January 2021, Volume XXXIV, Number 10
Where Eye Care Fits In
Bridging specialty and primary care
hen I was in medical school and matched in ophthalmology, a friend who is now a urologist started referring to me as an “eye dentist”. His logic was that because my patients would not need to undress and could be examined in a chair rather than a bed, that my practice would look more like a dentist’s than a physician’s. We laughed about this at the time, but throughout my training and career I have been repeatedly surprised by how often the truth behind his joke has shown through.
As with other specialties, the clinical, surgical, and business aspects of eye care have changed dramatically in the 30 years since I matched. Cataract surgery is still the most commonly performed surgical procedure in the United States, now is usually performed in physician-owned ambulatory surgery centers rather than hospitals. The use of lasers to “cure” patients of their dependence on eyelgasses has not only been proven effective and safe, but has also moved from the fringes of the eye care community to the mainstream. And advancements in eye care have not solely been surgical. For instance, there are now dozens of well-tolerated eyedrops available for the treatment of glaucoma, while in my residency there were only two or three, and each of these had its list of troublesome side effects. Despite all the medical and surgical advancements, eye care delivery is still fundamentally a combination of preventative and specialty care, where the concept of the “eye dentist” is at the root of the question, “Where does eye care fit into a patient’s overall health care?”
Eye Care as Primary Care
I am occasionally asked whether I consider myself a specialist or primary care doctor. I answer by saying that I am a primary care doctor for my patients’ eyes. In this regard, patients do not need to be referred to see me as they do for other types of specialists. Think about it – a patient with cardiac symptoms will usually be referred by their primary care provider (PCP) to a cardiologist. Likewise, a patient with GI symptoms will usually be referred by their PCP to a gastroenterologist. Although many patients are referred to me by their PCP’s, at least as many will find me on their own through advice of a friend, relative, or a Google search, and their PCP may never know that they were seen by me. Why is this?
Ophthalmologists are not only medical and surgical specialists, but also primary care doctors for the eyes.
I believe the answer to this question has to do with why the term “eye dentist” resonates. Most Americans know to see their dentist twice a year for cleanings and to give their dentist the opportunity to look for potential problems. Most of us keep to this schedule even though we are almost always asymptomatic. We also understand that what our dentist provides us is separate from and parallel to what our medical PCP does. They both take care of the parts of us that they are responsible for, usually without communicating with one another. There is a good chance your PCP does not know who your dentist is, and your dentist does not know who your PCP is.
For many of my patients, I perform the same type of service for their eyes that their dentist does for their teeth (minus the cleaning). Patients return to me on a schedule that I deem appropriate without either of us seeking input from their PCP. I update glasses and contact lens prescriptions (similar to a hygienist’s doing a cleaning) and look for signs of eye disease (much like a dentist’s looking for cavities). I usually will not send a letter back to the PCP for this type of service, and if I did, the PCP would likely not devote a lot of time to reading it. My patients remain fully clothed and are examined in a chair instead of a bed, exactly as my urologist friend predicted.
Another parallel with the dental profession lies in our ability to help PCP’s predict systemic disease. For instance, the status of the gums and teeth can allow dentists and hygienists to give feedback to PCP’s about their shared patient’s cardiovascular status. As eye doctors, we can do something similar. When we examine the posterior segment of a patient’s eye, it is the only time that a doctor can directly view that patient’s vascular system in vivo. In this way, we can often help diagnose vascular conditions such as hypertension, atherosclerotic disease, and diabetes mellitus before they even make it onto a patient’s problem list.
Eye Care as Specialty Care
Many eye doctors spend very satisfied careers engaged in the type of practice described above – the routine care of patients without significant disease. However, we are also trained as a specialist, and spend much of our time diagnosing and treating diseases such as glaucoma, uveitis, strabismus, cataract, macular degeneration, and so on. Many patients with disease are culled from our routine patient populations, while others are referred to us by their PCP’s. Once in our practices, some patients are best managed with surgical solutions (strabismus, cataract, retinal detachment, etc.), while others are better managed with medical ones (glaucoma, uveitis, dry eye, etc.).
