Document - University of Houston College of Optometry

2015
University of Houston College of
Optometry
4849 Calhoun Road
Houston, TX 77204
SUNDAY, JULY 19, 2015
7:00am
-
8:00am
Registration / Breakfast & Visit Exhibits
8:00am
-
9:00am
GP Lens Update
Edward Bennett, OD, MSEd, FAAO
Room 203
Attendees may select which lectures to attend:
9:00am
-
9:50am
9:50am
-
10:20am
10:20am
-
11:10am
11:10am
-
12:00pm
12:00pm
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1:00pm
1:00pm
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1:50pm
1:50pm
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2:20pm
2:20pm
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4:00pm
4:00pm
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5:00pm
GP Spherical and Toric Fitting and
Troubleshooting Update
Edward Bennett, OD, MSEd, FAAO
Room 203
OR
Contact Lens Management of the
Irregular Cornea
Maria Walker, OD, MS
Room 267
Break & Visit Exhibits
Track A
*Must be pre-registered to attend this
workshop.
Scleral Lens Update and Hands-On
Workshop
Stephanie Woo, OD, FAAO, Matt Kauffman,
OD, FAAO, Ashley Wallace-Tucker, OD,
FAAO, and Maria Walker, OD, MS
Room 203
OR
Track B
Myopia Control Part One: Soft Lens
Research and Applications
David Berntsen, OD, PhD, FAAO
Room 267
Track B
Myopia Control Part Two: Corneal
Reshaping
Katrina Parker, OD, FAAO
Room 267
Lunch & Visit Exhibits
Custom Soft Lens Applications and Fitting
Stephanie Woo, OD, FAAO
Room 203
OR
GP Multifocal Update
Edward Bennett, OD, MSEd, FAAO
Room 267
Break & Visit Exhibits
Specialty Contact Lenses Case Grand Rounds
Moderator Edward Bennett, OD, MSEd, FAAO with Stephanie Woo, OD, FAAO,
Katrina Parker, OD, FAAO, Matt Kauffman, OD, FAAO, and Maria Walker, OD, MS
Room 203
2015 Professional Responsibility Course for Texas Optometrists
Joe Deloach, OD, FAAO
NOTE: This course will include a screening of a previously recorded session presented by Joe
DeLoach, OD. Participants will receive CE credit for viewing the course – NO EXAM REQUIRED.
Room 203
Health and Biomedical Sciences Building in the Molly and Doug Barnes Vision Institute
4811 Calhoun Road, Houston, TX 77204
GP LENS UPDATE
Ed Bennett OD, MSEd, FAAO
AFFILIATIONS
Contact Lens Manufacturers Association: Consultant and
Executive Director, GP Lens Institute
ADVANCEMENT ONE: SCLERAL LENSES
A. Where is the GP Market going in the next 5 years? GP Lens
Update, Contact Lens Spectrum, October, 2014)
B. Last 100 fits of Irregular Cornea patients: GPLI Advisory
Board N= 52 responses)
C. SCLERAL LENS SETTLING RATES
A Comparison of the Rates of Short-Term Settling of Three
Scleral Lens Designs
Matt Kauffman, Chris Gilmartin, Ed Bennett & Carl Bassi
(Optometry and Vision Science, December, 2014)
D. IN THE NEXT 3 YEARS WHAT IMPACT DO YOU FEEL
SCLERAL LENSES FOR HEALTHY EYES (i.e., astigmats,
presbyopes) will have on the contact lens market Contact
Lens Spectrum, GP Lens Update, Oct., 2014 (N = 46)
E. CLINICAL EVALUATION OF A LARGE DIAMETER RIGID GAS
PERMEABLE LENS FOR THE CORRECTION OF
REFRACTIVE ASTIGMATISM
Presented at the Global Specialty Lens Symposium, Las Vegas
January, 2013 Results:
A. Soft lenses considered easier to handle
B. But LRGP are overall preferred for vision
C. 52% will remain in LRGP for the future.
F. GP SCLERAL MULTIFOCAL LENS DESIGNS [from Messer
B, Barnett M (2013); Woo S (2013), Bennett (2013)]
G. SCLERAL LENS DECENTRATION (GSLS article, April, 2014
CLS)
ADVANCEMENT TWO: CORNEAL RESHAPING
A. Earl Smith 2005 Eye growth may possibly be retarded, or halted through:
“A precise and pre-determined optical system at the corneal
plane that will manipulate the peripheral optics of the eye.”
OOK and Myopia Control
B. Several studies have confirmed that overnight orthokeratology
causes peripheral myopia defocus and this may, therefore,
provide a potential mechanism for myopia control.
C. BOTTOM LINE
1. Professor Brien Holden (GSLS, January, 2013) believes the
use of customary spectacles and CLs can encourage myopia
development
2. “We should fit every myopic child, young adult, and university
student with peripheral plus power lenses.”
ADVANCEMENT THREE: MULTIFOCALS/PRESBYOPIC CORRECTION
2014 Annual Report (Nichols J, CLS 1/15)
A. Survey for presbyopes wearing CLs, practitioner preference was:
1) Multifocal lenses: 70% (59% in 2008)
2) Monovision: 22% (27% in 2008)
3) Over-spectacles: 8% (14% in 2008)
B. FRONT SURFACE ASPHERIC MULTIFOCAL DESIGNS
C. EXCHANGE RATES: THE RESULTS OF A LARGE PRACTICE
D. Translating Designs: Intermediate Need
E. Hybrid Designs: Synergeyes Duette aspheric multifocal
F. POST-REFRACTIVE SURGERY MULTIFOCAL DESIGNS
ADVANCEMENT FOUR:
A. EDUCATIONALRESOURCES
1) GP Lens Institute (www.gpli.info)
2) Scleral Lens Education Society (www.sclerallens.org)
3) Orthokeratology Academy of America
(www.orthokacademy.com)
4) www.contactlenssafety.org (AOA-AAO)
4) Your best resource is your laboratory consultant
SUMMARY
GP SPHERICAL AND TORIC FITTING AND
TROUBLESHOOTING UPDATE
Ed Bennett, OD, MSEd, FAAO
AFFILIATIONS: Consultant: Contact Lens Manufacturers Association
I. SPHERICAL GP FITTING AND TROUBLESHOOTING
A. GP Lens Comfort
B. Empirical Fitting
1. Benefits
2. Approach
C. Inventory Fitting
D. Comfort and Lens Design
E. Evaluation
1. Base Curve-Diameter interaction
2. Lens design change effects
F. Guidelines for Fitting Young People
G. Lens Materials
1. Current Lens Materials
2. Material Dk and Lens Seclection
3. Plasma Treatment
H. Troubleshooting
1. Inferior Decentration
2. Dryness: Corneal Desiccation
3. Dryness: Reduced Surface Wettability
4. Patient Compliance
I. Resources
II. GP TORIC LENS FITTING AND TROUBLESHOOTING
A. Spherical Lens Problems with High Astigmatism
B. Toric GP lenses versus soft toric lenses
C. Back Surface Versus Bitoric Lenses
1. Indications
2. Manufacturing
3. Why back surface lenses are rarely necessary today
D. Bitorics
1. When you correct for induced cylinder
2. Why Bitorics in 2014 (Bennett/Parker Jan 2014, CL
E. Empirical Methods
1. Mandell-Moore
2. GPLI Toric and Spherical Calculator
3. Newman Guide
4. How to determine Base Curve Radii
5. How to determine other lens parameters:
a. Overall Diameter
b. Toric Peripheral Curves
c. Center Thickness
6. How to Select Lens Material
F. Diagnostic Lens Fitting
1. Representative Diagnostic Fitting Set
2. Determination of Base Curve Radii to Select
3. Spherical Power Effect Versus Cylinder Power Effect
4. SPE Examples
5. CPE Example
G. Irregular Corneas and Bitoric Lens Applications
H. Case Examples
1. Very High Astigmatism
2. SPE example
3. CPE example
I. Resources
J. Summary
1. Use empirical method
2. Communicate with your laboratory consultant
Scleral lens update and workshop
Stephanie L. Woo, O.D., F.A.A.O., F.S.L.S.
