Eye on Optometry

Company Name: Bausch + Lomb

Company Description: Bausch + Lomb, a Bausch Health Companies Inc. company, is a leading global eye health organization that is solely focused on helping people see better to live better. Its core businesses include over-the-counter products, dietary supplements, eye care products, ophthalmic pharmaceuticals, contact lenses, lens care products, ophthalmic surgical devices and instruments. Bausch + Lomb develops, manufactures and markets one of the most comprehensive product portfolios in the industry, which is available in more than 100 countries. For more information, visit www.bausch.com.

Author: Dr. Jill Saxon is the Senior Director of Professional Strategy at Bausch + Lomb and is part of the leadership team for U.S. Vision Care. Prior to joining Bausch + Lomb, Dr. Saxon worked as an optometrist for more than five years at Randolph Eyecare Center in Randolph, N.J., where she provided both adult and pediatric eye care. Earlier in her career, Dr. Saxon served as an optometrist at the National Naval Medical Center (NNMC) in Bethesda, M.D., as a Lieutenant in the United States Navy.

I’m often asked by students for advice as they begin their career. My answer is simple and consistent—never lose sight of why you chose to be an Optometrist.

I remember, early on in my career, I was taking care of a patient who had just returned from the war in Iraq. He was only 20 years old and had recently lost all his limbs following an IED explosion. Despite needing visual correction, with the physical limitations he was experiencing, he craved the freedom of not needing to continually ensure spectacles remained on. My desire was to give this young soldier, who gave us all so much through his sacrifice, the gift of sight.

A simple gesture, I fitted him with contact lenses. I also worked with his wife to teach her how to insert and remove his lenses for him, knowing he was unable to do so. He shared with me how wearing contact lenses completely changed his life. Through their use, and the independence they provided him, he shared that he was able to find strength and confidence. Most importantly, he was proud to be able to see his wife deliver their first child.

As optometrists, we don’t just help people see better; we can play a crucial role in their overall well-being. By providing outstanding patient care and offering them the latest innovations in eye health, we can help improve their vision.

We also have the rare opportunity in today’s world, dominated by digital devices, to still be able to build personal relationships with our patients and use this to educate them on vision care options they may not think of—or even think they need!

In recent years, the competitive landscape of our industry has changed significantly; the emergence of new channels has led to the increasing importance of health practitioners becoming educators and the need for advancements in vision care that address more patient needs than ever before. It is important for students to recognize the shifting paradigms in this field and identify some of the trends that will impact tomorrow’s practices.

Today’s patients are online, informed, and influencing tomorrow’s referrals

In the 21st century, the internet and social media are playing an increasingly influential role in patient behavior. Online health resources are becoming virtual office experiences for patients and presenting a new type of competition for the private practitioner. Years ago, word-of-mouth referrals and physician finder websites were useful tools for patients to identify local eye care practices. Today’s patients are walking into doctors’ offices more informed than ever before, having conducted thorough research online that includes reading user reviews.

With the rise of popular search engines, crowd-sourced business review sites and mobile-apps, practices are competing with “Dr. Internet”. Not only can a single online review influence public opinion and referrals, but patients are also less likely to make in-office purchases due to the availability of competitive pricing online. While they may still walk into “brick and mortar” practices to receive eye exams and even shop around for eyeglass frames and contact lenses, patients are increasingly making their final purchasing decisions online.

Optometrists must stand out in the hearts and minds of patients by fostering personal connections. As informative as the internet may be, it cannot replace the critical, two-way conversations between the patient and doctor.

The Patient’s Experience – what they’re telling us, and what they aren’t

Cut through today’s digital dominance and distinguish your expertise through meaningful conversations with patients to help improve their outcomes. The doctor-patient relationship is an invaluable and irreplaceable experience that no amount of technology can compete with. Forging relationships based on honesty and open communication can continue to grow and build trust over time.

For example, did you know that 35% of soft contact lens wearers experience blurry vision? And two-thirds of them aren’t telling their eye care providers about the problems they are having? Worse still, many of these patients are likely to blame themselves for their blurry vision rather than the contact lenses they are wearing, which may be the wrong option for them.

Let’s talk to our patients about options specifically designed for their needs.

Innovative options you may not be considering

We have an incredible opportunity to educate—and engage—our patients in conversations focused on identifying the best long-term solutions for them, providing innovative technologies that are designed to meet their needs today and tomorrow.

