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Thread: No drops in eye exam?

  1. #1
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    No drops in eye exam?

    When I went to have my first eye exam recently he didn't put any drops in my eyes prior to the exam. Was this a shortcut that may change the results or not?


  2. #2
    Bad address email on file QDO1's Avatar
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    he is the professional, trust his judgment

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    Quote Originally Posted by Dd
    When I went to have my first eye exam recently he didn't put any drops in my eyes prior to the exam. Was this a shortcut that may change the results or not?

    No, there are alternatives to some drops.

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    Quote Originally Posted by QDO1
    he is the professional, trust his judgment

    I'm just trying to find out if this is common practice. I've heard it is not.
    I've been told all AR is pretty much the same... should I trust that advice also?
    Trust but verify...

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    Verify

    DD:

    Thank you for trying to verify if this is common practice.

    There are reasons why drops are added before or after the exam. And there are reasons why no drops were added at all.

    We should not second guess the doctor without knowing anything else about your case.

    I would go back and talk to the doctor and ask him/her that question and see if you get an appropriate response.

  6. #6
    Bad address email on file QDO1's Avatar
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    Quote Originally Posted by Dd
    I'm just trying to find out if this is common practice. I've heard it is not.
    I've been told all AR is pretty much the same... should I trust that advice also?
    Trust but verify...
    most tests on adults (in the UK) who are not Diabetics are performed without drops. The drops we use can force your eye to perform in a certain way, and are useful in some instances. they are however uncomfortable and invasive, and people can have un-wanted side effects. On that basis I prefer the "only when i really need to" method of determining drug usage. What you might want to know is that drugs can be used in many situations in a test for many reasons, and new technologies have reduced the need for some types of routine drug usage

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    Not all AR is the same, most of the time you get what you pay for.

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    Redhot Jumper

    The optometrist I work for has served area familes here for over 24 years. In other words, he is exteremely professional and good at what he does.

    He very seldomly uses eye drops (mainly for diabetes, glaucoma, etc.).

    Please don't be worried.
    As others have said, just trust his judgement, and as him if this seems to bother you much.

    Thanks,
    Finklstiltskinberritacular

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    Okay... so perhaps I didn't fall into the category where he would consider using drops. That makes sense to me.
    People I know who wear glasses were surprised I didn't get them at the exam so I was wondering.

    Thanks for the replies.

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    Many of the indirect lenses I use can allow us to see quite far into the periphery without dilation so long as the pt is co-op enough. I don't think I even remember how to use a direct anymore??

  11. #11
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    From a vision examination viewpoint, diagnostic pharmaceuticals are almost always unnecessary. From a disease detection/evaluation viewpoint, mydriatics are the current standard of care, regardless of their utility.

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    Interesting topic. As an M.D who also dispenses and therefore takes vision plans, I have a hard time with this issue. I am used to dilating every single new patient who walks through the door. The concept being that if the patient is there for a "comprehensive exam" that entails looking at every inch of the retina. In older folks with murky media it is very difficult to get a truly good look at the macula without a dilation. In younger folks who are high myopes you may want to look at the periphery for lattice, holes, tears etc. I have found 2 choroidal melanomas in my career during a routine dilated exam. I have also found at least 5-10 juxtafoveal subretinal neovascularization in elderly patients with 20/20 vision (who would have lost total vision if it had not been caught). However, having said that I will admit that on a lot of these vision plans there is a strong temptation to simply do the refraction, take an undilated look with either a BIO or a 90 diopter lens and send the pt to the optical shop. I have started to do this with some younger patients who have large pupils,clear media and reasonable refractive errors. However I am still uncomfortable doing it with anyone else. Recently I was asked to join a vision plan which compensated $45 for the exam; the director told me..."just refract them, you don't really need to dilate them."

    Ilan

    P.S: Another easy and not too invasive technique that you can use in healthy vision plan type patients is to put a single drop of Neo 2.5 in each eye and send them to the optical shop. When they finish with the optician I see them again and they have a nice, little dilation. I immediately instill Pilocarpine 0.25% before they go home. Almost no patient has ever complained of this regimen. It is very gentle. WARNING: DO NOT USE PILO IN ANY HIGH MYOPE. IT CAN CAUSE RETINAL DETACHMENTS.

