Optometrists have a role in primary care evaluation, systemic disease management

Issue: December 2002

BySuzanne Bryla

Today’s primary care optometrist has a role in systemic disease management, which is being supported in optometry schools across the country. Optometry students are being taught to check respiratory function, blood pressure levels, blood glucose levels and cholesterol levels; perform urinalysis and heart monitoring; and analyze laboratory reports to help evaluate a patient’s systemic health.

As optometrists widen their scope of practice with new legislation from state to state, school curricula are reflecting changes in the profession of optometry.

For example, in some states where optometrists can prescribe glaucoma agents such as beta-blockers, which can affect respiratory function, optometrists may need to screen for respiratory disorders.

Students at the Nova Southeastern University College of Optometry in Ft. Lauderdale, Fla., are taught to test with the peak flow meter, explained Alan G. Kabat, OD, FAAO, who is associate professor and clinical medicine instructor at the university.

“In some patients, it’s important to know if they have respiratory dysfunctions prior to prescribing glaucoma agents, because we can really do some significant harm by prescribing these to the wrong patients,” he explained. “Often, the patient has no knowledge that he or she has a respiratory disease. So we teach our students that test.”

At the University of Houston College of Optometry, Marcus G. Piccolo, OD, FAAO, chair of the department of clinical sciences, said the college will be implementing a new, more in-depth course in clinical medicine in the fall of 2003. The new course, which organizes some of the school’s current curriculum into one course, will deal with information on physical diagnosis of systemic diseases.

“Our students will learn how to look at a patient — look at the color of their skin, look at their nail beds, listen to heart sounds and listen to lung sounds,” Dr. Piccolo explained. The studies are not focused on the student necessarily learning to treat a patient for systemic diseases, but rather to help identify those patients at risk, he told Primary Care Optometry News.

Blood pressure

Clinical courses at many universities are teaching optometry students to check blood pressure in every patient.

“Some patients are at risk, and clinicians aren’t aware of their risk,” said Joseph Sowka, OD, FAAO, an associate professor of optometry at Nova Southeastern University, where optometry students are taught to check blood pressure on their patients in every primary care evaluation. For example, “2% of children have hypertension and up to 5% are borderline,” he said. “Many people don’t realize that and would not normally check blood pressure on a child.”

Dr. Kabat added, “Many patients are undiagnosed hypertensives. Some are diagnosed, but poorly controlled. The level of control of their hypertension can directly affect their vision and the health of their eyes. Knowing that level helps us better manage those patients. There is no reason that we should not be checking blood pressure,” he said.

Students at the University of Houston College of Optometry are also being taught to include blood pressure screening in every patient.

“All of our students are taught how to take blood pressure, and they are taught that it should be part of a routine initial evaluation on a patient,” Dr. Piccolo said. “There may be times that a patient is seen on an interim basis for other things such as having something in his or her eye. In those cases, blood pressure isn’t always checked. But at some time, we would do a complete evaluation on that patient, and we consider blood pressure to be part of that evaluation.”

Students at the Eye Institute of the Pennsylvania College of Optometry are taught that checking blood pressure is standard of care, explained Andrew S. Gurwood, OD, FAAO, an associate professor of clinical sciences and an attending optometric physician at the Eye Institute. Dr. Gurwood said that it should be done in every primary care examination and in any case where hypertension would play a role in the etiology of the disease that is being investigated.

Dr. Sowka said digital blood pressure cuffs are probably very reasonable for a technician to use in the office, but there should be a sphygmomanometer and a stethoscope in the office that the doctor can use to verify a reading if necessary.

Blood sugar

Students are also being taught to draw blood and perform blood glucose testing in clinical studies, even though taking blood glucose samples may not be part of an OD’s primary care evaluation. Because state regulations and safety concerns limit testing blood glucose levels in an optometric practice, students are taught to be aware of the patient’s blood glucose levels. It may be information obtained from the patient, or ODs may request laboratory testing themselves.

