Can a general ophthalmologist diagnose/treat ON?

[Alicious]

I have had ON in the past, and was seen in January by a neuro-ophthalmologist who confirmed it, went through years of my records, did a workup, etc. For future attacks, should they occur, can a general ophthalmologist diagnose and treat ON? What is their role in the process? Getting into the neuro-ophth took two months, and that was on a rush basis, so I'm thinking that there must be other options for cases like mine that are already diagnosed as MS with an ON history.

I'm between ophths at the moment (one misdiagnosed me with a retinal issue, the next was a retinal specialist who won't treat me because there is no retinal issue), so while I plan to ask about this when I make an appointment with a general ophthalmologist tomorrow, I thought I'd see if you all have any good ideas or tips for finding an ophth who is good with ON, as well as more routine eye care.

(FWIW, I'm in a major metro area, so finding specialists is relatively easy. Neuro-ophths, however, are still not easy to get into. )

[22cyclist]

I have had ON in the past, and was seen in January by a neuro-ophthalmologist who confirmed it, went through years of my records, did a workup, etc. For future attacks, should they occur, can a general ophthalmologist diagnose and treat ON? What is their role in the process? Getting into the neuro-ophth took two months, and that was on a rush basis, so I'm thinking that there must be other options for cases like mine that are already diagnosed as MS with an ON history.

I'm between ophths at the moment (one misdiagnosed me with a retinal issue, the next was a retinal specialist who won't treat me because there is no retinal issue), so while I plan to ask about this when I make an appointment with a general ophthalmologist tomorrow, I thought I'd see if you all have any good ideas or tips for finding an ophth who is good with ON, as well as more routine eye care.

(FWIW, I'm in a major metro area, so finding specialists is relatively easy. Neuro-ophths, however, are still not easy to get into. )

A good one can diagnose it if it is not retrobulbar. Even if it is, and you are showing signs (Marcus Gunn pupil-RAPD effect, inability to read the ishihara plates, blurry spot/blind spot in vision confirmed by physician through testing.)

They do not usually treat with IV steroids though, that is usually left up to your neurologist. However, they will contact your neurologist and discuss you case so it is a faster route in most cases at least I have found it to be for me.

I too have been misdiagnosed with something other than ON by an opthalmologist, so you have to pick a good one, sometimes hard to do. We only have 2 neuroopthalmologists in our state, so wait times can be long. I would try an optho. I have a good one, just got lucky. He has all of the right equipment to check for ON.

Good luck! Perhaps Redwings will chime in she is a specialist in this area.

[Alicious]

Thanks for the input! In the short term I want a full medical exam on my eyes (I have other, more boring eye issues as well), and to have a doctor available who can be the ground level stop if I ever suspect ON again. I've asked locally for recommendations for great ophthalmologists, and people either recommend optometrists or the ophthalmologist who misdiagnosed me, so I'm going into this situation blind (har har).

[Redwings]

Hi Alicious,
Yes, of course a general ophthalmologist can diagnose and treat ON! Most cases of ON are treated by general ophths. There aren't that many neuro-ophthalmologists around for them to be the only ones capable of diagnosing and treating ON. The standard of care requires that general ophths have the equipment necessary for working up ON. I've had recurrent ON for 24 years and, up until 6 years ago, it was general ophths who treated me.

And of course a competent general ophthalmologist can diagnose retrobulbar ON (2/3 of cases are retrobulbar). A competent optometrist can diagnose retrobulbar ON (they just can't treat it). With some experience, it's not that difficult. ON is a clinical diagnosis anyway (http://eyewiki.aao.org/Demyelinating_Optic_Neuritis). Many neurologists have to use expensive MRI to look for ON because they don't have the resources to diagnose it any other way.

Simple cases of ON don't even need to be seen by a neuro-ophth. It's one of the major misconceptions that folks with MS seem to have about eye and vision care. That belief may come from so many MS patients being referred to a neuro-ophth because their neurologist, who isn't trained or equipped to examine eyes or vision, refers them to one. And with no other experience with eye care practitioners, they assume that that's how eye care delivery usually works, and that ON is so special that only a superspecialist like a neuro-ophth can handle it. And some of that belief may come from general ophthalmologists who don't like handling neuro-ophth cases referring them to neuro-ophths (plus the incompetent ones mismanaging a neuro case). But those individual docs shouldn't be taken as representations of the profession as a whole.

In the vastness of eye care practitioners, it's usually general ophthalmologists who get the referrals for ON. When a patient with blurry vision presents to their GP, the GP refers to a general ophthalmologist. And there are some people who self-refer to the ophthalmologists they have access to, and that's virtually always a general ophth because most neuro-ophths -- being superspecialists -- take patients by referral only.

Yes, of course general ophthalmologists can and do prescribe steroids for ON. It may just be a regional practice or individual choice about whether the ophth prescribes the steroids or refers to a neurologist. It isn't true that ophthalmologists usually refer a patient to a neurologist for treatment of ON.

In an initial case of ON in a person with no history of a causative condition, a patient doesn't have a neurologist to refer to. The ophthalmologist will usually start treatment of the ON and then refer to a neurologist for workup for an underlying condition. But the ophth is in charge of the case and treats it him/herself within the two-week optimum treatment window. Some ophths don't operate this way, and there are still medical texts that advocate waiting for a diagnosis of the underlying cause before treating, but that's obsolete thinking now (you can verify that for yourself if you're willing to search for and read the specialty literature).

