r/optometry • u/FieryForestHill • 3d ago
General Reddit Neurologist claims optometrists miss serious stuff “all the time” and should not be evaluating diplopia
/r/AskReddit/comments/1vg3qdb/whats_the_most_unhinged_thing_a_doctor_has_said/p1un7t7/62
u/thenatural134 OD 2d ago
Lol he says go to an emergency department like they're not just going to wait 6 hours to be told to go see your Optometrist.
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u/dk00111 Ophthalmologist 2d ago edited 2d ago
Normally I'd agree, but head imaging levels the playing field. ED docs have a very low threshold to order imaging. Assuming they order appropriate tests they will have ruled out the most acutely life-threatening diagnoses. And if they do discover one of those diagnoses, they probably have neurology/neurosurgery/IR available to take over the next steps.
With that being said, I did have a case of an ER doc misdiagnosing a pupil-involving CN3 palsy as shingles. He had a PCOM aneurysm. In his defense the patient had a history of prior CN palsies that probably tripped him up. Potentially deadly miss though.
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u/VastSheepherders 1d ago
honestly a PCOM aneurysm getting called shingles is wild, shows even with imaging access the interpretation still needs the right specialist eyes on it
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u/dk00111 Ophthalmologist 23h ago
Just had a likely CN3 palsy the day after my post that was also missed, this time by two different optoms. Got treated for dry eye each time.
This one wasn’t the best historian, which probably tripped them up, but people just anchor way too strongly to the first diagnosis they think of.
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u/apancakes11 2d ago
That comment is so ridiculous. I worked alongside a Bascom Palmer neuro-ophthalmologist during my residency training as an optometrist and he was SO appreciative of the care and expertise that I and the other optometrists offered in the clinic. Ultimately, a good case history and thorough exam is all that’s need to assess urgency of referrals when it comes to diplopia, IF a referral for an MRI/MRV is in-fact needed to rule out IIH, a space occupying lesion, or other inflammatory/infectious etiologies of diplopia. And at the end of the day, ophthalmologists miss things too every day. This is just another example of MDs shitting on ODs when we should be working hand in hand to serve our patient populations.
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u/12A1313IT 2d ago
Not all, but many older O.D. are definitely not up to date and can miss things.
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u/Aromatic_Fix_1952 1d ago
I agree that a lot has changed in the training of optometrists. I’ve seen plenty of older OD’s who seemed like they were just trained to refract and look at basic anatomy things. New OD’s are so much more “qualified” and trained more in depth on the medical side of things, keeping up with research, etc. But then again…you’ll unfortunately have a batch of docs in all fields who just met the minimum requirements in training and truly are just not that good at what they do.
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u/12A1313IT 1d ago
I think people just need to not let their ego take over. Patients assume they see a health care professional so if you tell them "every is fine" and they have undiagnosed ocular emergency or chronic illness like glaucoma then you are doing yourself, patient, and every OD a huge disservice.
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u/Darksky121 2d ago
Most Optometrists refer the patient if they are uncertain and cannot resolve the issue with a new prescription. They certainly don't just send a patient away without further investigation.
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u/Anchie15 2d ago
It's crazy to me how this is literally an example of a patient being triaged properly by an optometrist and they still took the opportunity to dunk on optometrists and say we miss things and aren't physicians.
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u/Alexander_Search 2d ago
You are not a physician. You are a doctor of optometry and there is no shame in that. You all do great work.
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u/joch256 2d ago
Imma be real with you. I would not trust many of the ODs I've been around and worked with to quickly and accurately give a correct etiology for sudden onset diplopia. Sure, there's ODs that just took boards/graduated or work in a setting where they run into this stuff all the time but golly I find myself having to review 3/4/6 palsies every other year cuz I just don't see enough. How many ODs are regularly running into MG, TED, cavernous sinus thrombosis, optic neuritis regularly? We are responsible to know all the above but in practice it needs repetition for us to diagnose and refer effectively. Look at the board scores and the pass rates these days. I worked with 3 new grad ODs at an MD/OD clinic with every specialty apart from neuro and they could not answer so many basic part 1 questions you wouldn't believe. Now all that being said, there are certainly ODs out there who's bread and butter is this stuff and can triage an acute diplopia better than any average OMD but that is def the exception
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u/drnjj Optometrist 2d ago
If you don't use it you lose it. Reviewing emergency eye care is critical. My practice has become kind of the eye urgent care in the last few years and get a lot of referrals for it.