  13. #13
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    Quote Originally Posted by ilanh
    Ilan

    P.S: Another easy and not too invasive technique that you can use in healthy vision plan type patients is to put a single drop of Neo 2.5 in each eye and send them to the optical shop. When they finish with the optician I see them again and they have a nice, little dilation. I immediately instill Pilocarpine 0.25% before they go home. Almost no patient has ever complained of this regimen. It is very gentle. WARNING: DO NOT USE PILO IN ANY HIGH MYOPE. IT CAN CAUSE RETINAL DETACHMENTS.
    I find myself faced with the same dilemna with optical plans. On younger people with large pupils and low refractive errors, I use one drop of Paramyd, when I can get it. I haven't found the need to use Pilo. Do you dilute it to .25% yourself? What about using alphagan or brimonidine for their mild miotic effect?

    Even on older folks I have found Paramyd to be effective if you instill it twice, separated by about two minutes. There are minimal side effects from this.

    If I'm just dilating to make it "easier" for me to see the retina, or to cover my backside, I don't charge, but if I am investigating something, or looking for a cause of px symptoms, and I use the full strength dilating agents, I bill the pxs medical insurance. In these cases, the refraction is one service and the dilation is another.


    How do you handle medical insurance billing (which normally does not cover routine care) when a px presents for a routine exam, simply to get new glasses, and they have no optical insurance?

    There is no single perfect way to do it.

  14. #14
    Bad address email on file QDO1's Avatar
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    I pose a question... say you were working for me in my magical practice, where eevrything is paid for. I pay YOU a set fee a day to do any eye-examinations that come in. How much time do you want for each patient, what would you do in the exam, what drugs would you routinely use. Pretend I have a top of the range topcon non-mydriatic RI camera, all the latest screening equipement, choice of the latest wing ding Nidek computer controled lane, or a more traditional lane. the slit lamp has digital photograqphy. etc.

  15. #15
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    Quote Originally Posted by QDO1
    I pose a question... say you were working for me in my magical practice, where eevrything is paid for. I pay YOU a set fee a day to do any eye-examinations that come in. How much time do you want for each patient, what would you do in the exam, what drugs would you routinely use. Pretend I have a top of the range topcon non-mydriatic RI camera, all the latest screening equipement, choice of the latest wing ding Nidek computer controled lane, or a more traditional lane. the slit lamp has digital photograqphy. etc.
    I'll have to think about this one a bit. I need a few days off for the holidays. (You know this means a long-winded answer.)

  16. #16
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    Quote Originally Posted by QDO1
    I pose a question... say you were working for me in my magical practice, where eevrything is paid for. I pay YOU a set fee a day to do any eye-examinations that come in. How much time do you want for each patient, what would you do in the exam, what drugs would you routinely use. Pretend I have a top of the range topcon non-mydriatic RI camera, all the latest screening equipement, choice of the latest wing ding Nidek computer controled lane, or a more traditional lane. the slit lamp has digital photograqphy. etc.
    In my practice there are techs who first take the patient to a "work-up room" where their glasses are neutralized, an automated refraction is done, puff tonometry, auto K's. They are then taken to an exam room where the tech does a retinoscopy and confirms with trial frames . I then come in and check the tech's refraction and refine the retinoscopy. I do the slit lamp exam and and instill a very mild dilating agent depending on age, race and pathology (I can elaborate on this for you privately if you would like). The patient goes to the optical shop and is brought back after their purchase for the completion of the dilated exam.

    Neo2.5 for young, light colored or lo-level pathology
    Mydriacyl 0.13 + N2.5 mixture for elderly or mild patholoy ("weak mix")
    Mydriacyl 0.25 + N2.5 mix for dark patients, people w/ retinal path ("strong mix"
    Myd 0.5% for people with serious retinal pathology

    Pilo 0.25% to bring down pupils (not in high myopes).

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    One of my favorite topics. I've been around long enought to have (almost) come full circle. I was taught it wasn't necessary to use any drops. It turned out that's because it was illegal for us to (in California). After we got the legislations that allowed it, I dilated everyone (OK there ARE some reasons not to use them, such as very narrow anterior angles). Then I got a retina camera and am dilating less frequently. If you go to my web site http://www.folsomeye.com you will find a link to a photo taken without dilation. My current regimen is to take a photo on everyone as a baseline, but on the next exam (or right then, if there is any suspicion) I'll probably dilate, as it's the only way to see the peripheral retina, and the best way to get a 3-D look at the retina (although my camera can even do that!, but it takes two pics for each eye). BTW I'm wondering if routine tonometry will ever be passe' now that they've removed IOP from the definition of glaucoma!

