# Optical Forums > Canadian Discussion Forum >  The end of "refracting-MD's?"

## Oedema

For some time now, I've been aware the phenomenon of "refracting-MD's," physcians trained in areas outside ophthalmology but basically practicing some form of optometry, and I've wondered both here and in my mind how they are legally and ethically permitted to practice in this capacity.

At least in Ontario, the registration of each physician contains the "Dr. X may practise only in the areas of medicine in which Dr. X's educated and experienced" condition on their licence.  Comprehensive eye care is typically an area that that physicians are not educated in unless they complete an ophthal residency.  While physicians are usually thought of as having an unlimited medical licsence, there are legal, ethical and practical limits to what each doctor does in their practice. 

Now, after a google search on the term "refracting-MD, I found this "refracting-MD" and  this from the CPSO:



> Current Referral Details:                                                                                   Allegations of Dr. Franklin's professional misconduct and incompetence have
>             been referred to the Discipline Committee of the College.  It is alleged that
>             Dr. Franklin failed to meet the standard of the profession and is incompetent
>             in his practice in performing eye examinations in the care of 28 patients.



Thoughts?

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## chip anderson

Should have left him in, too many OMD's think they are no longer required to refract.  Nice to think some MD's would be left that do.

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## Excalibur

> Should have left him in, too many OMD's think they are no longer required to refract.  Nice to think some MD's would be left that do.


in Canada, there are only approx 15 residency positions/per year in ophthalmology. Most OMDs often shy away from general ophthalmology practice and seek sub-specialty training and practice-- glaucoma, neuro-ophthalmology, cornea, medical or surgical retina etc etc. 

This has left primary eye care largely in the hands of optometrists, and in a very minor way family docs.

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## mike.elmes

What about the General Practitioner MD's that are refracting in Ontario...how do they get to do that? Do they take a refracting course?

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## Golfnorth

> What about the General Practitioner MD's that are refracting in Ontario...how do they get to do that? Do they take a refracting course?


Yes they take a refracting course. I believe that there's a grey area in the regulations that GP's are able to take advantage of.

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## Oedema

> Yes they take a refracting course. I believe that there's a grey area in the regulations that GP's are able to take advantage of.


Do you know what organization facilitates the course?  Do they attend any other courses on eyecare or just refraction?

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## Golfnorth

> Do you know what organization facilitates the course?  Do they attend any other courses on eyecare or just refraction?


Sorry Oedema I don't know any particulars.....just know that it must exist.

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## Oedema

http://www.cpso.on.ca/Doctor_Search/...14&iCPSO=23701



> On July 19, 2007, the Discipline Committee found Dr. Franklin to have committed
> an act of professional misconduct in that he failed to meet the standard of the
> profession.
> 
> Penalty hearing dates: October 10-11, 2007.

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## Golfnorth

> http://www.cpso.on.ca/Doctor_Search/...14&iCPSO=23701


I beleive in Dr. Franklin's case he was using only an autorefractor and not a phoropter to test eyes. At least that was what was told to me a few years back by a collegue. It may have nothing to do with the fact that he is an MD who refracts....just the fact that he was proved to have given poor care.

Regards,
Golfnorth

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## Oedema

Correct, the issue facing Dr. Franklin is failure to comply with standards of the profession while caring for his patients.  Whether he failed to do subjective refractions or tonometry or somthing else...  I guess we'll find out when the college posts it summary online.  My concern was never with the fact that this MD, and others, were doing refractions, but whether their exams comply with the minimum standard of care as established by ophthalmologists and optometrists.

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## chip anderson

Odd when so many opthalmologist seem to think that refraction isn't part of an eye exam any more.  So unless he made separate charges for refraction, he should be O.K.

Chip

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## orangezero

Trivia.... What year did medicare decide refraction was a non-covered service?

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## chip anderson

Question:  Just because Medicare doesn't compensate for this.  Why should it no longer be included as part of a routine eye exam for non-medicare patients?   After all it's why the patient came to see you.
Unless the patient has been informed of some potential danger, family history or such.  He goes to see the eye doctor to have his eyeglass prescription checked, period.  The fact that the eye doctor is smarter than this and checks for physiological conditions is a good thing but it's not what motivated the patient.

Chip :Rolleyes:

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## tmorse

> I beleive in Dr. Franklin's case he was using only an autorefractor and not a phoropter to test eyes. At least that was what was told to me a few years back by a collegue. It may have nothing to do with the fact that he is an MD who refracts....just the fact that he was proved to have given poor care.
> 
> Regards,
> Golfnorth


This MD has a month to appeal, so I'll wait for a summary too. But when I was in retail, the majority of Rx redo's came from the OMD rather than the Optometrists. I wonder if anyone knows just how much actual refraction training OMD eye specialist surgeons receive?

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## itek2od

> This MD has a month to appeal, so I'll wait for a summary too. But when I was in retail, the majority of Rx redo's came from the OMD rather than the Optometrists. I wonder if anyone knows just how much actual refraction training OMD eye specialist surgeons receive?


i've worked in two large us universities with popular omd residencies for the past 10 years.

in the usa, and i guess canada too, md's spend 3 years in residency specializing in the ophthalmology. the residents get lectures on refraction from attending omd's and OD's on staff. i'm sure they get tested on it every year in the (sp?) OPAK exams. However, the residents are also learning about diagnosing red eyes, treating systemic disease influences on the eye,  microsurgery, etc.  IMHO i'd say they spend <15% of their learning time on the trials and tribulations of refraction. By the time most of the patients get to an OMD, ideally, their refraction is not the problem. the onus is put on the resident to bone up on refraction and some do it better than others. if a resident is interested in becoming a retinologist, their focus isn't on refraction. if the the resident in aiming for cornea/refractive surgery/peds, refraction becomes a bigger part of their concentration, esp retinoscopy for peds OMD's.
so in short, it really depends on the resident's gumption for refraction, their specialty, and how many good lectures they received on refraction during their residency. 

 :Nerd:

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## MarcE

> so in short, it really depends on the resident's gumption for refraction, their specialty, and how many good lectures they received on refraction during their residency.