For patients who already have a known underlying condition, the ophth might refer back to the managing specialist to order and arrange some kind of systemic treatment (such as IV steroids for ON). It depends on how the individual doctors' medical delivery system is set up. Being the medical specialty for eye care, general ophthalmologists treat conditions that most people aren't even aware of. There's no basis for thinking that ON is so different that ophths usually refer back to a neurologist to have it done. None of my ophths ever even involved my neurologists when treating my ON. While in their chairs, I was an ophthalmology patient and managed accordingly.

You've raised the most important issue -- how to find a competent general ophthalmologist. I think a lot of us have stories about general ophths missing a diagnosis or erring in treatment. Heck, I've even read a few stories in forums about neuro-opths doing bizarre things.

Now that you're an established patient of your neuro-ophth, is there some reason why you can't see that doctor for a new case of ON? Taking two months for a new patient to get a consult is different than an established patient needing to come in on short notice for a new onset of ON.

Did your neuro-ophth tell you not to come back or that s/he couldn't see you again without a new referral and new consultation? Does your medical insurance pay for only the one consultation? If not, the neuro-ophth should function like any other specialist -- the patient continues to see them for ongoing care as needed.

If none of those situations applies, have you called the neuro-ophth to ask what you should do if you have another case of ON or other neuro-ophth issue? Even if the neuro-ophth can't see you again, s/he might be able to recommend a general ophth in your area. In your position, I'd call the neuro-ophth first.

Otherwise, finding a general opthalmologist is like finding any other competent medical specialist -- some asking around and some trial and error. Any general ophth is probably good with general eye care. Optometrists are good for general eye care. A lot of people with eye diseases get their general eye care from their optometrist and see their ophth for specialty care. Optometrists make referrals to ophthalmologists for conditions they can't or don't want to treat, and can often recommend a good one (because they don't want to refer their patients to bad ones).

You might have some success calling an ophthalmology office and asking if the doc has experience treating ON in MS patients. But, from my experience, office staff usually can't answer that question, and you may or may not ever get a call back about it. Offices often don't have time to pursue and call back about general inquiries.

If nothing else works, you might just have to make an appointment with the doc who is your best guess and ask if s/he is ready, willing and able to take you on as a patient with a neuro-ophth history. Some general ophths don't like to manage neuro-ophth patients and refer all of those patients out. If that happens, at least that doc might be able to recommend another ophthalmologist.

[onlyairfare]

Though my first ON episode was officially diagnosed by a neuro-ophth after referral by my regular ophth, my actual diagnosis of MS was made by my general ophthalmologist some years later when I had a recurrence of ON (yes, with Marcus-Gunn pupil). In the interim I had had leg weakness, so I fit the clinical definition of lesions separated in time and space. There was no MRI back than, and my family doctor and OB-GYN had done the work-up for other diseases that can mimic MS.

Since I was self-employed in my own business at the time and a dx of MS would have caused everyone in my office to lose their health insurance, I paid my eye doctor cash for all my visits, no insurance claims were filed, and he treated my intermittent ON, which was my only MS-related problem back then.

[Alicious]

Redwings--thank you! I was pretty sure that this was the case, but your input is very, very helpful. The complication with the neuro-ophth is that there are only two in the area and each teaches full time, so each only sees patients one day a week. Even as an established patient, getting in to see either of them is very, very difficult as there are so many patients and so very few appointments. So, while it could be done, I've also had other eye issues in the past that make me think I should have a gatekeeper who sends me on if it's really ON, or ON that warrants a subspecialist.

I just spoke with a technician at the ophth I will be switching to, who told me that this doctor handles many patients with MS/ON, and that in some cases absolutely sends them back to the neuro-ophth, but in general handles them himself. So, he should be the right sort of person to see for eye care in general, and also if I suspect ON again. Hopefully I like him; I was surprised at just how few ophthalmologists there actually are once I started looking. His website says he handles optic nerve disease, so we'll see how this goes. I wish I could stay with the retinal specialist; she was incredible. C'est la vie.

My basic history:
1/2007 Diagnosed with CSR

10/2010 Diagnosed with MS

11/2011 Eye issue came back; no pain, so neuro sends me to retinal specialist, who informs me I not only never had CSR, but that it was almost certainly ON both now and in 2007. Sends me to neuro ophth. Asks why original ophth never ordered angiogram.

1/2012 neuro ophth confirms recent ON, believes 2007 CSR to have been ON with pars planitis. Also asks why original ophth never ordered angiogram.

I'm actually in the process of asking the state medical board to investigate doctor #1 regarding the angiogram issue. Good times.


Thanks, onlyairfare! Technology certainly makes the process easier these days, and thank you for sharing your story. What a terrible position to be put in in order to protect the employees.

[artgirl]

Alicious
In my case my ophthalmologists who I have been seeing for 15 years(I love) did see me and treated me even with the fact that I had an MS specialists and a neuro opth (who I could not get into). He could not get my neuro on the phone so he called my PCP/RA doc and they both agreeed to treat. That however was only after he sent me to a retnia specialist that day to comfim the ON. After that I was put on 1000 mgs of steroids by him and follow ups. My MS specialist was and unfortuantly became useless after my ON go figure!. I do have a new app. this week with a new neuro but this time I am just going general neuro. Specialist did not help me at all.

[Alicious]

artgirl, how frustrating that the specialists didn't get their acts together! Thank goodness the rest of your team had their poop in a group, if you will.