SEVERAL STEPS ALLOW FOR QUALITY CARE OF PATIENTS

WORKING IN a Health Maintenance Organization (HMO) provides a collaborative environment within a team of professionals to manage patients’ medical care. In such a setting, optometrists provide primary eye care, play a role in early detection and preventative care and educate and coordinate additional services, such as diagnostic testing and referrals.

The case below illustrates the steps, taken by an optometrist in an HMO setting, that provided efficient and effective medical care to a patient who presented with ocular manifestations of a potentially life-threatening systemic disease.

PRESENTATION

An elderly, established monocular gentleman presented for a follow-up visit with a complaint of recurrent, intermittent blurry vision OD while driving. He said it lasted only a few minutes.

Exam revealed a BCVA of 20/25 OD and 20/100 OS. Pupillary testing did not exhibit an afferent defect in either eye, and motility was smooth and full. IOP was 12 mm Hg OU. Humphrey visual field showed no change from baseline. Fundus was stable, and cupping of the optic nerves was not significant to warrant suspicion of glaucoma progression.

ACCESS TO MEDICAL RECORD

From the medical record, which is available in its entirety to all physicians in the HMO, the optometrist found the patient was treated with latanoprost 0.005% ophthalmic solution (Xalatan, Pfizer) OD for primary open angle glaucoma, and had a long-standing stable history of refractive amblyopia OS. In addition, the patient was on an oral beta-blocker for hypertension.

The previously ordered bilateral carotid duplex did not reveal any stenosis. However, the recent laboratory blood tests, ordered by the primary care physician (PCP), revealed elevated Westergren sedimentation rate and C-reactive protein. These are hallmark laboratory findings of giant cell arteritis (GCA). Recognition of GCA is considered a true neuro-ophthalmic emergency, as permanent visual impairment from vascular ischemia may occur in 10% to 20% of patients.

TRANSITION TO PCP

With the suspicion of GCA and only one functional eye, it was imperative to start treatment as soon as possible. Given the HMO setting, the optometrist spoke to the PCP, and the patient was immediately transferred to the PCP’s care. The PCP prescribed oral corticosteroids, the standard of care for patients with a high suspicion of GCA, which the patient picked up immediately at the pharmacy. All happened in the same complex.

COORDINATION OF CARE

The PCP scheduled a follow-up with a neurologist to confirm the diagnosis of GCA through a temporal artery biopsy, and a consultation with a rheumatologist. Patients with GCA may be kept on corticosteroid therapy for up to two years. Therefore, the PCP monitors for systemic complications of this treatment, and the optometrist monitors for resolution of the ocular symptoms and any increase in IOP or posterior subcapsular cataract formation. Communication between the doctors is facilitated through the patient’s EHR.

COMMUNICATION

Effective communication and defined professional roles are the key components of successful interprofessional collaboration. For this patient, improved quality of patient management led to a quicker resolution of his symptoms and prevented permanent vision loss in the only functional eye. OM

Diana Shechtman, O.D., F.A.A.O., contributed to this column.

DR. LEWANDOWSKA is an assistant professor in the College of Optometry at Nova Southeastern University, Davie, Fla.