In Contact - July 2005
Crisis? What Crisis?
The title of Supertramp?s 1975 hit album Crisis? What Crisis? immediately sprung to mind when I first read the article ?IS THERE AN IDENTITY CRISIS IN OPTOMETRY?? by Earl Schmitt, O.D. Ed.D., as published in the Journal of Behavioral Optometry Volume 15/2004/Number 2/Page 49.
Irwin B Suchoff, the well known and respected editor of said journal has kindly given us permission to reprint the article in this edition of NZ Optics. I encourage all of you who are passionate and care about your profession, to read this thought provoking article, as well as the Letter to the Editor that follows on from this.
Earl writes about some concerns that had been building up regarding the direction of optometric practice, training and research in the USA. He made some of these conclusions while attending a CPD conference and I quote; ??by the conclusion of the last hour I was left with the unavoidable realization that I had heard a great deal about the most current medical practices available for the human eye, but nothing about vision or anything concerning vision care.?
If I've said that once, I've said it a hundred times!
He has a lot more to say and notes that we don't seem to have optometric experts, in many of the ?trendy? areas optometry?s moving into. He says, of the many presentations he heard that day ??not one iota of information had been generated by an optometrist, or had originated in an optometric institution.?
No one disputes the benefit of additional ?medical? knowledge, nor of learning from other professionals, but we begrudge the enforcement methods and current teaching trends that seem to be sadly lacking in child vision care, ?real? optometry, contact lenses and so on.
A recent example comes to mind: I was discussing a case - an eleven year old girl with recent reduced vision and headaches - with a recent graduate. The case potentially could have been due to raised intracranial pressure. The discs were slightly raised and margins slightly hazy, no APD, non-specific field defects and around 6/7.5 to 6/9 vision at distance and near, that did not improve with correction. Topography and retinoscopy were normal. Her PRA, NRA and accommodative amplitude were all low. She had recently had meningococcal vaccine shots. I referred her to a neuro-ophthalmologist to rule out the ?nasties?. I asked a recently qualified, DPA, TPA endorsed and skilled optometric colleague if they had any ideas, path-wise, or what other, non pathologic syndrome could potentially have similar symptoms?
Path wise they were great but had never heard of the non-pathological syndrome I was after, for a potential differential diagnosis.
Feeling Streffed?
Of course what I was hinting at was that this case also met some, if not all, of the criteria for Streff Syndrome, aka the Streff ?non-malingering syndrome? or ?juvenile bilateral functional amblyopia? [JBRA].
The patient has been cleared by the neuro-ophthalmologist and we will be embarking on accommodative flexibility training and may well follow with a low plus spec Rx for concentrated close work.
I?ll let you know how we go.
Another case with neurological concerns also comes to mind. A presbyopic, progressive-spectacle wearer booked in for a non-scheduled consult. He was experiencing pain around the left superior lid/orbit with left temporal and frontal headaches, for around two to three weeks. His one-year-old rimless Zeiss Individual?s looked in good nick. While we were talking he took them off, rubbed his forehead and sat there twirling them around by the temple. I did a full exam, fields and so-on to rule out any path, but had already made my tentative diagnosis?
Rimless glasses [and most others too] do not like to be twirled around by the temple. I noted they were fitting slightly askew. I checked out his near phorias with my Mallett box and found a small vertical fixation disparity which I also recorded at three metres with a new ?toy? I am trialing. We ?dotted-up? his progs and realigned them.
I made a follow-up call to the gentleman concerned, a few days later, and he advised me that things were now back to normal and that the symptoms had resolved. He has always presented with a small vertical phoria and the misalignment had pushed his reserves beyond the limit resulting in asthenopia, and potentially ocular tendonitis.
An easy fix, based on classical first-principles of basic optometry.
A gung-ho path-freak, lacking in basic optometric skills, could potentially have ordered unnecessary, expensive, specialist testing with hundreds more dollars for MR scans and so on. Never mind the stress, delays, time off work and uncertainty.
The spectacle induced symptoms would still be there. After all that.
No Panacea?
We get the importance of 90D, BIO and gonio shoved down our throats, ad nauseam. To the point, it seems, that these are the only tools an optometrist needs. A recent article confirms what some of us have been noting for some time.
