It was in a most unlikely source that I read something yesterday that crystallized the public health and education crisis we have about CI. Essilor, the world’s largest ophthalmic lens manufacturer, publishes a bi-annual international review of ophthalmic optics, Points de Vue or Point of View. The magazine is published in English, Spanish, French, German, and Mandarin. It is distributed by Essilor’s global subisdiaries to Optometrists, Opticians, and Ophthamologists around the world.
Turning the pages of the Spring 2010 issue, I was expecting to find various articles about lenses, and I did. Unexpectedly I came across an article on the early diagnosis of glaucoma. Its author, an ophthalmologist, underscored an important point crucial in early identification and treatment of the disease:
It is certain that about half of all patients diagnosed as having glaucoma and treated by professional ophthalmologists are not actually suffering from this disease.
I did a double take. Was the author saying that ophthalmologists were treating patients as if they had a disease, when in reality they didn’t? To dispel any doubt that this was exactly what he was saying the author repeated his premise in the next paragraph. He reiterated:
To improve the prognosis for glaucoma, it is important to focus on the at-risk population, and training for ophthalmologists must be improved. They would then be in a position to identify true glaucoma to avoid unnecessary treatments. It is estimated that about 50% of patients diagnosed after screening campaigns are subjected to treatments that are unnecessary.
It was refreshing in a way to read what Professor Sanchez had to say in this article. Chronic open angle glaucoma (COAG) is one of the most vexing problems in eye care. Even though for years we really had few ideas on how to treat it, we did whatever we could. This largely consisted of lowering eye pressure as much as possible, and doing anything that appeared to be protective of the optic nerve and its connections within the eye and to the brain.
Yet the conundrum remains. As Professor Sanchez admonishes, we treat a large number of patients for presumed glaucoma who don’t need to be treated, and we don’t identify true COAG patients early enough who could benefit from treatment – if we could only find what those effective treatments were for individual patients.
How does the situation in glaucoma compare to our current circumstances in treating convergence insufficiency (CI)? Essentially we have the opposite problem. In CI we have a very well defined condition, and one that is easy to identify clinically in its earliest stages. We now have definitive studies and guidelines, as reviewed extensively throughout these blog pages, on exactly how to treat the condition and normalize the patient’s visual function.
In part 1 of this series, Dr. Fortenbacher posed some serious questions about why some doctors overlook the patient with CI. The first possibility he posed was:
- Could it be lack of training?
That’s a distinct possibility. When I was studying to be a Doctor of Optometry, one of our College’s influential clinicians would dismiss the condition by stating that no one ever went blind or died from convergence insufficiency. That would be a very unfair value judgment for someone left to struggle for years with functional vision problems due to undetected or untreated convergence insufficiency, wouldn’t it?
Leonard J. Press, O.D., FCOVD, FAAO
The VisionHelp Blog 
It would be interesting to discover just how frequently an O.D. performs a thorough evaluation of a patient’s total ocular motor skills covering motility, accommodation and their integration.
When the OHTS was first published citing the importance of pachymetry I had an opportunity to speak with Ken Lombart and queried him as to whether or not the pachymeters were “flying out the door.” Shockingly he replied, “NO!”
With optometry’s focus on the practice of “medical optometry” and my experience with 4th year students externing in my office, it would appear as if an important part of an optometric examination is not being given the significance it demands. This is supported by the responses I get from patients who I see after having been elsewhere, that when questioned reply that many of the tests that I did they know they never had before.
Very valuable comments, Chuck. Your first point addresses the dilemma that even when studies provide outcomes that should translate into changes in clinical practice, those changes can be slow. If this is the case for ocular hypertension, one of the centerpieces of “medical eye care”, how much more so for CI?
Your second point will hopefully gain wide audience. As an extern preceptor you’re in a unique position to see an unselected sample of 4th year students putting what they know into action. So I’ll ask you this question: Your students are presumably from PCO. Dr. Scheiman, who is the principal investigator for the CITT study and has done a phenomenal job with it, is based at PCO. How is it possible that CI detection and treatment is not part of the culture? – Len
Hi Len,
I find it very interesting that you have entered into this conversation from the angle of advertising in the ophthalmic industry. Your post brings into view the role that the ophthalmic industry plays in directing responses from clinicians.