    Anyway, to answer the original question, I'd say that if the doc didn't take retina pics, and didn't dilate or schedule a dilation, I think the argument could be made that you have not had a complete eye exam. That may be ok for you, but not ok for others. I am sympathetic to the low reimbursements, and I hate what's happening in managed care. It is a real conunundrum.

  18. #18
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    As I've posted elsewhere, I think that the retina camera thing is a gimmick. First of all, you simply cannot see accurate details of the macula in those photos. It is critical to see early AMD changes, juxtafoveal SRN, epiretinal membranes, early diabetic changes (eg: flame hemm, Irma's, NVE etc). The retinal camera simply gives you a "gestalt" feeling of what is there without any actual detail. It's no more effective than "small-pupil" indirect ophthalmoscopy. Think about why we dilate patients: Is it to rule out major issues such as retinal detachment, vein occlusion, arterial obstructions etc? Not really; it is unlikely that a routine visit from a 20/20 patient will yield such a finding. The real reason why we do it is to look for SUBTLE problems which will cause bigger problems later eg: early AMD, NVE, lattice, atrophic holes, vitreoretinal traction, small emboli etc. None of these can be reliably detected with undilated photos. Although I am very sympathetic to those OD's who own these expensive cameras and want to create some value added billable services, I cannot find a place for it in my practice. And, believe me, I would love to because I also own such a camera and only use it for documenting pathology (I would dearly love to collect an additional $25 from every patient for "baseline photos").

  19. #19
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    Quote Originally Posted by ilanh
    The concept being that if the patient is there for a "comprehensive exam" that entails looking at every inch of the retina.
    How big are American eyes? If there's a few inches that some opticians don't even bother looking at, that's some retina! Maybe it's because your country is bigger and you need to see further.;)

  20. #20
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    I'm surprised that we have an eye doc saying that a retinal photo can substitute for a dilated retinal exam. There is NO camera yet developed that can view the peripheral retina.

    A camera can only supplement a dilated exam---not replace it. I've had a few docs that swear to me that they can see to the near periphery with their old direct ophthalmoscope in a undilated pupil. They are lying. No way. Impossible. It's about like the glaucoma doc only using a direct scope to view the nerve. Just not realistic---but he swears by it. I've always wondered what he has against a steroscopic view.

    I keep it simple. Dark irises get 2.5% phenylephrine and 1% Tropicamide. Light ones get Paramyd. Reverals are by Rev-Eyes. Works great but most people don't want to bother with the reversal.

    Everyone gets dilated every few years unless they say "no". It's their eyes. I don't think there is anything wrong with taking 'screening' retinal photos of everyone to beam to the room to show them what it looks like. I don't do this but would if I decided to get rid of my old retinal polaroid camera and spend the $35,000 for a new digital one.

    My opinion: I think all new patients deserve a dilated retinal exam. You just don't know what's in that eye unless you look...and you can't look without dilating. I'm just not that much of a gambling man.

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    Quote Originally Posted by ilanh
    As I've posted elsewhere, I think that the retina camera thing is a gimmick. First of all, you simply cannot see accurate details of the macula in those photos....Although I am very sympathetic to those OD's who own these expensive cameras and want to create some value added billable services, I cannot find a place for it in my practice. And, believe me, I would love to because I also own such a camera and only use it for documenting pathology (I would dearly love to collect an additional $25 from every patient for "baseline photos").
    A gimmick? Here I thought fundus photos were becoming the gold standard for early diabetes, and stereo pairs of the disk are already the gold standard for glaucoma diagnoses. No detail? Did you look at my example? Use the standard zoom feature of your browser to zoom in on the details and even look at individual nerve fiber bundles. Click on: http://www.obase.net/MillerLeft.jpg which is the very first photo I took of my employee's eye, undilated. I too would love to collect more $s for the baseline, but don't at this time for the promotional as well as preventive aspects of doing it. The nice thing about the Canon I have costs me nothing to use. It costs me to just sit there, but nothing extra to use (unless I choose to print the pics, and then it''s only paper and ink) and only about 30 seconds per patient. Time well spent. The patients are blown away by it. (and mine cost $25k; worth every penny of it)

