Throughout the years that we have written this column, we have tackled the therapeutic management of numerous conditions. However, we really never have addressed the underlying reasons for therapeutically managing patients with ocular disease.

Attending a recent continuing education lecture helped formulate the idea for this month’s column. The speaker was delivering an excellent lecture on managing anterior segment diseases and was presenting a particularly serious case of bacterial keratitis. The diagnosis and management was exceptional, and was well supported by evidence-based literature.

However, one member of the audience became upset with the lecturer and spoke out. He verbally reprimanded the speaker for, in his opinion, advocating that the audience (and all optometrists in general) accept the management of a condition with such a high risk of visual morbidity.

The audience member contended that it was irresponsible for any speaker to advocate that optometrists attempt to treat a potentially visually devastating condition––such as a centrally located bacterial keratitis––and, by doing so, would merely subject optometrists to the possibility of medical malpractice litigation, should the patient’s outcome be poor.

Clearly, the speaker was not advocating that any member of the audience practice beyond his or her personal comfort level. Rather, the speaker was factually detailing the diagnosis and the current state of disease management. Yet, the audience member continued to challenge the speaker and contended that therapeutic practice puts optometrists at risk of medico-legal suits with little, if anything, to gain.

Realities of Optometric Malpractice
Having served as expert witnesses in numerous optometric malpractice cases, we certainly can attest that there is no possible way to eliminate the risk of litigation, short of ceasing clinical care altogether. Fortunately, cases of malpractice in optometry are uncommon. In an 18-year span between 1991 and 2008, there were 609 payments related to optometric malpractice made in the United States.¹ This translates to roughly 34 cases per year, with the majority of involved parties settling for a relatively low figure of $50,000 or less.¹ Since 1991, claims against optometrists accounted for just 0.19% of payments made nationally.¹ Although very rare, the risk of a malpractice suit being filed potentially exists for every patient encounter with every optometrist.

This patient with infectious bacterial keratitis required expert ophthalmic care.

Revisiting the aforementioned example of bacterial keratitis, the audience member suggested that patients with such conditions immediately should be referred to eliminate the risk of a malpractice suit, should the outcome be poor. However, simply referring such patients will not eliminate your risk. Instead, the risk is present as soon as the patient enters your practice.

Regarding sight-threatening bacterial keratitis, should an optometrist refer the patient in anything less than an urgent, same-day basis, there could be a suit over a delayed referral.

If an optometrist immediately refers the patient to a general ophthalmologist, there could be an allegation that the referral was improper and that the patient should have been sent directly to a corneal specialist.

Finally, if an optometrist informs a plaintiff’s attorney that there was a high risk of visual morbidity with a centrally located bacterial infection that necessitated an immediate referral to a corneal specialist, there can be an allegation that, by not immediately starting the patient on antibiotic therapy prior to the referral, care was withheld, leading to attendant visual morbidity. While these scenarios may seem unreasonable or unbelievable, we have seen such allegations used by plaintiffs’ attorneys often.

In reality, a practitioner’s best defense against allegations of medical malpractice is to understand and adhere to the current standards of practice, as advocated and published by organizations such as the American Optometric Association and the American Academy of Ophthalmology.

Additionally, scrupulous documentation of all aspects of a patient’s care is absolutely mandatory. Your records are your best defense. We have seen many cases damaged or even lost simply by poor record keeping.

Many practitioners are unaware of the true nature of alleged malpractice by optometrists. There is the mistaken belief that the majority of suits involve the inappropriate use of therapeutic medications. In fact, however, most cases fall into the categories of: failure to diagnose, delay in diagnosis and misdiagnosis.¹

These are acts of omission, not commission; that is, the practitioner allegedly didn’t diagnose promptly or properly, rather than causing harm through therapeutic intervention. These errors of omission can occur in both therapeutic and non-therapeutic practices equally. So, fear of medical malpractice litigation is not a viable reason to avoid building a therapeutic practice.

The Changing Environment of Optometric Practice
Optometry’s traditional “bread and butter”––namely, refractive care––is in peril. Opticians are lobbying heavily for refractive privileges in many states. Larger ophthalmology offices routinely fit and dispense spectacles and contact lenses today (a practice that was virtually unheard of 20 years ago). We have also seen a massive shift in contact lens practice and profitability over the last two decades.