Industry and ophthalmic materials drive clinical care. Insurance reimbursement drives clinical care. The underlying truth here is that financial incentives drive clinical care. Education supports clinical ability, but sadly, education alone is not sufficient to change clinical practices. Education paired with financial incentive, however, can very quickly manifest a change in clinical practice.
In an ideal society, or in a non-capitalistic health care system, schooling and evidence-based research provide clinicians with an education, so that they may go forth and deliver care, offering their patients the “best options” for their needs. In the eye and vision care industry, these options may be tangible, such as glasses, contact lenses, or prescribed medications. Other times, these options are intangible, such as office-based vision therapy, or the use of diagnostic equipment to gather clinical data (where the patient undergoes a test, but often does not have something in hand to remind him of the test/service). And then there are those rare therapeutic options with tangible components, such as ortho-keratology as a treatment process (as opposed to the instant “solution” offered by contact lenses).
In practice, if a clinician does not offer an intangible therapy, intangible service or even a semi-tangible therapy (like ortho-K), s/he is simply less likely to offer this treatment as a therapeutic (or diagnostic) option. AND, if a clinician does not offer a tangible treatment, such as “Contact Lens Company X’s lens design of the month,” s/he tends not to offer that option either. When the service or treatment is not on the clinician’s mind, most days, it does not come up as a recommended solution for the patient’s problem. If it is not in the practice, the clinician cannot profit from offering such a service, so the incentive to bring the option to the forefront (like referring for treatment of CI) is only in the name of _good patient care_, not motivated by self-serving financial gain.
Don’t get me wrong: I understand we are all practicing to make a living, and there is nothing wrong with that. I’m just drawing attention to the fact that we have a tendency to recommend what we can offer, and to not recommend what we do not offer directly.
It is something we clinicians all do, in fact. When we get a new “toy” or device, we look for opportunities to put it to use. If we are in business for ourselves, we personally invested in the equipment, and we can only generate a return by USING the equipment. The new retinal camera becomes a great way to document crossing changes in the posterior pole! Before buying the camera, however, we managed by drawing the area of concern in a diagram: If the pathology was at a low level, would you have referred such a patient for retinal photos? Or would you simply have noted it and followed the patient? By noting it and following the patient, were you denying the patient of a level of care? If you think not, do you feel justified that you are now offering (and billing for) a higher level of care, now that you have the equipment in your office?
I think these are questions which we should ask ourselves, perhaps in consideration of whether we need to invest in more equipment, or if we need to consider referring for more services which we do not in fact offer directly. When we have the equipment (or service) in hand, we are simply much more likely to use it (offer it). What is our threshold for concern before we make an in-office referral? What is our threshold for concern before we make an out-of-office referral? Should they be the same level? Should they NOT be the same level?
What is the COST of making a referral for a service which we do not offer?
…It is the chair time of explaining the concern and writing a note to a fellow clinician.
When we see a patient who is in need of cataract extraction, lid biopsy, retinal consult, etc, do we decide not to write the referral because we are running behind? Or do we take the time to make sure that the patient gets the follow-up care that they need? I would like to think most of us do the latter. But how many of us under the same time constraints will refer a patient who needs VT? Or refer for retinal photos to document mild vascular changes due to hypertension, when a camera is not in the next room? This is not an ideal world: It is the real world, where each of us is trying to do the most work and deliver the best care we can in the time that we have, while still staying in business.
Of course there are exceptions to the rule: excellent primary care clinicians who diagnose functional vision disorders and refer for further evaluation and treatment to colleagues who can offer the patient those services needed. These docs garner respect from their patients by offering them options and answers, rather than down-playing the presenting problems as “non-life-threatening,” as Chuck mentioned above. These are clinicians who are caring for their patients as a first priority.
When a treatment or service offers the clinician the opportunity for financial gain, the clinician is more likely to invest the time to learn about the treatment (or service, or lens design), and expand the options he can offer to his patients. Often these financial incentives are generated by INDUSTRY. It is INDUSTRY which responds first to the increase in knowledge which studies provide. It is INDUSTRY which finds a way to benefit the patient, INDIRECTLY, by helping the clinician benefit from helping the patient.
