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• W2073381150 abstract "The concerns of optometrists Henning, Oshiro, Wang, and Warren regarding our article, “Diagnostic Yield of the Routine Dilated Fundus Examination”1Pollack A.L. Brodie S.E. Diagnostic yield of the routine dilated fundus examination.Ophthalmology. 1998; 105: 382-386Abstract Full Text PDF PubMed Scopus (20) Google Scholar echo the initial reactions of many ophthalmologists. Historically, the training of American clinicians has stressed the notion that more intense care is always desirable, as long as there is any incremental benefit to the patient—with the unspoken understanding that the corresponding increase in costs will be borne reliably by patients or third-party payers. Many are thus appalled to find that the marketplace for health care now rejects this model, and insists on weighing the benefits of more intense care against the incremental costs, particularly when many packagers of health care decline to purchase our traditional product lines.In our article, we attempted to begin the process of forming one such decision—whether to omit the dilated fundus examination during the routine vision care examination—by estimating the clinical yield of such examinations, at least for a population for which this might be considered an ethical strategy. We carefully avoided any value-judgement as to whether this strategy is ultimately “a good thing.”Henning and colleagues disagree with our interpretation of the American Optometric Association’s clinical practice guideline.2American Optometric AssociationComprehensive Adult Eye and Vision Examination. American Optometric Association, St. Louis1994Google Scholar Opinions may differ as to the emphasis embodied in this document. For example, immediately after the paragraph cited on the dilated fundus examination, one readsThe components of ocular health assessment and systemic health screening may [author’s italics] include:•Evaluation of the anterior ocular segment and adnexa•Measurement of intraocular pressure•Evaluation of the ocular media•Evaluation of the posterior segment•Visual field screening (confrontation)•Systemic health screening testsIt is not our intention to comment on optometric standards of care. On the other hand, we firmly believe that the “vision care” product described in our article takes as its inspiration the historical optometric standard of care, which of necessity omitted dilated examination of the fundus, as optometrists were until recently forbidden the use of mydriatic agents. Regardless of the pronouncements of the American Optometric Association, the apparent eagerness of optometric provider networks to bid on capitated “vision care” contracts as described in our article suggests that this historic practice pattern has not been wholly abandoned by the optometric profession.In our article, we explicitly acknowledged the possibility that our particular decisions as to which fundus lesions might be considered “clinically significant” could be subject to revision, and even cited lattice degeneration as one such example. For this reason, we included a table of all the fundus findings, to allow the reader to recalculate the results under his or her own interpretations. Nevertheless, our exclusion of lattice degeneration from the category of “clinically significant” fundus lesions was based on a careful assessment of the clinical implications of the finding of lattice degeneration in an asymptomatic patient free from risk factors for retinal detachment.We specifically defined “clinically significant” for our purposes to mean lesions with “significant potential for visual loss requiring possible intervention or additional follow-up.” Although it is true that lattice degeneration is associated with some 20% to 35% of retinal detachments,3Benson W.E. Morse P.H. The prognosis of retinal detachment due to lattice degeneration.Ann Ophthalmol. 1978; 10: 1107-1200Google Scholar this fact does not determine the prospective risk of retinal detachment in patients with lattice degeneration. This lesion occurs in 6% to 8% of the general population,4Byer N.E. Lattice degeneration of the retina.Surv Ophthalmol. 1979; 23: 213-248Abstract Full Text PDF PubMed Scopus (95) Google Scholar but the cumulative lifetime risk of retinal detachment in the presence of lattice degeneration is only 0.3% to 0.5% in the absence of other risk factors (as in our study population).5Byer N.E. Changes in and prognosis of lattice degeneration of the retina.Trans Am Acad Ophthalmol Otolaryngol. 1974; 78: OP114-OP125PubMed Google Scholar The risk of detachment remains below 0.4% even in the presence of lattice degeneration with round atrophic holes (which were not found in our study patients).6Murakami-Nagasako F. Ohba N. Phakic retinal detachment associated with atrophic hole of lattice degeneration of the retina.Graefes Arch Clin Exp Ophthalmol. 