Course description: This course starts with reviewing scleral lens indications and the basics of scleral lens
fittings. Updated information about the latest scleral lens designs and advancements is discussed. This
course teaches practitioners how to apply and insert scleral lenses on live patients. Scleral lens
evaluation is reviewed with the slit lamp and also ocular coherence tomography. Scleral lens care and
replacement is discussed. Ideal candidates are described. Troubleshooting scleral lenses is detailed.
Course Outline (2 hours)
I.
Review of scleral lenses (5 mins)
a. Designs
b. Differences from soft lenses and corneal GP lenses
c. Differences between scleral lenses for regular cornea vs. irregular cornea
II.
Ideal candidates for scleral lenses for normal corneas (5 mins)
a. Regular astigmatism
b. Myopia
c. Hyperopia
d. High myopia/hyperopia
e. Anisometropia
f.
Aphakia
g. Patients suffering from dry eyes with soft lenses
h. Patients with a presbyopic need
i.
III.
Patients desiring the best possible vision
Candidates for scleral lenses with irregular corneas (3 mins)
a. Keratoconus
b. Pellucid marginal degeneration
c. Post-transplant patients
i. Importance of checking endothelial cell count
d. Post-refractive surgery patients
i. RK patients: assists with fluctuation vision and dryness
ii. LASIK patients: may not be candidates for standard contacts
e. Corneal scarring
f.
IV.
Corneal GP complications
Scleral lens fitting (7 mins)
a. How to apply lenses
i. Large plunger
ii. Tripod method
iii. Two finger method
iv. Scleral ring insertion
v. Dalsey adaptives
b. How to remove lenses
i. Small plunger
ii. Air bubble method
iii. Lower lid method
c. Troubleshooting lenses
i. Fit
ii. Insertion
iii. Removal
iv. Follow up
V.
Slit lamp evaluation and OCT evaluation (5 mins)
a. Show practitioners how to evaluate a scleral lens on eye with NaFl and slit lamp
b. Evaluate scleral lens with OCT machine
c. Evaluating central fit
d. Evaluating limbal fit
e. Evaluating edges
VI.
Hands on workshop ( 90 minutes)
a. Inserting lens on a live patient
i. Lens selection based on patient information
ii. Proper lens cleaning and conditioning
iii. Preparing the lens
iv. Filling the lens with non preserved saline
v. Use of NaFl in bowl of lens
vi. Insertion method
1. Placement of bib or paper towel
2. Patient’s nose to floor and holding lower lid
3. Practitioner holding upper lid and inserting lens central and quickly
4. Checking for insertion bubbles
vii. Lens insertion methods
1. All devices are available for insertion and are utilized
2. Differences between methods
b. Evaluation of lens with slit lamp and NaFl
i. How to evaluate scleral lens fit
1. Evaluating central clearance
a. Cobalt blue light for initial assessment
b. Optic section with bright light to asses central clearance
i. Focus on anterior surface of scleral lens
c. Using known lens thickness to estimate central clearance
2. Evaluating limbal area
a. Cobalt blue assessment
b. Optic section assessment
c. Importance of no compression
3. Evaluating lens edges and periphery
a. Using pen light to evaluate fit
b. Using slit lamp to view edge lift and edge compression
c. Viewing edges 360
ii. Detecting bubbles
iii. Evaluation of conjunctiva
c. Evaluation of scleral lens with OCT machine
i. Central clearance evaluation
1. Using anterior segment to view and capture photo
2. Identifying lens thickness
3. Identifying and assessing central clearance
a. Using ruler tool to measure clearance in microns
4. Identifying central cornea
ii. Limbal clearance evaluation
1. Identifying limbus and limbal clearance
2. Measuring limbal clearace
iii. Lens edge evaluation and conjunctiva
1. Identifying edge of lens and conjunctiva
2. Distinguishing edge compression
3. Identifying a well aligned edge
4. Identifying edge lift
d. Keratometry or topography over scleral lenses
i. Evaluate flexure
ii. Methods to reduce or eliminate flexure
iii. Front surface toric options if no flexure
1. How to Rx
a. What info lab needs
b. Stabilization options
c. Evaluation of the fit
e. Removing a lens on a live patient
i. Different removal methods will be trialed on different patients
ii. Pop out method
iii. Plunger method
1. Vented plunger
2. Non vented plunger
f.
VII.
Repeat above procedure on a different patient
Session wrap up (5 mins)
a. Clinical pearls
i. Ideal candidates
ii. Fitting process
iii. Insertion/removal techniques
iv. Troubleshooting
Course goals:
1. Be able to successfully apply and remove a scleral lens on 2 different patients.
2. Be able to appropriately evaluate a scleral lens fit.
3. Describe ideal candidates for scleral lenses.
4. Describe the differences between scleral lenses for regular corneas vs irregular corneas.
5. Identify 2 techniques to help with scleral lens insertion.
6. Explain how to assess central clearance with use of a slit lamp.
7. Identify a good peripheral/edge fit of a scleral lens.
8. Describe the different layers on the anterior seg OCT of contact lens thickness, central clearance, and
central corneal thickness.