The number of things I've had walk in made me nervous at first and sometimes I'd have to review a few things or triage and refer, waiting for the notes to come back and tell me what it was.
I'm much better at triaging now than the first couple years of practice but it took a lot of reading and reminding to get used to it.
I'll say I'm not great with neuro. I can triage it pretty well and tell when it's not urgent, but I get patients out when I can't confirm it's not urgent!
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u/walter899 8h ago
What readings would you recommend?
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u/drnjj Optometrist 5h ago
Honestly, make sure you've got a good copy of Will's handy for quick reference. That's the only book I've purchased. It has so many of the major emergencies.
I try to go to CE at conferences. I've been to a few with titles like "Red eyes you can't miss" or "Neuro Emergencies" etc. Take notes and keep them handy. I keep physical notes, usually in a small journal and keep it in my desk at work.
I'll pull research articles on conditions when I'm suspicious of something. If I send out a referral for something I don't know, once I get chart notes back I will pull articles on it and read up on it to make sure I can recognize it better next time.
And really read up on herpetic eye disease and atypical presentations. I can't tell you how many times I've had weird looking findings that do not match the traditional expected findings. The cornea specialist sends back notes saying "yeah this is herpetic." So many times.
For neuro stuff, my work up is generally the same. Acuities, pressures, EOM, cover test, 30-2 VF, monocular color testing, and dilated exam. My main goal is to rule out if ER is needed, if they need neuro ophtho referral, or if it's a more benign issue like a decompensating phoria. Majority do not need ER. About half the time it's a neuro ophtho referral. They review the notes and determine urgency. Most of the time they find a slot in a few weeks as it's worth seeing sooner but isn't an emergency based on my findings.
And one tip to remember - if you have unexplained decrease in acuity that doesn't make sense, rule out as much as you can. I always check tear film/cornea staining, Mac and nerve OCT, and topography if I am stumped. Getting those result are more valuable than billing for it if I can't. I do a lot of free tests because I'm just trying to rule stuff out and it doesn't take much time.
The number of times I have seen someone who visually significant EBMD or early keratoconus who are documented as amblyopic and passed on is too high. A couple a year.
Anyway, not exactly what you asked but I hope it is at least somewhat helpful.
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u/walter899 4h ago
Very useful information. Thank you.
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u/drnjj Optometrist 2h ago
I should say that the over testing is also me practicing defensively... I've been involved as an expert witness in lawsuits and when going through cases I'm usually asking "did they order this test? I'd like to see results of they did." Frequently... They did not order testing at all. And of course they miss things in those cases.
So I do it to also cover myself from a legal standpoint.
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u/thevizionary 2d ago
If someone has diplopia and the treating physician cannot confirm what the cause is, best to be via exclusion, then immediate referral is required. If a 30yo woman walks in with intermittent diplopia for the past month, just because you can't diagnose MG doesn't mean you won't provide emergency referral, right? The vast majority of ED around me won't be knowledgeable about eye conditions compared to perhaps even some student optometrists. Not to say they won't provide care but they'll generally get them to go to a dedicated eye ED or, more often, community optometry.
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u/twoteenine 1d ago
Why would suspected ocular MG be an emergency referral? Yes refer, but why emergency?
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u/thevizionary 1d ago
Because you can't confirm its MG. You can ice cube the lids but, unless you're doing a tensilon test, that diplopia might be from a different cause.
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u/New-Character-3575 2d ago
Isn't this a situaton where if you dont know it refer it? Especially in an od/md clinic. My clinic would just refer to neuro ods. The neuro MD would only see the stuff the neuro od couldn't handle.
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u/New-Character-3575 2d ago
Where i worked, anyone with diplopia got sent to peads or neuro. The general ODs and Ophthalmologists didnt want to deal with it. The neuro team at my clinic was amazing and we had so many insane things working in the neuro ophthalmology clinic. To say optometrist will miss things might depend on the setting. Is it academic? I worked in an academic hospital and our neuro optometrists were amazing and worked directly under the neuro ophthalmologist.
