dark / blindspots appearing in my vision...

[Blake Patterson]

Hello,

I wanted to explain a situation I am experiencing and see if anyone had
any ideas as to what may be taking place.

About 10 weeks ago I was reading a book and first noticed that in the
periphery of my vision in my right eye, when I blinked there was a dark
spot. A split second later it was pretty much gone. At every blink.
Higher up and still off center in my vision I saw three colored lines
for a split second after I blinked as well - as if I had just looked at
three bright lines of light and this was the after image.

Shortly thereafter, I went to my optometrist and he examined my eyes
having heard my story. Retina and all else looks fine.

Now, 4-5 days ago I noticed a new dark spot - kind of a little slash
shape that is JUST off center of my vision. Same eye. I started
trying to evaluate what was going on and noticed that if I close my
left eye and read a line w/ my right, a little blank spot could be
shown as a letter one line down and a few over to the right was gone.
So it is a blind spot that appears dark for a instant and then goes
away somewhat.

I have concluded that it is missing vision and after the instant of the
dark spot after each blink, my mind fills in the missing info with the
surrounding field color and so it "goes away." If this had been a
fraction up and to the left, my right eye would be unable to see the
letter it is looking at in a book. That small blindspot would make me
rely on my left eye for reading.

Obviously, this is disturbing so I went to the optometrist again. He
did an exam and all looks fine. He is fitting me in for a field test
where they use dots of light to determine just where you blind spots
are. Depending on that he may want to issue an MRI, etc. He said
could be an optic nerve issue - I asked what and he mentioned a few
conditions like Lyme disease, etc.

I should add that on and off for the past 5 years I've had little
flashes of light appear - as if I am seeing the afterimage but not the
causal flash of a bright light - then go away. Seen eye doc several
times about it - again, all always looked ok. Never found out what was
causing that.

Also, I had an MRI for disiness about 4 years ago and nothing odd
found.

I am on meds for blood pressure (25mg atenolol) and cholesterol (zocor)
and acid reflux (prevacid). I am a 34yo caucasian male.

Anyone have any suggestions? I thought I may as well try to find
something out as I wait for the next step (that field test), hoping no
more spots appear. I assume these spots are permanent, whatever
happens...?

Thanks.





bp

[William Stacy]

I'd want a retinologist to take a look. Unless your o.d. is VERY good
and used scleral indentation all the way around, not every part of your
retina has been examined. Very few o.d.s and non-retinologist o.m.d.s
do this type of exam regularly. Could be you've just had a little
hemorrhage, but could also be a little peripheral retinal break (tear).

w.stacy, o.d.

Post by Blake Patterson
Hello,
I wanted to explain a situation I am experiencing and see if anyone had
any ideas as to what may be taking place.
About 10 weeks ago I was reading a book and first noticed that in the
periphery of my vision in my right eye, when I blinked there was a dark
spot. A split second later it was pretty much gone. At every blink.
Higher up and still off center in my vision I saw three colored lines
for a split second after I blinked as well - as if I had just looked at
three bright lines of light and this was the after image.
Shortly thereafter, I went to my optometrist and he examined my eyes
having heard my story. Retina and all else looks fine.
Now, 4-5 days ago I noticed a new dark spot - kind of a little slash
shape that is JUST off center of my vision. Same eye. I started
trying to evaluate what was going on and noticed that if I close my
left eye and read a line w/ my right, a little blank spot could be
shown as a letter one line down and a few over to the right was gone.
So it is a blind spot that appears dark for a instant and then goes
away somewhat.
I have concluded that it is missing vision and after the instant of the
dark spot after each blink, my mind fills in the missing info with the
surrounding field color and so it "goes away." If this had been a
fraction up and to the left, my right eye would be unable to see the
letter it is looking at in a book. That small blindspot would make me
rely on my left eye for reading.
Obviously, this is disturbing so I went to the optometrist again. He
did an exam and all looks fine. He is fitting me in for a field test
where they use dots of light to determine just where you blind spots
are. Depending on that he may want to issue an MRI, etc. He said
could be an optic nerve issue - I asked what and he mentioned a few
conditions like Lyme disease, etc.
I should add that on and off for the past 5 years I've had little
flashes of light appear - as if I am seeing the afterimage but not the
causal flash of a bright light - then go away. Seen eye doc several
times about it - again, all always looked ok. Never found out what was
causing that.
Also, I had an MRI for disiness about 4 years ago and nothing odd
found.
I am on meds for blood pressure (25mg atenolol) and cholesterol (zocor)
and acid reflux (prevacid). I am a 34yo caucasian male.
Anyone have any suggestions? I thought I may as well try to find
something out as I wait for the next step (that field test), hoping no
more spots appear. I assume these spots are permanent, whatever
happens...?
Thanks.
bp

[Blake Patterson]

It seems the couple of retinology practices I called just now only take
doctor referrals. I have the field test on Thursday (7 days from now)
and I don't think I talk to the doc (about results) until another apt,
so likely the following week. I wonder if 12-14 days is too long to
wait?

Two docs did a "normal" retinal eval in the last 2 months. Years ago I
did have an examl like the one I think you speak of - where they press
the eyeball all the way around to get a better look at the retina.
(All was fine) Hmm.




bp

Post by William Stacy
I'd want a retinologist to take a look. Unless your o.d. is VERY good
and used scleral indentation all the way around, not every part of your
retina has been examined. Very few o.d.s and non-retinologist o.m.d.s
do this type of exam regularly. Could be you've just had a little
hemorrhage, but could also be a little peripheral retinal break (tear).
w.stacy, o.d.

Post by Blake Patterson
Hello,
I wanted to explain a situation I am experiencing and see if anyone had
any ideas as to what may be taking place.
About 10 weeks ago I was reading a book and first noticed that in the
periphery of my vision in my right eye, when I blinked there was a dark
spot. A split second later it was pretty much gone. At every blink.
Higher up and still off center in my vision I saw three colored lines
for a split second after I blinked as well - as if I had just looked at
three bright lines of light and this was the after image.
Shortly thereafter, I went to my optometrist and he examined my eyes
having heard my story. Retina and all else looks fine.
Now, 4-5 days ago I noticed a new dark spot - kind of a little slash
shape that is JUST off center of my vision. Same eye. I started
trying to evaluate what was going on and noticed that if I close my
left eye and read a line w/ my right, a little blank spot could be
shown as a letter one line down and a few over to the right was gone.
So it is a blind spot that appears dark for a instant and then goes
away somewhat.
I have concluded that it is missing vision and after the instant of the
dark spot after each blink, my mind fills in the missing info with the
surrounding field color and so it "goes away." If this had been a
fraction up and to the left, my right eye would be unable to see the
letter it is looking at in a book. That small blindspot would make me
rely on my left eye for reading.
Obviously, this is disturbing so I went to the optometrist again. He
did an exam and all looks fine. He is fitting me in for a field test
where they use dots of light to determine just where you blind spots
are. Depending on that he may want to issue an MRI, etc. He said
could be an optic nerve issue - I asked what and he mentioned a few
conditions like Lyme disease, etc.
I should add that on and off for the past 5 years I've had little
flashes of light appear - as if I am seeing the afterimage but not the
causal flash of a bright light - then go away. Seen eye doc several
times about it - again, all always looked ok. Never found out what was
causing that.
Also, I had an MRI for disiness about 4 years ago and nothing odd
found.
I am on meds for blood pressure (25mg atenolol) and cholesterol (zocor)
and acid reflux (prevacid). I am a 34yo caucasian male.
Anyone have any suggestions? I thought I may as well try to find
something out as I wait for the next step (that field test), hoping no
more spots appear. I assume these spots are permanent, whatever
happens...?
Thanks.
bp

