Optometrists who practice full-scope care have learned the techniques and methods required to provide vision therapy, specialty contact lens fittings and low vision––yet their knowledge might be a bit dusty, their hands-on experience might be a little rusty, and they may not have the necessary equipment and tools in office to give the highest level of treatment and care the patient requires and deserves.
For a specialty contact lens fit, optometrist Gwen Gnadt uses a corneal topographer in her office to obtain precise measurements on a patient.
When this occurs, ODs need to reach out to those with the experience and expertise to do a thorough job. Optometrists who specialize in vision therapy, specialty contact lenses or low vision fit the bill.
So, are we handing off to specialty ODs as often as we should?
Specialty Contact Lens ODs
Probably not, says Gwen Gnadt, OD, of Eye Vision Associates in Lake Ronkonkoma, NY, who fits specialty contact lenses on a regular basis. She says that most of her specialty contact lens fits come to her by referral and, “about 80% [of the referrals come] from ophthalmologists, mostly corneal specialists, and [just] 20% from other ODs.”
Dr. Gnadt explains, “I feel that many ODs are reluctant to refer to a practice with an optical for fear that they might lose their patient. But, we try to make it clear both to the referring doctor and to the patient that we are only providing a specialty service, and that the referring doctor is their primary provider. We make every effort to get that patient back to their doctor.”
One way that Dr. Gnadt’s practice accomplishes this is by “telling the patients that I will be sending a letter to their doctor explaining our outcome. I also ‘cc’ that letter to the patient to reinforce that I have told them to return,” she says. “If a patient needs glasses and their referring doctor has an optical, I will tell them they should take their Rx there so their primary eye doctor has control.”
She also says she doesn’t necessarily perform a comprehensive eye exam when she receives a new patient as a referral. “It really depends on how much information the referring physician provides and how long it has been since the patient had an exam,” Dr. Gnadt says. “Of course, in my office I will do the pertinent contact lens-related examination, refraction, corneal topography and assessment of external ocular health.”
But, she adds, “it would be helpful if the referring doctor could provide me with as much of this information as possible for comparative data. For some of these patients, it can be very difficult to get consistent data on them.”
So, if you’re referring a patient to a specialty OD (or any specialist), be sure to share the appropriate patient history. This is another good step towards ensuring the best possible patient care.
Optometrist David Maze, a private practice vision therapist in Westmont, Ill., has taken precautions one step further by adopting a “no fill” policy for prescription lenses for patients who came in through referrals from outside docs.
“I strongly encourage patients to go back to their family eye care professional when I prescribe lenses,” he says. When it comes to referred patients, “if I determine a prescription is necessary, we do not and will not fill an Rx, even if the parent/patient asks us for convenience’s sake.”
David Maze, OD, works with a child in his fully-equipped vision therapy practice.
Dr. Maze has an optical in his practice, but developed this “no fill” policy in order to build trust with referring ODs. “I do think hesitation exists when referring to other ODs with an optical, but I think that mindset is changing. I think ODs are getting more comfortable sending us patients.”
Since 2005, Dr. Maze has been carefully tracking his referral sources to see how vision therapy patients find his practice. His percentage of referrals from ODs is about 25%.
Other health care providers, such as OTs, PTs, speech and language specialists, neuropsychologists, MDs and chiropractors, together account for about 35%––with occupational therapists contributing more than any of the other sources in that group.
The remaining 40% of referrals for vision therapy come from family and friends of current patients or word of mouth (30%), educators (5%) and Internet sites (5%), such as
OEP.org and other media.
While ODs have had specialty training in optometry school, it sometimes just isn’t enough. “Most ODs’ clinical experience with vision therapy has been at academic institutions and large clinics. Even with the best attending, that experience does not match that of a private practice with therapy,” Dr. Maze says. “I feel many of the externs that I teach learn the impact vision therapy can have in a child’s life as well as see the [benefits of a] collaborative effort [among ODs.]”
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Refractions and ocular health evaluations aren’t repeated if previously done, unless the referring doctor specifically asks him to do so, such as in cases of refractive amblyopia. And as far as dilations go, Dr. Maze says, “it is easier for everyone involved if the dilation is completed before the patient enters my office.”
He emphasizes to the patient that “the referring doctor is the ocular health expert, distance glasses expert and good at screening for binocular vision problems.” His practice always sends patients back to their referring OD for annual eye examinations, any ocular health concern and all glasses and/or contact lenses. “We try our best to send a copy of our findings/report to the referring OD as well as a thank you and a summary report upon the patient’s completion of therapy.”
ODs collaborating and comanaging with specialty ODs can make a winning combination for patients and help to unite us as a profession. “I haven’t met an OD yet who isn’t interested in the absolute best outcome for his/her patients,” Dr. Maze says.
Low Vision Specialists
Low vision specialists also seem to have a relatively low referral rate from other ODs.
Lisa Chan-O’Connell, OD, who provides low vision care for Lighthouse International in New York, says that in low vision, just like in specialty contact lenses and in vision therapy, “we have significantly lower numbers of referrals from optometrists vs. ophthalmologists.”
While these patients may already be in the hands of ophthalmologists treating the underlying ocular disease involved in their condition, Dr. Chan-O’Connell says that she too thinks there might be a hesitation among optometrists when it comes to referring out to another eye care practice.
Lisa Chan-O’Connell, OD (at rear), shows how to adjust an expanded field bioptic telescope.
“Ophthalmologists do not seem to hesitate when a specialty referral—such as retina, glaucoma, or neuro-ophthalmology—is needed.” Likewise, “optometrists have the abilities to treat a wide variety of ocular conditions, so when a specialty referral is needed, we should not hesitate to send our patients for [specialty care such as] low vision evaluations,” she says.
A low vision evaluation is similar to a comprehensive eye exam, but there are some significant differences. An extensive history must be taken on the patient’s condition as well as a detailed functional history that assesses different aspects of the patient’s everyday life.
The low vision specialist performs a trial frame refraction to allow the patient to maintain/adapt to an eccentric view position. Different charts are used for measuring visual acuities as well as contrast sensitivity function, and visual fields are tested if necessary.
These specialized charts and techniques are something that the average OD likely doesn’t use on a regular basis. That is why a referral to a low vision specialist is an invaluable resource when it comes to providing patients with targeted diagnosis and care. They also have specialty low vision devices conveniently in stock, and they’re used to producing atypical spectacle prescriptions such as those with high adds.
“Sending a patient for a low vision evaluation will be in the patient’s best interest, allowing them to continue functioning independently,” Dr. Chan-O’Connell says. “If patients are not referred and their difficulties are not addressed, the patient will only refer themselves or look for another OD to provide a solution to their problems.”
And that is true of all patients who need specialty care. “If the OD makes the referral, then the patient doesn’t [have to] try to look for answers on their own and they will be grateful that you are the OD that is really trying to help them,” Dr. Chan-O’Connell says.
Don’t buy into the myth that once you send your patient to another OD, you’ll never see that patient again. By and large, specialty ODs are doing their best to ensure that this doesn’t happen. It is not their intention to “steal” your patients, but simply to extend their particular experience, tools and techniques to you and your patients through their specialty services.