Posted by: Janet Hughes | September 5, 2008

Proposed rule is flawed. We need your help.

42-15650295“From a certain point onward, there is no longer any turning back. That is the point that must be reached.” (Franz Kafka)

Vision First reached that point. We’re on our way to helping many more children.  Now we need our Vision First form approved by the state to ensure our success.

The proposed permanent rule for Illinois’ new eye exam law was posted September 5th in the Illinois Register. Unfortunately, it mimics the emergency rule that needed 911 in June. Our Vision First form was not included as proof of an eye exam.

Do you think the Vision First form should be accepted as proof of an eye exam? If so, please sign our petition here…

Let your voice be heard over the next 45 days. Public comment period starts now and ends October 19, 2008 at midnight.

1. What is the “public comment period?” When a bill is passed into law, rules must be written regarding the law’s implementation. This rulemaking process has two steps:  first and second notice.  The public has the chance to comment on proposed rules during these two times.  For further information, visit JCAR for the Illinois Rulemaking Process.

2. The Vision First form should be approved. How can I help? You can help by signing our petition, writing a letter, and sharing our website and blog with your family and friends. You do not have to live in Illinois. Anyone anywhere can support our cause!

3. Where can I sign the petition? You can sign here!

4. Where do I send a letter? Send (or email) your letter to:

Ms. Susan Meister, Administrative Rules Coordinator
Illinois Department of Public Health
535 W. Jefferson Street, 5th Floor
Springfield, IL 62761
EMAIL: dph.rules@illinois.gov

Subject: Objection to proposed rule for Public Act 95-0671

Also, copy your letter to: JCAR@ilga.gov and VisionFirst@care2.com.

5. Do you have a sample letter? Yes! View a sample letter here or read my letter.

Your voice counts.

Together…we will be heard.

Copyright (c) 2008 Vision First Foundation. All rights reserved.
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Responses

  1. What a great blog you have here!!! I’m so glad to come across it!!!

    Kelly H.

  2. Thanks for your work on this issue!

    I hope, as a pediatric ophthalmologist, that the final form will correct 2 flaws:

    1) The glaucoma assessment is unnecessary and unrealistic. Testing intraocular pressure on unsedated 5-year-olds is notoriously difficult and inaccurate. As soon as the child squeezes (let alone cries), the pressure is artifactually altered. The incidence of glaucoma is extremely low. Furthermore, the few children who do have the disease have optic disc and/or corneal changes.

    2) The “Optometrist or physician who performs eye exams” or however it is worded, is an awkward way to exclude the word “ophthalmologist” from the form. Considering the criticisms already generated that this is an “Optometric Full Employment Bill,” I’m surprised the ODs asked for this phraseology.

    One other criticism of the bill in general: While it claims to mandate complete eye examinations, the law actually makes this optional, by not requiring either a dilated or cycloplegic examination. No optometrist or ophthalmologist would claim that a non-dilated non-cycloplegic exam is “complete,” yet I’ve been seeing lots of these exams passed off onto unsuspecting parents, whose children have received frankly wrong glasses prescriptions as a result.

    I’m sure Dr. Maino would agree — I hope he, Vision First, and others will work to rectify the problem.

  3. Thanks, Dr. Ticho, for appreciating my hard work on this important issue. It was nice hearing from you! Thank you for all you do, too, for our children.

    In regards to the proposed form and the new law, there’s good news and bad news. First the bad news: “glaucoma evaluation” is part of the minimal requirements stated in the Public Act and cannot be removed from the form. Second, I agree with you that the omission of the title “ophthalmologist” is awkward. But again, it’s in the law and cannot be changed. The Public Act states, “physician licensed to practice medicine in all if its branches.” Technically, a pediatrician could perform the eye examination.

    Regarding the claim that the bill mandates complete eye examinations, I could not find that word “complete” anywhere in the Public Act. I only found this, “the child shows proof of a completed eye examination.” I don’t think this was a typo. I believe it means that the eye exam was done. Therefore, the term “complete” found on the State’s proposed form should be removed.