[David Robins, MD]

On 6/30/06 11:22 AM, in article

Post by William Stacy
I'd want a retinologist to take a look. Unless your o.d. is VERY good
and used scleral indentation all the way around, not every part of your
retina has been examined. Very few o.d.s and non-retinologist o.m.d.s
do this type of exam regularly. Could be you've just had a little
hemorrhage, but could also be a little peripheral retinal break (tear).
w.stacy, o.d.

Interesting.

I, as well as most of the general ophthalmologist colleagues in my Kaiser
group, are adept at scleral depression. Not only do we see a lot of
peripheral retinal tears, but most of us also laser them, including doing
laser indirect ophthalmoscope treatment, or (old-fashioned) cryopexy if
needed. If we sent all the flashes and floaters to our retina specialist,
there would be not time left to do Mcugen/Avastin/Kenalog injections,
pneumatic retinopexy, retinal/vitreous surgery, etc.

We also treat, ourselves, A lot of diabetic retinopathy and diametic macular
edema. I also do YAG laser cyclodestruction if needed for recalcitrant
glaucoma.

Guess we seem to do more than a lot of other o.m.d's?


David Robins, MD
Board certified Ophthalmologist
Pediatric ophthalmology and adult strabismus subspecialty

[William Stacy]

Post by David Robins, MD
I, as well as most of the general ophthalmologist colleagues in my Kaiser
group, are adept at scleral depression. Not only do we see a lot of
peripheral retinal tears, but most of us also laser them,

Wow. most omds I know refer such cases to the vitreoretinal group (in
sacramento) which stays very busy indeed. Glad to hear that kaiser docs
are so versatile. My own mother had a retinal tear during cataract
surgery by a doc (not kaiser) who also had an "interest" in retina.
Several attempts by him to repair it failed, and she's not quite blind
enough in that eye to avoid constant diplopia without an opaque contact
lens. I confess to a bias in favor of sub-specialists...

w.stacy, o.d.

[Anon E. Muss]

On Sat, 01 Jul 2006 05:48:53 GMT, "David Robins, MD"

Post by David Robins, MD
On 6/30/06 11:22 AM, in article

Post by William Stacy
I'd want a retinologist to take a look. Unless your o.d. is VERY good
and used scleral indentation all the way around, not every part of your
retina has been examined. Very few o.d.s and non-retinologist o.m.d.s
do this type of exam regularly. Could be you've just had a little
hemorrhage, but could also be a little peripheral retinal break (tear).
w.stacy, o.d.

Interesting.
I, as well as most of the general ophthalmologist colleagues in my Kaiser
group, are adept at scleral depression.

I too, like Dr. Stacy, believe that you guys would definitely be in
the minority.

The vast majority of ODs I have spoken to are not comfortable and do
not perform indirect ophthalmoscopy with scleral depression on
patients who need it (i.e., patients with signs/symptoms of acute
PVD/RD). Most are also clueless that it is the "standard of care" for
such patients.

(In my case, I found binocular indirect ophthalmoscopy with scleral
depression to be the most technically difficult skill I ever had to
learn in Optometry school by far. It took me months of performing it
before I started to feel comfortable doing it.)

This has likewise been the case with most of the general OMDs I have
dealt with in private practice in SoCal. Especially the busier ones.

Post by David Robins, MD
Not only do we see a lot of peripheral retinal tears, but most of us
also laser them, including doing laser indirect ophthalmoscope
treatment, or (old-fashioned) cryopexy if needed. If we sent all the
flashes and floaters to our retina specialist, there would be not time
left to do Mcugen/Avastin/Kenalog injections, pneumatic retinopexy,
retinal/vitreous surgery, etc.

There are some OMDs around here that will do PRP or laser surgery for
small retinal tears. I don't know of any who will do cryopexy
(routinely).

Post by David Robins, MD
We also treat, ourselves, A lot of diabetic retinopathy and diametic macular
edema. I also do YAG laser cyclodestruction if needed for recalcitrant
glaucoma.

Don't know of any private practice OMDs around here that routinely do
grid or focal laser for DME. Most OMDs around here will do a simple
trabeculectomy, but for anything more than that -- say a Molteno or
cyclodestructive procedures -- will be turfed off to a glaucoma
sub-specialist.

None do pediatrics either -- say even something as simple as
congenital nasolacrimal duct obstruction surgery. Most aren't
comfortable enough with a direct gonioscope and won't do something
like a goniotomy for infantile glaucoma.

Post by David Robins, MD
Guess we seem to do more than a lot of other o.m.d's?

I bet it's just due to your mode of practice.

OMDs with slower private practices may do more. Those general OMDs
with busier practices seem to do less sub-specialty work.

I have never dealt with you personally, but since you work at KAISER I
was hoping you might be able to shed a little light on the following:

In my experiences, I have noted that KAISER MDs are notoriously
horrible at writing follow-up or progress reports. I have referred
dozens of my patients back to their KAISER MDs for medical problems
that came up during their "well vision" exams -- problems such as
retinal detachments, diabetic retinopathy, papilledema,
hypercholesterolemia, carotid bruits, basal cell carcinomas,
cataracts, congenital nasolacrimal duct obstructions, strabismus,
amblyopia, headaches, otitis media, HZO, hypertension, bacterial
keratitis, etc. I typically write referral letters including their
complaints, pertinent results of my examination, my recommendations
and the recommended time frame for examination. I ask the patient the
name of their KAISER MD and address it specifically to them. I have
gotten ZERO follow-up reports from KAISER MDs -- not even one. So I
end up chasing around patients asking them "Were you ever seen" for
their problems to which they will say "No" or "Yes. Didn't you get a
letter back from my KAISER doc?" Do you find this to be typical among
your colleagues at KAISER there that they do not write reports back to
their referring outside health care practitioners?

In the private practice world, there is financial incentive to write
follow-up letters. Doctors that don't write back follow-up letters to
patients referred to them for problems find themselves not getting my
referrals anymore, but KAISER patients are essentially a captive
audience. However, there is also something called professional
courtesy also that states that when a doctor refers you a patient you
respond back with a thank you and you state the results of your exam
and what was done.