There have been a number of cases where a retina appeared ?normal? with 90D fundoscopy, BIO and other traditional forms of ophthalmoscopy. We have, however, subsequently noted - when focussing a retina on a black and white video monitor, prior to recording a digital colour fundus image ? that things like choroidal nevi, ?cotton wool? exudates and other pathologies seem to appear out of nowhere. At times they?re hardly visible or not as clear on the colour image nor if one creates a ?red free? or black and white image, with software. I've noted retinal haemorrhages and cotton wool spots - in a potential preeclampsia of pregnancy - as well as other nevi, spots, dots and exudates. Surely one couldn?t possibly have ?missed? these with the all powerful 90D?
If you go back and take another look - knowing exactly where to look - you may note the faintest abnormality, but not as easily as on the monitor.
A recent case report published on the PCON supersite entitled, Advanced instrumentation detects lesion missed by four BIO examiners, by Sherman et al, proves the point. The lesions were detected with a scanning LASER ophthalmoscope and B-scan ultrasonography.
These distinguished researchers and clinicians are not some disgruntled, inferiorly-trained immigrants with an axe to grind?.
Balance
Again, we stress: Balance, wide ranging skills, experience and access to a broad range of diagnostic equipment makes for decent optometrists. Merely ?legitimising? a bureaucratically enforced splinter-skill or obtaining a piece of DPA-paper will not guarantee diagnosis or detection.
Nor Competence?
MATE!
Earlier I referred to a new ?toy? I was trialling.
This one, represented by the four-letter acronym, MATE, could only have come out of Aussie!
Medmont, already international winners for their well designed, functional and good value perimeter and topography unit, have developed a functional optometric test ?chart? system known as the AT20R Visual Function Tester and its hand-held Bluetooth remote controlled Medmont Acuity Testing Environment [MATE].
It has also just won a 2005 Australian Design Award. [See article elsewhere in this issue of NZ Optics]
It took only minutes to install on a spare laptop and soon proved its value, when later that day, I had a hyperactive five year old who did much better with the AT20R than he had on my usual projector system. The remote controller has tons of options and one can easily switch between, Snellen, LEA, LogMar, bars, metric, imperial, lines, charts, staircasing, illiterate E, and more.
we've all had patients that complain that they have ?memorised? our Snellen letters on classical charts and projectors. The MATE?s option of selecting ?random letters? will put an end to that. Being able to view them on the hand controller saves having to turn your head to see what they are, thus ensuring better posture for the examiner.
There are also contrast tests that are response-based [via simple ?yes? or ?no? press of a button] and provide a read-out of their contrast score. Some novel, animated and fun ?fixation? targets for inattentive kids also proved useful. In the aforementioned case, with the skew, spec-induced vertical phoria, the red/blue anaglyphic fixation disparity target - with binocular peripheral lock - also proved its worth. One can manually ?move? the perceived misaligned retinal markers using the MATE?s remote control arrow keys until the patient sees alignment. The fixation disparity ?error? is then displayed on the remote?s LCD screen, in minutes of arc.
Although theoretically ?correct? I'd rather Medmont included an option in forthcoming models, or via software upgrades, to rather provide the fixation disparity in prism dioptres. That is, after all, the manner in which we would likely correct such an imbalance and having an indicated starting point would be more useful than a read out in minutes of arc.
I prefer a 6 metre test distance, using mirrors, and again this has been thought through in that the images can be reversed for mirror viewing. The AT20R is also easily set-up and calibrated for varying test distances, monitor settings and screens. In our situation, with multiple rooms to re-equip, one option is simply having one such unit available for sharing between rooms, as needed for specialised testing. We are trialing it on this basis, using a spare laptop which is easily portable ? running on batteries - as is the rechargeable remote controller. As all functions are controlled via the Bluetooth remote, one doesn?t need access to the computer or monitor. The ideal setup, for my demands would be a nice flat TFT monitor wall mounted behind the patient and viewed in a mirror at 3 metres. Nice, clean, modern and hi-tech.
There are many other features and functions so check them out at the Medmont site. Medmont is now represented in around 20 countries on most of the continents. Not bad for a one-man start-up that did not exist until the late 80?s and especially so for one competing against multimillion multinationals that pretty much had the perimetry and topography markets to themselves.
Keep it up guys.
One wonders what they have up their sleeves for the future?
