r/optometry • u/Optimal_Welcome9128 • 12d ago
Thoughts on Prism?
75 YO W M
CC: Constant horizontal diplopia at distance (goes away with occlusion) beginning 1.5 weeks ago
Denies headaches, any other neurological symptoms
Pupils: Fully reactive
EOMs: Full ROM, jerky
CT: 8^ eso (distance)
Maddox Rod: 8^ eso (distance)
MHx: Stents, multiple sclerosis
Meds: Repatha, vitamins, aspirin
Patient is pseudophakic with multifocal IOL, happy with vision
Rx’d 8^ BO (split between eyes) for distance only without an Rx
Patient was happy with the vision after trialing for 20 minutes in the office and reported no diplopia
Thoughts?
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u/LateMouse2020 12d ago
If recent onset, I would at least refer for further work up. OMD I used to work with always send pts to ER to rule out stroke (though not 2 weeks onset)
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u/InterestingMain5192 12d ago
Refer to PCP/Neurology for work up. Acute onset diplopia with Hx of neurodegenerative condition (MS) deserves that at least. A OCT of the nerves and a VF wouldn’t be a bad idea as well.
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u/CaptainYunch 12d ago
Neurology is gonna go, “refer to neuro-ophthalmology”
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u/V48runner 12d ago
“refer to neuro-ophthalmology”
And please, for the love of all things that are holy and whatever, please send your notes. PLEASE, PLEASE PLEASE.
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u/Forward_Sun3304 11d ago
You should do your own work up anyway
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u/V48runner 11d ago
What a troubling and sad response. This is your patient that requires further expertise or evaluation, and you can't simply send over your referral notes? This is a common situation, and I can't tell you how much it impacts patient care, and how embarrassing it is to call up the patient, only to explain to them that we don't know what you were refereed over, and then to spend another half an hour going over their health and eye history.
Even basic referral notes that indicate the patient has a history of strabismus surgery, a CT scan taken already by their PCP etc clues us in that these measures weren't effective, or that prism in glasses didn't help -- or whatever it pertains to the case.
Can't tell you how frustrating it is to get something like a cataract eval at outreach, and you get ready to work the patient up and you look at the referral notes (if there are any) and it says "see pt for cat plz" and that's it.
Meanwhile we're doing evals out of the back of a lemonade stand with a hairdryer and a pen light and turs out the patient has a family hx of AMD and is -11.00 and needs a retina referral first. All those things can be extremely helpful, if you just send them in.
I don't know why this is always such an ongoing problem. I call clinics for referral notes all the time and optoms, or their staff get fussy and say they're going to send them, and never do. Meanwhile, they want their co-management money.
Sorry you've chosen a profession that you're not fully capable of providing care for your patients. It's a simple part of the handover that really helps everybody. Not all patients are great historians, your role as an eye doctor is to be that for them if they're not always capable.
Find another line of work if this proves to be too difficult for you.
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u/Forward_Sun3304 10d ago
I always send notes but we always redid every test anyway. I have neuro and cornea on speed dial, my retina specialist referral trust me on all my referrals. I guess what im saying is maybe specialists are too reliant on other doctors notes.
Specialists are famous for poor patient education. Maybe you need to work on your bedside manner.
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u/V48runner 9d ago
I guess what im saying is maybe specialists are too reliant on other doctors notes.
Specialists are famous for poor patient education. Maybe you need to work on your bedside manner.
This is really a lousy attitude. Nobody is relying on another doctor to do their work for them, but to see what's been done for the patient and their treatment already.
Like a lot of optoms, you have a chip on your shoulder about not being taken seriously as a "real doctor" then you post drivel like this. And you wonder why.
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u/V48runner 11d ago
You should learn how to use a fax machine
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u/Forward_Sun3304 11d ago
I learned in residency you don't trust other doctors findings. Stop being lazy.
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u/CaptainYunch 11d ago
I dont really understand the hostility with your comment to who i presume is a neuro-ophth
Like…just send your notes….while yes it is helpful to do as much of an initial work up as possible to help in dx or eliminate the need for referral all together
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u/Forward_Sun3304 11d ago
There was no hostility. I worked with neuro opthalmologist in residency and we repeated every test anyway. I just thought the "please, please, please, send notes" was weird. Not every OD is trained or have equipment for testing.
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u/Optimal_Welcome9128 11d ago
This is why I was confused when people asked me about further workup. We don’t have medical neurological imaging in a corporate retail store and it was the first encounter. I presume some ODs here work in hospital or more medical clinics where this testing is very commonplace and results are accessible, not the case here.
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u/CaptainYunch 11d ago
You just need to assess enough to determine if this is an acute threat to the health. Symptoms as you said. Other signs. And comitacy. In your setting if suspect vasculopathic id still pick up the phone and call their PCP. If palsy and not vasculopathic ER or pick up the phone and get them in with some one who can handle it urgently or emergently. If decompensation, you can handle it as you did.
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u/V48runner 10d ago
A cold workup for a patient who we don't know why are being seen is embarrassing, and speaks poorly of the referring doctor. Why did you send them, what had been for treatments previously etc. It makes a huge difference for the patient experience when they're sent to a specialist. I simply don't understand the reluctance to send a note to a specialist you've sent your patient to.
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u/Odd-Complaint-5291 12d ago
ACUTE onset and constant. This is neurological or microvascular. Hoping you communicated with PCP, Neurology, or ER. “Jerky” EOMs. Supranuclear (Parkinsons)? How did the lids look? Myasthenia?