My experience is that it depends on if they have any vested interest in the refraction, i.e. do they dispense?  A non-dispensing OMD or OD doesn't have to pay for the remake, so they don't focus on or excel in refractions.  Also, if they don't dispense, they are probabaly seeing 40-60 pts/day.  No time to check the autorefractor in that practice.
It isn't very nice to say, I know.  But it's my experience and the experience on many others on this board, I'm sure.

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## AdmiralKnight

> Comprehensive eye care is typically an area that that physicians are not educated in unless they complete an ophthal residency.


I think that's the point right there. Refracting MD's don't give a comprehensive eye exam. You go in, you get our RX, you leave. I also think that's where they can get away with it too. Most people don't know what's involved when it comes to a full exam, but when it comes to laws, it's up to the consumer to know what they're getting.

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## tmorse

> i've worked in two large us universities with popular omd residencies for the past 10 years.
> 
> in the usa, and i guess canada too, md's spend 3 years in residency specializing in the ophthalmology. the residents get lectures on refraction from attending omd's and OD's on staff. i'm sure they get tested on it every year in the (sp?) OPAK exams. However, the residents are also learning about diagnosing red eyes, treating systemic disease influences on the eye, microsurgery, etc. IMHO i'd say they spend <15% of their learning time on the trials and tribulations of refraction. By the time most of the patients get to an OMD, ideally, their refraction is not the problem. the onus is put on the resident to bone up on refraction and some do it better than others. if a resident is interested in becoming a retinologist, their focus isn't on refraction. if the the resident in aiming for cornea/refractive surgery/peds, refraction becomes a bigger part of their concentration, esp retinoscopy for peds OMD's.
> so in short, it really depends on the resident's gumption for refraction, their specialty, and how many good lectures they received on refraction during their residency.


MANY THANKS FOR THE UPDATE. :cheers:

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## Scandiamed

> For some time now, I've been aware the phenomenon of "refracting-MD's," physcians trained in areas outside ophthalmology but basically practicing some form of optometry, and I've wondered both here and in my mind how they are legally and ethically permitted to practice in this capacity.
> 
> At least in Ontario, the registration of each physician contains the "Dr. X may practise only in the areas of medicine in which Dr. X's educated and experienced" condition on their licence. Comprehensive eye care is typically an area that that physicians are not educated in unless they complete an ophthal residency. While physicians are usually thought of as having an unlimited medical licsence, there are legal, ethical and practical limits to what each doctor does in their practice. 
> 
> Now, after a google search on the term "refracting-MD, I found this "refracting-MD" and this from the CPSO:
> 
> 
> Thoughts?


Dear OEDEMA,

Found this interesting site by accident.

See CPSO revised charges : out went " Incomp". Problem was charges of insufficient charting of NEGATIVE findings in 26 pts. Am in good company with Toronto Leading Neuro-ophthalmologist who was fined $100,000 ,by our now defunct Medical Review Committee , which decided her notes were incomplete. Still after 35 y. of OHIP there is NO TEMPLATE. (Just like handing out parking tickets, an easy way of making money.) NO PATIENT WAS INJURED. NO DIAGNOSIS WAS MISSED. Problem was with one lady who was referred to OPHTHALMO.(FREE under OHIP) because of symptoms she said were Meniere's but went to Optom who charged her $40 for changing Reading Rx by -0.25 & suggested she complain about me to our College. Other was SECOND OPINION from pt with early cataract, who had seen local Optom., & who I referred to Teaching hosp (where she was going for N/Surgical opinion re post car accident) for Stratus OCT (NOT COVERED by OHIP) in the EYE DEPT. She objected to having paid me $60 as she said I did not improve on the OPTOM's Rx.

BTW was first in Ont. in late 1970s to use HUMPHREY AUTO-REFRACTOR + trial lenses + auto-lensometer (with UV detection) + Mentor Biomicroscope + Humphrey Visual field. Difference of opinion with Ophthalmo. peer reviewer as to use of TONOPEN with mini-latex condom on SCLERA avoiding X-infection, local anaesthetic(according to ALLERGAN unknown danger to foetus), & CORNEAL DAMAGE. (Now DIATON through-the-lid-tonometry approved by USA F & D. & on sale in Canada for $2,800. See Google DIATON).Also Retinal camera will make handwritten diagrams obsolete.

MAIN POINT: 30 years REFRACTION with NO MISSED DIAGNOSES and NO MEDICO-LEGAL CASES.

President BUSH's excellent decision on electronic records will no doubt be copied by Canuck authorities and so solve the Chart problem for ever.

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## Oedema

Scandimed,

could you please edit your post so it is a little clearer as to what you're trying to say?  Are you saying that you are a physician?

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## Scandiamed

Am MD with 20y+ experience in GP + UK Dip. Musculoskeletal diseases (incl. Rheumatoid dis & eye involvement) + U.Tor Dips. in Public Health & Industrial Health.

Peer Assessor Kitchener Ophth. Dr. KISKIS wanted more negative findings in chart + wanted IOP readings on ALL pts over 40 y unless they object.
Not in Official Guidelines. Disliked scleral tonometry. with Tonopen. (Avoids use of Local anaesthetic) LA Ophtho.Dr.WALLACE, inventor of TONOPEN has patent for new Tonopen to read IOP from scleral readings.(Coming to market in a few years according to personal communication with Dr.Wallace)

Use Advanced Humphrey-Zeiss autorefractor with glare/low contrast testing + RAYNER lenses+Plus German OCULUS cleanable Trial Frame.

Worked mainly in places where there was shortage of refractors. Not in Centre of Urban Cities.

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## HarryChiling

In my experiences around the Baltimore, MD area.  Most of the larger OMD practices have OMP doing the refraction as well as just about everything else. (checking angles, applying drops, tonometry, visal fields, retinal photos, biometry, and surgical assisting).  These OMP are often involved with the bulk of the exam with the doctor lookign over the resutls to various tests and diagnosing.  At most the OMD may check the refraction.

We often see from certain offices axis readings n 5o increments even in patients with large amounts of cylinder, after seeing many Rx's from certain offices you get a feel for who's refining the Rx's and who's not.

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## Scandiamed

Who are OMPs.

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## chip anderson

Why Ophthalmic Medical Practioners Or perhaps Ophthalmic Medical Police?