Mates in Crisis
In addition to the US based article on the crisis in optometry, another excellent article appears in this edition. Written by respected Alexandra optometrist, Laurence O?Connell, creator of the Medmont Atlas, the well researched article discusses the increasingly apparent optometric manpower crisis in NZ that is fast becoming reality. As predicted and due, in the main, to the HPCA/Board/DPA/Immigrant MCOptom fiasco it is also being aggravated by, among other things, the selection and admission criteria that govern optometric student selection in NZ. Read it as these issues will affect all of us, not just provincial practices.
Feedback on these issues continues to roll in and I am reliably informed that only two potential immigrant optoms could be bothered to sit the OCANZ entry exams, now necessary to gain the privilege of being allowed to ?do time? in, for example, Eketahuna. The rest would rather stay home.
One recent potential optometric immigrant, having spent many weeks in NZ checking things out, had the following to say;
?..we are therefore putting things on hold - maybe during this time the MCOptom problems will be resolved or take away completely the option of practising in NZ.
They went on to say ?Had you not spent the time corresponding we could have already made the move and be horrified to discover this. Also travelling around NZ it was amazing to come across ?high tech? (practices) where NZ Optoms did not have in practice or perform BIO or gonio. Many had only picked up such equipment at Uni.?
The Aussies also seem to have hit a bit of a hiatus in their delayed desire for therapeutics.
There are more with similar complaints/observations/frustrations. In one case there were two families keen to move to NZ, consisting of one optometrist, two dispensing opticians and a skilled tradesman. With a perennial dispenser shortage this would have been an added bonus and a win-win-win for NZ.
Ditto for skilled tradesmen. We could do with watertight housing.
Bureaucratic Bungling
Alas the PC Pollies, so hell-en-bent on dictating our lives have done NZ another disservice.
Looking at the election polls it seems many more people are getting pissed off. Labour has apparently added around 40,000 extra state employees in their term. Incompetence and delays are now affecting people in all walks of life. Many more are frustrated by childless-pollies telling families how to; discipline their kids [give them booze and condoms?], dictating educational models [NCEA?], banning spanking [one wonders how much of that takes place in the dark recesses of parliament?] and a whole host of issues they have no clue about. One actually has to have kids, live-in spouses and pay the bills to know what family dynamics are all about?.
Maybe a read of the latest cult book Freakonomics, will help explain some of the lunacy we have had to live with during Labour?s reign?
don't forget to Vote.
For anyone but Labour?
VIEWPOINT - IS THERE AN IDENTITY CRISIS IN OPTOMETRY?
By: Earl Schmitt, O.D., Ed.D.
Not long ago I attended an educational seminar designed for optometrists in general practice. The speakers presented eight hours of lecture and information, all ostensibly intended to update the clinical capabilities and enhance patient care skills to the audience of optometrists. Each speaker demonstrated commendable levels of knowledge and familiarity with their particular topic of discussion; these included the most recent advances in refractive surgical procedures and the design and application of new aphakic lens implants. A review of current glaucoma medications was given, as well as a discussion of useful antimicrobial pharmaceuticals and related agents. Throughout the presentations both local and systemic implications of the various products were emphasized, as applicable. Given the increased scope of health care responsibility that optometry has assumed, the value of the information presented during the seminar was indisputable.
However, about halfway through the day several themes gradually became increasingly?evident to me. This subliminal trend persisted, until by the conclusion of the last hour I was left with the unavoidable realization that I had heard a great deal about the most current medical practices available for the human eye, but nothing about vision or anything concerning vision care. Moreover, among the dozens of studies, papers, research articles, and clinical projects that had been referred to or cited by the various speakers, not one iota of information had been generated by an optometrist, or had originated in an optometric institution. By the end of the day we had been regaled about the benefits optometrists might render to patients by using various products that had been discovered by others, developed by other professional disciplines, and applied according to protocols devised and approved by others. We had been encouraged to refer certain patients for surgical regimens that would be performed by others, in return for which optometrists would be then be minimally included under ?the umbrella of co-management.
Upon leaving the seminar and during my drive home, I mulled over these noisome realities. I recognized further that this tendency to emphasize the accomplishments and directives of other professional investigators had permeated virtually every optometric seminar and continuing education assembly designed for general optometric practitioners that I ?had attended over the past several years. ?That the modern-day optometric clinician must strive to be knowledgeable of medically related issues in order to remain competitive in our abilities to provide optimal care, particularly as determined by third-party reimbursement plans, is not in dispute. Nor is it the point of this paper.