Course Title: Soft Custom Lens Applications and Fitting
Presenter: Stephanie L. Woo, O.D., F.A.A.O.
Course overview: This course will review soft custom contact lenses for regular corneas and irregular
corneas. Patient candidacy will be discussed as well as different soft custom designs. Fitting soft custom
torics , troubleshooting soft custom lenses and implementing soft custom torics into optometric
practice will also be reviewed.
Course Outline: 50 minutes total
I.
Definition of soft custom lenses (5 mins)
a. What soft custom toric lenses are
b. How they are different than standard soft toric lenses
c. How soft custom lenses for irregular corneas differ
II.
Good Candidates (3 mins)
a. Defining good candidates for soft custom torics for regular corneas
b. Soft custom lenses vs gas permeable lens options
c. Pros and cons
d. Defining good candidates for soft custom lenses for irregular corneas
e. Pros and cons and comparison between gas permeable lenses
III.
How to design soft custom toric lenses (5 mins)
a. Fitting nomogram
b. Rule of 3
c. Arc length design
d. Sagittal depth method
IV.
Fitting soft custom lenses for irregular corneas (5 mins)
a. Empirical fitting vs diagnostic fitting
b. Designs available
c. Differences between designs
V.
Fitting of soft custom lenses (7 mins)
a. Data needed
b. Empirical vs diagnostic fitting explained in detal
c. HVID
i. Different methods used
1. Topographer
2. Reticle
3. Loop
4. Soft Lens
d. Lens material selection
VI.
Soft lens designs and their parameters (15)
a. Different designs
b. Parameters
c. Materials
d. Markings
e. Replacement schedule
f.
VII.
Customization
Troubleshooting soft custom lenses (5 mins)
a. Problems with vision
b. Problems with comfort
c. Problems with movement
d. Problems with replacement
VIII.
Implementing soft custom lenses into practice (5 mins)
a. Identifying good candidates
b. Pros and Cons
c. Reviewing different options
d. Marketing
i. Warranty
ii. Vision options
iii. Customer service
e. Patient education
Course Goals:
1. Identify patients that are good candidates for soft custom lenses for regular and irregular
corneas
2. Discuss the pros and cons of custom soft lenses vs. gas permeable options
3. Be able to name 2 methods of designing soft toric lenses
4. Explain 2 reasons diagnostic fitting is preferred over empirical fitting
5. Be able to name 2 different types of soft custom lenses and their differences
6. Be able to identify potential problems with soft custom lenses and how to resolve them
7. Discuss how to market soft custom lenses
Contact Lens Management of the Irregular Cornea Maria K. Walker, OD.MS.
4901 Calhoun Road
Houston, TX 77098
Tel: (713) 743-6421
[email protected]
Course Description: This course is intended to provide practitioners with information on selection and management of specialty contact lenses for the irregular cornea. Course Objectives: o To provide a clinically applicable basis for specialty lens selection according to patient characteristics. o To review the availability of soft, corneal GP, and scleral contact lenses in the management of irregular corneas. o To provide an overview of the fitting process of rigid contact lenses. o To provide information on managing the wearing of rigid contact lenses. Outline: I.
Using topography to determine the best lens modality for a patient a. Soft versus rigid i. Shape and power are best evaluated using a corneal topographer. ii. If the astigmatism is symmetrical, the patient may be successful with extended parameter soft lenses. iii. Once shape (elevation) and/or asymmetrical power distribution create instability, may need to thicken soft or consider rigid. b. Corneal gas permeable versus scleral lenses i. The shape of the eye usually determines which type of lens the patient will be most successful in. ii. Large differences in elevation (300um rule) across the cornea will make fitting a corneal lens difficult, so the best option is to vault over the entirety of the cornea with a scleral lens. iii. Patient sensitivity and lifestyle play a role in decision-­‐making. iv. Pros and cons of wearing GP versus scleral lenses. 1. Comfort, lens handling, patient anatomy, lifestyle II.
Soft CL for irregular cornea a. Generally reserved for mild irregularities and individuals who cannot adapt to rigid modalities b. Custom soft contact lenses available for the irregular cornea. III.
Custom corneal GP lenses for an irregular cornea a. Keratoconus-­‐specific lenses i. Choosing the lens parameters: Base curve, eccentricity values, edges, and diameters. 1. Metrocone lenses with adjustable “A” value 2. KBA lenses with adjustable “e” value 3. Quadrant specific eccentricity manipulations b. Post-­‐surgical lenses i. Large diameter, vault over the surgical zones. (11-­‐12mm) ii. Reverse geometry for oblate corneas c. Managing the most common fitting limitations and complications of corneal lenses i. Edge profile and its role in patient comfort and lens awareness ii. Improving visual satisfaction with corneal lenses. IV.
Scleral contact lenses for the irregular cornea a. Choosing the scleral lens candidate and setting patient expectations b. Adjusting the central clearance zone and base curve c. Adjusting the limbal clearance zone d. Adjusting the scleral landing zone e. Managing scleral contact lenses i. Proper application, removal, and cleaning techniques to improve patient satisfaction and outcomes. ii. The front surface of lenses and interaction with the eyelids and tear film. iii. Management of the sub-­‐lens tear film reservoir. Myopia Control Part One: Soft Lens Research and Applications
David A. Berntsen, OD PhD FAAO
University of Houston
College of Optometry
505 J Davis Armistead Bldg
Houston, TX 77204-2020
713-743-5836
[email protected]
Course Description:
This course reviews recent myopia theories and clinical studies in children. Eye care providers
will gain an evidence-based understanding of the ability of various treatments to slow myopia
progression in children, emphasizing current soft contact lens research.