We recall a time when contact lenses were sold in individual glass vials and preciously cared for by a patient for a year or more, due to their expense. At one time, “contact lens insurance” was sold to help patients cope with the cost of damaged and lost lenses. During this time, contact lenses themselves were significant sources of revenue.

Today, all of that has disappeared with the overwhelming change to disposable lenses, causing the practitioner’s profit margins for these devices to plummet. Patients are increasingly using the Internet and wholesale distributors to obtain their replacement lenses.

Online Spectacles
Perhaps the greatest motivation for building a therapeutic practice (or any specialty optometric practice, such as complex contact lens fitting, low vision rehabilitation, or pediatric vision and vision therapy) is patients’ ability to now purchase their spectacles via the Internet.

Traditionally, patients received spectacles from trained professionals such as opticians, optometrists and ophthalmologists. Such professionals took detailed measurements, including segment height and interpupillary distance, to complete the spectacle order. Once finished, the spectacles were verified to have been made according to the required specifications and were placed on the patient’s face and adjusted for the optimal fit and use.

For all of this labor, the dispensing professional rightfully profited from the spectacles through a significant cost markup.
However, tradition is beginning to give way to technology in the spectacle arena. In 2007, 5% of surveyed patients reported receiving spectacles from an online source.² Additionally, that year, 1.7% of all spectacles were ordered and delivered directly to the patient from online retailers.2 (It was estimated that 2.8% of all spectacle prescriptions were ordered and delivered directly to patients in 2010.2)

While those numbers may not be overtly concerning, practitioners are undoubtedly noticing that more patients are now requesting segment height and interpupillary distance be included in their spectacle prescriptions. There has to be some degree of concern that the profitability of spectacles may follow the trend that occurred with contact lenses.

Building a Therapeutic Practice
Therapeutic care is profitable, provided that there is acknowledgement of and adherence to a few basic principles:

• Capitalize on your time and services. Simply put: The practitioner must not devalue their professional services or time. Many optometrists are so grounded in material sales that they fail to capitalize on their most valuable assets––namely their diagnostic knowledge and clinical skills.

Fees for service should be set at an appropriate level commensurate with the complexity of the case and the time invested in managing the condition. Fees should be charged for each and every visit, be it consultation or follow-up. Too often, optometrists charge for the initial visit, but advise patients that “there will be no charge for the follow-up.” This is a recipe inconsistent with professional respect, reward or financial compensation. No other healthcare profession, be it veterinary medicine or chiropractic, follows such a recipe.

• Bill for separate procedures. Another infrequently practiced policy is billing appropriately for separate procedures. Epilating an inward-turned eyelash may seem insignificant because of its mild complexity (as compared to a glaucoma work-up, for example).

But, in reality, it took time and practice to understand how to properly approach the eyelash, remove it and avoid complications. Remember––you paid someone money and time to teach you these techniques, and it took great effort and repetition to master them. It is not appropriate to simply “give them away.”

• Don’t forget the Rx. Another critical point on building a therapeutic practice is to always write prescriptions. This may sound basic, but many optometrists simply do not use their Rx pads as often as they should. In fact, many rely on samples for the bulk of their treatment.
While this may save the patient a few dollars, it does little to establish the practice as a center for excellence. Remember the old adage, “That which costs me nothing is worth nothing.” Utilized improperly, samples can change patients’ perceptions from expertise to expectation.

Optometrists who espouse that the profession should adhere to refractive care and avoid therapeutic need to see how optometry is changing. Therapeutic care does not increase medico-legal exposure. Additionally, it seems reasonable to believe that spectacle dispensing will become less profitable in the near future, just as contact lenses did years ago.

Yet, it is highly unlikely that the necessity of therapeutic ocular disease management will diminish any time soon.
The best reason that we can advocate to practice therapeutic optometry is simple. Remember, even in today’s connected world, a patient still cannot be treated for a case of sight-threatening bacterial keratitis over the Internet!

1. Duszak RS, Duszak R Jr. Malpractice payments by optometrists: An analysis of the national practitioner data bank over 18 years. Optometry. 2011 Jan;82(1):32-7
2. Citek K, Torgersen DL, Endres JD, Rosenberg RR. Safety and compliance of prescription spectacles ordered by the public via the Internet. Optometry. 2011 Sep;82(9):549-55.