Outbreak Optometry: Clinical Care After the COVID-19 Pandemic - Dr. Craig Thomas

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In this webinar re-broadcast, Dr. Craig Thomas discusses techniques for re-starting optometric practices, post-COVID-19.

He also describes ideas for new services, including in-office allergy testing as part of an OSD workup.
 

Ed Makler

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In this webinar re-broadcast, Dr. Craig Thomas discusses techniques for re-starting optometric practices, post-COVID-19.

He also describes ideas for new services, including in-office allergy testing as part of an OSD workup.

I heard the original and live broadcast of Dr.Thomas’ presentation

Dr. Thomas has a way to deliver a talk that is well prepared and informative and it will certainly pick up your spirits.

He has a new approach to an approved optometric procedure that may not be for every office.

if your office initiates this procedure, it certainly will expand the scope of optometry while still adhering to board rules.

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AdminWolf

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The part about SLIT therapy is interesting. I worked in Allergy clinics in the late 90s, and it was considered new and somewhat controversial then. Since then there isn't much controversy -- it works for many types of environmental allergens people commonly encounter (dust, pollen, etc..)

The question I have for LCT (and for everyone really who may be more up-to-date than me on the science)

In traditional immunotherapy, you'd set up the skin test and tailor the treatment (ie, the allergen concoction you challenge the patient with) based on their local environment, with the allergens they'd most likely encounter in their daily lives.

LCT mentioned a particular company for the slit therapy -- how do they come up with the proper mix of allergens? Or do they just have a standard uniform panel?

thx
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Laurence Craig Thomas

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Adam Farkas,

Thanks again for presenting the webinar.

For anyone that is going to view it, it is a full two hours. Give it 15 or 20 minutes to get going - then I really think you will enjoy the course and learn something.

I gave this talk on April 14 and because of my inexperience with the technology, I made a couple of mistakes in the presentation. First, I said the treatment is customized to the patient based on the test results. At least with the AllerFocus product, that is not true and they have a standard, uniform panel.

Fortunately, that fact does not appear to matter very much. The AllerFocus serum (i.e., sublingual drops) is a broad spectrum preparation as opposed to a patient-specific preparation; but, since I am a new allergist, that is good enough for me right now.

If I am understanding things properly, patient-specific therapy is expensive and is delivered via injection only in the allergist's office. As always, I am the type of doctor that believes some therapy is better than no therapy so again, this is good enough for me right now.

In addition, I made comments in the presentation that "now" we could do this diagnostic test where before, we could not.

That is not true.

We could always do the test (at least in Texas) - the problem was getting paid.

The insurance companies would not pay us because we are optometrists.

That is the part that has changed - at least for Medicare and most of the private payors.

It never had anything to do with the Texas Optometry Board.

As a matter of fact, if you call the Texas Optometry Board and ask them if it's OK to perform diagnostic allergy skin testing to assist in the differential diagnosis of allergic conjunctivitis, they will tell you that they do not interpret Texas Optometry Board rules over the phone and you should read the rules for yourself, consult your attorney if you don't understand the rules, and as the preachers say, "govern yourselves accordingly."

That is what they will tell you so please do not call them.

Optometrists that practice in Texas, DO NOT CALL THE TEXAS OPTOMETRY BOARD and ask them if it is OK to perform diagnostic skin testing to assist in the differential diagnosis of allergic conjunctivitis. If you have questions, call me at 972-658-0545.

Last thing, I said the sublingual immunotherpay that we can do is FDA approved. That is not true, but again, fortunately, it does not matter.

The antigen serum that comprises the sublingual immunotherapy is FDA-approved, but the approval designates that the therapy be delivered intravenously - not via the sublingual route. Therefore, even though the serum is manufactured in an FDA-approved facility and in an FDA-approved manner, because of the delivery method (i.e., sublingual), its use is considered "off-label" when the therapy is delivered in that manner.

The only thing that means is that insurance will not cover the cost of the drops, whereas they will cover the cost of the injections. I wonder how that happened?

Anyway, those are my corrections.

Fast forward - I have tested 4 patients since the lecture and have prescribed immunotherapy for one of those patients.

This has started off very well. The staff understands what we are trying to do for our patients and my limited sample size of patients has been very enthusiastic about the test and the impact the results have on their health-related decision-making going forward.

That is all...
 
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AdminWolf

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I gave this talk on April 14 and because of my inexperience with the technology, I made a couple of mistakes in the presentation. First, I said the treatment is customized to the patient based on the test results. At least with the AllerFocus product, that is not true and they have a standard, uniform panel.

Fortunately, that fact does not appear to matter very much. The AllerFocus serum (i.e., sublingual drops) is a broad spectrum preparation as opposed to a patient-specific preparation; but, since I am a new allergist, that is good enough for me right now.

If I am understanding things properly, patient-specific therapy is expensive and is delivered via injection only in the allergist's office. As always, I am the type of doctor that believes some therapy is better than no therapy so again, this is good enough for me right now.