Flexner?s report,1 in 1910 to the Carnegie Foundation for the Advancement of ?Teaching still is considered the standard of how a profession is defined. Overriding all other implied criteria is Flexner?s recognition of an organization?s quest for identity. It was Flexner?s opinion that only when a group of like-minded individuals banded together to select their own cohorts; educated these neophytes in a post-secondary environment according to a self-defined and regulated curriculum; defined their own standards of public service; practiced and enforced self-regulation; accepted responsibility for the activities of its members and was accountable to peer review and other criteria, could that group earn the right to be defined as a profession. Of particular note was the obligation to seek out, generate, disseminate, and apply new knowledge. It is with regard to this last category that I find optometry, as a profession, most deficient.
As practiced today, vision care largely is predicated upon a host of hypothetical constructs.2 When taken at its most simplistic level, ophthalmic compensation for an unacceptable refractive status often can provide the distressed patient with a large measure of relief and satisfaction. But, unless a substantial number of ancillary and supportive tests are taken by the clinician, no evaluation can be made regarding the stability or effectiveness of the patient?s total vision system. Moreover, no clinical test in isolation is all that informative. From current perspectives, only when clinical data are compared within the framework of a rational model is it possible for the practitioner to construct a performance profile which can reflect how well an individual patient may perform visually. 3,4
Even so, and despite the reality that the majority of clinical phorometric findings most often are obtained according to standard protocols, the interpretation of any single test, or series of tests, for that matter, is dependent upon the practitioner?s preconceived notions of how the human vision system functions. Such impressions are founded largely on his or her training, professional biases, and imagination. To illustrate, I propose that there is no consensus as to the meaning of a lateral phoria; there is even less agreement regarding the etiology of such an entity. The same may be said regarding the end points of nearly all of the standard analytical tests taken during a routine clinical vision examination. Further, clinical findings can change over time, apparently in response to environmental demands or therapeutic administrations. Do such vacillations represent coping behaviors, or do they merely reflect fundamental and inherent physiological interactive potentials between the subsystems of accommodation and convergence?
Some insight can be realized if these clinical data are grouped into one of several recognized patterns or syndromes. But again, such a structuring is dependent upon certain assumptions and hypothetical constructs. The format by which data are arranged for inspection by the practitioner will depend significantly less on scientific validation than on the collective past clinical experience and accumulated anecdotal information that has been assimilated and formalized by certain inquiring minds. From such conceptualization has come the currently recognized modular constructs that clinicians can utilize when analyzing standard problems of binocular vision which are not otherwise compromised by intervening pathologies.
These models, however, and excluding none, are predicated on an exquisite body of clinical assumptions.5 Yet, too often missing is the insight and understanding of what is being tested, the reasons how and why the patient is responding, the mechanisms that result in the data being generated, and the logic behind the therapeutic options and choices available to remedy the problem at hand. How many optometric practitioners, students or teachers of optometric clinical science, for that matter, could articulate the principles which underlie the model of vision care which they or their institutions espouse? But of greater importance, who could establish the unequivocal validity of the basic assumptions upon which such a model is constructed? Where is the experimental and scientific proof needed to define the individual and collective clinical tests that are taken, to ratify the syndromes which are in popular use today, and of most basic importance, to identify where and for what reasons the various test findings originate and change?
Before any of these issues can be addressed, however, the optometric community must recognize that much of its routine practice regimen does, indeed, rest upon hypothetical constructs. Not that this is altogether deplorable; apparently what is done has met with considerable success, if the enthusiastic acceptance of optometric care by the general public is any measure. But is shrewd guesswork a satisfactory basis upon which to build a profession? By assuming the trappings of medically oriented eye care we may add a certain luster to our professional image. Even so, the specter of clinical assumptions and hypothetical constructs cannot be avoided. For instance, who can demonstrate with certainty the cause or origins of the glaucomatous conditions we now so often treat, or describe with certitude the pharmacokenetics of the steroid preparations which we apply so confidently?