Are my experiences with KAISER MDs/OMDs in these cases also atypical?

[David Robins, MD]

Post by Anon E. Muss
On Sat, 01 Jul 2006 05:48:53 GMT, "David Robins, MD"

Post by David Robins, MD
On 6/30/06 11:22 AM, in article

Post by William Stacy
I'd want a retinologist to take a look. Unless your o.d. is VERY good
and used scleral indentation all the way around, not every part of your
retina has been examined. Very few o.d.s and non-retinologist o.m.d.s
do this type of exam regularly. Could be you've just had a little
hemorrhage, but could also be a little peripheral retinal break (tear).
w.stacy, o.d.

Interesting.
I, as well as most of the general ophthalmologist colleagues in my Kaiser
group, are adept at scleral depression.

I too, like Dr. Stacy, believe that you guys would definitely be in
the minority.
The vast majority of ODs I have spoken to are not comfortable and do
not perform indirect ophthalmoscopy with scleral depression on
patients who need it (i.e., patients with signs/symptoms of acute
PVD/RD). Most are also clueless that it is the "standard of care" for
such patients.
(In my case, I found binocular indirect ophthalmoscopy with scleral
depression to be the most technically difficult skill I ever had to
learn in Optometry school by far. It took me months of performing it
before I started to feel comfortable doing it.)
This has likewise been the case with most of the general OMDs I have
dealt with in private practice in SoCal. Especially the busier ones.

Post by David Robins, MD
Not only do we see a lot of peripheral retinal tears, but most of us
also laser them, including doing laser indirect ophthalmoscope
treatment, or (old-fashioned) cryopexy if needed. If we sent all the
flashes and floaters to our retina specialist, there would be not time
left to do Mcugen/Avastin/Kenalog injections, pneumatic retinopexy,
retinal/vitreous surgery, etc.

There are some OMDs around here that will do PRP or laser surgery for
small retinal tears. I don't know of any who will do cryopexy
(routinely).

Post by David Robins, MD
We also treat, ourselves, A lot of diabetic retinopathy and diametic macular
edema. I also do YAG laser cyclodestruction if needed for recalcitrant
glaucoma.

Don't know of any private practice OMDs around here that routinely do
grid or focal laser for DME. Most OMDs around here will do a simple
trabeculectomy, but for anything more than that -- say a Molteno or
cyclodestructive procedures -- will be turfed off to a glaucoma
sub-specialist.
None do pediatrics either -- say even something as simple as
congenital nasolacrimal duct obstruction surgery. Most aren't
comfortable enough with a direct gonioscope and won't do something
like a goniotomy for infantile glaucoma.

Post by David Robins, MD
Guess we seem to do more than a lot of other o.m.d's?

I bet it's just due to your mode of practice.
OMDs with slower private practices may do more. Those general OMDs
with busier practices seem to do less sub-specialty work.
I have never dealt with you personally, but since you work at KAISER I
In my experiences, I have noted that KAISER MDs are notoriously
horrible at writing follow-up or progress reports. I have referred
dozens of my patients back to their KAISER MDs for medical problems
that came up during their "well vision" exams -- problems such as
retinal detachments, diabetic retinopathy, papilledema,
hypercholesterolemia, carotid bruits, basal cell carcinomas,
cataracts, congenital nasolacrimal duct obstructions, strabismus,
amblyopia, headaches, otitis media, HZO, hypertension, bacterial
keratitis, etc. I typically write referral letters including their
complaints, pertinent results of my examination, my recommendations
and the recommended time frame for examination. I ask the patient the
name of their KAISER MD and address it specifically to them. I have
gotten ZERO follow-up reports from KAISER MDs -- not even one. So I
end up chasing around patients asking them "Were you ever seen" for
their problems to which they will say "No" or "Yes. Didn't you get a
letter back from my KAISER doc?" Do you find this to be typical among
your colleagues at KAISER there that they do not write reports back to
their referring outside health care practitioners?
In the private practice world, there is financial incentive to write
follow-up letters. Doctors that don't write back follow-up letters to
patients referred to them for problems find themselves not getting my
referrals anymore, but KAISER patients are essentially a captive
audience. However, there is also something called professional
courtesy also that states that when a doctor refers you a patient you
respond back with a thank you and you state the results of your exam
and what was done.
Are my experiences with KAISER MDs/OMDs in these cases also atypical?

Most of the Kaiser docs I know do most of the procedures I discussed.
Although I don't, many do office blepharoplasties and other lid procedures
for ectropion or entropion, minor basal cell excisions, puntoplasties,
pterygium surgery, etc. This reduces the load on the subspecialist
oculoplastics people. The retina work we do keeps the retianl person able to
handle real retina work. Argon laser trabeculoplasty, and now SLT is done by
the generalist. Some real comprehensive ophthalmologists also do horzontal
strabismus surgery in older children trhoug adults. All depends what their
interests and skill sets are.

No, I think that except for a short occasional note back, most do not send
notes back. The problem is, we have very little support staff. I have 1
medical assistant, who is really working hard to keep the rooms filled,
schedule followups, check on failed appointments, schedule surgery, handle
patient messages, etc.

I'm also rather busy - besides the patients, and now going into electronic
charting (which adds a lot of time) I read diabetic screening photos and
fill out patient cards and record the info electronically, do IOL
calculations, read fluoresceins and fields. Guess when I get to do that?
After patients end, until I leave about 7:30 pm or later. Doesn't leave a
lot of time to dictate a formal letter back. For that I have to apologize.

As you rightly point out, it is a captive audience, and no real financial
incentive to write letters to get more patients. The occasional pt I get
from outside, if it is something interesting, or misdiagnosed, I do try to
get back. Sometimes I call if the diagnosis really was out of line. I get
perhaps one outside referral every few months.

Even getting information back to the referrring general ophthalmologist or
pediatrician regarding strabismus cases they have sent me used to be a
problem. However, I developed a strabismus database that I now use in
real-time when seeing patients, as the electronci medical record customized
for strabismus. I can generate a "form" letter which exctracts a lot of
information from the exam and history I did, and formats it in letter form.
By touching one button, and then print, I get the letter to the front desk,
sign it, and it can be sent.

BTW, although I am a pediatric ophthalmologist, I don't do direct gonios or
glaucoma/Molteno surgery on infants. That IS best left to the few pediatric
glaucoma specialists. Most general glaucoma specialists won't touch them
either.

[Anon E. Muss]

On Sun, 02 Jul 2006 04:48:18 GMT, "David Robins, MD"
<***@bigfoot.com> wrote:

[snip]

Post by David Robins, MD
I'm also rather busy - besides the patients, and now going into electronic
charting (which adds a lot of time) I read diabetic screening photos

Thanks... I had a couple more questions/comments if you don't mind:

1. Recently, I have had quite a few KAISER patients who have been
diabetics (mostly type II) for many years tell me that their annual
"diabetic eye exam" now consists of a non-mydriatic posterior pole
fundus photograph. These photographs are then sent to an OMD for
evaluation and diabetics are now only seen for physical examinations
by an OMD if these photographs demonstrate retinopathy. IOW, yearly
routine dilated fundus examinations by an eye doctor are apparently
not the standard of care at KAISER. Is that true?