MEDICAL EXAMPLE:
If you recall, when pachymetry was first identified as a factor in measuring relative risk for OHT vs glaucoma, a lot of marketing went into this area. Drug companies offered IOP-adjustment calculators to adjust tonometry readings based on pachymetry readings. Advertising for pachymeters increased, and more pachymeters were developed and marketed. And in the first year, reimbursement for pachymetry was HIGH. Inside of 1-2 years, the reimbursement rate for this service was cut substantially, and it was no longer reimbursable more than once per calendar year per patient. Where is the clinician’s incentive to drop a couple thousand dollars on a device which can only recoup pennies at a time? The cost of investing in a higher level of patient care needs to yield a substantial enough profit margin in a short enough time span that the clinician feels it is worth his/her while to make an investment in the equipment. If the clinician opts not to invest, they can always justify their stance, “I’ll just refer to someone if I need to.” Many clinicians who put off buying pachymeters in the first year found that they could practice just fine without them when the financial incentive decreased.
FUNCTIONAL EXAMPLES:
The CITT study proves that office-based vision therapy (OBVT) is the best way to successfully treat CI. But lenses may also support patients with CI. Cooper Vision comes out with the “Early Presbyopia” (EP) contact lens which can offer a low ADD with minimal negative impact on distance vision, in a hybrid between a single vision contact lens and a low multifocal lens. By marketing to behavioral optometrists, they have found a niche for this lens design, and provided behavioral ODs with more options to offer their patients who want CL’s but really should be wearing a low near-point ADD to address their symptoms of near-point stress.
Recently, Kodak and Essilor began marketing their “Anti-fatigue” lens designs which offer a +0.6 ADD, with Kodak adding a low amount of BI prism. These progressive lens designs assist early presbyopes and patients with CI. Once a clinician has been educated on using such lenses as an option, he may begin offering them in his practice, especially if it both resolves the patients’ concerns and simultaneously turns a larger profit than single vision lenses.
IN SUMMARY:
Expanded options, generated by industry, offer the clinician more ways to serve their patients’ needs. The fastest way to get clinicians to embrace a new way of serving their patients with new knowledge is to find a way to educate the clinicians on how they can profit from the new knowledge. The reps may well be the health care industry’s primary education force, educating clinicians on new studies which back their products.
-Samantha Slotnick
Thanks for your thoughtful and well-considered comments, Samantha. I’ll try to address them in sequence. I framed the discussion through Essilor primarily because of the serendipity of reading Points de Vue and the glaucoma article mentioned. There is another article in the same issue by Linda Bennett, O.D., whose father is Irving Bennett, O.D. – the brains behind Optifair, which was the original mega-meeting that showcased industry together with CE independent of optometric organizational sponsorship. Linda tells of her success story in practice, and when she first introduced Varilux to the practice she purchased, she sold the product based on function. She writes that she used the parable of a car, and the analogy that a Varilux multifocal is to a lined bifocal what an automatic transmission is to a stick shift. Linda, by the way, does a very nice job of incorporating VT in her practice, and her father and I have spent many hours discussing the need to expand awareness of CI.
It is fair to say that Essilor is an example in our profession where a company went directly to the public and at the same time worked hard to fund studies published in our journals, to sponsor CE, to support the Colleges of Optometry, and to court us educationally beginning all the way from the student level. I totally agree with you that our lens companies, and Essilor in particular can and hopefully will do more to drive awareness in the profession. Last February at SECO I had the privilege of moderating a panel during the opening session with Jack Schaeffer (CLs), Paul Freeman (Low Vision), Joe Sowka (Glaucoma), and Andrea Thau (Infants). We had a marvelous panel discussion on intra-optometric referrals. This was strictly due to the initiative of Glen Steele and Paul Ajamian, the CE organizers. It was well received, and our profession needs more of this type of cross-pollination.
During the same SECO meeting, I was invited to attend a discussion led by Rod Taharan, of Essilor. Many recognizable individuals from the CE circuit were in attendance. Rod’s message was that CE lecturers should find a way to get back to the basics of our profession in terms of lenses. So many of our CE programs are oriented toward disease, that we are at risk of losing the value of what we can do for patients through lens application. And yes, the newer low plus add multifocal lenses you cite provide very good opportunities for synergistic messages. After all, there is just so much one can do with a lens – and then what? If the condition is CI, something that most practitioners can relate to, then let’s use the science that’s out there to its fullest extent in benefiting patients.