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## Oedema

> Peer Assessor Kitchener Ophth. Dr. KISKIS wanted more negative findings in chart + wanted IOP readings on ALL pts over 40 y unless they object.
> Not in Official Guidelines. Disliked scleral tonometry. with Tonopen. (Avoids use of Local anaesthetic) LA Ophtho.Dr.WALLACE, inventor of TONOPEN has patent for new Tonopen to read IOP from scleral readings.


What's the rationale for scleral Tonopen?  Numerous papers completely dismiss the reliability and clinical usefulness of scleral readings using the original tonopen.  If you're concerned about risk to fetus from the anesthetic then consider digital punctal occlusion for 3minutes.

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## HarryChiling

> Who are OMPs.


Ophthalmic Medical Personel (www.jcahpo.org)

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## Scandiamed

Recent paper by U.Toronto Eye researcher showed that many Hospital GOLDMANN tonos were not calibrated for years and certainly not sterilized between patients as per Ont. Gov. Regs. DISPOSABLE tips available but rarely used in Toronto.

Tonopen with Latex mini-condom avoids X-infection + scleral tonometry avoids any damage to cornea. Divide scleral readings by 2. Original tonometry was scleral by Dr.DONDERS. Have not missed Glaucoma in 50,000 pts.over 25y. 

After 50y., movement away from Goldmann to newer Tonometers. iCARE an example. Also through-the-lid DIATON tonometer USA approved @ $2,500. PROVIEW though-the-lid @ $100 useful for follow-up. China buying lots. Inventor Dr.B.FRESCO MSc OD FAAO in Toronto.

Single IOP as valuable as non-fasting Blood sugar. Suggest Tonometry OK for follow-up but nowadays non-mydriatic fundus camera + Fast Vis. Field + OCT + HR3 gives precise diagnosis + hard copy.. Note Bascom Palmer charges $1,500 PER EYE for technical assessment.

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## Oedema

The new developments in tonometry technology are wonderful, but tonopen is still an instrument intended for use on the central cornea.  Any peer reviewed literature supporting your protocol for scleral tonopen (ie. reading divided by 2)?

As for concerns over sterilization of goldmann tonometer tips, thats an easy one to deal with in your own practice...just sterilize it between patients.

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## Scandiamed

As previously posted new patent awarded to LA OMD WALLACE for TONOPEN modified for scleral reading. Should be on sale in a few years. Compare scleral/corneal figues for yourself. 

Repeat through-the-lid DIATON approved by USA govt.; on sale in Can. & USA.

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## Oedema

> As previously posted new patent awarded to LA OMD WALLACE for TONOPEN modified for scleral reading. Should be on sale in a few years. Compare scleral/corneal figues for yourself. 
> 
> Repeat through-the-lid DIATON approved by USA govt.; on sale in Can. & USA.


That's great that new tonometers will soon be available.... But where does the protocol for doing scleral tonometry *with a tonopen* and dividing the measurement by 2 come from?

Pardon, my skeptism, but it just seems highly speculative given that we don't even really know how much to adjust IOP measurements based on Pachymetry  of the central  cornea.

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## Scandiamed

New tonometers DIATON & PROVIEW are NOW on sale.(see Google)

Maths. of through-the-lid scleral tonometry using DIATON on its web site.

Agree about thickness cornea; thats why IOP not State of Art basis of DIAGNOSIS. OK for simple screening if more advanced instruments are too expensive for a community OD/MD. Better than nothing. OK for follow-up if same machine used @ same time of day.

Situation similar to cardiology before invention echocardiogram/ Doppler/ CAT/MRI with mercury BP + stethoscope, 

Ant & post.OCT/HRT3/fundus camera gives precision instead of subjective impression and multiple variable factors affecting IOP. Technical revolution.

There were papers on Scleral tonometry in the 1950s; but like battery engines vs gasoline, the GOLDMANN took the lead. Also like battery engines, scleral tonometry is now returning (DIATON) because patients like it and its safe (no xinf./no corneal damage/no allergic reaction). Patients are usually not read the ALCAINE warnings.

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## Scandiamed

*Comparison of the Diaton Transpalpebral Tonometer Versus Goldmann Applanation*
_R. S. Davidson 1; N. Faberowski2 ; R. J. Noecker3 ; M. Y. Kahook1_
1. Ophthalmology, Rocky Mountain Lions Eye Institute, Aurora, CO, USA. 
2. Ophthalmology, Denver Health Medical Center, Denver, CO, USA.
3. Ophthalmology, UPMC, Pittsburgh, PA, USA.

*Financial Disclosure*
The authors have no financial interest in the subject matter being presented 
*Background*
Diaton tonometry is a unique approach to measuring intraocular pressure (IOP) through the Eyelid. It is a non-contact (no contact with cornea), pen like, hand-held, portable tonometer. It requires no anesthesia or sterilization. 
*Purpose*
To investigate the agreement in the measurement of intraocular pressure (IOP) obtained by transpalpebral tonometry using the Diaton tonometer versus Goldmann applanation in adult patients presenting for routine eye exams. 
*Methods*
Retrospective chart review of consecutive IOP measurements performed on 64 eyes of 32 patients age 34-91 years with both the Diaton tonometer and Goldmann applanation. Results between groups were examined using analysis of variance (ANOVA) where appropriate. 
*Results*
Mean IOP was 15.09 +/-4.31 mm Hg in the Goldmann group and 15.70 +/-4.33 mm Hg in the Diaton group (p=0.43).
Mean IOP variation between groups was 1.74 +/-1.42 mm Hg (range 0-8). 83% of all measurements were within 2 mm Hg of each other. 
*Conclusions*
The transpalpebral method of measuring IOP with the Diaton tonometer correlates well with Goldmann applanation. Diaton applanation may be a clinically useful device for measuring IOP in routine eye exams.
For full details please visit:





*Comparison of the Diaton Transpalpebral Tonometer Versus Tono-Pen Applanation*
Theodore H. Curtis, M.D.1, Douglas L Mackenzie, M.D.1, Robert J. Noecker M.D.2, and Malik Y. Kahook M.D.1
1The Rocky Mountain Lions Eye Institute, University of Colorado Health Sciences Center, Aurora, CO
2Eye and Ear Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
*Financial Disclosures*
None of the authors have financial interests relevant to the subject discussed.
Purpose
To compare intraocular pressure (IOP) measurements obtained with Diaton trans-palpebral tonometry versus Tonopen applanation tonometry in children and adults. 
*Introduction*

Goldmann applanation is the gold standard for IOP measurement 
It has been supplanted by TonoPen applanation in many settings because of it's ease of use, portability, convenience, and minimal training requirements. 
The TonoPen requires contact with the corneal surface, and has the risks of iatrogenic corneal injury, spread of pathogens, and requires topical anesthetics. 
*Introduction*

The newly-developed Diaton tonometer is a handheld device that measures pressure through the tarsal plate (Figures 1 & 2). 
It avoids contact with the cornea and the need for topical anesthesia. 