    Now the good news: Vision First IS working to rectify these problems. I hope you will join us in our efforts during the rulemaking process. Public comments are now being accepted until October 19 at midnight.

  4. First, Dr. Ben Ticho’s concern about glaucoma checking on preschool children has some reasonable thinking, but like Mrs Hughes stated, it is the law so we’ll need to deal with that.

    Second, another law that is outdated is the term, “physician licensed to practice medicine in all of its branches.” Can not blame you if you are bothered. It demeans the speciality of ophthalmology.

    The parents and public have been very confused, especially in the past when the health form for the physical had a box for “eyes” to check. The superintendent of schools in our area had a fit. He showed us completed health forms that said, “eyes-OK,” “eyes-yes,” “eyes-two,” “eyes-blue.” He wanted to know what was going on? We think you agree the only providers to do eye and vision examinations should be the ophthalmologist and the optometrist. But there are those old ancient laws again…

    Now the issue of improper glasses is one that better get resolved. What you think might be improper glasses, is our opinion, a difference between optometry’s training and what your understanding of what corrective glasses are for. I do not include all OMD’s. This thinking is based on written testimonials in major professional journals.

    I am sure Dr. Maino would welcome your visit to ICO and you two could talk it out. It would be great for the public and the world of information we live in, as well as the thousands of optometrists worldwide that are learned improperly.

    What do you think?
    Floyd Mizener, OD, DOS, Phd

  5. Dear Dr. Ticho,

    Just a few comments. You stated that, “The glaucoma assessment is unnecessary and unrealistic. Testing intraocular pressure on unsedated 5-year-olds is notoriously difficult …” Testing children for IOP may be unrealistic…but it is still necessary and as you know…even though testing children’s IOP may be unrealistic, we should at least make the attempt to do so. (BTW I have completed an automated visiual field on a 4y/o!! so you can’t always go by age.)

    You also stated that: “The ‘Optometrist or physician who performs eye exams’ or however it is worded, is an awkward way to exclude the word “ophthalmologist” from the form. ..” As far as I was aware, optometry did not necessarily want this wording….but some of your non OMD collegues may have wanted it so … Also…as far as I know, Ophthalmologists are considered to be physicians….(BTW for many government programs, so are optometrists considered physicians…) so I do not understand your concern.

    All in all….your concerns are minor when compared to the major impact this law can have on the children of Illinois. Let’s all work together to give the best eye and vision care to our children…after all, that is what we all want. Right?

  6. Thanks to Drs. Maino, Mizener, and Janet for their thoughtful comments.

    1) Glaucoma: The bottom line is that the form should have left actual pressure measurements off, and instead stated something like:
    Glaucoma: Present: Absent: Uncertain
    That way, the doctor gets to use his/her best judgement on how to assess glaucoma risk (with pressure measurement if possible, or not if impractical)

    2) OD vs “physician…” wording. Dr. Maino is probably right that somebody probably wanted to preserve the possibility that primary care doctors might still retain a role in the process. That is clearly not going to happen given the law’s requirements. So, I apologize to the ODs for implying, as I did, any ulterior motives in leaving out the word ophthalmologist (!).

    3) Improper glasses from noncycloplegic exams. The mistakes I’m referring to are not OD vs MD philosophy issues, but problems from not controlling accommodation. Something like giving +1.00 when the child has +8.00 cyclopleged; even if you philosophically decided to prescribe +1.00 for whatever reason, it would be wrong to do so without knowing that the full refraction was +8.00. I get along quite well with optometrists (despite quibbles with some of the more aggressive vision therapists, but that’s another discussion!). This shouldn’t have become an OD / MD thing — ICO and IAO should have taken the opportunity to work together for once!