“If there is enough clinical suspicion that a patient may be diabetic and has not yet been diagnosed, we are obligated to direct that patient appropriately and recommend or order that testing ourselves,” said Dr. Kabat. “I’ve had patients who blatantly have diabetic retinopathy, but have not been diagnosed with diabetes. We may also have patients who have been diagnosed but aren’t checking their glucose levels properly or who have complications. I think we have the obligation to direct that patient so that he or she can get better control of the systemic disease.”

However, Dr. Kabat does not find it necessary to check blood glucose levels on every patient. “If an optometrist is trained and can legally perform blood glucose screenings in his or her state, then I think he or she should be doing this in the office or sending at-risk patients to an internist or a laboratory for testing. But it’s not necessary in the general population. I think that’s probably overkill,” he said.

Dr. Gurwood added, “I think it’s the patient’s responsibility to be on top of his or her own blood sugar.” ODs should be regularly asking patients questions about their blood glucose levels.

“Blood sugar control is extremely important in managing diabetics and in helping to diagnose diabetics,” Dr. Kabat said. “I would not necessarily say that we should be making that diagnosis, but we should play a role in that diagnosis and, obviously, in ongoing management.”

Ordering lab testing

ODs should be routinely ordering laboratory studies when patients have any signs of retinopathy or any clinical signs or symptoms that indicate that they need laboratory testing, Dr. Gurwood said. “You should be looking for diseases of hyperviscosity and hypercoagulopathy,” he said. “You may also need to order tests for autoimmunity or of an infectious nature. You may even need to order tests that suggest cardiac etiology – such as an electrocardiogram (EKG) – Doppler flow analysis studies and neuroimaging.”

Dr. Sowka said that he orders a plethora of lab tests when diseases are suspected, including neuroradiological images. “Basic neurological screenings should be understood by optometrists and performed on patients where applicable. And that is being taught in our curriculum as well,” he said.

The American Optometric Association has guidelines that pertain to systemic health screening. The AOA’s “Comprehensive Adult Eye and Vision Examination” document suggests that a screening may include blood pressure measurement, blood glucose level screening, as well as carotid artery assessment, said Jeffrey L. Weaver, OD, MBA, MS, director of the AOA Clinical Care Group. The AOA’s guidelines are not meant to dictate or take away the doctor’s choice of what should be done, but offer guidance and recommendations, Dr. Weaver explained.

“If we have knowledge or suspicion of a systemic disease, we are obligated to intervene and direct the patient appropriately,” Dr. Kabat said.

For Your Information:

Alan G. Kabat, OD, FAAO, is an associate professor and clinical medicine instructor, Nova Southeastern University College of Optometry, 3200 South University Dr., Ft. Lauderdale, FL 33328; (954) 262-1470; fax: (954) 262-1818; e-mail: kabat@nova.edu.

Marcus G. Piccolo, OD, FAAO, is chair of the department of clinical sciences, University of Houston College of Optometry, 4800 Calhoun Road, Houston, TX 77204; (713) 743-1971; fax: (713) 743-0730; e-mail: mpiccolo@uh.edu.

Joseph Sowka, OD, FAAO, is an associate professor of optometry at Nova Southeastern University, 3200 South University Dr., Ft. Lauderdale, FL 33328; (954) 262-1472; fax: (954) 262-1818; e-mail: jsowka@nova.edu.

Andrew S. Gurwood, OD, FAAO, is an associate professor of clinical sciences and an attending optometric physician at the Eye Institute of the Pennsylvania College of Optometry, 1200 West Godfrey Ave., Philadelphia, PA 19141; (215) 276-6134; fax: (215) 276-1329; e-mail: Agurwood@pco.edu.

Jeffrey L. Weaver, OD, MBA, MS, is director of the American Optometric Association’s Clinical Care Group. He can be reached at the AOA, 243 North Lindbergh Blvd., St. Louis, MO 63141; (314) 991-4100; fax: (314) 991-4101; e-mail: jlweaver@aoa.org.