1983; 220: 175-178Crossref PubMed Scopus (32) Google Scholar Furthermore, prophylactic treatment in this setting has not been proven effective against retinal detachment.7Folk J.C. Bennett S.R. Klugman M.R. et al.Prophylactic treatment to the fellow eye of patients with phakic lattice retinal detachment analysis of failures and risks of treatment.Retina. 1990; 10: 165-169Crossref PubMed Scopus (23) Google Scholar Thus, in the absence of other risk factors for retinal detachment, authoritative opinion is frequently given against routine prophylactic treatment of lattice degeneration.8Robertson Jr, J.E. Meyer S.M. Hereditary vitreoretinal degenerations.in: Retina. v. 1. C.V. Mosby Co, St. Louis1989Google ScholarThe statement of Henning and colleagues that lattice degeneration “ …is found more commonly in moderate myopes” [than in emmetropes? than in high myopes?] appears to be taken at second hand from a study of Celorio and Pruett.9Celorio J.M. Pruett R.C. Prevalence of lattice degeneration and its relation to axial length in severe myopia.Am J Ophthalmol. 1991; 111: 20-23Abstract Full Text PDF PubMed Scopus (107) Google Scholar They examined only patients with 6 diopters or more of myopia, and found lattice degeneration less common in those patients with the very greatest myopia (24 diopters or greater). These eyes remain at high risk for many disorders of the fundus, and were quite properly excluded from our study population. When all patients are taken into account, the association between lattice degeneration and degree of myopia remains quite well established.10Karlin D.B. Curtin B.J. Peripheral chorioretinal lesions and axial length of the myopic eye.Am J Ophthalmol. 1976; 81: 625-635Abstract Full Text PDF PubMed Scopus (64) Google Scholar The observation that our use of exclusion criteria omitted patients with peripheral retinal disorders was emphasized in our article, in the context of our attempt to describe a body of patients for whom “vision care” services might represent an ethically appropriate screening exercise.Henning and colleagues would also prefer a prospective study design. This approach creates its own difficulties, particularly the inevitable increase in the level of attention of the participating ophthalmoscopists, who are necessarily aware that their findings on direct ophthalmoscopy are to be compared with subsequent indirect ophthalmoscopy. Even so, the cited study by Siegel et al11Siegel B.S. Thompson A.K. Yolton D.P. et al.A comparison of diagnostic outcomes with and without pupillary dilatation.J Am Optom Assoc. 1990; 61: 25-34PubMed Google Scholar found a rate of 6.4% for “clinically significant” lesions of the posterior pole, and 4% for clinically significant peripheral lesions among 500 “typical adult subjects,” compared with a rate of 2.73% in our study population, from which all patients with known risk factors for fundus disease had been excluded. These results are hardly in conflict. The finding in the Siegel study of 287 peripheral anomalies among 500 subjects suggests either a very unusual study population, or a very different concept of the normal or insignificant variations of the peripheral fundus from ours.Henning and colleagues emphasize the virtues of stereoscopic examination of the fundus, particularly the relative advantages of the binocular indirect ophthalmoscope. With this, we have no disagreement. However, this discussion entirely misses our point. All our patients underwent binocular indirect ophthalmoscopy—the goal was to determine how many lesions were lurking in the peripheral fundus to be discovered.On the other hand, we disagree with the disparagement of the direct ophthalmoscope, which remains close at hand in each of our examining lanes. The direct ophthalmoscope provides ready access to a high-magnification view of the fundus, and is of great value in such determinations as the optical significance of a cataract, or detection of strabismus.Ultimately, the point of our article was to stimulate discussion of these and other issues. It is no longer reasonable to base a “standard of care” on individual pronouncements or committee resolutions, no matter how principled or high-minded. Every decision on how to perform routine care necessarily commits resources, and we can no longer avoid the hard decisions as to the allocation of these resources among competing health care goals, all of which are desirable, but which together exceed our resources. The only rational way to proceed is to attempt, as we have, to determine the clinical value of each component of our “standard of care.” The concerns of optometrists Henning, Oshiro, Wang, and Warren regarding our article, “Diagnostic Yield of the Routine Dilated Fundus Examination”1Pollack A.L. Brodie S.E. Diagnostic yield of the routine dilated fundus examination.Ophthalmology. 