Course Learning Objectives:
 To review the current prevalence of myopia
 To provide an overview of the treatment effect size found by multiple clinical studies
utilizing various treatments to slow the progression of myopia
 To discuss what we have learned about myopia mechanisms from the most recent
clinical trials utilizing progressive addition lenses, orthokeratology, and soft bifocal
contact lenses
 To explain current blur-based theories of myopia progression
 To discuss current lens designs being considered for the control of myopia
 To discuss what eye care providers can currently tell their patients based on the most
recent evidence
Outline:
I. Myopia overview
a. current prevalence estimates
b. evidence of increased prevalence
(Vitale et al. 2008 and 2009)
II. Overview of treatments studied and the reported reductions in myopia by published
clinical studies
a. spectacles (bifocal and progressive addition lenses [PALs])
b. GP lenses
c. undercorrection
d. orthokeratology
e. soft bifocal contact lenses
f. pharmaceuticals
i. atropine
ii. pirenzepine
III. Blur-based theories of myopia in the literature
a. accommodative lag
i. Animal research supporting (positive and negative lens experiments
across multiple animal models)
b. peripheral defocus
i. Evidence of local retinal mechanism (Smith et al. 2010 and 2013)
ii. Evidence of peripheral hyperopia influencing eye growth independent of
central defocus (Smith et al. 2009)
IV. What we have learned from PAL clinical trials
a. Bifocal studies (PAL and lined bifocal)
(COMET-Gwiazda et al. 2003and Fulk et al. 2000)
i. greater effect in subgroup with high accommodative lag and near
esophoria (Gwiazda et al. 2004)
b. COMET2 (2011) results in subgroup of children with high lag and esophoria
c. STAMP (Berntsen et al. 2012) results in children with high accommodative lag
d. Potential explanations of treatment effect
i. Accommodative lag
1. Change in accommodative lag with +2.00-D add in myopic
children (Berntsen et al. 2010)
2. Studies of relationship between accommodative lag and myopia
progression
a. Adults (Allen and O’Leary 2006; Rosenfield et al. 2002)
b. Children (Weizhong et al. 2008; Berntsen et al. 2011
[CLEERE Study Data]; Berntsen et al. 2012 [STAMP Data
including lag measured through near add]; Cheng et al.
2014)
ii. Peripheral defocus
a. Standard spectacles can increase peripheral hyperopic
defocus (Lin et al. 2011)
b. Better success with larger add area of executive bifocals?
(Cheng et al. 2013)
c. Peripheral myopic defocus caused by PALs on superior
retina associated with less myopic progression in children
(Berntsen et al. 2013)
V. Orthokeratology
a. Effect on axial elongation in myopic children
i. Non-randomized studies (Cho 2005; Walline 2009; Kakita 2011;
Santodomingo-Rubido 2011)
ii. Randomized clinical trials (Cho and Cheung 2012; Charm and Cho 2013)
b. Effect of orthokeratology on peripheral refraction profiles (Kang and Swarbrick
2011)
c. Potential effect of baseline myopia on Ortho-k efficacy
VI. Soft Bifocal Contact Lens Studies
a. Recently reported studies
i. Walline et al. 2013 (BLIMP Study – Proclear “D” lens)
ii. Anstice and Phillips 2011 (concentric design)
iii. DISC Study (Lam 2014)
b. Peripheral defocus with commercially available spherical lenses (Moore 2014)
c. Peripheral defocus with commercially available multifocal lenses (Kramer 2013)
VII. What’s Next?
a. Need for Clinical Trials/Future directions in myopia research
b. Bifocal Lenses in Nearsighted Kids (BLINK) NIH/NEI Clinical Trial now enrolling
BLINK Study: www.blinkstudy.org
c. Other randomized clinical trials in progress
VIII.
What you can tell your patients now
a. Currently available treatments with promising results
i. Dropout rates by modality (SCL < Ortho-K < GPs)
b. Potential risks/benefits of currently available interventions
c. Proposed evidence-based treatment strategy for myopic children
i. Less myopic than -2.00: soft bifocal
ii. Between -2.00 and -5.00: ortho-k or soft bifocal
iii. Greater than -5.00: soft bifocal
IX. What’s Next?
a. Need for Clinical Trials/Future directions in myopia research
b. Potential for treatment effect rebound? (Atropine Data: Tong et al. 2009)
Myopia Control: Corneal Reshaping
Katrina E. Parker, OD, FAAO
July 19, 2015
A. Introduction
1. Terminology/ definition
2. Reverse geometry lens anatomy
3. Corneal Shape
B. Myopia
1. Myopia progression
2. Myopia prevalence
3. Retinal abnormalities associated with myopia
4. Effects of corneal reshaping on myopia
5. Onset of myopia
C. Orthokeratology Fitting
1. Fitting goals
2. Interpreting sodium fluorescein pattern
3. Ideal candidates
4. Fitting techniques
5. Dispense/Follow up schedule
6. Common adjustments to correcting fitting problems
D. Orthokeratology Safety
1. Risk of microbial keratitis
2. Patient compliance
GP MULTIFOCAL UPDATE
Edward S. Bennett, OD, MSEd, FAAO, FSLS
UMSL College of Optometry
Affiliations: Consultant: Contact Lens Manufacturers Association
I. CONTACT LENS ALTERNATIVES
A. Single Vision/Reading Glasses
B. Monovision
C. Bifocals/Multifocals
II. MONOVISION VERSUS CL BI/MULTIFOCALS
A. Results of recent comparison studies
III. CONTACT LENS MULTIFOCAL USE TODAY
A. Why use is not higher
B. How to increase use within the practice
C. Rule of Threes
IV. PATIENT CONSULTATION
A. How effectively present the options
B. Use of the “Sandwich approach”
V. PRELIMINARY EVALUATION
A. Evaluation of tear film
B. Importance of pupil size
C. Anatomical considerations
VI. ASPHERIC MULTIFOCAL FITTING AND TROUBLESHOOTING
A. Aspheric advancements
B. Aspheric candidates
C. Aspheric design and fitting considerations
D. Front surface versus back surface designs
E. Representative lens designs
F. Lens reorder rate
G. Troubleshooting
1. Poor Vision
2. Inferior Decentration
VII. SEGMENTED, TRANSLATING DESIGNS
A. What is translation?
B. Characteristics of a translating segmented design
C. Benefits
D. Good and poor candidates
E. Important factors to consider when fitting
F. Translating multifocal designs
G. Troubleshooting
1. Lens Rotation
2. Lens picked up too superiorly by upper lid
3. Poor translation
4. Poor vision at distance
5. Poor vision at near
VIII. OTHER MULTIFOCAL LENS DESIGNS
A. GP refractive surgery designs
B. Scleral GP multifocals
C. Hybrid lens designs
IX. ISSUES AND CONTROVERSIES
A. Initial comfort
B. Are they successful?
C. Fee considerations
X. RESOURCES
A. GP Lens Institute
1. Webinars, cases, laminated cards
2. Building your practice with GP multifocals module
B. Laboratory Consultants
XI. SUMMARY
I Hybrid contact lens case report:
RM, a 29 year old Hispanic female presented to the clinic for a comprehensive eye exam.
She complained that her vision in the right eye was blurry and she also had constant
headaches. She had never worn glasses or contact lenses.
Hybrid lenses were ordered empirically based on keratometry values and refraction.