Patients that need medical or surgical care will often share waiting-room space with routine ones, and most of our clinic schedules have a combination of both types of patients. What adds to the complexity is that some patients with mild medical problems (non visually-significant cataract, for example) will think of their exams as “routine”, and wonder why their visit may be coded as a medical one.
How Often Should Healthy Patients See an Eye Doctor?
We have established that eye doctors serve two functions for patients: (1) we are primary care doctors for their eyes, and (2) we medically and surgically manage eye diseases. One of our national organizations, The American Academy of Ophthalmology (AAO), has created the following recommendations for the timing of routine eye care in completely asymptomatic adults who do not require spectacle correction (eyeglasses or contact lenses):
Age (years) Frequency of Evaluation
Under 40 Every 5-10 years
40-54 Every 2-4 years
55-64 Every 1-3 years
65 and older Every 1-2 years
The main reason for us to perform scheduled eye examinations on otherwise healthy people is to discover problems early enough in the course of the disease that patients can be treated successfully. The analogy to dentistry is apt again. The dentist probes and x-rays to find small asymptomatic cavities that can be more easily treated while still in the early stages. If these cavities go undetected, they can lead to bigger problems that require more invasive and costly repairs, often with different definitions of success.
We can often help diagnose vascular conditions.
Dentists, of course, are not the only ones who understand the importance of testing asymptomatic people in order to catch diseases at stages that are more easily and successfully treatable. Blood pressure monitoring, routine bloodwork, colonoscopies, mammograms, and Pap smears are all examples of this strategy within medicine. The routine eye examination is just one more example of where someone is looking for early disease in populations of asymptomatic individuals.
The AAO schedule for routine eye exams is a rough guide, and many situations exist where patients should be seen more frequently. Diabetics, of course should be seen annually, along with patients on certain high-risk medications (most notably hydroxychloroquine). Anyone in eyeglasses or contact lenses should also be seen annually to have their prescriptions updated. Patients with family histories of glaucoma, age related macular degeneration, early cataract, or many other significant causes of vision loss should also be seen more frequently than are listed above.
Because of its asymptomatic nature and ability to cause irreversible vision loss, the single most important reason to follow the AAO’s schedule for routine eye examinations is glaucoma. Glaucoma affects about one in every fifty Americans (3 million people), is completely asymptomatic until very late in the course of the disease, and is difficult to diagnose with the equipment available to the average PCP. Importantly, vision loss from glaucoma cannot be reversed, so all treatment regimens are focused on the prevention of vision loss, which is the opposite of cataract or wet macular degeneration management, where treatment is based on the reversal of vision loss. If we diagnose glaucoma in someone once they notice their vision loss, it is usually much, much too late for us to help them in a meaningful way.
There are additional diagnoses that are also important to diagnose early, while patients are still asymptomatic. Some of these include diabetic retinopathy, age-related macular degeneration, and precancerous choroidal nevi. In each of these cases, early detection can lead to sight-saving, or even life-saving results.
As eye doctors we are both primary care providers for the eye, and specialists that PCP’s should refer patients to for the medical and surgical management of diseases of and around the eye. Primary care providers should familiarize themselves with the recommendations for timing of routine eye examinations as published by the AAO, understanding that this schedule represents the bare minimum, and many patients with specific situations should be seen more often than what is listed here. Evaluating asymptomatic patients routinely is the single best way for us to not only diagnose and treat asymptomatic eye diseases at stages when treatment is most effective, but also aid PCP’s in the diagnosis and management of many systemic diseases. For these reasons, PCP’s should refer their asymptomatic, healthy patients for eye exams in much the way they refer them for colonoscopies, mammograms, and the like.
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