    4) I agree that the above concerns are relatively minor. Indeed, I’m obviously not against testing children’s vision or detecting previously unsuspected eye disease. I have already found plenty of kindergartners with important refractive errors and significant amblyopia, as well as unsuspected cataracts and other pathology, as a result of this law. BUT — I’ve done lots and lots of normal exams too! Parents took off work, used up gasoline, and spent part of their paychecks. They got something in return — reassurance that their child’s eyes are okay; but, I wonder if that could have been done without the expense and bother. Modern photoscreeners are quite good — high sensitivity, few false positives or false negatives. One machine set up in a school gym could have screened whole kindergarten classes in a morning.

    Bottom line is that mandatory unfunded vision examinations which do not necessarily include cycloplegia or dilation may not be a cost-effective means of achieving our shared goals (detect and treat latent ocular disease). What scientific studies were used to justify the law? If government was spending its own money on this, they (hopefully) would have done a careful cost-benefit analysis. How much money is it worth spending on normal exams to find how many kids who might have been missed by good photoscreening? How much money should be taken away from other needs to fund this?

    This objection does not mean the law is not worthwhile, just that it was passed without clear fiscal consideration. Proponents have argued that vision testing is at least as important as dental and immunization requirements. I would argue that there should be cost analysis of these health mandates as well. To force people to pay for something they didn’t necessarily want should require a strong justification. How much is this law costing Illinois parents? What is the expected yield? (If the government really thinks vision exams are so worthwhile, should they pay for them?)

    Again, this isn’t or should not be an OD vs MD issue — we (should) want the same things. This is a health care dollar / limited resource issue, in my humble opinion.

  7. Oh, one other thing about the form (as if the above wasn’t long enough!):

    I don’t like the refractive assessment reading: Normal, Hyperopia, Myopia, Astigmatism. How much hyperopia and astigmatism is “normal?” If checking “hyperopia” implies “abnormal,” shouldn’t almost all those kids get glasses? Obviously, the vast majority of 5-year olds are hyperopic, and the vast majority of these kids are “normal” and should not receive glasses. I would have appreciated more guidance on what information the form designers intended to elicit here.

  8. [...] Today our form seeks approval from the Illinois Department of Public Health (IDPH) during the new eye exam law’s rulemaking. DPH proposed the State form shall be the only form accepted as proof of an eye exam. The proposed rule is flawed. We need your help. [...]

  9. Parents are testifying all over the state; rejoicing about their preschool child being discovered early enough to correct not only eye health and health-related eye conditions, but visual losses and high refractive errors besides functional misuse of the binocular system including scores of amblyopia cases.

    A victory for the child and the parents who would have faced this failure of not doing it right the first time and suffering the consequences
    that would have resulted otherwise.

    We have to congratulate the parents and the teachers who uncovered a failed effort of the state and lay screeners trying to suppress the need of a comprenhensive eye and vision examination by an optometrist or ophthalmologist.

    The reason supporting this failed program was promoted as good economics, but that cost is failure when 60% of children with problems were not never discovered.

    It does not take a math genius to figure out that most of the state taxpayers money was wasted due to the cost of administrative salaries, pensions, etc. Many parents would have paid for examination professionally and be 100% finished.

    The parents are challenging the state and local governments for their vision budget.

    Now it is interesting to see, although the Vision First Foundation and its pProfessionals have developed an even better fine-tuned eye and vision form for the eye doctor, the non-optometrists are trying to reduce the information originally required to a sign-off status due to their lack of optometric education. This reduces the quality needed and the parents and teachers are ready to roar.

    Floyd Mizener, OD, DOS, PhD

  10. [...] love this quote. It’s full of wisdom, strength, and hope. Just what I need during the current permanent rulemaking of Illinois’ new eye exam [...]

  11. [...] 2005 but it was repealed the next year. The Department of Public Health (DPH) hasn’t approved the rule for Illinois’ new kindergarten requirement. Is this the 1800’s or the 21st century? [...]


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