Figure 1: The Diaton Transpalpebral Tonometer
Figure 2: Using the Diaton Tonometer 
*Methods*

We looked at 74 eyes of 38 consecutive patients who received both Tonopen and Diaton tonometry 
TonoPen measurements were taken in the sitting position following topical anesthesia with proparicaine. 
Diaton measurements were performed in the sitting position with the patient gazing at a 45? angle, placing the eyelid margin at the superior limbus. If necessary, gentle traction was placed on the brow to align the lid with the limbus. The device was activated when the signaling mechanism indicated the device was vertical. 
*Results*

Age range 3-91 years of age (mean 47.5 years). 
The average IOP with the Diaton was 16.24 (+/-5.11 mm Hg; range = 7-32 mmHg). 
The average IOP with the TonoPen was 16.37 (+/-4.90 mm Hg; range = 8-33 mmHg). 
The mean variation between the two modalities was 1.59 mmHg (+/-1.31 mm Hg; range = 0-6 mmHg). 
Eighty-one percent of all measurements were within 2 mmHg of each other (Table 1). 
There was no statistically significant difference in mean IOP values obtained with the two devices (p=0.87). Table 
*Conclusions*

The Diaton tonometer pressure measurements correlated well with TonoPen measurements in this retrospective review. 
We did not find problems performing the exam in children, and many were reassured by the fact that no drops were needed. 
There may be a notable benefit in patients after refractive surgery or with corneal pathology since the Diaton does not applanate the cornea. 
The Diaton tonometer appears to be a clinically useful device in the IOP measurement of both children and adults. 
*References*

Li J, Herndon LW, Asrani SG, Stinnett S, Allingham RR. Clinical comparison of the Proview eye pressure monitor with the goldmann applanation tonometer and the TonoPen. Arch Opthalmol 2004;122:1117-21. 
Eisenberg DL, Sherman BG, McKeown CA, Schuman JS. Tonometry in adults and children: a manometric evaluation of pneumotonometry, applanation, and TonoPen in vitro and in vivo. Ophthalmology 1998;105:1173-81. 
Diaton: digital portable tonometer of intraocular pressure through the eyelid. Operation Manual. Ryazan State Instrument Making Enterprise. Ryazan, Russia. 
Garcia Resua C, Giraldez Fernandez MJ, Cervino Exposito A, Gonzalez Perez J, Yebra-Pimentel E. Clinical evaluation of the new TGDc-01 "PRA" palpebral tonometer: comparison with contact and non-contact tonometry. Optom Vis Sci 2005;82:143-50. 
Troost A, Yun SH, Specht K, Krummenauer F, Schwenn. Transpalpebral tonometry: reliability and comparison with Goldmann applanation tonometry and palpation in healthy volunteers. Br J Ophthalmol 2005;89:280-3. 
Losch A, Scheuerle A, Rupp V, Auffarth G, Becker M. Transpalpebral measurement of intraocular pressure using the TGDc-01 tonometer versus standard Goldmann applanation tonometry. Graefes Arch Clin Exp Opthhalmol. 2005;243:313-6.
For full details please visit:

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## NorthStar

http://www.cpso.on.ca/Info_Public/Di...g.htm#FRANKLIN

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## Oedema

> http://www.cpso.on.ca/Info_Public/Di...g.htm#FRANKLIN


  Truly scarey reading.  Absolutely unbelievable.

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## Dave Nelson

> Trivia.... What year did medicare decide refraction was a non-covered service?


I wasn't aware it was no longer covered. My understanding was that all Provinces dropped refraction as a cost-saving measure, since it seems to be universally accepted that refraction is not medically essential in the non-symptomatic patient, ie, routine eye exam. Provinces, I thought, are still free to re-instate refraction as a covered service, but then they would have to drop something else. 
As to MDs refracting, here in B.C. a GP asked the College of Physicians and Surgeons if he could refract some years back. They said he could, if he received proper training and endorsement from an ophthalmologist, which he did. In terms of eye examinations, in simplistic terms, GPs function bascically the same with eyes as they do with other organs: they do not need to recognize 300,000 eye diseases and disorders, they only need to differentiate a healthy eye from an unhealthy eye, then make the referral if indicated.

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## chip anderson

Dave:  

Same with us contact lens tech, optician types.  We just have to recognise the un-healthy from the healthy and refer.  I don't have to know what type ulcer, what treatment is indicated, etc.  Just be able to tell this needs some one smarter than I working on it.

Chip

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## optical maven

MD's in Ontario are allowed to perform any medical function without training beyond their MD license.  This includes any surgery or any other controlled act other than scaling teeth.  Without further training, they are allowed to do cosmetic/plastic surgery, eye exams or dispense glasses.  In practical terms however the CPSO would not be happy if a GP did kidney transplants.  On the other hand, look at the recent controversy with people dying following liposuction from family physicians doing the procedure.  In Franklin's case he was only refracting eyes.  He neglected to perform a glaucoma test, or any other function beyond autorefraction.   I once saw a young girl with a macular hole, corrected acuity of 20/100 in the eye, with a clear health acocunt from a refracting MD.  That's why autorefraction is only part of a complete eye examination.

