Missouri solo practitioner dispenses recommendations, then prescribes therapy

Issue: December 1997

ST. ANN, Mo. - In solo private practice here, Donald E. Walter Jr., OD, believes good patient care is more than just educating the patient.

"Too often, optometrists spend time educating the patient on what options are available - soft disposable, rigid gas permeable extended wear or polycarbonate - but when it comes time to medicate a condition, the clinical task is to make the decision for the patient, not to present options and expect the patient to decide," he said. The crucial part, he said, is the ability to follow through on a recommendation by writing the appropriate prescription.

TPA since 1986

Dr. Walter has been putting his prescribing philosophy into practice for more than 10 years - Missouri passed therapeutic pharmaceutical agent (TPA) legislation in 1986 - and said writing prescriptions is now second nature. "I feel most optometrists in Missouri prescribe pretty comfortably because the battle to prescribe was won a long time ago," he said.

In 1995, Missouri's 875 licensed ODs successfully obtained glaucoma treatment privileges. Dr. Walter treats only a handful of glaucoma patients, as his practice profile is mostly contact lens patients (85%) in an age range of 15 to 50 years. Overall, he writes an average of one or two prescriptions a day.

One of the things Missouri optometrists learned with TPA privileges, Dr.Walter said, is that "patients don't always come to you to lay out all their options." He said that lesson can carry over to other aspect of practice.

"You learn to prescribe disposable contacts or prescribe polycarbonate because that's your recommendation," he said. "It's not about faster or cheaper care - patients come to you for that recommendation."

ODs who do not prescribe are missing out on "the paradigm shift we had when we started prescribing what the patient needed," Dr. Walter said.

Treating inflammation

In what he realizes is a departure from most prescribing optometrists, Dr. Walter said his most frequent prescription is for a steroid. "The most common condition I see in the office is inflammation of the anterior segment, and more often than not it's an allergic conjunctivitis," he said. "Generally, I'll use prednisolone."

Dr. Walter's normal prescribing pattern with a steroid is to use a pulse with a taper. "I realize it might be unusual in that I don't use much besides steroids, but that's the nature of this practice. I see a lot of fairly young people, and they've got inflammation that needs to be knocked down," he said.

The antibiotic he prescribes most often is gentamicin because he favors a broad-spectrum aminoglycoside.

"I don't want to use anything too heavy for fear of building resistance," Dr. Walter said, "but if something is happening that threatens the line of sight, I go to pretty heavy dosages of fluoroquinolones right away. We find gentamicin, however, to be highly effective with most bacterial problems we see."

When it comes to treatment for the handful of glaucoma patients he sees, Dr. Walter usually starts with a beta-blocker or latanoprost (Xalatan, Pharmacia & Upjohn). His second choices include apraclonidine (Iopidine 0.5%, Alcon) or brimonidine tartrate (Alphagan 0.2%, Allergan).

"And anytime I see the discs starting to get cupped out, I have no qualms about referring," Dr. Walter said of his glaucoma patients. In Missouri, he noted, optometrists enjoy a good relationship with ophthalmologists.

Follow the leaders

Although prescribing is a comfortable process for him, Dr. Walter said ODs who are not fully prescribing only need to remember that others have already blazed the therapeutic trail.

"This is not uncharted territory," he said. "So at least prescribe an antibiotic and see how it works. Write out your first prescription and see what happens; it's going to be fun."

For Your Information:

Donald E. Walter Jr., OD, may be contacted at Contact Lens Associates, 500 Northwest Plaza, Ste. 400, St. Ann, MO 63074; (314) 291-3500; fax: (314) 291-3515. Dr. Walter has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any company mentioned.