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Why aren’t ODs referring to each other?


Know those optometric colleagues locally who have invested both time and money into the technologies and educated themselves on contemporary care algorithms.

The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM Medica.

A 55-year-old male patient presents to your office. The patient has a family history of glaucoma. Both his father and grandfather had glaucoma.

The patient is not taking any medications and doesn’t have any known allergies. He is a low myope OU and presbyopic. He has a slight asymmetry in his cup-to-disc ratio with 0.4 OD and 0.6 OS.

There are no signs of neural rim thinning. There are no signs of Krukenburg spindles or pseudoexfoliation syndrome. Angle estimation is open with Van Herrick Angle Depth Estimation. The patient’s’ intraocular pressures (IOP) are OD 23 mm Hg and OS 25 mm Hg at 9:30am.

All other ocular findings were unremarkable.

What is the next step?

Previously from Dr. Brujic and Dr. Kading: Optimize patients’ CL experience by avoiding 3 bad habits

Using the right technology

If you are in an office that is equipped with the appropriate diagnostic technologies, you would then educate the patient on the findings and help the patient better understand glaucoma. A conversation would ideally occur in which the patient’s questions and concerns would be answered followed by appropriate diagnostic testing.

This would typically include gonioscopy to assess the angles in all four quadrants, an optical coherence tomography (OCT) assessment of the optic nerve including nerve fiber layer thickness, and a measurement of ganglion cell complex thickness. OCT angle measurements may provide additional diagnostic value.

Since the Ocular Hypertensive Treatment Study,1 central corneal thickness measurements have become the standard of care. This is due to the increased risk patients with thinner corneas who are also ocular hypertensive have in developing glaucoma over a five-year time period.


Threshold visual field testing would also be warranted for these patients, along with photodocumenting the optic nerves.

Other diagnostic tests that offices may include as part of a glaucoma work-up include:

• Corneal hysteresis

• Dynamic contour tonometry

• Pattern electroretinogram measurements

Related: Why opticals must exceed, not meet, expectations

Patient referrals

What if you practice in an office that doesn’t have access to diagnostic technologies such as OCT, threshold visual fields, and fundus photography?

Many practitioners may look to the closest ophthalmologist and refer the patient for a glaucoma work-up based on the suspicious findings. But is there any reason we are not referring them to our OD colleagues who are currently equipped to care for these patients?

We personally know several optometric thought leaders in the glaucoma arena who encompass both optometry and ophthalmology. The medical care of glaucoma patients is within the scope of optometry, and many ODs in the profession are embarking on a full-scope practice modality.

Knowing this and ophthalmology’s increasing surgical role, it is incumbent upon optometry to look within the profession to help fill the void of medical care for patients when appropriate.

As such, it is critical for optometrists to seek those within the profession who have vested into caring for patients with certain conditions. It is  important for ODs who provide advanced care for certain ocular conditions to educate their colleagues in their vicinity on the technologies or training that they may have.

Related: The benefits of cleaning out your practice

Contact lens fitting

Advanced contact lens fittings are another area that justifies intraprofessional referrals.

With the speed at which advanced designs continue to evolve and revolutionize the vision and comfort we provide our patients, it is critical to seek appropriate practices to refer patients in need of this care.

Although keratoconus patients immediately come to mind as those needing specialty contact lens services, other conditions include:

• Pellucid marginal degeneration

• Severe dry eye

• Corneal injuries

• Persistent punctate epitheliopathy

• Epithelial basement dystrophy

• Penetrating keratoplasty

For some patients, contact lenses can change their lives.


Dry eye treatment

Dry eye is an area of eye care that is evolving quickly. Advanced technologies have changed the way ODs diagnose and treat this condition. We both graduated from optometry school in an era in which the only treatments for dry eye were artificial tears and warm compresses through things such as rice in a sock or boiling an egg and placing it in a wash cloth.

Today we have remarkable options including:

• Advanced topical therapeutics

• Oral nutrition

• Scientifically designed warm compresses

• In-office thermal delivery systems

• Punctal occlusion

• Ways to clean the lid margin like never before

Additionally, insights into diagnostics, including point of care testing for inflammation and osmolarity; imaging technologies that image the meibomian glands, lipid layer and eyelid dynamics; and advanced slit lamp examination techniques; give us unique perspectives on the health of the ocular surface. Incorporating these technologies allows us to provide more appropriate and targeted therapies to our dry eye sufferers.

Related: It’s about ocular health, not sales

Future of intraprofessional referrals

The remarkable thing about all that has been discussed is that it has been embraced by the optometric community. As our scope has evolved, we have embarked on the challenge to better care for our patients. Many of these technologies are seen in optometric practices that have vested into advanced ocular care for their patients.

Several things are evident within the coming years. The population is aging, and baby boomers are in need of advanced ocular care. Optometry is appropriately equipped to handle the medical care of a number of these patients as ophthalmology’s role continues to become increasingly surgical in nature.

Know those optometric colleagues locally who have invested both time and money into the technologies and educated themselves on contemporary care algorithms.

Additionally, if you have advanced technologies to care for patients, make sure to educate your local colleagues so that they know you are a resource for these services when indicated for their patients.

It is only with a true team effort within the optometric community that our patients will receive the best care possible.


1. National Eye Institute. Results--Ocular Hypertension Treatment Study (OHTS). Available at: https://nei.nih.gov/glaucomaeyedrops/ohts_backg. Accessed 6/12/17.

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