1998; 105: 382-386Abstract Full Text PDF PubMed Scopus (20) Google Scholar echo the initial reactions of many ophthalmologists. Historically, the training of American clinicians has stressed the notion that more intense care is always desirable, as long as there is any incremental benefit to the patient—with the unspoken understanding that the corresponding increase in costs will be borne reliably by patients or third-party payers. Many are thus appalled to find that the marketplace for health care now rejects this model, and insists on weighing the benefits of more intense care against the incremental costs, particularly when many packagers of health care decline to purchase our traditional product lines. In our article, we attempted to begin the process of forming one such decision—whether to omit the dilated fundus examination during the routine vision care examination—by estimating the clinical yield of such examinations, at least for a population for which this might be considered an ethical strategy. We carefully avoided any value-judgement as to whether this strategy is ultimately “a good thing.” Henning and colleagues disagree with our interpretation of the American Optometric Association’s clinical practice guideline.2American Optometric AssociationComprehensive Adult Eye and Vision Examination. American Optometric Association, St. Louis1994Google Scholar Opinions may differ as to the emphasis embodied in this document. For example, immediately after the paragraph cited on the dilated fundus examination, one reads The components of ocular health assessment and systemic health screening may [author’s italics] include:•Evaluation of the anterior ocular segment and adnexa•Measurement of intraocular pressure•Evaluation of the ocular media•Evaluation of the posterior segment•Visual field screening (confrontation)•Systemic health screening tests It is not our intention to comment on optometric standards of care. On the other hand, we firmly believe that the “vision care” product described in our article takes as its inspiration the historical optometric standard of care, which of necessity omitted dilated examination of the fundus, as optometrists were until recently forbidden the use of mydriatic agents. Regardless of the pronouncements of the American Optometric Association, the apparent eagerness of optometric provider networks to bid on capitated “vision care” contracts as described in our article suggests that this historic practice pattern has not been wholly abandoned by the optometric profession. In our article, we explicitly acknowledged the possibility that our particular decisions as to which fundus lesions might be considered “clinically significant” could be subject to revision, and even cited lattice degeneration as one such example. For this reason, we included a table of all the fundus findings, to allow the reader to recalculate the results under his or her own interpretations. Nevertheless, our exclusion of lattice degeneration from the category of “clinically significant” fundus lesions was based on a careful assessment of the clinical implications of the finding of lattice degeneration in an asymptomatic patient free from risk factors for retinal detachment. We specifically defined “clinically significant” for our purposes to mean lesions with “significant potential for visual loss requiring possible intervention or additional follow-up.” Although it is true that lattice degeneration is associated with some 20% to 35% of retinal detachments,3Benson W.E. Morse P.H. The prognosis of retinal detachment due to lattice degeneration.Ann Ophthalmol. 1978; 10: 1107-1200Google Scholar this fact does not determine the prospective risk of retinal detachment in patients with lattice degeneration. This lesion occurs in 6% to 8% of the general population,4Byer N.E. Lattice degeneration of the retina.Surv Ophthalmol. 1979; 23: 213-248Abstract Full Text PDF PubMed Scopus (95) Google Scholar but the cumulative lifetime risk of retinal detachment in the presence of lattice degeneration is only 0.3% to 0.5% in the absence of other risk factors (as in our study population).5Byer N.E. Changes in and prognosis of lattice degeneration of the retina.Trans Am Acad Ophthalmol Otolaryngol. 1974; 78: OP114-OP125PubMed Google Scholar The risk of detachment remains below 0.4% even in the presence of lattice degeneration with round atrophic holes (which were not found in our study patients).6Murakami-Nagasako F. Ohba N. Phakic retinal detachment associated with atrophic hole of lattice degeneration of the retina.Graefes Arch Clin Exp Ophthalmol. 