Monday, July 8, 2013

Going Blind? We don't care

Newest "expert" panel of the US Gov't says that there is no proof to say screening for glaucoma helps, nor is there proof to say early treatment improves the 'outcome".

This ignores Rumsfeld's rule: The absence of evidence is not the evidence of absense.

I mean, when there is a treatment for a disease that causes blindness, are you going to be part of the "double blind" study that doesn't treat you?

Glaucoma is increased pressure inside the eye. With time, the pressure destroys the nerves you see with: it starts with a decrease in peripheral vision.

this is from Dr. Higgon's webpage:

see that "early glaucoma" part? you probably wouldn't notice it. As it gets worse, you might first "notice" you've lost your side vision when you don't see a car or a pedestrian in your peripheral vision (as did my uncle, whose car was hit from the side).

However, there is "inadequate evidence" that treatment for people without symptoms can prevent more serious vision loss and blindness, the panel wrote Monday in the Annals of Internal Medicine.
That doesn't make sense. The NIH says you need screening.

Early symptoms are mild: Which is why so many folks end up with tunnel vision without treatment....and remember: the "symptoms" mean you have lost your vision already.

"It's clear that the treatment can improve the disease," Moyer told Reuters Health. "It's not crystal clear that the treatment of disease before it's noticeable improves the outcome."
It's not "crystal clear". It's probable, it makes sense that treatment would stop the damage, but never mind. 

What's more, most glaucoma tests available in primary care offices aren't very accurate,

It's hard to do the measurement with the old fashioned "pressure" gauge during the yearly physical exam.

I used to use the Shultz tonometer. This is called "direct tonography": you numb the eyeball with drops, and then place a measuring device on the eye, and check your pressure directly.

This is the old fashioned one we used:

You lowered it to the eye, until the outer part hit the eyeball, and the middle part measured how much pressure difference there was.

Problem? If the person moved, they might end up with a scratched eyeball (abrasion of the cornea).

But the newer version is more expensive (usually only specialists have it) and easier.

Dr. Singh has a nice video here:

there is now a "puff" test that is quicker and easier to do, however it's not as accurate. 

We didn't do a lot of the tests because most of our older patients already we seeing eye doctors who had done the test...and so we only did a few a year and sort of forgot to check about it...the dirty little secret is if you don't do a test a few times a month, you are probably going to do it wrong.

Even if we came  up with a "positive" test, we just sent them to the eye docs for a second opinion...

there is a "third" way to test for glaucoma: Look into the eye with an opthalmoscope. But the dirty little secret is that it's a subtle change (and most of us can only see major problems, since few primary care practitioners "dilate" the eye before the do a proper examination, you need to put in those drops that make your iris open wide, and make your eyes sensitive to light and hard to drive home from the office, before you do the examination).

So the first part, saying the test isn't accurate by primary care docs/practitioners is correct.

The problem is the last part of the sentence.
What's more, most glaucoma tests available in primary care offices aren't very accurate, according to the USPSTF, and can't discern when vision problems are likely to get worse. That could lead some people who never would have developed advanced glaucoma to be diagnosed and treated unnecessarily.

Translation: Well, the drops might stop you from going blind, but hey, we don't know, because few docs who pick up the disease on the screening test are willing to let you maybe go blind (and sue them) by not treating you when they diagnose it.

But that means a lot of money for you to spend (or your insurance company to spend) on eyedrops and repeat examinations of your vision. But now the government is paying for it, and man, it costs money.

So let's just not screen you. 

I don't have the US pricetag, but this "NICE" article (NICE is the health care rationing board in the UK) breaks down the costs to 100L a year (about $150) and less than a million pounds (or about a million and a half dollars) to treat 70 percent of those who need it (the 70 percent is the estimate of how many people actually will use their medicine).

Ironically, the NICE is willing to pay for screening and treatment, which tells you something since they are tightwads.

But what about that part you might not need treatment?

The cornerstone of pushing the new "health care" bill was that it would pay for yearly screening examinations on everyone. Supposedly, diseases would be caught early and either cured or treated early, so the patient would end up healthier and cost less money in the long run.

And since the health care bill was  passed, we see one report after another about how such screening tests are "not cost effective" or should only be used in a few patients.

That's because we were told to do them (and sued if we didn't do them), but most people don't go to docs for yearly exams, so no problem.

But now, if they all come in, the cost of screening everyone, mainly low risk people to pick up a few isolated cases, is too high.

Voila: One "screening test" after another is being discarded.

OK. You want to take the chance?

Dr. Angelo Tanna, a glaucoma researcher from the Northwestern University Feinberg School of Medicine in Chicago, said screening can still be useful when performed by an ophthalmologist.

ah, but most of us see optometrists, not opthalmologists.

So the end result should be the government paying for the test for older folks and to pay for a visit to the optometrist every two years or so.

That's what I do...

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