2. Do you think, in the long run, that electronic charting will end
up taking less time for you personally than paper charting?

[snip]

[David Robins, MD]

Post by Anon E. Muss
On Sun, 02 Jul 2006 04:48:18 GMT, "David Robins, MD"
[snip]

Post by David Robins, MD
I'm also rather busy - besides the patients, and now going into electronic
charting (which adds a lot of time) I read diabetic screening photos

1. Recently, I have had quite a few KAISER patients who have been
diabetics (mostly type II) for many years tell me that their annual
"diabetic eye exam" now consists of a non-mydriatic posterior pole
fundus photograph. These photographs are then sent to an OMD for
evaluation and diabetics are now only seen for physical examinations
by an OMD if these photographs demonstrate retinopathy. IOW, yearly
routine dilated fundus examinations by an eye doctor are apparently
not the standard of care at KAISER. Is that true?

YES. This means of screening (screening for disease) has been shown to be
effective. Better than not getting any screening, which was was happening
when the only means was a dilated exam, which was inconvenience and hard to
schedule for some. In addition, the load of diabetics is so large that the
majority were not getting screened regularly. We now screen (between photos
and dilated exam) at least 80% of the diabetics, a large step up from
before. Almost all diabetics will show disease in the range of the photos
well before they need care. Whether or not there are some microaneuryms
peripheral to the field of the photos is almost a not issue, since they are
not treatable. In addition, it has been shown in studies that if there is no
retinopathy, and the pt is is reasonable control, two years can elapse
between screenings, as it is very rare to have treatable disease by that
time. In this way, most people get adequate screening. Once any background
disease is seen, screening is stepped up to at least once a year. I am
amazing how much more

I can see more on a photo than during an indirect exam supplemented by a 90D
exam in selected areas. We used to use Polaroid photos, now digital photos
on our computers. I can blow up and maniplulate photos as needed, and is is
less common to overlook early disease on a photo than on an office exam
these days. If it is more severe, then they stop having photos and get
office dilated exams. It has greatly reduced seeing pts coming in with a
surprise of advanced background or proliferative disease that had gone
undetected. Some pts still manage avoid screening by either not responding
to appt requests, or cancelling and not rescheduling.

This coupled with the internists getting a better ahndle on our pts labs
electronically has also reduced the numbers of pts who were out of control,
and had fallen through the cracks by not following up with their doctor. The
system helps find these pts.

Post by Anon E. Muss
2. Do you think, in the long run, that electronic charting will end
up taking less time for you personally than paper charting?

I'm not sure it will take less time. It will make records accessible (no
lost charts or charts out to someone else) and certainly legible. I'm told
that long-term there is still about a 10% time penalty involved in EMR over
paper charts. The other thing is, it is easy to hand-draw (retina, corneal
lesions, etc) in a paper chart, a lot harder in an electronic chart. It is
still a feat to get fields, photos, etc into the electronic record, and be
able to access them easily.

The Fed is pushing for EMR's for everyone soon. Aside from some smaller
offices that have systems. I believe Kaiser is the first to have such a huge
system. It has been many years in the making, since it is on such a grand
scale. We have had some pieces of it for years - I have instant electronic
access to labs, x-rays, ekg's, and a list of diagnoses since 1995, as well
as the preventive health prompts (when due for diabetic testing, labs and
tests of other types). This means I can look at a long-term trend easily. It
also means that if the chart is not available, I still have something to go
by. Ut, pretty soon, it will all be electronic, mandated from our CEO who
feels that electronic records are part of the key technology for the future
success of good medical care.

The only way electronic charting can be faster is by customization of form
records, and the use of shortcuts, which each doctor does according to their
style. Trouble is, these are not yet customizable down to the subspecialty
level, but will be getting there. My particular database for strabismus that
I described is not part of the Kaiser system (yet).

[Anon E. Muss]

On Sun, 02 Jul 2006 07:03:57 GMT, "David Robins, MD"

Post by David Robins, MD

Post by Anon E. Muss
On Sun, 02 Jul 2006 04:48:18 GMT, "David Robins, MD"
[snip]

Post by David Robins, MD
I'm also rather busy - besides the patients, and now going into electronic
charting (which adds a lot of time) I read diabetic screening photos

1. Recently, I have had quite a few KAISER patients who have been
diabetics (mostly type II) for many years tell me that their annual
"diabetic eye exam" now consists of a non-mydriatic posterior pole
fundus photograph. These photographs are then sent to an OMD for
evaluation and diabetics are now only seen for physical examinations
by an OMD if these photographs demonstrate retinopathy. IOW, yearly
routine dilated fundus examinations by an eye doctor are apparently
not the standard of care at KAISER. Is that true?

YES. This means of screening (screening for disease) has been shown to be
effective. Better than not getting any screening, which was was happening
when the only means was a dilated exam, which was inconvenience and hard to
schedule for some.

I certainly agree with the *last* statement.

The one prior to that does not reflect what I have been told by local
retinal specialists, endocrinologists and what I have read in the
literature. I will have to investigate that.

[snip]

Post by David Robins, MD
Almost all diabetics will show disease in the range of the photos well
before they need care.

[...]

Post by David Robins, MD
In addition, it has been shown in studies that if there is no
retinopathy, and the pt is is reasonable control, two years can elapse
between screenings, as it is very rare to have treatable disease by
that time. In this way, most people get adequate screening.

I would imagine these arguments and policy were debated by some at
KAISER. They certainly don't reflect the recommendations of the AAO's
PPP for DR.

Post by David Robins, MD
I am amazing how much more I can see more on a photo than during an
indirect exam supplemented by a 90D exam in selected areas. We used to
use Polaroid photos, now digital photos on our computers. I can blow
up and maniplulate photos as needed, and is is less common to overlook
early disease on a photo than on an office exam these days.

This is certainly true.

I have picked up things in fundus photos that I missed during fundus
examinations and visa versa. I wouldn't want to manage my glaucoma
patients without both periodic optic nerve (stereoscopic)/retinal
nerve fiber layer photographs and actual fundus examinations.

[snip]

Once again, thanks for taking the time to respond.

[David Robins, MD]

Post by Anon E. Muss
On Sun, 02 Jul 2006 07:03:57 GMT, "David Robins, MD"

Post by David Robins, MD

Post by Anon E. Muss
On Sun, 02 Jul 2006 04:48:18 GMT, "David Robins, MD"
[snip]

Post by David Robins, MD
I'm also rather busy - besides the patients, and now going into electronic
charting (which adds a lot of time) I read diabetic screening photos

1. Recently, I have had quite a few KAISER patients who have been
diabetics (mostly type II) for many years tell me that their annual
"diabetic eye exam" now consists of a non-mydriatic posterior pole
fundus photograph. These photographs are then sent to an OMD for
evaluation and diabetics are now only seen for physical examinations
by an OMD if these photographs demonstrate retinopathy. IOW, yearly
routine dilated fundus examinations by an eye doctor are apparently
not the standard of care at KAISER. Is that true?