RM presented for the contact lens dispense:
OD: Duette HD/ +4.50/ 8.2/ 14.5
OS: Duette HD/ +2.00/ 8.0/ 14.5
With the lenses, her vision was 20/30 in the OD and 20/20 in the OS. SCOR was +0.50 OD
and +1.75 OS. The lens fit looked great – the GP was centered and the soft skirt was well
aligned with about 1 mm of movement on blink. The lenses were dispensed to her after her
contact lens insertion/removal training. I re-ordered the OS with a new power.
1 week later the OS was dispensed (Duette HD/ +3.50/ 8.0/ 14.5)
1 month later the patient arrived for a contact lens follow up. The hybrid lens fit looked
great OU (GP was centered and soft skirt was aligned and the lenses moved about 1 mm
with blink).Her vision was 20/20 OD and 20/20 OS and she was very happy with the
comfort and vision of her new contacts. She also stated her headaches were improved as
well.
II. Presbyopic Scleral CL case report:
DR, a 61 year old African American male presented to the clinic for a comprehensive eye
exam and contact lens evaluation on March 24, 2014. He had been wearing corneal gas
permeable multifocals of unknown parameters for 10 years. The current pair was about 2
years old. He had no significant health or ocular history.
The lens fit showed both lenses lid attached with good centration and average edge lift.
Both lenses were slightly scratched and presented with mild deposits.
With lenses removed, the corneas had a very small amount of punctate staining in each eye
near the inferior periphery. Other ocular health was unremarkable except for some
nuclear sclerotic cataracts in each eye, which were 1+. Posterior fundus photos were taken
and were reported to be unremarkable.
Keratometry values were: OD: 45.25x45.50@095, OS: 44.25x45.25@088. Mires were
distinct and clear.
After thorough discussion of different lens options, the patient decided to proceed with
scleral contact lenses. DR returned for a scleral lens fitting on April 8, 2014. First, eye
dominance was determined with 2 different tests. Both tests confirmed the patient was
right eye dominant. The Blanchard OneFit Multifocal set was used.
OD: Blanchard/ Onefit P+A Multifocal/ 7.10/ -6.25/ 14.6 OAD/ Boston XO/ Dominant OS:
Blanchard/ Onefit P+A Multifocal/ 7.20/ -5.00/ 14.6 OAD/ Boston XO/ Non-Dominant
The lenses to be ordered:. OD: Blanchard/ Onefit P+A Multifocal/ 7.10/ -9.75/ 14.6 OAD/
Boston XO/ Dominant/ Dot. OS: Blanchard/ Onefit P+A Multifocal/ 7.20/ -9.00/ 14.6 OAD/
Boston XO/ Non-Dominant
DR was seen for a 1 week and 1 month scleral lens follow up. He was still doing great with
the lenses and claimed, “This is the best vision of my life!” His corneal health was great – no
staining or edema. The vision remained 20/20 at distance and 20/20 at near binocularly.
Some of the most exciting advances in scleral lenses are their applications for normal
corneas. There are several companies who have developed scleral lenses for normal eyes.
The small diameter of 14.3-14.9 of these lenses is familiar to current soft lens wearers, so
they are less apprehensive to try them. The dK of scleral lenses is very high and can help
reduce/eliminate neovascularization seen in some contact lens patients.
III. Post Radial Keratotomy with Scleral Lenses
This case pertains to the management of post-radial keratectomy patient with scleral
contact lenses. Patient KW was a 58yo WM who underwent several RK procedures in the
early 1990’s and ultimately had 64 radial and several T-cuts OU. He was experiencing
severe visual fluxuations with spectacles and custom soft lenses. KW was initially fitted
with 16.5mm scleral contact lens with an overall sagittal depth of 4300 in the right eye and
4200 in the left eye. There was 300um of apical clearance, and with this fit the patient
experienced increased lens awareness and midday fogging (MDF). A decreased vault was
implemented, using a design that mimicked reverse geometry designs, in order to reduce
patient complications without creating barring on the mid-peripheral cornea. This
individual was still experiencing intermittent episodes of MDF with lower vault, so we
began treatment with preservative-free artificial tears as the application solution. The
clinical outcome improved and the patient is visually and comfortably satisfied.
IV. Penetrating Keratoplasty Management
Case two is the management of a penetrating corneal injury in a 32yo HM. Patient AG
experienced a penetrating anterior segment injury (nail) one year prior to being sent to us
for a CL fit. A metal nail had perforated his cornea and iris, entering the posterior segment
and resulting in the need for crystalline lens extraction and corneal laceration repair,
leaving the patient with iris atrophy/pupillary correctopia and irregular corneal
astigmatism. The patient reported to our clinic complaining of severe blur, and excessive
glare due to iris destruction. We were unsuccessful with scleral lenses due to nasal
pinguecula and difficulty with lens handling. The patient was ultimately fitted with
spherical, large diameter corneal contact lens. The patient did well with these lenses, but
was still reporting excessive glare and lens awareness. The GP lens was then piggybacked
with a soft prosthetic contact lens: 14mm OAD with 10mm (4mm pupil) black
annular/clear pupil. The annular blackout was used to reduce glare from the correctopia,
and the lens chosen had a low modulus to accommodate draping over irregular cornea and
conjunctival pinguecula. The patient is doing well and is seeing 20/25 out of the injured
eye.
V. Corneal Trauma: Scleral Lens Application
Case number one will be about a 40 year old male who is a construction worker and had a
nail penetrate into his left eye. He has undergone numerous surgeries and has had several
complications including a corneal transplant, cataract surgery, vitrectomy, retinal tear,
endophthalmitis, refractive surgery and a trabeculectomy. I will show the patients corneal
topography and discuss how we fit a corneal GP lens. Ultimately, the patient failed in a
corneal GP design, so we refit him into a scleral lens with a notch. The fitting process with
the notch will be discussed in detail.
VI. Specialty GP Lenses in Post Penetrating Keratoplasty
Case number two will describe the contact lens fitting process for a 46 year old female, who
had a herpes keratitis infection and underwent a penetrating keratoplasty (PKP). Her
corneal topographies will be demonstrated and compared for the normal right eye versus
the PKP left eye. Her right eye was fit with a bitoric gas permeable contact lens, while the
left eye was fit with a quadrant specific design. We fitting process of a quadrant specific
lens will be detailed.
2015 Texas Professional Responsibility Course
“Eight Shades of Gray”
UNIVERSITY OF HOUSTON COLLEGE OF OPTOMETRY
JOE W. DELOACH, OD, FAA0
COURSEMASTER
Welcome to the Professional Responsibilities Course
sponsored by the University of Houston College of
Optometry. As you know, this course is a requirement for
Texas license holders. What you may not know is that all
fees associated with this course are devoted to permanent
projects that are important for the future of the profession.
