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BLOG: The optical management of ocular disorders
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In my early years in practice, I worked with a multispecialty ophthalmology practice in a hospital setting. We had plenty of ophthalmologists, residents, fellows and physicians.
I was recruited to provide the unique optometric skills of low vision, contact lens and refractive management to a host of ophthalmic problems where vision could not be improved with further medical or surgical intervention. My tools were specialty refractions, prisms, magnification, contact lenses and therapy.
My Pennsylvania College of Optometry classmate and, as it turns out, lifelong friend is Richard Edlow, OD who practiced in a similar clinical setting in Baltimore. Together, we authored a paper that highlighted our mutual experience and suggested that our experience could be the basis for a new mode of practice for optometry. We both used the tag line: “Optical management of ocular disorders” on our business card and letterhead.
This was not well received by the leadership of optometry of the day. We were both grilled and roasted in our quest to become fellows in the Academy of Optometry. Our medical model colleagues felt that we were not prescribing drugs and doing procedures while our traditional colleagues felt that we had no business in a hospital or being aligned with ophthalmologists. We, of course paid no attention to those who doubted our path and went on our merry way forging new relationships and putting optometry on the map in this new arena.
The actual tasks that we performed in this area of optometry changed as we moved forward in time. In the early 1980s, we spend much of our time fitting aphakic contact lenses. We had more Permalens in our fitting stock than CooperVision. The most common low vision referral was for disciform macular degeneration. We learned that as the disease progressed we could always add more plus power to the system and improve reading.
We developed a therapy program to teach eccentric reading at the very close focus of a high plus lens. We fit keratoconus and corneal transplants with K-readings and retinoscopy. We developed great relationships with our friends in ophthalmology because we were an important part of the team. One of my subspecialty friends used to call our service “the final common pathway.” Many patients with significant ocular problems needed to pass through the optometry service to get back to the functions of life.
Although today much of the nuts and bolts of the care we provide has changed, we still provide the optical management of ocular disorders. The “optical” has broadened a bit to include a number of vision-based therapy programs and the “ocular” has broadened to include neurological-based vision problems, but the mission is the same. We provide unique optometric services to patients with medical problems in a multiple disciplinary setting. We communicate and collaborate to facilitate the best possible medical care.
As clinical care evolves and changes, it is amazing how the pendulum swings from one end to the other. I have seen how keratoconic contacts have gone from large diameter to small and now back again to very large. I have gone from trial frame refractions to automated phoropters and now back to trial frames.
This week I had the opportunity to see a patient with age-related macular degeneration. Of course, is this time era, she was in her late 90s and has had years of anti-VEGF injections that have maintained good central acuity, but she still struggles with near tasks and reading in particular. She has a small central island of vision with a wide paracentral scotoma. She had multiple strong reading glasses that had lost their effectiveness. Measurements showed that the most recent readers checked out as a 4-D add.
Back in the day, this would be a clear case to increase the magnification. But advancements in medical care have skewed this population to a much older age, and injections have worked to preserve central acuity. These forces have worked together to change the pendulum once again. In this case, her best reading was obtained with a 1.25-D add.
Our training in optics and visual science provides us with a unique perspective on ocular disorders that affects vision. This, combined with experience in a setting that allows us to evaluate and manage patients with vision loss, creates a mode of optometric practice that is rewarding for all.
Reference:
Edlow RC, Edmonds SA. J Am Optom Assoc. 1983;54(11):1020-1024.