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## Oedema

> I wasn't aware it was no longer covered. My understanding was that all Provinces dropped refraction as a cost-saving measure, since it seems to be universally accepted that refraction is not medically essential in the non-symptomatic patient, ie, routine eye exam. Provinces, I thought, are still free to re-instate refraction as a covered service, but then they would have to drop something else. 
> As to MDs refracting, here in B.C. a GP asked the College of Physicians and Surgeons if he could refract some years back. They said he could, if he received proper training and endorsement from an ophthalmologist, which he did. In terms of eye examinations, in simplistic terms, GPs function bascically the same with eyes as they do with other organs: they do not need to recognize 300,000 eye diseases and disorders, they only need to differentiate a healthy eye from an unhealthy eye, then make the referral if indicated.


He's asking about Medicare in the USA (a la "free" medical insurance for those over the age of 65).  Currently Medicare will pay for seniors eye exams but the refraction is a procedure that is not included in their billing scheme.  We don't really have anything in Canada called "medicare."

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## chip anderson

What treatment is indicated for a macular hole?   Beyond a lot of follow-up, pictures and insurance billing?

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## Ory

> What treatment is indicated for a macular hole? Beyond a lot of follow-up, pictures and insurance billing?


 I've seen macular holes go from 20/400 to 20/30 again with treatment.  It really depends on whether it is a full thickness or partial thickness hole.  There's also typically a serous detachment surrounding the hole which can be stuck back down and improve quality of vision.  

Typically a vitrectomy is performed, then they inject a gas bubble and have the patient lay face down as much as possible for a few weeks.

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## chip anderson

Thanks Ory.   Don't personally know too much about treatments for the back of the eye, despite having sat through hours of presentations and having a daughter that has had a vitrectomy.

Chip

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## LandLord

> Typically a vitrectomy is performed, then they inject a gas bubble and have the patient lay face down as much as possible for a few weeks.


and then they get a cataract!

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## Scandiamed

Eye exams included Ophthamoscopy with PANOPTIC + confirmation with expensive UK Rayner Trial lenses; (not only auto-refraction with HUMPHREY-ZEISS). SCLERAL Tonometry peformed as thought necessary. No missed case of glaucoma found by CPSO in 25 years.

Optometrist from Lindsay was hostile witness. Only after trial found out that he had sent secret complaints to CPSO. Patient of his came to me for a second opinion. No significant difference. She then demanded $60 returned; when I declined, she complained to CPSO.

Through-the-Lid DIATON scleral tonometry now received Canadian federal approval and is sold here to GPs at Primary Practice meetings.

Ontario Opticians will soon have the right to refract as in BC & Manitoba. Refraction being taught to opticians @ Georgian & Seneca colleges.

BC has a $10,000 private 6-months course for Optician licence.

GPs will refract as well as opticians and probably Nurse Practitioners. 

BTW Canada, UK & USA selling prescription single vision specs. for $30 on the web.

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## tmorse

[quote=Scandiamed;245756]

BC has a $10,000 private 6-months course for Optician licence.

quote]

This is hardly breaking-news. The BC private Opticianry course has been in operation for twenty-four (24) years. Why this post? :Confused:

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## NorthStar

"Dr. Franklin acknowledged in his evidence that he performed scleral tonometry on
patients at the relevant time. Dr. Franklin testified that he believes that scleral
pressure is approximately double corneal pressure. He made reference to the fact that
he had been told this by somebody 25 years ago. When he was specifically asked
about research studies in this regard, he replied that some people in India had
measured pressures on cadavers, but he presented no evidence in support of this."

"Dr. Franklins C.V. has been exaggerated. It indicates that he is a member of the
Glaucoma Research Society. However, he testified that there was only an invitation to an annual speakers dinner with no other involvement. He is also listed as a member of the Jung Foundation but in effect is only a donor. Dr. Franklin testified that the Glaucoma Society and Jung references should be removed from his C.V."

"Dr. Franklin was found by the Committee to lack insight and he did not always accept opinions that did not accord with his views"

"Nevertheless, the Committee is troubled by the fact that Dr. Franklin continues to express the view that scleral tonometry is acceptable notwithstanding the extensive evidence that it is not."

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## Oedema

> Eye exams included Ophthamoscopy with PANOPTIC + confirmation with expensive UK Rayner Trial lenses; (not only auto-refraction with HUMPHREY-ZEISS). SCLERAL Tonometry peformed as thought necessary. No missed case of glaucoma found by CPSO in 25 years.
> 
> Optometrist from Lindsay was hostile witness. Only after trial found out that he had sent secret complaints to CPSO. Patient of his came to me for a second opinion. No significant difference. She then demanded $60 returned; when I declined, she complained to CPSO.
> 
> Through-the-Lid DIATON scleral tonometry now received Canadian federal approval and is sold here to GPs at Primary Practice meetings.
> 
> Ontario Opticians will soon have the right to refract as in BC & Manitoba. Refraction being taught to opticians @ Georgian & Seneca colleges.
> 
> BC has a $10,000 private 6-months course for Optician licence.
> ...


The only ophthalmoscopy technique used is panoptic?  Wow! Just b/c it's new doesn't give it anymore credibility than a direct ophthalmoscope - both are pretty useless and I only reserve them for squirmy children that don't sit still for BIO or too small for the slit lamp.  

 And why in the world do you remain so fixated on this scleral tonopen technique of yours?  There is absolutely no published research towards it's validity/repeatability.  If you're reasonably skilled with a Goldman there should be absolutely no risk of harm in applanation.

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## chip anderson

Actually I think scleral tonometry came about for O.D.'s back when they were not allowed to use anesthesia.  Don't think I have ever heard of an O.D. using any other form of tonometry.   I the last two decades OMD's seem to trust air puff stuff for preliminary exams.  Don't see why you  jumped on this poor GP.   
Every one has known that corneal tonography was more reliable but don't think it is used much today unless a problem is at least suspected. 
Why just think a half second of valuable "chair time"   (now much more important than a mere patient) is required for the air  puff.  Several actual minites required for a Goldman.

Chip :Rolleyes:

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## Oedema

> Actually I think scleral tonometry came about for O.D.'s back when they were not allowed to use anesthesia.  Don't think I have ever heard of an O.D. using any other form of tonometry.   I the last two decades OMD's seem to trust air puff stuff for preliminary exams.  Don't see why you  jumped on this poor GP.   
> Every one has known that corneal tonography was more reliable but don't think it is used much today unless a problem is at least suspected. 
> Why just think a half second of valuable "chair time"   (now much more important than a mere patient) is required for the air  puff.  Several actual minites required for a Goldman.
> 
> Chip


Think about it for a moment Chip, NCT at least has published literature to support it's use for screening, and it can very well be accurate enough for screening.  If it reveals a possible problem then go ahead and recheck with goldman.  Personally I'd rather save my money and just use goldman.