Regarding your points about our capitalistic system, much as Essilor has enjoyed success with practitioners in “selling” the benefits of premium lens types, we should not be shy about “selling” the benefits of therapy. It is a technology partly based on human performance factors. It is not necessarily for every practice nor for every patient. But CI has earned a strong position in the marketplace.
Which leads to your points about what it costs the primary care OD to make a referral. Being blessed with a significant number of referrals from ODs in my area, I recognize that, as you put it, there are numerous factors in looking at the cost of making referral. This goes back to the SECO panel that I mentioned above, and the key to intra-optometric referral is education. The uniqueness of CI is that there isn’t any referral that can be made to an ophthalmologist or neurologist that will aid the patient’s issues as revealed in the CISS. If an OD doesn’t provide or refer for VT, beyond what lenses or prisms can do (and again the CITT is very clear about the limitations of ophthalmic solutions) – then the primary advice given to the patient is to “deal with it”. Or worse yet, to patronize the patient, re-assuring them that “your eyes are fine”. More often than not, the patients who benefit from VT all have the same basic question: “Why wasn’t I told about this option before?” And when there is collaboration between you and the referring OD, the patient’s success as you note above reflects very well on the judgment of the referring OD, and poorly on those who overlooked or trivialized the condition. That message is spreading, and is what – as you’ve noted – spearheaded the advancement of the profession in many other areas of practice.
To your final point, we don’t have big issues in our field with cost of equipment. While computers in general and HTS in particular have phenomenally augmented our success, one can still do a fine job with CI using relatively low tech, low cost approaches. That is why we don’t as yet have heavy industry support for the educational outreach needed to get to the next level of awareness. Perhaps it will come from some philanthropic source. Perhaps it will come from research based grant funding. Perhaps it will come from the media industry if 3D systems elicit enough binocular challenges that are amenable to therapy. I am optimistic that if we keep discussions like this in a public forum, we will get to the next level of awareness.
I like the statement by your preceptor: “no one ever went blind or died from convergence insufficiency.” No one ever died or went blind because of dry eye, myopia, astigmatism or hyperopia either. (OK myopia can lead to retinal detachment and blindness in very rare cases)
The import of the statement is that only life threatening or sight threatening conditions need be detected or treated. While few preceptors may say such a thing there is an undercurrent of unconcern about non-life-threatening conditions. You can see it in the news reports of accidents when the reporter states that so-and-so was taken to the hospital with non-life-threatening conditions. Does it matter if so-and-so lost an arm or leg? or was disfigured?
If someone expresses such a sentiment to me, my response will be to suggest that he/she put a very small pebble in their shoe and walk around with it for a week. Life and sight are not threatened, so why should the condition be treated?
Ernie Loewenstein
Point very well taken, Ernie. I related the incident because as an OD student at the time, I was highly impressionable. From what I gather it is truer than ever that at that stage of our career, we’re very susceptible to value judgments from preceptors, particularly those who attain iconic status via their disease acumen.
Jim Thimons and I do a joint lecture on BV Disorders masquerading as Disease, and vice-versa. Jim has a wonderful working relationship with Carl Gruning, and respects that the value of treating CI can be as high if not greater than the value of treating Dry Eye. We are in agreement that it is time for our field to temper the value judgments that have left patients with unresolved functional vision problems to needlessly suffer or struggle. How do we broaden this awareness further?
As a doctor who specializes in vision therapy and does not provide primary care, I find that the OD’s who practice in commercial settings tend to refer more than the OD’s in private practice. My theory as to why is that they are more comfortable referring out for services they do not provide i.e. management of medical conditions. I don’t think it has to do with them being any less busy, because often times they are seeing patients every 15minutes and often are not able to delegate as much to staff. The OD’s also seem to be younger and perhaps optometric education in binocular vision problems is getting better. I also think that what is lacking is a real understanding of the effect binocular and accommodative problems have on quality of life. It is easier to understand how decreased visual acuity might affect QOL, but less tangible for some to see how ci can affect QOL. Of course, you still only diagnose the problems you are actually looking for, so if the diagnostic tests or a through hx is not being performed, ci can be easy to miss.