YES. This means of screening (screening for disease) has been shown to be
effective. Better than not getting any screening, which was was happening
when the only means was a dilated exam, which was inconvenience and hard to
schedule for some.

I certainly agree with the *last* statement.
The one prior to that does not reflect what I have been told by local
retinal specialists, endocrinologists and what I have read in the
literature. I will have to investigate that.
[snip]

Post by David Robins, MD
Almost all diabetics will show disease in the range of the photos well
before they need care.

[...]

Post by David Robins, MD
In addition, it has been shown in studies that if there is no
retinopathy, and the pt is is reasonable control, two years can elapse
between screenings, as it is very rare to have treatable disease by
that time. In this way, most people get adequate screening.

I would imagine these arguments and policy were debated by some at
KAISER. They certainly don't reflect the recommendations of the AAO's
PPP for DR.

Post by David Robins, MD
I am amazing how much more I can see more on a photo than during an
indirect exam supplemented by a 90D exam in selected areas. We used to
use Polaroid photos, now digital photos on our computers. I can blow
up and maniplulate photos as needed, and is is less common to overlook
early disease on a photo than on an office exam these days.

This is certainly true.
I have picked up things in fundus photos that I missed during fundus
examinations and visa versa. I wouldn't want to manage my glaucoma
patients without both periodic optic nerve (stereoscopic)/retinal
nerve fiber layer photographs and actual fundus examinations.
[snip]
Once again, thanks for taking the time to respond.

A lot of the AAO recommendations are based on historical opinion of
ophthalmologists, rather than evidence based medicine (the new catchphrase).
It is also based on traditional practice patterns (once a year ...).

My understanding is that there is sufficient evidience in the literature to
support a q2 years screening protocol (a large study in Britain??) I believe
Kaiser also reviewed a huge number of records and did its own study. The
capture of medical information in the system makes research projects like
that easier than in other venues. We have been doing this for a number o
years now, and even I must say I am impressed with the success.

Retinologists always want patients back in 1 year - it is traditional. For
example, even after a long-healed retinal tear, they recommend a yearly exam
with them eve IN THE ABSENCE OF ANY NEW SYMTPOMS. Yield is close to zero,
and eats up a lot of time that could be better used serving those who need
it. Medicine is not a bottomless well. There is only so much manpower to go
around, and needs to be put to use where it will do the most good for the
greatest number of people. Or else the system fails (lots of HMO's have
folded over the years).

[Blake Patterson]

I just found out that these spots are almost certainly hypertensive
retinopathy.

I have been on 25mg/day of Atenolol to control bp. It's been doing its
job for a few years - home and office readings in range. But I've
gained 15-20lbs and stopped execising (new baby) for past few months
and took bp a few days ago - it was 143/95.

I've taken readings for last 48hrs and the diastolic has been averaging
around 90 and just now I got a 151/107. Clearly I need to get under
control with adjusted meds - and then longer term exercise, sodium
control, etc.

Will see doc tomorrow. On phone he suggested 2x 25mg/day to start.

Hopefully - if this was the cause of these spots - new spots will not
appear once bp under control again.





bp

Post by David Robins, MD

Post by Anon E. Muss
On Sun, 02 Jul 2006 07:03:57 GMT, "David Robins, MD"

Post by David Robins, MD

Post by Anon E. Muss
On Sun, 02 Jul 2006 04:48:18 GMT, "David Robins, MD"
[snip]

Post by David Robins, MD
I'm also rather busy - besides the patients, and now going into electronic
charting (which adds a lot of time) I read diabetic screening photos

1. Recently, I have had quite a few KAISER patients who have been
diabetics (mostly type II) for many years tell me that their annual
"diabetic eye exam" now consists of a non-mydriatic posterior pole
fundus photograph. These photographs are then sent to an OMD for
evaluation and diabetics are now only seen for physical examinations
by an OMD if these photographs demonstrate retinopathy. IOW, yearly
routine dilated fundus examinations by an eye doctor are apparently
not the standard of care at KAISER. Is that true?

YES. This means of screening (screening for disease) has been shown to be
effective. Better than not getting any screening, which was was happening
when the only means was a dilated exam, which was inconvenience and hard to
schedule for some.

I certainly agree with the *last* statement.
The one prior to that does not reflect what I have been told by local
retinal specialists, endocrinologists and what I have read in the
literature. I will have to investigate that.
[snip]

Post by David Robins, MD
Almost all diabetics will show disease in the range of the photos well
before they need care.

[...]

Post by David Robins, MD
In addition, it has been shown in studies that if there is no
retinopathy, and the pt is is reasonable control, two years can elapse
between screenings, as it is very rare to have treatable disease by
that time. In this way, most people get adequate screening.

I would imagine these arguments and policy were debated by some at
KAISER. They certainly don't reflect the recommendations of the AAO's
PPP for DR.

Post by David Robins, MD
I am amazing how much more I can see more on a photo than during an
indirect exam supplemented by a 90D exam in selected areas. We used to
use Polaroid photos, now digital photos on our computers. I can blow
up and maniplulate photos as needed, and is is less common to overlook
early disease on a photo than on an office exam these days.

This is certainly true.
I have picked up things in fundus photos that I missed during fundus
examinations and visa versa. I wouldn't want to manage my glaucoma
patients without both periodic optic nerve (stereoscopic)/retinal
nerve fiber layer photographs and actual fundus examinations.
[snip]
Once again, thanks for taking the time to respond.

A lot of the AAO recommendations are based on historical opinion of
ophthalmologists, rather than evidence based medicine (the new catchphrase).
It is also based on traditional practice patterns (once a year ...).
My understanding is that there is sufficient evidience in the literature to
support a q2 years screening protocol (a large study in Britain??) I believe
Kaiser also reviewed a huge number of records and did its own study. The
capture of medical information in the system makes research projects like
that easier than in other venues. We have been doing this for a number o
years now, and even I must say I am impressed with the success.
Retinologists always want patients back in 1 year - it is traditional. For
example, even after a long-healed retinal tear, they recommend a yearly exam
with them eve IN THE ABSENCE OF ANY NEW SYMTPOMS. Yield is close to zero,
and eats up a lot of time that could be better used serving those who need
it. Medicine is not a bottomless well. There is only so much manpower to go
around, and needs to be put to use where it will do the most good for the
greatest number of people. Or else the system fails (lots of HMO's have
folded over the years).

[Blake Patterson]

Folllowing to my last post...

