In Contact - May 2009

Sea Change?

Reading NZ Optics, in particular the various classified advertisements, shows how things have changed in optometry in a relatively short time since practice ownership was deregulated.

Recent adverts have headings such as ?OPTICAL SHOP FOR SALE? and ?OPTOMETRIST WANTED: Part time position for a new shop??
Fortunately there were also a few adverts that followed the more professional approach with headings such as ?Practice Wanted? and ?Practice for Sale?.

I also hear more and more people referring to an optometric practice as a shop or store. There appear to be some cultural reasons for this. Such terminology is however often used by younger optometrists and in particular those that have only worked in commercial style chains with little experience or exposure to the more professional mode of traditional private practice. In some ways that's a contradiction. Many younger optometrists are in fact also therapeutically qualified. One would think that this engenders a more medical approach to their thinking?
Most optometrists would surely agree that they didn't spend four to eight years studying to become shop keepers or store owners?
A recent newsletter from the American Academy of Optometry 'President?s Calling' included a pertinent article by respected optometric leader Mert Flom dealing with ?Change Leadership?. In an explanatory table he made this statement, ?In 1922, nine optometrists, later many more, act to change optometry from a business to a profession.?
that's what optometry is, a profession. It changed from old style shoptometry to a more modern profession long ago.

Corporatisation is attempting to effect a swing in optometry from a profession to a fully fledged retail business.

While some may think It's just semantics, there is a difference between say ?prescribing spectacles? and ?selling glasses? there's a difference between an ?eye test? and ?optometric examination? and between ?patient? and ?customer?.
I recently brought up this issue at a meeting of around fifty optometrists, dispensing opticians and practice managers. It was a worthwhile debate and the consensus was that most would be happy with the terms ?client? and ?practice?.
Shop, store and customer were not preferred terms.
Optometrists need to be wary of the commercial pressures to dumb down their profession. In some circles we are regarded as expensive human autorefractors that talk back too much. There are those that would be more than happy to see the demise of professional optometry and a law change that would allow prescriptions to be generated by electronic autorefractors.
Some think these concerns are simply the jaundiced views of biased, old-school optometrists however it is in fact younger optometrists who should be most worried. What will they be doing with their obsolete, expensive degrees in a decade or so if customers in an optical shop can be sold glasses from the results of an autorefractor? Anyone can be a shop keeper and operate an autorefractor. Why spend thirty grand or more on an optometric degree and lose a few hundred grand of income while studying? One could get a damn good autorefractor and edging machine for 30K and in four days - never mind four years - be clipping the ticket in a compact optical shop. Some already do.

It's in their own interest for young graduates to get behind professional optometry and support it at all levels.

One place to start is by using professional terminology. Coupled with a professional approach this will help patients know the difference between professional optometry and retail shoptometry.

 

KISS

 

Attending conferences can be dangerous. It's not just the liver damage and injured limbs from extreme sports.
I'm sure many of us have had the experience of hearing about a rare case at a conference and then finding one such case is booked in the following Monday. In my case I returned from the well regarded CCLS conference in Rotorua to find a book full of among other things, some of the most challenging keratoconics [KC] and grafts I had seen for some time.
There was a KC referral from Christchurch with a long history of failing to succeed in any form of contact lens wear over more than a decade. It took all my skills and many trial lenses to get anywhere near what one would consider a reasonable outcome. A 5.41mm BCOR, 9.4mm diameter PGA -23.75D on the right and a 6.64/6.30mm BCOR, 9.0mm diameter -11.00D seemed to solve a few problems in this case. I am yet to see if it succeeds long term.
A similarly complex case, on referral from an Auckland colleague who is near retirement was next. He wanted me to take over the management of a long term severe cone.
That was followed by an extreme cone I've been managing for some time. we've been trying to keep him at 6/12 with an RGP on his very steep, nipple-cone right cornea while the left grafted cornea settles. When seen for his first fitting of the grafted eye I was faced with what appeared to be graft rejection with severe epithelial staining and inflammation. A referral to a corneal surgeon for managing the apparent rejection issue was part of the management. A variety of large and medium diameter lenses and designs refused to centre or stay put on his grafted eye.
For those who attended my case series at the CCLS meeting I mentioned that rarely do I get edge fluting with 8.3 and 8.4 base curve piggyback si-hy carriers. Of course this graft proved me wrong as not a single off the shelf disposable would stay on the cornea. Eventually I settled for a small, steep toric RGP that provided the best fit and vision. We are awaiting a quiet eye before proceeding to long term wear.
The next case was a referral for a complex refit by one of my colleagues in the practice. The keratoconic gentleman concerned had been re-fitted by me with a toric periphery RGP in 2002. Since then he?d been living in the provinces and reported a history of having tried ten sets of Quad-sym lenses, none of which had worked. The lenses were showing a pretty weird fit with massive ?fresh air? edge lift, flat fitting apex, resultant hurricane staining, opacification and an almost ?square? NaFl fitting pattern. The lenses were rotating significantly ?off axis?, aggravating the problems. VA was okay but comfort wasn't. The lenses were also popping out and sliding around. In this case I went back to basics and with steep spherical base curves and custom tetracurve peripheries managed to get an excellent fit and improved vision. I must admit I made one fitting change in order to tweak the base curve by a few hundredths of a millimetre, change the diameter by 0.1mm and reduced the minus after a few days of re-adaptation. It was of course worth ?splitting hairs? as the following email excerpt confirmed; ?Good morning Alan, The new lenses are great. I am able to wear them all day comfortably. Long and reading vision a lot better than the previous pair. Left eye better than right eye. However, I am able to see a lot more without strain.?
[Right vision is limited by the severity of the cone and apical scarring.]
When refitting referrals I note that too many practitioners take the complex route, when basic principles and more simplistic designs could work a treat and solve problems. Branded speciality lenses can be fantastic in the right cases but I rarely use quadrantic asymmetric designs. I reckon I only have one or two cases still in such designs. They are very complex lenses. They often don't orientate at exactly ?six-o-clock?. If one starts rotating a lens designed to have four different peripheral edge lifts in four quadrants of the ?pie? then one ends up with a worse problem than one started with. It's a little like rotation of a soft toric; if every lens/brand shows different rotation from the previous one, you end up chasing your tail. A different approach is needed.
I'd try a toric or and Bi-Sym before succumbing to a Quad-sym. A piggyback would be another consideration.
I also see more and more practitioners assuming trendy, large diameter lenses are an easy problem solver. In the aforementioned cases that had been the route practitioners had followed. On the whole for these cases smaller, in the 8.4 to 9.2mm range, proved the best solution.
that's not to say large diameters don't work as the next case that presented needed an 11.00mm Rose K2 IC. No small diameter lenses would centre or stay put on his complex graft.

In most of the aforementioned extreme cases topographic fitting simulations were not much help either. Diagnostic lenses, NaFl and a Burton lamp were the best starting point.

 

Etc.

 

Rugby and F1 are getting interesting and will help make the dreary Kiwi winter a little more tolerable. It will also be interesting to see how the NZ economy and housing market behave over the next few months.

Will we see Financial Armageddon as some predict?

 

For more information or any comments email Alan at incontact@optom.co.nz.