Visus writes: Get OK with OCT
In this week’s column I want to highlight a throwaway comment made by one of the erstwhile statesman of the profession Mike Kilpartrick. In the Optician feature on different towns and cities of the UK discussing his practice in Bath, Mike is attributed as ‘expressing some reservation about investing in OCT facilities because he says they can often lead to bad practice, over-reliance and a rise in hospital referrals’.
I am purposely leaving some wriggle room because he may have been misquoted or misunderstood, but taking this at face value what on earth are the major players in the field of OCT – Topcon, Heidelberg, Nidek to name but three – doing in marketing such equipment to optometrists? Surely they could find a few plano ret mirrors and internally illuminated Snellen charts and plonk us upstart pseudo-clinicians back in the dark room we came from.
What a load of ill-informed tosh. Lets take it step by step. Bad practice. OK I admit it. I have got an OCT, not only that but I have had it for some time, so I must not only be bad, I must be terrible?
What, then is bad practice in optometry? The definition of optometry promulgated by the World Council of Optometry is ‘Optometry… autonomous, educated, and regulated… provide comprehensive eye and vision care… includes refraction and dispensing, detection/diagnosis and management of disease in the eye…”
Detection, diagnosis and management of disease is fundamental and it must therefore rely on various methods of ocular examination. When I qualified this was the direct ophthalmoscope and very few practices were equipped with slit lamps. There were no automated field analysers or volk lenses. At what point in history, some of it very recent indeed, would Mr Kilpartrick like to call time on the adoption of new ophthalmic technologies by optometrists? The non-contact tonometer (NCT), the halogen bulb or the plane mirror retinoscope?
Pre-eminent among new instruments is the OCT. In my opinion practising without one of these is at best foolish at worst, bad. If you don’t have one, you or your business owner does not have an appropriate business plan to enable you to practice to your full abilities and that is clearly bad. Why? because you are going to do at least two things; first you will miss identifiable, treatable, ocular disease risking your patients eyesight, your reputation, and possibly registration. Why make it difficult for yourself to tell if that drop in VA is due to cataract, dry ARMD or occult neovascular membrane?
Secondly, and well under the fitness to practice radar, is that you run the risk of unnecessarily alarming patients by referring them when they do not have any reason to be anxious. You can make the diagnosis, reassure them and manage what you have seen.
The second allegation is that OCTs make one ‘over-reliant’. On what? On using your eyes and brain to make a clinical decision? Or the income stream they engender if established with an appropriate business plan. There once was (in some places still is) over-reliance on NCT, which led directly to our lords and masters at the College and elsewhere confusing competence at applanation with a contractual issue. But just as it isn’t the OCT that leads ‘to bad practice, over-reliance and a rise in hospital referrals’ it wasn’t the NCT either.
While NCT was implicated, the apparent high false positive referral was at least partly ophthalmology failing to understand the epidemiology of a disease with low prevalence. It was also simple laziness (or a bone-headed obstinacy to charging patients for repeat measures) thanks to optometrists taking the easy way out and relying on a number generated by a machine to generate a clinical decision. This is a direct consequence of a retail focused attitude to income.
Finally, ‘a rise in hospital referrals’. This is a double-edged sword. First it’s anecdotal and at least initially inevitable when adding new kit. However, I am not the only user of an OCT, and a plethora of other equipment, to find that some patients I refer are discharged because the HES cannot find the lesion or disagree with my diagnosis.
There is more than a hint of embarrassment at our equipment over theirs. Nowhere is this more true than in HES units where the OCT resides in medical retina and is barely used in glaucoma assessment despite evidence that assessing ganglion cell integrity will identify glaucomatous loss missed in 24-2 fields, not least because the fields test parameters are antiquated and rooted in the past.
It is my personal view that OCT is now an absolutely vital tool, easily integrated into any practice, enthusiastically accepted by patients and well within the capabilities on any optometrist to use and interpret. I would advise any new optometrist offered a job in a practice without an OCT to walk on by and let the non-believers wither on the vine.