Thank you for choosing UHCO for your continuing
education.
The development and production of the 2015 Professional Responsibility Course is underwritten by the Harris Lee Nussenblatt Lecture Series Endowment.
This endowment was established in 1992 by the Nussenblatt Family in memory of former Associate Professor Harris Nussenblatt, OD.
The Lecture Series focuses on issues related to professional ethics, public health and practice administration
Preface
The content of the Professional Responsibility Course is at the discretion of the Texas Optometry Board. This year, the Board requested only a few issues be addressed. The rest of the agenda will address the core concept of this course, professional ethics. UHCO and the Coursemaster thank the following leaders of our profession for their contribution and advice in developing this years program: Ron Hopping, Jeff Jones, Clarke Newman, Stacie Virden, Peter Cass, Laurie Sorrenson, Kevin Katz, and Bj Avery. Special thanks to Clarke Newman for his research and invaluable opinions and to Jeff Jones for supplying the title of the course.
AGENDA I – TEXAS OPTOMETRY BOARD
Drug prescribing information ◦New classification of Schedule II Drugs
◦Reference for pain management drugs
◦Rules 280.5 and 280.10 listing types of drugs that may be prescribed Professional designation Importance of reading newsletter
Issues with EHRs
New Rule 277.10 – Remedial Plans
AGENDA II – SITUATION ETHICS
What are the challenges in ethical behavior
Examples of challenges in ethical behavior
New Drug Prescribing Information
Reclassification of Hydrocodone to Schedule II
Implementation Dates
October 6, 2014 – the actual adoption date
April 8, 2015 – the actual implementation date for the majority of the regulation changes
What this really means for Texas ODs
Optometrists in Texas cannot prescribe Schedule II narcotics and most all pharmacies are already using the adoption date as the implementation date. You must find alternate sources of pain management for your patients.
New Drug Prescribing Information
Misc. Issues
• To find or look up the classification of any controlled substance – reference www.dea.gov/druginfo/ds.shtml or www.deadiversion.usdoj.gov/schedules
• You can find a good deal of information on controlled substances, drug abuse and patient diversion tactics at http://www.pharmacy.texas.gov/sb144.asp
• To review the medications that you are allowed to prescribe under current Texas law, reference www.tob.state.tx.us, specifically Rules 280.5 and 280.10
Practice of License Holder
Professional Identification
The Statute: Section 351.362
Rules: Rule 279.10
Name(s) of the optometrists practicing at a location must be visible before entry into the reception area
Does not apply to doctors acting in a temporary capacity as defined in the rule as “no more than two consecutive months”
Practice of License Holder
Professional Identification
Legal identification per state law includes:
‐ Optometrist
‐ Doctor, Optometrist
‐ Doctor of Optometry
‐ O.D.
It is illegal to use any designation or advertising that could mislead the public into thinking you are any other health care practitioner other than an optometrist. This is not the Optometry Board’s law – this is a State law the Optometry Board must uphold. www.statutes.legis.state.tx.us/Docs/OC/htm/OC.104.htm
Texas Optometry Board Newsletter
The Optometry Board releases a newsletter once a year to all licensees. The newsletter identifies issues the Board feels are important to all practicing optometrists as well as explanations of all new Rules passed since the last newsletter.
You are legally obligated to stay abreast of and follow the law. “Ignorance” is not an excuse.
The newsletter is the easiest way to keep up with any new laws or rules and you are encouraged to read it “cover to cover”. If you are not receiving the newsletter, contact the Optometry Board.
Texas Optometry Board 512‐305‐8500
Electronic Medical Records
This is really easy folks. You cannot put statements into a record that do not accurately reflect the services you provided on that date of service.
Since wellness or routine care examinations can often reveal very little to no change from visit to visit, it is imperative your documentation, that will often look very similar year to year, be representative of the care delivered during that date of service.
Additional documentation such as review of history statements and/or attestation statements are a good means of making it clear your patient’s records are completely accurate and truthful (remember, most all EHRs have an internal audit feature that tracks the time and date of every entry!)
Examination and Medical Records All optometrists are encouraged to review the examination requirements found under Rule 277.7 that apply to the initial evaluation of a patient where an ophthalmic prescription is generated.
(1) An accurate identification of the patient;
(2) The date of the examination;
(3) The name of the optometrist or therapeutic optometrist conducting the examination;
(4) Past and present medical history, including complaint presented at visit;
(5) A numerical value of the monocular uncorrected or monocular corrected visual acuity in a standard acceptable format;
(6) The results of a biomicroscopic examination of the lids, cornea, and sclera;
Examination and Medical Records
(7) The results of the internal examination of the media and fundus, including the optic nerve and macula, all recorded individually;
(8) The results of a retinoscopy. A tape from an automatic refractor is acceptable;
(9) The subjective findings of the examination. A tape from a computer assisted refractor/photometer is acceptable if the instrument is being used to obtain subjective findings;
(10) The results of an assessment of binocular function, including the test used and the numerical endpoint value;
(11) The amplitude or range of accommodation expressed in numerical endpoint value including the test used in the examination;
(12) A tonometry reading including the type of instrument used in the examination; and
(13) Angle of vision: the extent of the patient's field to the left and right. he initial evaluation of a patient where an ophthalmic prescription is generated
Documentation Notes
Be aware that the Board Rules require that the examining optometrist PERSONALLY make and record the examination elements listed in orange (biomicroscopy, internal evaluation, subjective refraction)
Optometrists should also be aware that, although not a requirement of the Texas Optometry Board, the rule that the attending physician personally “make” the patient’s HPI is commonly cited, while the rest of the history may be delegated to an assistant/technician as long as the it is clear the physician has reviewed the information
NEW Rule 277.10 – Remedial Plans
This Rule gives the Board the authority to resolve typically more minor violations by mutual agreement to a remedial plan
If the licensee completes the requirements of the remedial plan, the violation is removed from the licensee’s record two years after completion of the remedial plan and is not reported to the national physician data bank
Remedial plans may be issued a maximum of once every two years
Remedial plans may be initiated by the Executive Director of Investigative Committee but must be approved by vote of the Board
Remedial plans may include a $1,000 administrative fee
And now…
Situation Ethics
Are Ethics a Real Issue?
We all face “ethical” decisions every day – it’s not limited to what most would consider as lying, immorality, religious beliefs or generally being a “good or bad person”
Ethical decisions can range from something terrible like deciding to rob a bank to something seemingly benign like not handing out bonuses to your staff because you really want to buy a new car
Our decisions are influenced by a host of internal and external influences
Not all decisions have a “right” answer – many are “shades of gray” (thanks Jeff!)