Nice points, Valerie. Years ago a wise mentor once remarked: “One misses more by not looking than by not seeing”. As someone who enjoys a significant referral relationship with many ODs, my personal experiences have been fairly balanced between ODs in different practice settings. I do agree that ODs in corporate settings tend to be more aggressive about having patients not tie up chair time with problems not amenable to services offered within the corporate setting. Perhaps there is a deeper factor in play here, but I would be speculating as to the doctor’s perspective on how the private practice patient expects the doctor to personally treat their “condition”, versus sending the patient to another OD for consultation. It takes a concerted effort on the part of the VT specialist to appeal to ODs in all settings, and I won’t say it’s easy.
I fully agree that at one point in time there was lack of awareness in understanding the implciations of BV/Accom problems. The COVD QOL was a major step forward, though we were often preaching to the choir. But now that the CISS has appeared in studies published in the Academy Journal and published online on the AOA website and featured in the AOA News, can there be any excuse for lack of awareness?
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As sad as it is to say, I still think the majority of OD’s are either not checking or do not know how to interpret the results of their testing. More education is needed in what actually to look for. For example, if you rely on only cover test and regular NPC done one or two times, you would catch the extreme CI cases only. If you do phorias but don’t check vergence ranges, you might not refer the 4exo patient (even if they have a BO break of 6) or if the range is high but the recovery low say break of 30 with a recovery of 8 (in an extreme example) I would still diagnose CI and expect poor reading stamina in the history, but I don’t think most primary care docs know this. At least in WI, binocular vision is rarely addressed in the general educational seminars. If AOA made a push (similar to what was done with Infant See) about Vision and Learning and how to diagnose and refer appropriately, a difference might be made. Last year I was speaking with a primary care doc about how business was going and about referals. I mentioned that alot of the OD referals I get are the more complicated vision therapy cases i.e. strabismus and rarely for straight convergence insufficency. His answer was “of course, because we can handle the easy cases”. Really?
I do not disagree, Valerie. Rather than expanding the scope of practice, the heavy CE emphasis on disease has shifted the scope of practice, and binocular vision testing has been lost in the shuffle. AOA had a nice push last year, with the PLRG test designed to detect CI, and the CISS. That kit alone would help primary care ODs detect CI rather easily – at least to a greater degree than is done now. But to have the paradigm shift required, the profession will have to acknowledge that the Clinical Practice Guidelines AOA publishes are being neglected. It is time to aggressively ride the CITT outcomes toward this end.
Working from the other side of the ophthalmic world ( secondary & tertiary medical surgical care)I find the dichotomy interesting that more emphasis is given in the training of our students(at all levels; didactic, clinical training and externships) to early RPE changes in dry AMD than to a struggling child with a binocular dysfunction.
I see children every day for consultation related to poor performance at school or concerns regarding learning and am amazed that binocular dysfunction is not given the same level of importance in the assessment as complpex and rarely disgnosed neuro-ophthalmic problems. In particular it is concerning that most students know less about basic CI, CE, AI etc than they do OCT.
While maintaining or improving the visual performance of all patients is our primary responsibility it is difficult to understand the comments made above about this relative value system that dimishishes Binocular issues in favor of more easily quantified organic disease. In the disease world we have tables that equate vision loss with cost to society in an 80 year old with AMD and 20/100 VA. Sadly we have not developed a mechanism to address the pure cost of failure by a child in acheiving their utmost capacity. What is the cost to society of subpar performance for a lifetime?
Does it filter thru to the next generation?
I think it is time that the profession recognize that our strength is in the universal approach we take to the management of our patients. The solutions we bring to all aspects of our patients problems and not just those found in the disease textbooks. I do not treat binocular dysfunction but am delighted to have a colleague ( Carl Gruning) who specializes in that area who I regularly refer my newly diagnosed BD patients to. It has been the best of both worlds and I feel strongly that the impact being made is important and potentially lifelong.
Thank you very much, Jim, for taking the time to share your thoughts on this issue. The type of collaboration that you enjoy with Carl Gruning is one that I am privileged to have with a number of colleagues in my area. The challenge is for us to elaborate the model so that it grows beyond a select few, and becomes the norm rather than the exception.