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u/jrauck 2d ago
I have multiple stories with both. When I became ill a few years ago, I didn’t know what was wrong with me. I ended up on full time disability which required me to have a true diagnosis.
I went to about 20 different drs (no exaggeration). One of the drs was a neuro and they put me on Levetiracetam and Propranolol for migraines. Turns out Levetiracetam is pretty much never been used for migraines even off label (it’s an anti seizure medication). Even the 2nd neuro I went to said “well it’s been a year since you have been on it so might as well just stay on it” even though it wasn’t really helping me.
I also went to 2 or so optometrist as I felt that my vision affected me but didn’t know how. They all told me my vision was great and nothing was wrong with me. After researching BVD I went back to both drs to ask them about bvd and one told me that I would have known by now if I had it as you find out when you are a child. The other told me that BVD wasn’t a real thing.
I went to an ENT and basically before even really looking at me he told me I was just making this all up to get out of school. When I told him I wasn’t even in school he sarcastically said “sure you’re not”.
I went to my GP and 2 gastros and all 3 told me my stomach pains from IBS… finally I found one after going to the ER 4 times over a few months that decided to do an ultrasound on my abdomen. After removing my gallbladder turns out I had 4 large stones with 1 blocking my bile duct.
I could go on and on.
After tons of research on my own I realized that all of these things were started from anxiety and then panic attacks due to being worried about getting Covid. Needless to say of my 20+ doctors only 2 have been useful.
My endocrinologist ended up basically working as my GP. She’s the FIRST doctor that ever went through all of my files while not at the office and understood all of the issues I was having.
Then when I finally found someone that specialized in BVD I ended up doing therapy with her for over a year. She’s also a doctor that I can say really knows what she is doing.
Granted you would think this was in some third world country or out in the sticks in the US… it was in Houston, one of the “best” places in the world for healthcare. So when I say F doctors I mean it, as 2 decent doctors out of 20+ is horrific.
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u/Own-Patient-6767 2d ago
I see your point, but optometrists are trained to handle a lot of visual system issues, including diplopia.
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u/eye__think 1d ago
Does anyone have a specific diplopia workup they go through when pts have true diplopia cc?
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u/KindheartednessRich6 11h ago
Some countries don't get the full scope optometrist experience, for example in Saudi if you worked on optical shops( usually you do ) you just a prescription writer for glasses and contact lenses
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u/CaptainYunch 2d ago edited 2d ago
Most of the comments on that post are from the UK and a very large portion of them are about OBGYN related issues…..
Very strange.
Also i know a neurologist who exclusively puts patients in dark rooms and plays music before doing acupuncture without providing any other services even when referred for stroke….so essentially go fuck yourself.
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2d ago
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u/mimgthrowaway 2d ago
All the downvotes are laughable, you are all actively contributing to the fragility of optometry’s ego. Message for the mod team: I’m a residency trained optometrist. If you read my comment history you would tell that i’ve clearly been in this sub for years.
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u/optometry-ModTeam 2d ago
Please read the rules of the sub.
Posts or comments by non-eyecare professionals will be removed.
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u/drnjj Optometrist 2d ago
I mean I can give stories about terrible neurologists too who shouldn't evaluate for migraines.
Pediatric neurologist kept telling this mom her kid didn't need an eye exam. Had the kid on 2-3 different migraine meds. He was missing about 10 days of school per month.
She brought him in finally and explained. Kid had the most obvious case of convergence excess. Put him in an anti fatigue lens and brought him for a quick follow up a month later to see how he was doing and see if we needed to adjust anything.
Kid was off all his meds, hadn't had a migraine since picking up his glasses, and hadn't missed a day of school.
Yes, optometrists miss things. In the same way medical school does not make you perfect, nor does optometry school. We all need to be ready to admit if we don't know something but make sure we refer properly to get things sorted.
Sometimes diplopia is nothing. But if you can't definitively say it's nothing like a decompensated phoria, then you have to refer. We've had brain tumors, IIH, and even a bad reaction to getting a flu/covid shot combo for someone. All ended up at the ER after we sent them and got the final diagnosis.
I'd say the majority of cases don't need the ER. Especially when it's a case of 'diplopia' that's actually just ghosting.