Much of the information in the next few slides can be found in the excellent reference [email protected]
“Ethics Unwrapped” identifies 22 moral standards that define how we make decisions. The next slides review eight standards considered most applicable to doctors.
Moral Standards
Role Morality
Actions or decisions are justified because of the unique role we play (as doctors) in or because we separate our personal beliefs from our work beliefs. EX: Selling patient ocular supplements when you wouldn’t take them yourself
Conflict of Interest
Actions or decisions are influenced by professional or economic interests
EX: “Stretching” medical necessity (is that specular microscopy REALLY necessary even though it will add to the month’s bottom line)
Moral Standards
Ethical Fading
“What was I thinking?” Decisions are based more on an emotional response than a rational response (“moral disengagement”)
EX: Insider trading with a pharmaceutical company
Incentive Gaming
Decisions or actions influenced by potential incentives, usually monetary.
EX: Incentive bonus systems – employed doctors and/or staff
(NOTE: Unwrapped authors define the new American Dream as “minimal effort for maximum gain”)
Moral Standards
Incrementalism
No one wakes up one day and decides to lose their morality. It is almost always a progressive lowering of the ethical bar, often based on prior success with lower standards.
EX: Stretching medical necessity progresses to billing fraud
Moral Equilibrium
Also called “moral licensing” – keeping score on our good behavior allows us to justify a certain degree of behavior we otherwise would not consider acceptable
EX: Indigent care efforts make it reasonable to overbill patients with insurance
Moral Standards
Moral Imagination
Success defined by many as winning. In the movie “Margin Call”, Jeremy Irons says “there are only three ways to win – be first, be smarter or cheat.” When winning rules our lives, our emotional barometer can lead our imagination to find ways to cheat and consider it part of doing business.
EX: Embezzlement
Moral Myopia
Possibly the most common and deadly – it is the “everyone is doing it” scenario. Blurring the right behavior is often fueled by potential for financial gain.
EX: The classic scenario of “run this test – you’ll get paid” forgetting the rule of medical necessity
Again, we must emphasize that not all seemingly straight forward “ethical” decisions are always so clear cut. While some actions are obviously unethical (billing for services not rendered) others can be “shades of gray” (individual decisions regarding medical necessity of care).
With that in mind, let’s look at some “situations” and how they can often be difficult to address
Situation Ethics – Case One
A fifteen year old patient, cheerleader at her school, presents with an obvious chlamydial conjunctivitis (Effects, at a minimum, 4% of all females 14‐19 y/o. Gottlieb – Pediatrics 12/2009). Are you obligated to inform the minor’s parents of this diagnosis and are you required to report this STD to the health department?
The Legal Ins and Outs
In Texas, a minor may consent to treatment of STDs by a physician without parental consent. The attending physician has the authority to decide if the parents have rights to the medical records. (Texas Family Code Title2; Subtitle A; Chapter 32; Subchapter A; Sec. 32.003). The question is does this apply to an optometrist?
In Texas, the attending health care provider is required to report the diagnosis of all STDs to the Texas Department of State Health Services (www.dshs.state.tx.us). This DOES apply to an optometrist. NOTE: It is widely believed that STDs are significantly under reported!
The Ethical Dilemma
FACT: Treatment and education are essential
Can you just call it an infection and let it go at that?
Can you say you’re not sure of a positive diagnosis and just treat as an infection of “unknown or non‐confirmed etiology”?
How do you discuss the situation with the minor in private?
Can you just refer the condition out to someone else?
Is it better to not report and break the law or report and potentially cause real problems for your patient?
So Who Can Get Me?
 The Texas Optometry Board
 The Texas Department of State Health Services
 The minor (the consent issue could be problematic and make it necessary to refer a minor wanting to consent to treatment to a physician as defined by Texas law)
 Yourself – remember your Oath?
“I WILL advise my patients fully and honestly of all which may serve to restore, maintain or enhance their vision and general health.”
Situation Ethics – Case Two
One of your highly valued employees is pregnant. She is conducting herself in a manner you feel is detrimental to her health and the baby’s health – smoking, gaining too much weight, drinking heavily on the weekends. What would you do?
The Legal Ins and Outs
There is no legal requirement or authority on your part. The controlling Texas case on this subject is Collins vs TX, (TX Court of Appeals, 1994). Legally, there must be clear and convincing evidence of mental illness or intent to harm before a woman may be committed to care against her will (FYI – Collins was using cocaine during her pregnancy)
Firing the employee is very complicated. Texas is an employment at will state but this means little when it come to protected classes like pregnant employees. If the employee pushed for wrongful termination, the suit would be long, painful, expensive and with potential for significant penalty to the employer from an unpredictable jury.
The Ethical Dilemma
Do you have rights as an employer to protect your practice and your employee by counseling the employee on her actions in general and how they may effect her work performance (smoking, drinking, obesity)?
More importantly, do you have a duty as an individual, friend, counselor or humanitarian to discuss the situation with the woman?
So Who Can Get Me?
Your employee ‐ Equal Employment Opportunity Commission and hungry legal counsel will be happy to assist with wrongful termination, gender discrimination, pregnancy discrimination (Pregnancy Discrimination Act of 2014)
Yourself – your duty of care obligations as a health care provider and humanitarian Situation Ethics – Case Three
A parent brings a child in for an examination. The parent is obviously intoxicated and in no condition to drive. What should you do?
The Legal Ins and Outs
In Texas, this is a no‐brainer. See Texas Child Endangerment – Drunk Driving Protection Act. The Act provides a separate mechanism for charging and punishing a person who drives while impaired with a passenger under the age of 15. The statute’s penalties are more severe than Texas’ traditional DWI penalties. The Ethical Dilemma
Should you consider the significantly damaging effects conviction of the parent would bring?
Would providing transportation or a taxi home remove your obligations to report?
Should you consider the mental trauma the child will go through seeing their parent taken away in cuffs?
How can you be sure the parent meets the definition of legally intoxicated?
So Who Can Get Me?
The courts. Failure to report carries potential jail time of 30 days to 5 years and fines ranging from $300 to $10,000, or both.
The parent – if your assumptions are wrong!
Yourself – could you live with injury to a child that could have been avoided if you would have reported the potentially dangerous situation?
Situation Ethics – Case Four
One of your employees is strongly suspected of stealing from one or more of your other employees. You feel the only way to get to the bottom of this is make the suspect take a polygraph test. What can/should you do?
