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OD students, patients benefit from training with advanced technology
Schools implement the latest diagnostic equipment to better prepare future optometrists for clinical practice.
Today’s optometry students have opportunities to use high-technology diagnostic tools, providing valuable experience that informs their future clinical priorities when it comes to purchasing equipment.
We spoke with Nate R. Lighthizer, OD, FAAO, an assistant dean at the Oklahoma College of Optometry at Northeastern State University, and fourth-year optometry student Myranda Partin about transitioning into clinical practice.
Primary Care Optometry News: What are some of the diagnostic tools you have experience using, and what value has the experience brought to your education?
Partin: Here at the Oklahoma College of Optometry at Northeastern State University I have access to much of the latest and greatest technology. It really helps me become familiar with the diagnostic devices before getting into clinic and using them on patients. It enables me to learn about the amount and type of information I can collect with various tests so I can recognize the data and understand what it means. Even if I might not have all of the equipment I train on in my private practice, other ophthalmologists and other larger MD-OD clinics will. Having experience with a wide variety of tools will be a big advantage later. The experience will also make me more valuable to a future practice or referral network.
I know how to read OCT scans and visual fields. The low vision clinic here has incorporated great technology such as Macular Integrity Assessment (Centervue) confocal microperimetry, and the vision therapy program uses 3-D virtual reality technology. In the electrodiagnostic clinic, I gained experience using full-field electroretinography (ffERG) and pattern ERG and visual-evoked potential (VEP) with our testing system.
PCON: Do all optometry schools offer an electrodiagnostics clinic?
Lighthizer: Today it is virtually universal, but this was not the case 8 years ago when I graduated. At that time, the study of electrophysiology was confined to research centers and large practices in big cities. There was no such thing as “accessible” electrodiagnostics.
Technology has changed this, and, today, electrodiagnostic tests can be performed in a patient-, staff- and doctor-friendly manner. The change with regard to the tests’ accessibility and cost shows how much this area has changed in a short time.
PCON: With regard to electrophysiology studies such as ffERG, what is the teaching approach, and how is the information gathered used in patient management?
Lighthizer: Electrophysiology, with its objective, functional results, is an important piece of any given patient’s complete management puzzle. For the care of both retina and glaucoma patients, the use of OCT is understood to be the standard of care. OCT provides an objective picture of the structure of ganglion cells and nerve fiber layer. It does a great job at that. Visual fields are sort of the flip side of OCT: subjective measures of visual function. These tests rely on the participation of patients, and some are very good at taking them, but many struggle with visual fields.
Electrodiagnostic tests provide objective functional data that, combined with OCT and visual fields, complete the clinical picture. Adding electrophysiologic data such as ERG allows for earlier diagnosis and treatment of disease. By addressing conditions when cells are dysfunctional but not dead, intervention has a better chance of resulting in improvement of the condition.
I tell patients that the test is similar to an EKG for the visual system, meant to detect retinal problems before there is major structural damage. Patients seem to understand that comparison and are receptive to a test like ffERG, sometimes called flash, that provides an additional component to objectively study visual function in patients with retinal vascular occlusions and diabetic retinopathy.
This test measures generalized dysfunction in response to stimulus of the entire retina, with flicker ffERG particularly inciting a response from the cone cells. As the flash stimulus is intense, ffERG is especially helpful in monitoring disease progression and treatment efficacy in moderate to severe retinopathies.
The test is also beneficial in patients who have media opacities, because the full-field light stimulus is able to penetrate through to the retina. The ffERG test can be a useful tool for optometrists managing patients with dense cataract and it can be used before and after surgery to monitor healing and visual improvement.
PCON: What is the test like for patients?
Partin: If they can look at a computer, they can do the test. Typically, a technician puts the sensors on the patient and runs the test. The device plays tranquil music and the procedure is relaxed for the patient, the technician and the doctor. We sometimes refer to it as a mini-spa treatment.