1983; 220: 175-178Crossref PubMed Scopus (32) Google Scholar Furthermore, prophylactic treatment in this setting has not been proven effective against retinal detachment.7Folk J.C. Bennett S.R. Klugman M.R. et al.Prophylactic treatment to the fellow eye of patients with phakic lattice retinal detachment analysis of failures and risks of treatment.Retina. 1990; 10: 165-169Crossref PubMed Scopus (23) Google Scholar Thus, in the absence of other risk factors for retinal detachment, authoritative opinion is frequently given against routine prophylactic treatment of lattice degeneration.8Robertson Jr, J.E. Meyer S.M. Hereditary vitreoretinal degenerations.in: Retina. v. 1. C.V. Mosby Co, St. Louis1989Google Scholar The statement of Henning and colleagues that lattice degeneration “ …is found more commonly in moderate myopes” [than in emmetropes? than in high myopes?] appears to be taken at second hand from a study of Celorio and Pruett.9Celorio J.M. Pruett R.C. Prevalence of lattice degeneration and its relation to axial length in severe myopia.Am J Ophthalmol. 1991; 111: 20-23Abstract Full Text PDF PubMed Scopus (107) Google Scholar They examined only patients with 6 diopters or more of myopia, and found lattice degeneration less common in those patients with the very greatest myopia (24 diopters or greater). These eyes remain at high risk for many disorders of the fundus, and were quite properly excluded from our study population. When all patients are taken into account, the association between lattice degeneration and degree of myopia remains quite well established.10Karlin D.B. Curtin B.J. Peripheral chorioretinal lesions and axial length of the myopic eye.Am J Ophthalmol. 1976; 81: 625-635Abstract Full Text PDF PubMed Scopus (64) Google Scholar The observation that our use of exclusion criteria omitted patients with peripheral retinal disorders was emphasized in our article, in the context of our attempt to describe a body of patients for whom “vision care” services might represent an ethically appropriate screening exercise. Henning and colleagues would also prefer a prospective study design. This approach creates its own difficulties, particularly the inevitable increase in the level of attention of the participating ophthalmoscopists, who are necessarily aware that their findings on direct ophthalmoscopy are to be compared with subsequent indirect ophthalmoscopy. Even so, the cited study by Siegel et al11Siegel B.S. Thompson A.K. Yolton D.P. et al.A comparison of diagnostic outcomes with and without pupillary dilatation.J Am Optom Assoc. 1990; 61: 25-34PubMed Google Scholar found a rate of 6.4% for “clinically significant” lesions of the posterior pole, and 4% for clinically significant peripheral lesions among 500 “typical adult subjects,” compared with a rate of 2.73% in our study population, from which all patients with known risk factors for fundus disease had been excluded. These results are hardly in conflict. The finding in the Siegel study of 287 peripheral anomalies among 500 subjects suggests either a very unusual study population, or a very different concept of the normal or insignificant variations of the peripheral fundus from ours. Henning and colleagues emphasize the virtues of stereoscopic examination of the fundus, particularly the relative advantages of the binocular indirect ophthalmoscope. With this, we have no disagreement. However, this discussion entirely misses our point. All our patients underwent binocular indirect ophthalmoscopy—the goal was to determine how many lesions were lurking in the peripheral fundus to be discovered. On the other hand, we disagree with the disparagement of the direct ophthalmoscope, which remains close at hand in each of our examining lanes. The direct ophthalmoscope provides ready access to a high-magnification view of the fundus, and is of great value in such determinations as the optical significance of a cataract, or detection of strabismus. Ultimately, the point of our article was to stimulate discussion of these and other issues. It is no longer reasonable to base a “standard of care” on individual pronouncements or committee resolutions, no matter how principled or high-minded. Every decision on how to perform routine care necessarily commits resources, and we can no longer avoid the hard decisions as to the allocation of these resources among competing health care goals, all of which are desirable, but which together exceed our resources. The only rational way to proceed is to attempt, as we have, to determine the clinical value of each component of our “standard of care.”" @default.
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