The Legal Ins and Outs
The Employee Polygraph Protection Act of 1988 prohibits employers from “requiring, requesting, suggesting or causing” an employee to take a polygraph test – with exceptions. One of the exceptions is investigation of a crime in your business. There are requirements and regulations involved in these exceptions, a lot of them.
You cannot take any action against an employee for refusal to take a polygraph test
The Ethical Dilemma
How sure are you? If you are that sure, would it be better to find other ways to terminate the employee?
Can you threaten to polygraph everyone in hope the perpetrator will confess or run? (remember – illegal to “suggest” the polygraph!)
Provide extra security for your employee’s personal items – like individual lockers http://www.lockers.com/products/extra‐wide‐standard‐metal‐locker‐double‐
tier‐3‐wide‐6‐feet‐high‐15‐inches‐deep
So Who Can Get Me?
The “suspect” – if you try to push illegal polygraph testing
The “suspect” – if you take actions related to their employment that you cannot prove
Your other employees – unlikely legal action but you have an obligation to protect them
Situation Ethics – Case Five
Your associate is making false claims to Medicare by up‐coding office visits and performing medically unnecessary tests. What should/can you do?
The Legal Ins and Outs
The False Claims Act (FCA) allows for treble damages (damages being the fraudulent claim amount) PLUS $11,000.00 fine PER CLAIM Fraud is no longer just criminal activity – FCA states that providers “should know” what is medically necessary and should know all billing, coding and reimbursement laws and regulations. Not knowing can now be considered synonymous with fraud.
The False Claims Act specifically states providers are obligated to self report erroneous billing practices, especially fraudulent activity – even if discovered during a self‐audit (new annual Federal requirement for MC/MD providers)
The Ethical Dilemma
“Self reporting” means you will, at a minimum, pay back the fraud or abuse claims. If the violation is excessive, the addition per claim fine is possible if not likely. This can also easily open the door for a full audit as well as reporting you to all other Federal agencies for potential investigation (all other payers, IRS, DEA, EEOC…you name it, it is “tattle time” in Washington)
These actions can obviously have significant financial impact on you, your practice and the livelihood of your employees.
So Who Can Get Me
EVERYONE – CMS to start with then the potential reverse funnel to all other payers, IRS, DEA, EEOC. These actions by the Feds are unlikely if you fess up. BUT THE POTENTIAL RAMIFICATIONS OF NON‐DISCLOSURE ARE SEVERE IF NOT FINANICALLY FATAL
Situation Ethics – Case Six
A patient comes in at 5:00 on Friday with symptoms of flashing lights for the last day. You have plans for the evening, the symptoms do not sound very severe so you conduct a decent but not dilated retinal evaluation using your OptoMap but find nothing. You tell the patient to return in a month. Two weeks later you see them at the mall and they tell you they just had retinal detachment surgery. What would you do?
The Legal Ins and Outs
Dilated retinal evaluations, especially with symptoms of potential retinal disease present, is a standard of care issue no matter what time of day (See AAO Preferred Practice Pattern “Posterior Vitreous Detachment, Retinal Breaks and Lattice Degeneration” and AOA Optometric Clinical Practice Guideline “Retinal Detachment and Related Peripheral Vitreoretinal Disease”)
OptoMaps are wonderful but are not a legal substitute for a dilated retinal evaluation (Texas Optometry Board Rule 279.3 (a)(1)(B)
The Ethical Dilemma
Whether the patient actually had a retinal break at the time you evaluated them or not, your care was sub‐standard. The only issue remaining is patient management. Suggestions include:
Do not deny or admit to anything
Show great concern and compassion
Isolate but do not alter the medical record in any way
So Who Can Get Me
The patient – this would be a clear case of negligent care. No one could prove there was a retinal break when you examined the patient but they can easily prove you did not follow standard of care
Yourself – remember the Oath?
With full deliberation I freely and solemnly pledge that: I will practice the art and science of optometry faithfully and conscientiously, and to the fullest scope of my competence…
I WILL strive continuously to broaden my knowledge and skills so that my patients may benefit from all new and efficacious means to enhance the care of human vision
Situation Ethics – Case Seven
You diagnose a new patient as a significant glaucoma suspect and suggest additional testing. Your patient refuses to proceed with anything their vision insurance doesn’t cover and will not give you any medical insurance information. What would you do?
The Legal Ins and Outs
“Informed Consent” is the responsibility of the doctor. “Informed refusal” is the right of the patient. Doctors are very unlikely to be held responsible for the medical consequences of informed refusal if the standards for informed consent are met
Sec. 351.360. PROFESSIONAL STANDARD OF THERAPEUTIC OPTOMETRIST.
A therapeutic optometrist, including an optometric glaucoma specialist, is subject to the same standard of professional care and judgment as a person practicing as an ophthalmologist under Subtitle B.
The Ethical Dilemma
There really isn’t one. You have three choices:
Provide comprehensive, documented informed consent – this must include documentation of the risks and potential complications of non‐compliance. Continue to follow up with the patient with your best medical recommendations. ATTEMPT TO PIN DOWN WHY YOU HAVE A CARE REFUSAL ISSUE AND SOLVE THAT PROBLEM
Give the patient the option of seeing another eye care provider
“Divorce” the patient – let’s talk about that concept
So Who Can Get Me
With proper informed consent, no one. Anyone can attempt to sue you for anything but proper documentation usually prevails. This applies to this patient, the abusive contact lens patient, the patient who won’t take their medication and the like.
Situation Ethics – Case Eight
You are fairly certain you have the flu and are running a fever. You also have a full schedule and are behind on your lab bills. What would you do?
The Legal Ins and Outs
Texas Optometry Act 351.454(a) ‐ “An optometrist or therapeutic optometrist may not practice optometry or therapeutic optometry while knowingly suffering from a contagious or infectious disease, as defined by the Texas Department of Health, if the disease is one that could reasonably be transmitted in the normal performance of optometry or therapeutic optometry.”
OSHA/CDC regulations prohibit health care workers with known contagious disease from treating patients if there is likelihood of disease transmission
The Ethical Dilemma
The responsibility of the world on your shoulders – practice bills to pay, staff members rely on you for income, new house needs new furniture
Do you really have a contagious disease? Are you just convincing yourself it’s just s sinus infection? So Who Can Get Me
Honestly, more people than you think. A patient or employee COULD file a complaint against you with CDC or OSHJA – both really bad things
And remember show and tell?
This is not to be fooled with. If you have a contagious disease that could be communicated to another person through the normal activity of your business, stay home till you are well
Thank you for your attention and have a great 2015
[email protected]
www.tob.state.tx.us