The traditional treatment method (ie, in an allergist's office) involves the preparation of vials with a customized mix of allergens at varying concentrations, based on your response to the test panel. Again, in most allergist's office they have a standard panel of allergens (peanuts, et cetera) but also a tailored one, based on your local environment.

If you need immunotherapy, you get a shot a week, and the concentration of the allergens increases over time as your immune system adapts to the challenge. It takes literally months to see improvement using this method, but it works.

Every clinic I've seen or worked in had a "shot room", where patients were scheduled like every 10 minutes or so, different from the regular patient flow, because it was so quick & just required a tech to do.

SLIT therapy is the same sort of thing, except the patient takes vials home and sticks them in the refrigerator. They then use a dropper to apply a small amount underneath the tongue daily. The efficacy or oral treatment was under debate for a long time, and the US lagged in its implementation (vs Europe) but it is now becoming popular here as well.

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Allan Panzer

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In case anyone wonders, I am going to start next week.
As usual I am always interested in new ideas. I believe as LCT believes that our traditional practice is under fire. Serious fire. He has always catered to those in need of major testing and intervention.

For all of you who think he over tests, go spend a day or even an hour in his office.

You will quickly realize that the demographic is somewhat different than "most". Not all...I'm sure there are others.

In most offices, when we see patients with issues, they are referred out and we never see them again.

In LCT office..they seldom leave except for some retina intervention.

The thought of providing my patients with some assistance other than Bepreve, Pazeo or some other stupid expensive drops is enticing.

I like stuff like this and I learn from my brother LCT..the rest of you just sit back and say I can't do that.

I say..when do I start?
See that is the difference. BTW...one thing that he has not brought up in a big way is that most of us will not be selling the SLIT...and therein lies the issue.

We are so used to selling something, that it is hard to quit selling.

Yes, I still sell high end glasses. Unfortunately I see a day when that too may go away.

So, selling a service is certainly appealing. One that everyone needs...golden.

One that helps people...icing on the cake. I mean how much better does it get?

As for the TOB...years and years ago I wanted to do sleep testing. There was a small gadget called a sleep strip...I bought them for like $50 and tested patients.

Then I graduated to an actual study...I asked the TOB...and the answer after they debated for hours was..
drum roll...well it's not excluded.

I don't do that many and I do not bill insurance. I do not prescribe...I use it to see why a patient has Normal Tension Glaucoma. Therefore I can justify it.

This is a really big area. Everyone has allergies..everyone.

Now the question is only..do we get paid for it. If so, I'm in because it is such an area of misery.

OMDs aren't going to much care because they don't even want to do it.

Come to find out the OMD I refer to has been doing it for several years...but fell off the wagon...quit doing it.

So, just send them my way...my second OMD said..I don't want to do it..I"ll send them to you.

Yep, maybe one per month if I'm lucky. But I have a ton of my own patients and some are going to be excited not to get shots..we shall see.
 

Paul Farkas

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The lack of comments indicates that most have not invested the 2 hours in participating in the Webinar.

This could be a major expansion in your practice, especially now when there could be a drop off of patients after the first opening wave. Patients over sixty will think twice before seeing a health care practitioner, if not an emergency.

Even the emergency room patient load has dropped dramatically. Patients with true emergencies fear going into the hospital ER for fear of COVID-19...
https://www.pbs.org/newshour/show/are-americans-in-medical-crisis-avoiding-the-er-due-to-coronavirus

So expect a drop in routine optometric care by the senior population for quite sometime.

Can you offer this allergy diagnosis service as part of optometric practice?

Allergy testing issues to address:

Should you do it without in depth courses to understand allergy?

Should you check with your state board that allergy testing falls under the scope of optometric practice?

Should you check with your malpractice insurance carrier, if you are covered in the event of a law suit?

You can add additional "should I" or just do it!

You can use the model advanced by the State of Israel... Israel does it without asking permission and it becomes "Historical fact".

Congratulation to Dr CraigThomas for leading the way!
 
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AdminWolf

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Can you offer this allergy diagnosis service as part of optometric practice?

Allery testing issues to address:

Should you do it without in depth courses to understand allergy?

Should you check with your state board that allergy testing falls under the scope of optometric practice?

Should you check with your malpractice insurance carrier, if you are covered in the event of a law suit?

You can add additional "should I" or just do it!

You can use the model advanced by the State of israel... Israel does it without asking permission and it becomes "Historical fact".

Congratulation to Dr CraigThomas for leading the way!

The basics of allergy and immunotherapy aren't that difficult to grasp; most healthcare professionals could probably pick the concepts up with a few courses.

The risks of providing this service are relatively low -- anaphylaxis is probably at the top of the list of things to really worry about in-office. Though if a person has very serious allergies, it is likely they've been seen by a board-certified allergist before, and are aware of them (and thus won't need this testing from their OD.)