What I'm wondering is how this GP could think scleral tonometry with a tonopen is even remotely acceptable when there is no published research to support it's use in that situation.  Now consider this; the MD's scleral technique involved performing tonopen on the sclera and then dividing the reading by 2.  Where in the world did that ever come from?  How is it even reasonable when the nonogram for adjusting IOP based on *corneal thickness* is bunk?  I wonder, did he even get a 5% confidence using tonopen on the sclera?

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## rbaker

As I recall, tonometry is a screening tool. If you really want to evaluate the inflow/outflow you will perform tonography. Do you hold the position that scleral applination will work in this case.

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## Oedema

> As I recall, tonometry is a screening tool. If you really want to evaluate the inflow/outflow you will perform tonography. Do you hold the position that scleral applination will work in this case.


Clinically, no one does tonography.  Applanation tonometry is good enough for clinical management of glaucoma (it's the standard of care!) and monitoring other conditions.  It's not really necessary to know the exact fluid mechanics of an individual patients aqueous production and outflow - if that's an important consideration such as angle recession glaucoma then we already know that outflow is not likely respond well to topical therapy and we can approach it from the production side. 

Tonography can however have various uses in research.

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## NorthStar

http://www.ibegin.com/users/Scandiamed

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## optical maven

Franklin was doing Schiotz tonometry, which is antiquated and invalid.  Do you really think these guys work inside an optical store, disregard their medical training, and then use the cutting edge in technology?

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## NorthStar

There is a family physcian shortage, yet refracting MD's take the time to do sight testing in optical stores rather than work as a family doctor.  Must be a good reason. ($?)

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## NorthStar

Dr. Franklin testified that he used an autolensometer to assess the patients current
prescription for eyeglasses. He used an autorefractor followed by trial lenses. He
testified that he did an external eye exam followed by a retinal exam using an
ophthalmoscope with a slit lamp aperture. He performed scleral tonometry in cases
where he felt it was indicated. His practice was to chart only significant positive findings.

note: "ophthalmoscope with a slit lamp aperture" is not equivalent to actually using a slit lamp

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## optical maven

I've said before that MD's in Ontario are allowed to do any contorlled act, except scaling teeth, but including dispensing glasses.  They need no further training beyond their MD.  We have all seen the poor work these guys do.  After the controversy of cosmetic surgery, the CPSO made up new guidelines, but still did not restrict any MD, no matter their training, to perform cosmetic surgery.  The CPSO is sure not going to restrict refracting.

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## NorthStar

The CPSO doesn't hold them up to the same eye exam standards as eye doctors.  Unfortunately, the public does not know the difference, and, unless they have experienced a full eye exam, often they believe a sight test is a full eye exam.  As well, refracting MD's are often confused as optometrists.
But with the shortage of family doctors, what is the motivation for refracting MD's to work for optical stores instead of working as family physicians (what they are trained for)?

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## Oedema

> The CPSO doesn't hold them up to the same eye exam standards as eye doctors.  Unfortunately, the public does not know the difference, and, unless they have experienced a full eye exam, often they believe a sight test is a full eye exam.  As well, refracting MD's are often confused as optometrists.
> But with the shortage of family doctors, what is the motivation for refracting MD's to work for optical stores instead of working as family physicians (what they are trained for)?


Makes me wonder whether or not these refracting MD's have either residency/internship under their belts?

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## optical maven

Most are GP's and have no more training than that.  I even knew of one fellow who was an anesthetist.

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## NorthStar

Do you mean this one?:
http://www.cpso.on.ca/Doctor_Search/...09&iCPSO=56787

What is disturbing is that with all the complaints early in his career as a resident in anesthesia the CPSO determined Dr. Im was too unprofessional to practice medicine and stripped his licence of all medical priveleges except for "refractive optometry" in an optical store - if there is such a specialty.
So the CPSO deemed him not professional enough to be a medical doctor, but OK as a refracting MD.
Then in 2004 he was arrested.

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## NorthStar

From CPSO: http://www.cpso.on.ca/docsearch/deta...=4&id=%2023701
Appeal denied, but the suspension seems to have been eliminated leaving only a 1wk preceptorship and a couple of inspections. 
This case sets a precedent that refracting MD's are not subject to the same standards as eye doctors, only to the standards of a "general practioner limited to eye exams" - whatever that means.  Specifically, in the decision it was decided that a dilated fundus exam is not a standard of care required by a GP.  Essentially this sets up a lower standard of eye care permitted for refracting MD's.  
So if they miss an undiagnosed or symptomless retinal tear or disease - no liability.  How does this help protect the public?  Unfortunately, the John Q. often assumes the refracting MD is a optometrist.

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## LandLord

North Star, I know exactly how you feel.

There are receptionists, or "certified" optometry assistants who measure, fit, dispense, fill Rx's and counsel patients every day.  They provide a different level of care than opticians, and John Q often assumes the assistant is an optician.

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## NorthStar

Nobody goes blind from a seg. ht. that is 1-2mm too high, but that is for another thread.

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## Shwing

back to the original discussion (sorta), here in Alberta, the government is considering de-insuring eye exams completely.

They de-insured (this means: paid/ not for by the government) eye exams for those between the ages of 19 and 64 back in '94.  .

Anyway, the Ophthalmologists have been asking for de-insurance of eye exams for everyone all along- Why?  because none of them are General Ophthalmologists- all 100 +/- in the province are sub-specialists, and so none are refracting, so why waste tax-payer $$ paying for eye exams no-one is doing?  

Except my guy, but he's old as PMMA...
:-}

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## NorthStar

Slap on the wrist
http://www.cpso.on.ca/whatsnew/commi...t.aspx?id=1448

Another refracting MD who received his MD license in 1960 and in 2003 self-imposed a "[restriction on his practice to perform] eye refractions only."
http://www.cpso.on.ca/docsearch/deta...=5&id=%2017542

Again refracting MD's seem to be held to a lower standard of eye care by being permitted to perform refraction without obligation to perform ocular health assessment.