The unacknowledged task, as I see it, is first to identify those clinical procedural assumptions and modular hypothetical constructs that we have so long taken for granted, as these apply to vision and the vision process. The various models of data analysis then should be codified, appended with the specific theoretical concepts that pertain to each expressly defined paradigm. In this manner the validity of each of the hypothetical constructs and clinical assumptions subsequently could be examined, as could be the analytical models currently in vogue. Predictably, some overlap and commonality will be found. Could a unified theory then be developed that would explain and clarify the functional bases of vision?
I submit there is some urgency to this issue. For one thing, the overall question of testing the validity and clinical interpretation of findings is long overdue. For another, optometry has within its background and history a legitimate claim to the study of vision and its attendant characteristics. Not to capitalize on this heritage would be to default the essence of our primary responsibilities to another profession. In that same vein, it is a matter of identity. Optometry has conceptualized and assimilated an immense body of hypothetical and practical knowledge concerning vision. The principles are available to be examined. If optometry does not assume this task, others will, and with a modicum of research could lay claim to much of what we have originated over the past one hundred years.
What I propose here is no simple matter. But the issue needs to be confronted. We have within our ranks the intellectual fortitude to pursue these questions with precision and sound scientific enterprise. It would then be possible to attend all optometric seminars and programs of continuing education that would include matters of vision care.
References
1. Flexner A. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. Bulletin number four. Boston: DB Updike, Merrymount Press, 1910.
2 Franke AW. Introduction to optometric visual training. Santa Ana, Calif: Optometric Extension Program Foundation, Inc. Curriculum II 1988 Feb,;60(5):171.
3. Bartlett JD. Scholarship in optometry. J Am Optom Assn 1989 May; 60(5):342.
4. Suchoff IB. On authoring. J Behav Opomt 1990;1(2):29.
5. Scheiman M, Wick B. Clinical management of binocular vision, 2nd edition. Philadelphia: Lippincott Williams & Wilkins, 2002: 53-97.
Corresponding author: Earl Schmitt, O.D., Ed.D., Northeastern State University, Oklahoma College of Optometry, 1001 N. Grand Ave.,Tahlequah, OK 74464
A letter in response to the article
Dear Dr. Suchoff,
Congratulations!! When the OEP Journal arrived the title, ?Is There an Identity Crisis in Optometry?? caught immediate attention. What a pleasure to read the article. We were very impressed and want to thank you for bringing this problem to the forefront by publishing the article.
It is not only our ?identity? that is being lost, but there is the possibility that our whole profession will be lost. If the emphasis on the ?medical model? is not stopped, the medical profession will swallow optometry. Osteopathy already is in that position. Very few students today choose to follow the original and much needed ?osteopathic model? with the result that there is little difference between osteopathy and medicine. Today, our students are proud to do rotations in the offices and clinics of ophthalmologists and do not realize that they are not learning anything about their profession of optometry but rather are being trained to be technicians and aids to the ophthalmologist. We had personal experience because of cataract surgery. The resident optometrist did the follow-up examination that had nothing to do with vision. He was only checking to be sure the healing process was taking place properly. How does that relate to being a doctor of optometry?
We have asked why the medical model predominates in the optometric colleges. The answer is that it is what today?s students want. Babies and children want many things that we know are not what will lead them in the right direction of development as they grow so, as parents, we do not comply. If students want the medical model they should be at a medical school. If they choose the optometric path, then they should receive that which will give them a basis on which to build their development to become the best doctors of optometry. More optometry and less medicine should be taught in colleges of optometry!
It is hard to understand why so many clinicians do not understand the wonders they can perform. Optometry is a unique profession giving them the ability to perform miracles. We have had retarded children who, with optometric guidance and therapy, overcome their problems and become normal, productive citizens. Or, children who were born with subnormal vision and were helped to achieve their dream of being able to get a driver?s license. And, to see a child with poor self esteem, unable to achieve, blossom with self-confidence. These are pleasures worth working for.
Our column, ?Our Optometric Heritage,? in COVD?s Visions newsletter has a dual purpose. First, to keep the history of optometry alive so that, by knowing out past, those who come after us will have the ability to enhance the future of this wonderful profession. But most of all, it is with hope that we will educate those who read it so they will know the wonders of being an optometrist. We try to bring out the background of the ?why? what we do does work and show that there is research to backup our thinking.
Again, thank you for publishing the article.
Albert A. Sutton, O.D., M.S., FCOVD Tamarac, FL
For more information or any comments email Alan at incontact@optom.co.nz.