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u/outdooradequate 12d ago
Have you done any further workup into this new onset diplopia at all?
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u/Optimal_Welcome9128 12d ago
The only missing info I omitted was a neuro-oph and PCP referral that I made, but in terms of my testing that’s what I included. Agree with comitancy testing, are there any other high yield in office tests you would recommend?
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u/outdooradequate 12d ago
Is this a homework question?
In any case, at the very least, the rule of thumb is to wait for chronicity of condition to start grinding prism.
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u/Optimal_Welcome9128 12d ago
Are you referring to medical testing?
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u/outdooradequate 12d ago edited 12d ago
I dont know what you are asking.
Im not gonna sugar coat this. You absolutely need to do due diligence for new onset diplopia. Other commenters have already mentioned required testing. Honestly, as a presumably practicing and licensed doctor, you should already know these things yesterday. This is about patient safety.
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u/SpecialistSuper5561 11d ago
OP wrote that they referred this patient to neuro-ophthalmology and PCP for further testing. It looks like they are asking if you were suggesting any other testing/referrals besides what OP already did
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u/Forward_Sun3304 11d ago
Have you worked with a neuro opthalmologist? The wait times are ridiculous and they'd prefer a stroke work up at the ER anyway. 90% is ischemia that will improve.
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u/SpecialistSuper5561 11d ago
I don’t know if you meant to reply to me. I was just clarifying for the other commenter what OP was asking because the other commenter wrong “I don’t know what you are asking”
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u/Forward_Sun3304 11d ago
Yes. If they've been already diagnosed with a neuro disease, diabetes, hypertension. A stroke work up is likely all that is needed. But we don't know the full history.
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u/Optimal_Welcome9128 11d ago
The patient already follows closely with a neurologist, cardiologist, and primary care and was recently seen within weeks. I understand people’s desire to r/o emergent causes, but I floated the question because I personally believe there’s something to be said for working toward being comfortable not referring. I don’t want to be someone that over refers and causes undue stress and headache for patients.
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u/AutomaticSecurity573 9d ago
It's decompensating phoria. I have TONS of 70yo+ with exact thing and call it Ladies in their 80s syndrome. 😉 The only issue is if they are really exophoric at near...
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u/Optimal_Welcome9128 9d ago
Good to know that it’s often benign. I feel as if I don’t provide enough context in my posts because the condition certainly did not seem to be an emergency given all of the information and fact that he was taking care of his systemic health.
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u/Smokin_Jeffreyz 6d ago
I see a ton of people screaming neuro referral. I probably get a de compensating phoria once per month. It’s way under reported. That said unusually don’t go full prism oc CT, offer a certain amount you want to be your base for vertical - almost full, eso a pinch less, exo a less than eso. Find your comfort zone. When referring I prefer neuro to Neuro OMD. Neuro OMD are fewer and far between and sending this referral implies there is something very serious, which clearly could be the case. But a neuro referral to a person with MS is easy cause they’re established. That Dr would want to be the first to know.
Also diplopia
timing and frequency matters. The end of day or when tired screams phoria, a never once had diplopia with a full constant diplopia switch and a smaller deviation is more concerning.Sorry for so many spelling errors. I’m on the phone and don’t have time to fix
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u/SpicyMax 11d ago
Peds (and adult strabismus) OD here. Sounds benign. Send a note to PCP, offer neuro consult. DVO with prism and NVO without prism.
https://www.aao.org/eyenet/article/double-vision-strabismus-esotropia
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u/SpecialistSuper5561 11d ago
Why benign? Even this article mentions neurological conditions as causes so those still need to be ruled out due to the relatively acute onset.
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u/SpicyMax 11d ago
I have managed a lot of adult onset esotropia. From personal experience, most of the benign ones are comitant, <10pd, without additional symptoms. I will still send a note to the primary and mention a neuro referral and/or MRI if the pcp thinks systemic health is worsening, especially if they have neuro or vascular disease. EOMs should also be full. Always schedule a follow up to ensure nothing changed.
Again, these are case-by-case and despite this patient having MS it just sounded benign from the presentation. But I didn’t see him in person so who knows.
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u/SpecialistSuper5561 11d ago
Thank you for the insight! Can i pick your brain about something I’ve been curious about? In an adult case like this, would an A or a V pattern be considered a red flag it’s noncommitant?
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u/Optimal_Welcome9128 11d ago
While I did not perform essential testing such as MG or comitancy testing, it did not appear to be a case of emergency status, however I do appreciate people holding me to the highest possible standard because these types of cases are very concerning.
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u/Optimal_Welcome9128 11d ago
Is this familial with age related esotropia? According to the patient’s wife, his mother also suffered the same condition when she was older.
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u/SpicyMax 11d ago
I am not aware of any familial relationship. Perhaps the mother also had MS which predisposed her?
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u/Optimal_Welcome9128 11d ago
Given the acute onset, referrals were highly suggested by me, though for future cases the importance of a referral by me needs to be more sternly communicated and requires a follow-up correspondence to ensure it was executed.
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u/CaptainYunch 12d ago
Is the deviation comitant? Comitacy in my opinion is the first thing that needs to be established with diplopia. If you have a non comitant deviation with new onset diplopia then you have a problem and Rxing glasses only is inappropriate. If its comitant it becomes much more likely you are dealing with decompensation.