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## eyemanflying

> Slap on the wrist
> http://www.cpso.on.ca/whatsnew/commi...t.aspx?id=1448
> 
> Another refracting MD who received his MD license in 1960 and in 2003 self-imposed a "[restriction on his practice to perform] eye refractions only."
> http://www.cpso.on.ca/docsearch/deta...=5&id=%2017542
> 
> Again refracting MD's seem to be held to a lower standard of eye care by being permitted to perform refraction without obligation to perform ocular health assessment.


It's nice to see that all of the O's have their fair share of problems, oversights and exceptions to the rules...

1. The refracting MD's think they are Ophthalmologists and make their own sets of rules.

2. The Optometrists (most, not all) think that their assistants do not require training, certification or post education.  Straight from Harvey's grill to reception to pre-exam performing field testing, operating auto refractors and contact lens training/dispensing.   

3.  The Opticians...well, we are unfortunately fortunate enough to have Mr. Bergez.  

;)

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## NorthStar

You mean optical stores don't hire "burger-flippers" to work the dispensary or just shift a salesperson over from the shoe department?  A relative of mine worked their way through college dispensing eyewear at a prominent optical store in T.O., alone 75% of the time with only on-the-job training, to do everything from frame selection to grinding and pick ups.  It wasn't until years later when I informed them that that was illegal and they realized they could have gotten in trouble.
Anyway this is for another thread.
Eye exams that don't provide standard of care ocular health testing has the potential for harm; dispensing eyewear with uncertified personel has the potential for eyestrain.  IMO it is essential that dispensing be done by trained certified personel; if you have incompetent staff the real harm will be to your reputation and eventually your bottom line regardless if you are an optician or optometrist.  Patients may be inconvenienced and frustrated, but unlike undetected, undiagnosed eye disease, there is no permanent damage to vision.

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## eyemanflying

> 1.  IMO it is essential that dispensing be done by trained certified personel; if you have incompetent staff the real harm will be to your reputation and eventually your bottom line regardless if you are an optician or optometrist. 
> 
> 2.  Patients may be inconvenienced and frustrated, but unlike undetected, undiagnosed eye disease, there is no permanent damage to vision.


I agree with number #1.

I beg to differ with number #2.  

In most cases, #1 goes undetected.  However, suppose that patient from #1 falls down their stairs or crashes their car with their new bifocal lenses???  

Now you have a bigger, expensive problem and one that requires a lawyer.  It is also one that is fully visible to the industry, your peers and the general public.  That's alot to gamble on for saving a few bucks an hour.

Meanwhile, Betsy is gone back to flippin burgers.

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## NorthStar

#2 same thing could happen to a perfectly fitted first time bifocal wearer.
And improper fitting or bifocal height does not cause eye damage. And according to the Ontario Opticians college website there have been a number of opticals dispensing without licensed opticians over the last number of years - if there was truly damage being done there would have been a public outcry in the media.  And in the U.S., a much more litigious country than Canada, aren't there some states in which opticians are unregulated, allowing anyone to dispense? (ed: in 28 states there is opticians are unregulated - anybody can call themselves an optician and open an optical store.)
Anyway this issue probably has been extensively discussed on other threads. This thread is about the CPSO allowing a lower level of eye care to exist, similar to the scenario of plastic surgeons vs. less qualified cosmetic surgeons.

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## eyemanflying

There will always be good, bad and characters in all professions regardless of regulation.

:cheers:

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## Oedema

Check out this example of one "refracting MD's" exam findings.  I'm sure you'll agree that it's extraordinarily thorough!:drop:
http://forums.studentdoctor.net/show...=1#post8812741

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## LandLord

Question for the ODs who have worked at least 10 years. It feels like the issue of blindness being caused by non-OD refraction has been over-proselytized.

Do you know what percent of your patients have gone blind?

In what percent have you detected asymptomatic sight-threatening disease? (Not including cataracts) 

Have you missed any?

What percent would have actually gone blind if the patient had waited until symptoms arose?

What percent of the population is blind in countries where no eyecare exists?

Yes, I know there are some evil, greedy refracting MDs, OD's and RO's. 

But honestly, is non-OD refraction a REAL problem or is it just a turf war$?

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## Oedema

> Question for the ODs who have worked at least 10 years. It feels like the issue of blindness being caused by non-OD refraction has been over-proselytized.


Only in practice on my own less than a year:




> Do you know what percent of your patients have gone blind?


Zero, none.  Detected plenty with existing/recent blindness, all but one only monocular so far.  The one bilateral blindness can partially be blamed on a GP failing to refer and gettting the diagnosis WAY wrong.




> In what percent have you detected asymptomatic sight-threatening disease? (Not including cataracts)


about 15% of my patients present with some form of potentialy blinding condition (this is excluding cataracts btw... my opinion of cataracts is that they are stictly part of the refractive continuum, hearing every patients tell me they have a family history of cataracts drives me nuts).

More importantly though are the patients I've detected systemic disease in: several diabetics, hypercholestrolemia in a 22 yo, one brain tumor, carotid artery stenosis, vitamin B1/B12 deficiency, 




> Have you missed any?


None so far:cheers:
c

BTW, why would you guys even want to do refraction?  There's plenty of expertise needed in ophthalmic dispensing, we need more lens experts, not more refractionists anyways.  Which brings me to this point, if you're not prepared to handle eye health then refraction is just going to be a major PITA as you're going to waste your time going through the motions with people that just don't have the potential to see very well/or as well as they'd like.  Being able to look at the eye and find the cause saves me alot of time with the phoropter!

And for those of your who are thinking I'm practicing is some place with a special population full of eye disease ridden old foggies....  Wrong, I'm in the fittest city in canada, with some of the longest life expectancy, and still blows my mind how many weird things I see in a day, especially in relatively young patients.

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## YrahG

> And for those of your who are thinking I'm practicing is some place with a special population full of eye disease ridden old foggies.... Wrong, I'm in the fittest city in canada, with some of the longest life expectancy, and still blows my mind how many weird things I see in a day, especially in relatively young patients.