Opthalmologists out there - tell me, if these spots ARE hypertensive
retinopathy, would that have been visible in a standard retinal exam?
Thanks.



bp

Post by Blake Patterson
I just found out that these spots are almost certainly hypertensive
retinopathy.
I have been on 25mg/day of Atenolol to control bp. It's been doing its
job for a few years - home and office readings in range. But I've
gained 15-20lbs and stopped execising (new baby) for past few months
and took bp a few days ago - it was 143/95.
I've taken readings for last 48hrs and the diastolic has been averaging
around 90 and just now I got a 151/107. Clearly I need to get under
control with adjusted meds - and then longer term exercise, sodium
control, etc.
Will see doc tomorrow. On phone he suggested 2x 25mg/day to start.
Hopefully - if this was the cause of these spots - new spots will not
appear once bp under control again.
bp

Post by David Robins, MD

Post by Anon E. Muss
On Sun, 02 Jul 2006 07:03:57 GMT, "David Robins, MD"

Post by David Robins, MD

Post by Anon E. Muss
On Sun, 02 Jul 2006 04:48:18 GMT, "David Robins, MD"
[snip]

Post by David Robins, MD
I'm also rather busy - besides the patients, and now going into electronic
charting (which adds a lot of time) I read diabetic screening photos

1. Recently, I have had quite a few KAISER patients who have been
diabetics (mostly type II) for many years tell me that their annual
"diabetic eye exam" now consists of a non-mydriatic posterior pole
fundus photograph. These photographs are then sent to an OMD for
evaluation and diabetics are now only seen for physical examinations
by an OMD if these photographs demonstrate retinopathy. IOW, yearly
routine dilated fundus examinations by an eye doctor are apparently
not the standard of care at KAISER. Is that true?

YES. This means of screening (screening for disease) has been shown to be
effective. Better than not getting any screening, which was was happening
when the only means was a dilated exam, which was inconvenience and hard to
schedule for some.

I certainly agree with the *last* statement.
The one prior to that does not reflect what I have been told by local
retinal specialists, endocrinologists and what I have read in the
literature. I will have to investigate that.
[snip]

Post by David Robins, MD
Almost all diabetics will show disease in the range of the photos well
before they need care.

[...]

Post by David Robins, MD
In addition, it has been shown in studies that if there is no
retinopathy, and the pt is is reasonable control, two years can elapse
between screenings, as it is very rare to have treatable disease by
that time. In this way, most people get adequate screening.

I would imagine these arguments and policy were debated by some at
KAISER. They certainly don't reflect the recommendations of the AAO's
PPP for DR.

Post by David Robins, MD
I am amazing how much more I can see more on a photo than during an
indirect exam supplemented by a 90D exam in selected areas. We used to
use Polaroid photos, now digital photos on our computers. I can blow
up and maniplulate photos as needed, and is is less common to overlook
early disease on a photo than on an office exam these days.

This is certainly true.
I have picked up things in fundus photos that I missed during fundus
examinations and visa versa. I wouldn't want to manage my glaucoma
patients without both periodic optic nerve (stereoscopic)/retinal
nerve fiber layer photographs and actual fundus examinations.
[snip]
Once again, thanks for taking the time to respond.

A lot of the AAO recommendations are based on historical opinion of
ophthalmologists, rather than evidence based medicine (the new catchphrase).
It is also based on traditional practice patterns (once a year ...).
My understanding is that there is sufficient evidience in the literature to
support a q2 years screening protocol (a large study in Britain??) I believe
Kaiser also reviewed a huge number of records and did its own study. The
capture of medical information in the system makes research projects like
that easier than in other venues. We have been doing this for a number o
years now, and even I must say I am impressed with the success.
Retinologists always want patients back in 1 year - it is traditional. For
example, even after a long-healed retinal tear, they recommend a yearly exam
with them eve IN THE ABSENCE OF ANY NEW SYMTPOMS. Yield is close to zero,
and eats up a lot of time that could be better used serving those who need
it. Medicine is not a bottomless well. There is only so much manpower to go
around, and needs to be put to use where it will do the most good for the
greatest number of people. Or else the system fails (lots of HMO's have
folded over the years).

[Anon E. Muss]

tell me, if these spots ARE hypertensive retinopathy, would that have
been visible in a standard retinal exam?

If the retinal exam was thru a dilated pupil and using indirect
ophthalmoscopy (via a binocular head-mounted *and* slit-lamp fundus
lenses), hypertensive retinopathy that would cause visual complaints
(e.g., retinal hemorrhages, nerve fiber layer infarcts) is typically
quite obvious.

Through an undilated pupil, these can be easily missed.

<rant>
Every eye doctor should check blood pressure routinely and make it an
intregal part of every eye examination, as much as checking visual
acuities, intraocular tensions and pupils.

Undiagnosed hypertension is a huge public health problem and I
routinely find people with elevated blood pressure readings who I
refer to their internist and get put on hypertensive medications.

Optometrists could learn a lot from the medical model where one looks
at the patient as a whole, but specializes on the eyes rather than
merely thinking of a patient as a pair of eyes.
</rant>

[LarryDoc]

Post by Anon E. Muss
Optometrists could learn a lot from the medical model where one looks
at the patient as a whole, but specializes on the eyes rather than
merely thinking of a patient as a pair of eyes.

And many of us do. We recently had an interesting discussion on our
private forum about this very issue. I, for example, check BP on many
patients---targeting those whose medical or family history, presenting
complaints, or my observations indicate a possible risk.

An example from my office: Two weeks ago patients comes in for
"routine" contact lens check up. History indicates previous
hypertension. He has a few sub-conja hems and states he hasn't taken his
meds for a year or so because he feels fine. BP was something like
180/120. Off to the MD for him.

Another: Woman with recent history of repeated sub-conja hems concerned
about it. My questioning turns up headaches, ringing in the ears,
dizziness. BP was around 220/160 or higher. Stopped exam and had her
driver take her to the ER (faster than 911/paramedics from my office)
where she was admitted to ICU on the verge of a stroke. She's well now.

</rant>

LB, O.D.

[Anon E. Muss]

Post by LarryDoc

Post by Anon E. Muss
Optometrists could learn a lot from the medical model where one looks
at the patient as a whole, but specializes on the eyes rather than
merely thinking of a patient as a pair of eyes.

And many of us do.

I realize some do. And I was writing as a fellow OD myself. I just
don't think the majority of us do.

Post by LarryDoc
We recently had an interesting discussion on our private forum about
this very issue. I, for example, check BP on many patients---
targeting those whose medical or family history, presenting
complaints, or my observations indicate a possible risk.

Why don't you check blood pressure routinely as part of your eye
examinations? Lots of articles in the literature argue that all
health care practitioners should routinely screen blood pressure, not
merely based on family/patient history, complaints, signs or
symptomology.