Still, there is a process involved for the entire set-up and testing, so knowing how to best incorporate the test into a private practice is important for patient flow, similar to how visual fields are done.
PCON: What other new technology are you excited about using?
Partin: I am part of a research project looking at OCT angiography. The images are incredible, and it is amazing to see a change in foveal densities, for example. I am confident the technology will continue to evolve, and it will be extremely valuable for identifying early changes in diabetes and age-related macular degeneration patients. By having images to show patients we can further educate them on how important systemic disease control is to their vision.
Lighthizer: The technology’s value really comes back to enabling earlier diagnosis. We did not have OCT 25 years ago; we relied on visual fields to diagnose glaucoma. Now we know that patients have lost close to half of their ganglion cells by the time they have visual field defects. OCT changed the game, and VEP, ERG and ffERG are doing the same.
PCON: There are a lot of decisions for a practitioner to make in terms of purchasing devices that make sense for his or her practice. How do you prioritize the must-have technology?
Partin: The decision is complicated. There are the simple financial and accounting aspects of cost, depreciation and income to consider. Other questions include: How many patients will I be seeing that are at high risk of glaucoma and retinal disease? If you are buying a practice, what equipment does it have? Is it up to date? When evaluating different manufacturers’ products, talk to the representatives and evaluate your patient base and your location. What is considered “standard” in your market?>
Lighthizer: Not only did we not have electrophysiology or OCT-angiography when I started to practice, we also did not have the dry eye disease products that are available now. Diagnostics such as the TearLab Osmolarity Test, LipiView (TearScience), InflammaDry (Quidel) and meibography are mainstays, as are treatments such as LipiFlow (TearScience), BlephEx (RySurg) and amniotic membranes. What will we have 10 years from now?
Optometrists also must consider whether reimbursement is in place for the tests and treatments they offer.
PCON: How do you teach and discuss procedures that vary according to a state’s scope of practice laws?
Lighthizer: Our state law in Oklahoma says that we can work in the ocular adnexa, that is, the structures around the eye, but we cannot penetrate the eye. We can remove benign lumps and bumps in the ocular adnexa, such as skin tags, seborrhea keratoses, cysts, verruca and chalazions. Students get experience with these procedures through observation and classroom instruction. During specialty care clinic, fourth-year students can perform laser procedures, primarily, capsulotomies, iridotomies and selective laser trabeculoplasty. Under an attending doctor’s supervision, students also get training in the optometry surgery clinic. They use a radiofrequency unit and surgical scissors, among other instruments, to surgically manage benign lumps and bumps.
Primary care optometrists are an important health access point for patients. To be able to take care of a small skin tag near the eye is a service to our patients. Students are well trained on how to properly evaluate all lumps and bumps.
Partin: These services also go a long way toward educating patients as to what optometrists do and represent the continued evolution of the field. I want the public to know that we spend 4 intense years studying the eye, literally, layer by layer, inside and out.
- References:
- Berrow EJ, et al. Doc Ophthalmol. 2010;doi:10.1007/s10633-010-9226-1.
- Kreuz AC, et al. Arq Bras Oftalmol. 2014;doi.org/10.5935/0004-2749.20140101.
- Pescosolido N, et al. Journal of Diabetes Research. 2015;doi.org/10.1155/2015/319692.
- For more information:
- Nate R. Lighthizer, OD, FAAO, is an associate professor at Northeastern State University Oklahoma College of Optometry (NSUOCO), assistant dean of Clinical Care Services, director of continuing education and chief of specialty care clinics. He is also a member of the Primary Care Optometry News Editorial Board. He can be reached at: lighthiz@nsuok.edu.
- Myranda Partin is a fourth-year optometry student at NSUOCO. She can be reached at joiner@nsuok.edu.
Disclosures: Lighthizer reports he is on the advisory board for Aerie Pharmaceuticals and Alcon and receives speaker honoraria from BioTissue, Diopsys, Nidek, Optovue and Shire. Partin reported no relevant financial disclosures.