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    Quote Originally Posted by William Stacy O.D.
    A gimmick? Here I thought fundus photos were becoming the gold standard for early diabetes, and stereo pairs of the disk are already the gold standard for glaucoma diagnoses. No detail? Did you look at my example? Use the standard zoom feature of your browser to zoom in on the details and even look at individual nerve fiber bundles. Click on: http://www.obase.net/MillerLeft.jpg which is the very first photo I took of my employee's eye, undilated. I too would love to collect more $s for the baseline, but don't at this time for the promotional as well as preventive aspects of doing it. The nice thing about the Canon I have costs me nothing to use. It costs me to just sit there, but nothing extra to use (unless I choose to print the pics, and then it''s only paper and ink) and only about 30 seconds per patient. Time well spent. The patients are blown away by it. (and mine cost $25k; worth every penny of it)
    First point. I have a freckle at 9.00 o'clock on my retina in my right eye. In a meeting about RI, 10 optometrists and doctors tried to find it, each was given 5 miniutes, and then I was dilated, and they were gien a further 5 miniutes, after being told there was something to see, and I even told them where it was. No one could see anything to note with a ophthalmoscope or Volk Lens etc

    A lot of jaws dropped, and deep intakes of breaths were herad when the camera, where an image was taken before dilation, showed it plain as day, 1/4 way into the image, the dilated image was even more spectacular

    Second point... with a decent image as a baseline, year by year very small changes can be observed. You could take 10 normal pictures (individually each picture could be judged as normal), for the same patient over 10 years, if these pictures had small variations, that would not be normal for that patient. whats the alternative? - a few hand writen notes, even with a hand drawn diagram would not pick up on a changing patient in such a subtle way

    Third point - with broadband now widespread in the workplace, it is easier now to avoid not working in isolation, but share interesting pathology with another Dr for a second opinion, or even use the actual image in a referal. This will speed up the Triage process, and prepare the hospital what is comming in. By having more than one professional review an image, the patient sometimes can be better served, and the professionals can learn from eachother

  23. #23
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    Quote Originally Posted by William Stacy O.D.
    A gimmick? Here I thought fundus photos were becoming the gold standard for early diabetes, and stereo pairs of the disk are already the gold standard for glaucoma diagnoses. No detail? Did you look at my example? Use the standard zoom feature of your browser to zoom in on the details and even look at individual nerve fiber bundles. Click on: http://www.obase.net/MillerLeft.jpg which is the very first photo I took of my employee's eye, undilated. I too would love to collect more $s for the baseline, but don't at this time for the promotional as well as preventive aspects of doing it. The nice thing about the Canon I have costs me nothing to use. It costs me to just sit there, but nothing extra to use (unless I choose to print the pics, and then it''s only paper and ink) and only about 30 seconds per patient. Time well spent. The patients are blown away by it. (and mine cost $25k; worth every penny of it)
    Great photo. Plenty of detail. I can honestly say there is more in the phote than I normally see with BIO and/or Volk...and you can look at it for as long as you want.

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    Quote Originally Posted by fjpod
    Great photo. Plenty of detail. I can honestly say there is more in the phote than I normally see with BIO and/or Volk...and you can look at it for as long as you want.
    Thanks. I really love being able to take the time to slap a mm rule on a 5 inch high optic disk and measure the cup/disc with REAL precision. And on the suspicious ones, do the same a year later and pronounce them glaucomatous or glaucoma free with some conviction. And to QDO1 (previous post), that happens all the time. I see something and quickly flip through all my previous exams. Sometimes it's there, and I get to brag a bit about my bio skills, but often it's not in the notes, and I'm still a hero, because now I can even boast that I have the technology to see stuff I that "wasn't visible" before! win, win (oh, and I'm getting used to seeing these tiny really tiny things that are just normal, as they show up a year later with no change. Maybe I'll post some of those pics later in the week.) One last thing, I said it only takes a minute of my time. Of course it's so easy I could delegate it, but I have too much fun watching with the patient as the pic materialzes on the screen. Fun, imagine that! My favorite thing to say is "it isn't every day you get to see your own arteries and veins, and part of your brain"... Maybe it's a flashy gimmick, but that's why I chose optometry in the first place. Love those toys...

  25. #25
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    My original reason for getting the exam in the first place was to detect eye or other disease. I know you folks can find an awful lot looking in the eye and I don't think I'd had an exam as an adult. Unless you count the license bureau. ;)
    I'm pretty much set on getting another exam from whoever I end up doing business with for my glasses.

    I was actually a little surprised to find I was more than far sighted and needed more than the readers I've been using.

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