The question I would pose is how much of the OSD you see in your office do you think has this sort of a component? Is this something that has been reasonably studied? I know many of the dry eye experts (LCT, Crystal Brimer, etc.) are starting to implement this sort of testing in their offices, so this may be something that is becoming more common generally.
 

paula newsome

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The basics of allergy and immunotherapy aren't that difficult to grasp; most healthcare professionals could probably pick the concepts up with a few courses.

The risks of providing this service are relatively low -- anaphylaxis is probably at the top of the list of things to really worry about in-office. Though if a person has very serious allergies, it is likely they've been seen by a board-certified allergist before, and are aware of them (and thus won't need this testing from their OD.)

The question I would pose is how much of the OSD you see in your office do you think has this sort of a component? Is this something that has been reasonably studied? I know many of the dry eye experts (LCT, Crystal Brimer, etc.) are starting to implement this sort of testing in their offices, so this may be something that is becoming more common generally.
 

paula newsome

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So i watched the 2 hour presentation and all I can say is kudos. We will be incorporating this procedure in our office with our training on Friday, May 15th. We are so excited.

Dr. Thomas, once again your presentation was well organized, user friendly and just makes sense for any eye care provider that sees patients with dry, itchy, watery eyes.

During our few weeks of COVID 19 hours managing urgent and emergent care, several things stood out but one in particular was the importance of our eyes to the general population and there is a TON of OSD in the general population especially during this time of the year and the fall of the year.

Our number one patient to present to the office was one with red eyes followed by patients with blurred vision sometimes due to uncontrolled diabetes. Needless to say, we have our red eye patients coming back in once our team members get trained on our new allergy detection processes.

What is even more amazing is that most docs are not managing the OSD but giving patients several samples of dry eye drops and letting the patient chose which one they like better. That is a lazy way of "doctoring" but really good for my practice-smile!

What Dr. Thomas has done in this 2 hour presentation is to share another way via a new tool that we can use in our armamentarium to better serve our patients.

The webinar was extremely informative while sharing a way to better care for our patients. Did I say that we may be able to add to our bottom lines while doing the testing?

All of those are wins-win for the patients with better care. Win for the team members with better technology and tools to use to manage those that we serve and win for the practice by adding to our bottom lines. I love creating win-win scenarios!

Thank you Dr. Thomas for sharing this tech with us. The webinar as always was excellent.
 

Allan Panzer

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The Allergy Lady Cometh..She went to Dr.Thomas' office today and has arrived to train me tomorrow..

You folks...need to consider expending your horizons...assuming you are fortunate enough to be in a state that allows this.
 
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Laurence Craig Thomas

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I have tested 10 patients in the past three weeks and prescribed sublingual immunotherapy for 3 of them. This field of optometry is quite exciting and all patients have been extremely enthusiastic and appreciative of the information provided by the test.
 
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AdminWolf

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I have tested 10 patients in the past three weeks and prescribed sublingual immunotherapy for 3 of them. This field of optometry is quite exciting and all patients have been extremely enthusiastic and appreciative of the information provided by the test.

Immunotherapy in general takes several months before benefits are seen. How are you motivating patients to stick with it, particularly b/c with SLIT the patient is dosing at home? (it is sort of easier to enforce compliance with the shots -- if patients aren't showing up, you know it...)

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Allan Panzer

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I did five patients on day one. Those were to familiarize myself with the test.
Today marked my first real patient.

It is so exciting to be taking part in what is clearly ground breaking changes to our profession.

This technology is not new..it is new to Optometry.

I did not jump on the hearing aide programs...even though I saw them at VEW.

But this? This is a great service to our patients.

We can make a difference! Interestingly many patients do not have significant allergies.

I tested my wife who always complains about stuffy nose. And there were not positives. When and if you undertake this technology, you won't wonder who or what has allergies. It's very clear.

So, not being sure, I sent her to a pulmonologist who ordered a ton of tests.
None were positive.

Can't wait to do more testing.
 

Laurence Craig Thomas

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I did one today like that. I was sure the guy had significant allergies, but his results came back fairly normal. I was going to post on this patient tomorrow because he has recovered from a COVID-19 infection acquired in March. Very interesting case.
 

Allan Panzer

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It's an exciting time to be an Optometrist!
Ok, it's always an exciting time to be an Optometrist.

So anyone else delving into this new frontier?

It's thrilling. And so many of your patients think it's pretty darn nice of you to provide the service.

My only problem is that right now, the volume of patients is a bit low to say the least.

One other thing I am finding pretty amazing is that the patients who are coming do not seem to mind spending money.

IPL..expensive frames...and on and on..

Those who are out of work or lacking funds aren't coming in...the others seem to be feeling like getting procedures and buying expensive frames.

Today I had the Lindberg rep showing frames..

I pointed two patients to him and both bought....can you even imagine?

A third looked but she was getting ready for medical school and was a bit careful.

She asked what I had and I said..Frames in a box...end of year runs.
 
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