Post by LarryDoc
An example from my office: Two weeks ago patients comes in for
"routine" contact lens check up. History indicates previous
hypertension. He has a few sub-conja hems and states he hasn't taken his
meds for a year or so because he feels fine. BP was something like
180/120. Off to the MD for him.
Another: Woman with recent history of repeated sub-conja hems concerned
about it. My questioning turns up headaches, ringing in the ears,
dizziness. BP was around 220/160 or higher. Stopped exam and had her
driver take her to the ER (faster than 911/paramedics from my office)
where she was admitted to ICU on the verge of a stroke. She's well now.

***A real life example from my office:

On 06/01/2006, patient D.R., a 29 year old Caucasian gentleman was
seen in our office with the chief complaint of it being hard to see
with his current RGPs. Patient felt fine, medical history was
unremarkable and he was not taking any medications. Corrected visual
acuities with the contacts were OD 20/30 and OS 20/30. Blood pressure
was 230/150 in the right arm, seated, @ 16:14. Repeat blood pressure
reading was 230/140 in the left arm, seated, @ 16:16. Indirect
ophthalmoscopy with a non-contact fundus lens was completely normal. A
diagnosis of hypertensive urgency was made. Patient's MD was called,
patient was admitted to ER and blood pressure was slowly lowered over
the course of a few hours to prevent organ ischemia/hypoperfusion.
There was absolutely no symptoms or signs to indicate this
hypertensive urgency; it was only picked up as a result of making BP
measurement a routine part of every eye examination I do. This patient
hadn't been to his family practice MD in years, and it is likely IMHO
that if the hypertensive urgency wasn't picked up by me, it would be
not been picked up until it progressed to malignant hypertension,
which brings me to the next example who was not so lucky...

***Another real life example from my office: On 3/16/2006, patient
PT, a 49 year old Caucasian lady presented to my office with the chief
complaint of gradually decreasing vision. Symptoms were vague and she
was a poor historian. Patient claimed to feel fine edical history was
unremarkable and she was not taking any medications.

Uncorrected visual acuities were OD CF @ 4' -> PHNI and OS 20/200 ->
PHNI. Blood pressure was 220/140 in the right arm, seated, @ 11:18am.
Confrontation visual fields revealed a inferior nasal quadrantopia OD.
Pupils revealed a grade 1 afferent pupillary defect. Slit-lamp
examination was unremarkable. Dilated fundus examination revealed
obvious and severe papilledema with diffuse hard exudates, macular
stars and retinal hemorrhages. Examination of the fundus periphery
revealed Elschnig's spots of choroidal non-perfusion. Patient's
internist called and patient admitted to hospital for 2 days to
control the blood pressure.

Patient came back 04/10/2006 with blood pressure down to 142/88.
Visual acuities unchanged, APD still present, but visual field defect
no longer present. Fundus appearance essentially unchanged.

Pateint returned on 05/25/2006 with blood pressure down to 110/84.
Corrected visual acuities now OD 7/400 and OS 20/70. Fundus
appearance unchanged.

A retinal consult was obtained on 06/01/2006 and retinal specialist
diagnosed of subfoveal lipid migration OD, hypertensive retinopathy
and hypertensive choroidopathy. IVFA and OCT confirm diagnosis and
there is absolutely nothing that can be done medically or surgically
to improve her vision.

***Final real-life example:

This story was related to me by a fellow OD and it happened a few
years ago. Patient came into office with chief complaint of red eye
started this AM. Diagnosis of subconj heme made. Slit-lamp and IOPs
normal. Undilated fundus exam normal. OD considered checking BP and
asked patient when saw Dr. last. Said was there less than 1 week ago
and the MD checked BP at that time and it was normal. Because of this
OD decided not to check BP and patient was discharged by OD* and told
of normal natural course of resolution. Patient didn't feel 100% and
was in local pharmacy later that evening and decided to check BP with
automated machine. BP was 180/120. Patient told OD a few weeks later
that MD was changing asthma medications and as a result of that a
hypertensive urgency was iatrogenically created by MD. OD felt like
an idiot, patient was lucky and OD was lucky. OD now checks BP on
everyone as part of eye exam, even if patient saw MD for physical
earlier that day and it was normal.

[Dick Adams]

Post by Anon E. Muss
Why don't you check blood pressure routinely as part of your eye
examinations?

Hey, better check for STDs as well. For instance, the clap, you know,
can have serious ocular consequences.

(Is there anybody doing refractions anymore?)

--
Dicky

[Scott Seidman]

Post by Anon E. Muss
Why don't you check blood pressure routinely as part of your eye
examinations?

You guys don't routinely check blood glucose, but find plenty of
pathologies pointing to diabetes. Why don't you routinely do a finger
stick for glucose?

As a patient, I would say check my blood pressure if a retinal pathology
requires hypertension to be ruled out. Otherwise, I would frankly consider
it an invasion of privacy. If an OD came at me with a blood pressure cuff,
I would ask why, and if I weren't satisfied with the answer, I would not
consent.

A diagnosis of hypertension can carry some pretty significant insurance
ramifications. While MD's take elevated BPs very seriously, they actually
think pretty hard before they write down that diagnosis. In my
(nonprofessional) opinion, it's not a diagnosis that should appear on an
OD's chart, except as a patient-provided history, or when a pathology
requires elevated BP to be ruled out.

[LarryDoc]

Post by Scott Seidman

Post by Anon E. Muss
Why don't you check blood pressure routinely as part of your eye
examinations?

If a patient has not been to his/her primary care physician within
recent memory I certainly do offer to take BP. Routinely.

Post by Scott Seidman
You guys don't routinely check blood glucose, but find plenty of
pathologies pointing to diabetes. Why don't you routinely do a finger
stick for glucose?

If a patient has ocular signs of diabetes and *is not* aware of having
the disorder, he/she is immediately referred to a MD for diagnosis and
treatment. That is a very rare occurrence. If he/she *is* aware, a
report is immediately faxed to the MD.

Not to mention a *finger stick* glucose test at the moment is not
appropriate for diagnosing diabetes.

Post by Scott Seidman
As a patient, I would say check my blood pressure if a retinal pathology
requires hypertension to be ruled out. Otherwise, I would frankly consider
it an invasion of privacy. If an OD came at me with a blood pressure cuff,
I would ask why, and if I weren't satisfied with the answer, I would not
consent.

Try the other way around. I ask if the patient has had BP checked
recently and if not would he/she like to have it done. No invasion
there, eh?

Post by Scott Seidman
A diagnosis of hypertension can carry some pretty significant insurance
ramifications.

A diagnosis of untreated, uncontrolled HT can carry some pretty
significant ramifications like stroke, heart attack and death.

Post by Scott Seidman
While MD's take elevated BPs very seriously, they actually
think pretty hard before they write down that diagnosis. In my
(nonprofessional) opinion, it's not a diagnosis that should appear on an
OD's chart, except as a patient-provided history, or when a pathology
requires elevated BP to be ruled out.

ODs take elevated BP very seriously. We write down the findings simply
as BP readings. We don't diagnosis HT. We refer the person to the MD
who has the responsibility for the medical diagnosis and treatment for
HT.

