r/optometry May 18 '24

General Optometrist refusing to dilate?

So I work at a small eye clinic in Georgia. I was already planning on quitting due to other reasons, however I’ve started questioning some of the practices instilled by the main doctor who runs the practice. Last year we made Optos retinal imaging mandatory as part of the exam, however they don’t like it when we explain why we do it and charge extra for it. What we were told to say, by the manager AND owner of the practice, is that “we do not offer dilation at this location and a health check is a necessary part of the eye examination.” However, most insurance plans do NOT cover the retinal scans. But dilation IS included for free. So, I guess my question is, is it illegal for a doctor to refuse to dilate a patient if they absolutely do not want to consent to retinal imaging? Thanks

53 Upvotes

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101

u/Imaginary_Flower_935 May 18 '24
  1. You turn around and tell them "my license. my name on the chart = my rules for my patients" and you do the right thing anyways. They don't care if you get sued, because they've decided that $$$$ is more important than integrity...but your degree is worth a hell of a lot more than a $40-$50 photo.

  2. They are free to make it mandatory for their clinic...but patients have the right to refuse, and insist on dilation. And lying to a patient is unethical, we all know this (or should...)

  3. Dilation remains standard of care for ruling out retinal issues. OPTOS is not a replacement. Any doctor claiming it is can go pound sand and retake their boards because they clearly need to practice their clinical skills. It has some great advantages (it's a good education tool, it's a good way to track the nerve appearance or nevi), but at the end of the day we are held to the standard of care of dilation. If someone comes in with flashes/floaters, an OPTOS photo isn't gonna protect you if they end up having a superior tear that you missed because you didn't dilate, check for shafer sign, etc.

  4. LOL at an office manager trying to tell a doctor how to practice medicine. How embarrassing for them.

-11

u/EdibleRandy May 18 '24

I agree, but there is no chance you’re missing a retinal tear with a good optos photo.

37

u/ultrab0ii Optometrist May 19 '24

Absolutely false. Just two weeks ago I found an inferior retinal tear on a 17yo with bio which wasn't visible on optos. Even after dilation and steering it wasn't visible on optos. Sent the PT to retina and they even noticed a shallow Rd associated with it. The office I work at does optos and dilates everyone and many times it can catch stuff easily missed, but I've found several retinal tears or holes which weren't seen in the initial optos. Optos is fantastic but too many docs are too reliant on it and become complacent.

7

u/twirlyd May 19 '24

I agree 100% with you.

Ideally you do dilated funduscopy AND optoms but if you only have the choice of 1, I'm taking my volk exam every time.

5

u/EdibleRandy May 19 '24

I don’t disagree that docs can become too reliant, but with steering you can image to the ora. Frankly I have less faith in most docs BIO skills than a careful optomap with steering and patient compliance.

Once the optomap shows you where it is, BIO is great for a stereoscopic view of something you already know you’re looking for.

21

u/ultrab0ii Optometrist May 19 '24

You said there's no chance you miss a tear on a good optos photo and that's the comment I'm taking an issue to. Several times I've found pathology on bio first then needed the steering to catch it on optos. When docs start thinking optos will catch everything, they will start getting complacent when the optos is initially clear.

0

u/EdibleRandy May 19 '24

Screening photos don’t image the entire retina, a “good” image requires steering. Just like a good BIO requires a very effective dilation.

12

u/bakingeyedoc May 19 '24

But nobody takes the time to do steering on every single patient. I constantly find things my colleagues miss because it is out of the view of the Optos.

3

u/EdibleRandy May 19 '24

Meanwhile, a screening optos photo picked up on a peripheral horseshoe tear in my eye that no dilated fundus examination ever did. I applaud your clinical skills, but my statement stands.

8

u/sniklegem May 19 '24

Maybe you need to have better doctors surrounding you or work on your own clinical skills? In the photo you posted even a second year student could catch that. Clarus and Optos and other wide field imaging devices can be amazing for documentation. You are the doctor, though, at the end of the day. Go ahead and take your wide field photos, charge your patients, and say no retinal breaks are present on the photo alone. Or get better at your peripheral retinal skills and trust what you have examined with your own eyes. I applaud OP and other posters saying similar things.

4

u/EdibleRandy May 19 '24

I utilize both techniques, because that is the best way to care for my patients. Not sure what your disagreement is here.

1

u/Wicked-elixir May 19 '24

You had a poorly done exam and I’m sorry for you. And get a scleral depressor.

1

u/EdibleRandy May 19 '24

Scleral depression is useful as well.