I'm thinking it, especially since your anecdotes don't come near statistical data from the National Eye Institute at the National Institutes of Health.
http://www.nei.nih.gov/eyedata/pbd_tables.asp

I have found more often than not numbers unless actually looked at seem to have a way of messing with us, I have worked with a doctor who would worry about a specific case for days upon end and not even realize that the patient they are worried about was 2-3 days ago and many exams ago.  Unless you actually have numbers showing 15% I would find that hard to believe, hey if you do you should do a research on why your neck of the woods has more disease then the rest.

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## Oedema

add up the prevalence of AMD and diabetic retinopathy and you get close to 15% without any additional conditions.

But I'm wouldn't put much confidence in that data as it seems to indicate that the prevalence of either myopia and hyperopia among seniors is only 35%??  Yes maybe only 35% of stubborn seniors wear their glasses but they ALL have it.

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## YrahG

> add up the prevalence of AMD and diabetic retinopathy and you get close to 15% without any additional conditions.
> 
> But I'm wouldn't put much confidence in that data as it seems to indicate that the prevalence of either myopia and hyperopia among seniors is only 35%?? Yes maybe only 35% of stubborn seniors wear their glasses but they ALL have it.


The percentages in this case don't add up like you suggested, the percentage are of selected groups by their ages so if you add them all up the percentages are going to average out amoung each disease group, then their is no way of showing which patients have concurrent conditions of AMD and Diabetic Retinopathy and how they would be counted in this study. 

Another note is that those under the age of 40 were not included because of insignificant data, this group is larger than the data set and would no doubt lower the percentages.

Unless your seeing nothing but 40yo+ patients 100% of the time 15% would not hold up, again if you have more recent data I am always willing and ready to read up some more on the topic since it is fascinateing.

I find that the part I admire about optometry is the amount of care that goes into the patients in a practice by those exceptional few, it is more likely that the lower percentage takes up 15+% of your empathy for the patients situation. That's something that I truly admire.

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## LandLord

Some of us who have been around a while and have worked with OD's may be more jaded but my impression of most OD's over the age 30 is that they are concerned about 2 things.  *Reduced chair time* and *increased conversion rate.*

*The ones under 30 still feel like doctors.*

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## optical maven

I have never forced any person to convert.

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## NorthStar

Dr. Franklin retired anyway.  He graduated Med School in 1959 so he was no spring chicken.
Suspension lifted in Dec. 11, 2009; failed to renew his license March 15, 2010
http://www.cpso.on.ca/docsearch/deta...=3&id=%2023701

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## Oedema

I don't think I'll ever get over how ridiculous that "Dr." Franklin is, the man's rationale for how he practiced.... SENILE?

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## NorthStar

His exaggerations on his credentials and views on IOP measurement even after the college decision (see Scandiamed's earlier posts on this thread; Scandiamed is Dr. Franklin himself) combined with complete arrogance yet all he received was basically a slap on the wrist. Perhaps because of his age the CPSO assumed he would just retire soon anyway. 

But the CPSO's attitude, as with this case and Dr. Im's, seems to allow medical doctors who are unfit to practice medicine are still OK to practice what they call "refractive optometry" (quote from the case of Dr. Im; whatever that means) in an optical store. And with Dr. Franklin's precedent-setting case, refractive MD's don't have to worry about performing a dilated fundus exam. Thus their refraction-oriented exams (or are they just sight tests?) remain quick to crank those refractions through.

Looking at a back issue of Optical Prism January 2010: Dr. Franklin MD posted a classified ad selling his Mentor Slit-lamp, Tonopen and trial lenses.

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## One science

> For some time now, I've been aware the phenomenon of "refracting-MD's," physcians trained in areas outside ophthalmology but basically practicing some form of optometry, and I've wondered both here and in my mind how they are legally and ethically permitted to practice in this capacity.
> 
> At least in Ontario, the registration of each physician contains the "Dr. X may practise only in the areas of medicine in which Dr. X's educated and experienced" condition on their licence.  Comprehensive eye care is typically an area that that physicians are not educated in unless they complete an ophthal residency.  While physicians are usually thought of as having an unlimited medical licsence, there are legal, ethical and practical limits to what each doctor does in their practice. 
> 
> Now, after a google search on the term "refracting-MD, I found this "refracting-MD" and  this from the CPSO:
> 
> 
> Thoughts?


I think this Dr. really thought that what he was doing was good or he acted this way because a big and ugly lack of professionalism. Or can he have had a too big ego? If yeah, he doesn't deserve to be called a Dr.

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## One science

I want to belive that he did all those things without being conscient of it.

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## NorthStar

http://www.thewhig.com/2015/01/14/lo...of-malpractice 

http://www.cpso.on.ca/CPSo/GetDocume...pe=PastFinding 

Dr. Roger Cyril Wales, a recent, very similar case to Dr. Franklin's.  Elderly GP doing refractions.  Fully believes that with his experience finger tonometry is accurate, his skill with an ophthalmoscope is as effective as dilated exam and his manifest refractions on kids makes cycloplegia unnecessary.
At least this time, dilated exams are deemed to be the standard even for refracting MD's, unlike the findings in the Franklin case.

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## optio

The CPSO findings seem to suggest that cyclopegia on children is standard practice.  I certainly do not cycloplege all children and I'm certain very few ODs do.  What are ODs to make of this "precedent?"

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## NorthStar

My interpretation is that these were cases that in which further testing with cycloplegia was indicated.

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## NorthStar

A case of a refracting ophthalmologist, Dr. Shin, not elderly at all, but has never had hospital privileges and at one time worked a dozen Walmarts then switched to Loblaws Superstores until his license suspension.  Criminal investigation for defrauding OHIP started in 2006, 2013 found guilty at trial (had to pay back $45K - that was only for 2006-07 billing period), CPSO response suspending his license May-Oct 2015.  That explains his preference for cash-only patients! 

http://www.cpso.on.ca/public-registe...=4&id=%2063718 

FYI this is available to the public on the CPSO website

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## Chris Ryser

Maybe this thread should closed are there is a publication ban on it. Or remove the link.

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## kcchohan2

There are no guarantees without a website, you will not  capture any of those potential patients conducting online searches for  eyecare-related products and services. To Find the best *Best Eye Care Practice in USA* you have to go for top searches in webs.

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