got them on. In areas where ODs are not allowed, the ODs can start resenting the OMDs for not going to bat for them. Pretty soon, all our referrals somehow end up going to Ogden instead of staying local in the valley. Then the local OMDs get perturbed by not enough referrals from the ODs, so they might vow to never go to bat for the ODs. A vicious cycle.

The patients are the ones who really lose from this situation currently happening in Northern Utah. IHC/Selecthealth claims in their T.V. commercials that they are “Simply There” and according to their website, “SelectHealth offers members respect, convenience, excellent service, and affordable health coverage.”

Did you see the convenience part? How is it convenient to wait for weeks to see an eye doctor for a routine eye exam? I suppose it’s convenient for SelectHealth that people don’t want to wait for weeks so they go see an optometrist instead, and SelectHealth won’t allow optometrists to bill them and they won’t reimburse the patients either. I think that must be their evil master plan: subtly encourage patients to see non-network doctors so that they don’t have to pay out any money.

By the way, SelectHealth’s copay for eye exams is $35. So what’s another $10 to the patient to see a big box doctor for a $45 eye exam. Yet another way they encourage the OMDs to dislike the ODs for having such a thing as commercial optometry.

Insurance in general hasn’t done anything to help private practice ODs. We were much better off years ago when 90% of optometry exams were private pay. Vision Insurance is as worthless as haircut insurance. It only adds a middleman who takes from both the patient and the eye doctor. If we all just stopped taking vision insurance and slightly decreased our fees, the whole populous would be better off.

I was listening to OD Conversations’ OD Radio podcast about school screenings. They don’t allow comments on their site, so I’ll comment on my blog.

They were talking about how they work with the school nurses and help out with screenings. They also implemented some additional tests to help catch more subtle problems. Wow, I’m jealous.

I contacted the local district nurses (they don’t have any in the school full-time, just traveling ones), and they gave me the brush off. They said they run their programs according to state guidelines and that they don’t need any additional help.

Now that my son is in school, this year I’m going to try to infiltrate the program from the inside by volunteering as a parent in the PTA to help with screenings.

The United States Public Health Service Commissioned Corps has their own YouTube Channel.

I searched for an American Optometric Association YouTube channel but didn’t find one.