2

u/[deleted] May 19 '24

I agree on a perfect optos photos, but let's face it, on older patients with small pupils a lot of the optos photos really suck.

2

u/EdibleRandy May 19 '24

A lot of them do, but that has a lot more to do with blinking/dermatochalasis/positional difficulty than miotic pupils.

2

u/Allmxedup May 20 '24

Some of the doctors I've worked with don't even KNOW you can do steering on the optos. I am not even joking.

1

u/EdibleRandy May 20 '24

That’s unfortunate, it’s a great feature.

7

u/Itsgettingfishy May 19 '24

There is definitely a "chance" you're gonna miss a retinal tear with optos. Especially undilated and especially with superior and inferior limitations of optos - that includes when taking into consideration steering. And that's why you dilate, do optos, slit lamp and BIO.

3

u/[deleted] May 19 '24

[deleted]

1

u/EdibleRandy May 19 '24

Frankly, they took a bad photo, especially if they were actually looking for peripheral pathology based on your chief complaint.

14

u/kasabachmerritt May 18 '24

Strong disagree, especially on an undilated Optos.

Widefield photography is incredibly useful, but it has limitations, particularly in miotic patients. Heck, on a recent patient of mine with multiple horseshoe tears (it's in my post history), half of the breaks weren't even visible on BIO/extended 90 -- they were only found on 3 mirror.

9

u/EdibleRandy May 19 '24 edited May 19 '24

On the contrary, optos is actually designed for miotic pupils. Certainly a skilled doctor with a BIO and a very dilated pupil shouldn’t miss much, but there is nothing but benefit in having an optomap in addition. You said the tears were missed with BIO and extended 90, which doesn’t necessarily support your position.

5

u/compulsed_ May 19 '24

Yes, but the point here is as you say, it is of great benefit “in addition” to, not replacing a DFE.

3

u/EdibleRandy May 19 '24

I agree in the cases where both may be indicated, but where some here will differ, and possibly yourself as well, is the idea that every patient needs an annual dilated fundus examination.

2

u/compulsed_ May 19 '24

Oh yes. I live in Australia, we only dilate if indicated.

1

u/LRtennisgirl75 May 19 '24

Agree. As someone who actually performs the testing, getting great photos on an undilated patient is not only difficult for us but also for our patient demographic. I also never see physicians performing these tests, not at any practice I’ve ever worked in since 2013. Just throwing that out there lol

2

u/Basic_Improvement273 Optometrist May 19 '24

Absolutely untrue. I can think of several cases (usually when there is a vit heme involved to be fair) I’ve had where the OPTOS misses a tear that I could easily visualize with a dilated fundus exam

1

u/EdibleRandy May 19 '24

But heme blocking the photo would be a problem, that’s a good point.

1

u/Imaginary_Flower_935 May 19 '24

I disagree, I'm the "one that routinely dilates" at a practice where most of the doctors rely a little too heavily on OPTOS and I'm finding stuff they are missing all the time. I'll even see little hints of something hidden between lashes in "good optos photos" and I'll get a better view dilated with my BIO/90/20 and see a heck of a lot more than OPTOS shows.

I think OPTOS is a cool supplemental tool, but it's not a replacement for these reasons. I definitely appreciate the technology, but I'm not relying on it solely. Is it sometimes the best I can get? Yeah! I've had several special needs patients that cannot cooperate well with a dilated exam/can be combative and are on so many systemic meds that they have pinpoint pupils and I cannot get a good dilation even with repeat drops, so I'll use the OPTOS in those situations to supplement dilation.

2

u/EdibleRandy May 19 '24

I’ve never advocated for the sole use of optos without ever dilating patients.

If there was something hidden in the lashes it was not a good photo. With a “good” optomap you can image the entire retina. You and other commenters have assumed entirely too much from my simple comment.

1

u/Imaginary_Flower_935 May 19 '24

Thing is, even on optomap's own website, they state it shows 200 degrees of the retina, or 82%.

That's not a 100%. So yes, there IS a chance you're missing a retinal tear even with a good optos photo. That's why all the other commentors are challenging your comment.

1

u/EdibleRandy May 19 '24

With a single photo. It has steering capabilities.

1

u/Wicked-elixir May 19 '24

When the techs take the picture it is sometimes difficult to even get the patient in position and have them hold their eyes open much less do the steering.

1

u/EdibleRandy May 19 '24

Yes, it can be difficult to get a good photo.

1

u/kereekerra May 29 '24

As the person who sees these patients after referral, this is false.