Most of the time, we look at healthy, normal eyes that need a few
diopters of optical correction.

LB, O.D.

[Scott Seidman]

Post by LarryDoc

Post by Scott Seidman
While MD's take elevated BPs very seriously, they actually
think pretty hard before they write down that diagnosis. In my
(nonprofessional) opinion, it's not a diagnosis that should appear on
an OD's chart, except as a patient-provided history, or when a
pathology requires elevated BP to be ruled out.

ODs take elevated BP very seriously. We write down the findings
simply as BP readings. We don't diagnosis HT. We refer the person to
the MD who has the responsibility for the medical diagnosis and
treatment for HT.

What would you write down as the reason for the referral to the PC?

[LarryDoc]

Post by Scott Seidman

Post by LarryDoc

Post by Scott Seidman
While MD's take elevated BPs very seriously, they actually
think pretty hard before they write down that diagnosis. In my
(nonprofessional) opinion, it's not a diagnosis that should appear on
an OD's chart, except as a patient-provided history, or when a
pathology requires elevated BP to be ruled out.

ODs take elevated BP very seriously. We write down the findings
simply as BP readings. We don't diagnosis HT. We refer the person to
the MD who has the responsibility for the medical diagnosis and
treatment for HT.

What would you write down as the reason for the referral to the PC?

A simple report. It would look like this:
BP xxx/xxx, date, time, which arm, sitting. Report to: name of MD.

If there were ocular signs, those would be noted.

LB, O.D.

[Anon E. Muss]

On 6 Jul 2006 12:47:09 GMT, Scott Seidman

Post by Scott Seidman
You guys don't routinely check blood glucose, but find plenty of
pathologies pointing to diabetes. Why don't you routinely do a finger
stick for glucose?

I think your question would be more apppropriately worded, "Why don't
you routinely screen for diabetes via a blood test?"

Short answer: Because the medical community does not recommend all
health care practitioners routinely screen for diabetes mellitus, but
does recommend all health care practitioners screen for hypertension
via measuring blood pressure.

Post by Scott Seidman
As a patient, I would say check my blood pressure if a retinal pathology
requires hypertension to be ruled out. Otherwise, I would frankly consider
it an invasion of privacy.

You are free to feel however you want and free to reject any tests you
want. It is just your eye doctor's responsibility to inform you why
he wants to perform any test and the risks of your refusal.

However, the next chance you get, why not ask your internist, family
practice doctor or any other health care practitioner you like if they
think it's a good idea for their optometrist (or any other health care
practitioner) to screen for hypertension via taking blood pressure
measurements on a routine basis?

Post by Scott Seidman
If an OD came at me with a blood pressure cuff, I would ask why, and
if I weren't satisfied with the answer, I would not consent.

Would you do the same if a dermatologist, ophthalmologist, neurologist
or nurse practitioner did the same on a routine basis?

(BTW, a doctor should always be able to explain why he wants to
perform any test.)

Post by Scott Seidman
A diagnosis of hypertension can carry some pretty significant insurance
ramifications. While MD's take elevated BPs very seriously, they actually
think pretty hard before they write down that diagnosis. In my
(nonprofessional) opinion, it's not a diagnosis that should appear on an
OD's chart, except as a patient-provided history, or when a pathology
requires elevated BP to be ruled out.

As an OD, I have never diagnosed anyone with primary or essential
"hypertension", however I have diagnosed the following related to
blood pressure:

Malignant hypertension
Hypertensive retinopathy
Hypertensive choroidopathy
Hypertensive urgency
Isolated elevated blood pressure reading

For example, with the last diagnosis, I typically will write a letter
to the patient's internist or family practice doctor informing them of
the blood pressure reading and the results of their eye examination.

IOW, I screen for (don't diagnose) primary hypertension as part of a
routine comprehensive eye examination, but when the readings are
elevated then refer to the proper health care practitioner as
appropriate based on the recommendations of the medical community as a
whole.

Hope that helps!

[Salmon Egg]

On 6/30/06 10:51 AM, in article

Post by Blake Patterson
I wanted to explain a situation I am experiencing and see if anyone had
any ideas as to what may be taking place.
About 10 weeks ago I was reading a book and first noticed that in the
periphery of my vision in my right eye, when I blinked there was a dark
spot. A split second later it was pretty much gone. At every blink.
Higher up and still off center in my vision I saw three colored lines
for a split second after I blinked as well - as if I had just looked at
three bright lines of light and this was the after image.

When I first started reading this, I thought ocular migraine, but from the
verbal description it is very difficult to tell what someone else sees.
Moreover, I am not a medical person, so anything I say should not be given
much weight anyway.

If I were you, I would run to a good ophthalmologist as quickly as possible,
Based upon his posts, I respect William Stacey but I think you want a
medical specialist. It would not hurt to mention ocular migraine. From what
I know, that is not an eye problem per se but a neurological problem
occurring between the retina and the brain. In any event, get medical
attention for piece of mind.

Bill
-- Ferme le Bush

[Blake Patterson]

Thanks for the advice.

I did just visit an opthalmologist and he examined my eyes and has set
a field test to be done next week. (I've got to go in at 7am or so to
get squeezed in that week) and if all is fine there he may want to go
down the neuro / MRI route.

Hopefully no more progression between then and now.





bp

Post by Salmon Egg
On 6/30/06 10:51 AM, in article

Post by Blake Patterson
I wanted to explain a situation I am experiencing and see if anyone had
any ideas as to what may be taking place.
About 10 weeks ago I was reading a book and first noticed that in the
periphery of my vision in my right eye, when I blinked there was a dark
spot. A split second later it was pretty much gone. At every blink.
Higher up and still off center in my vision I saw three colored lines
for a split second after I blinked as well - as if I had just looked at
three bright lines of light and this was the after image.

When I first started reading this, I thought ocular migraine, but from the
verbal description it is very difficult to tell what someone else sees.
Moreover, I am not a medical person, so anything I say should not be given
much weight anyway.
If I were you, I would run to a good ophthalmologist as quickly as possible,
Based upon his posts, I respect William Stacey but I think you want a
medical specialist. It would not hurt to mention ocular migraine. From what
I know, that is not an eye problem per se but a neurological problem
occurring between the retina and the brain. In any event, get medical
attention for piece of mind.
Bill
-- Ferme le Bush

[William Stacy]

Post by Salmon Egg
If I were you, I would run to a good ophthalmologist as quickly as possible,
Based upon his posts, I respect William Stacey but I think you want a
medical specialist.

I appreciate that, but not only did I recommend ophthalmology
consultation, I was more specific and specified retinologist (aka
vitreo-retinal sub-specialist). I've witnessed quite a few general
ophthalmology exams and not one of them included scleral depression. I
hope his o.m.d. does it, unless he/she is able to spot the trouble
without going the extra mile...

w.stacy, o.d.

[m***@gmail.com]

Hi Blake, obviously this was a number of years ago. How did you fair with additional hypertensive treatment?