There are also a variety of reasons why patients may not be wearing contact lenses. In fact, current data indicates that the majority of patients with astigmatism and presbyopia are currently corrected with only with spectacles1.

In recent years, innovations in contact lens technology offer patients both clear vision and all-day comfort, addressing traditional perceived barriers to wearing contact lenses. These innovations open up new opportunities for patients and eye care professionals alike.

However, despite innovation in contact lenses, only 25% of eyeglass only wearers said their eye care professional presented contact lenses as an option during their last eye exam2. As providers, we need to expand the conversation with patients and talk about the benefits these innovative technologies can provide them.

Today’s contact lens options no longer carry some of the traditional limitations of preceding lens generations. Contact lenses have become accessible options to more patients than ever before. But are we talking to our patients about all the options available to them?

Here’s something to think about:

– There are more than 73 million vision-corrected astigmatic patients in the U.S., yet only 24 million wear contact lenses1.

– About 70% of eyeglass-only wearing astigmatic patients believe it is their astigmatism that is the barrier to wearing contact lenses1.

Furthermore, patients in need of multifocals may not consider contact lenses as an option for vision correction. But maybe that is simply because the possibility has yet to be offered to them.

We have the opportunity to inform these patients that not only may contact lenses be suitable for them, but with the innovations in lens designs, materials and expanded parameter ranges3, lenses can provide the comfort they want as well as the performance they need.

Above all else, always remember why you chose to become an Optometrist, and the opportunity you have to make an impact on every patient you treat. You can be an exceptional eye care professional by offering support, education and heartfelt counsel. The decisions we make in our practices can alleviate patients’ concerns and make them more comfortable beyond the simple act of fitting them with contact lenses. By embracing and delivering the latest innovations to meet evolving patient needs and forging a closer doctor-patient relationship, we can truly impact the lives of those we care for. After all, the commitment to the happiness and well-being of others is at the heart of why we do what we do. Don’t ever lose sight of that.

References

1. The 2016 Multi-sponsor Surveys, Inc. Target Report on the Market for Toric Contact Lenses.

2. The 2017 Multi-sponsor Surveys, Inc. Study of the U.S. Consumer Contact Lens Market.

2. CONTACT LENSES 2017. Continuing upward trends in daily disposable prescribing and other key segments maintained a healthy industry. Contact Lens Spectrum. https://www.clspectrum.com/issues/2018/january-2018/contact-lenses-2017

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NPR.0187.USA.18

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Company Name: CooperVision

Company Description: CooperVision’s dedication to prescription contact lens design, materials and manufacturing excellence enhances the wearing experience of contact lens patients the world over. CooperVision concentrates on all day wearing comfort in the widest variety of lens designs, materials and wearing options.

Author: Jennifer A. Palombi, OD, FAAO, Senior Manager, Professional and Scientific Communication

Each year, a third or fourth year student at each college of optometry has the opportunity to serve as a CooperVision student ambassador. The program is designed to give a student with an interest in the contact lens industry an opportunity to partner with CooperVision and to facilitate sponsorship and other opportunities at their school. The Student Ambassador acts as a liaison between the optometry school and CooperVision and receives a $500 educational grant for their time and effort.

Micaela Crowley, O.D., a former student ambassador from Nova Southeastern University College of Optometry described the impact that the student ambassador experience had as she entered her optometry career. “It was an excellent opportunity to learn about contact lenses in a way I would have never learned without this position,” said Dr. Crowley. “It provided insight as to how the industry side of optometry approaches patient care. I was pleasantly surprised!”

Lacie Spagnola, a current CooperVision student ambassador at the University of Missouri-St. Louis College of Optometry, agrees that the experience provides invaluable insights, even as she begins her clinical career. “I wanted to get involved in optometry school and was interested in getting familiar with our clinic. This has helped me to do both and learn more about contacts. It has allowed me to have a better understanding of contacts now that I am in a contact lens course as well,” said Spagnola.

Lacie went on to describe the relationship-building opportunities that the program has already provided her as she enters the next stage of her education. “Being a student ambassador for CooperVision has helped me to build relationships with other faculty and doctors at my school,” said Spagnola. “I work with the faculty to keep contact lenses stocked in our contact lens room, so it has allowed me to lay the groundwork for a good relationship with them when I enter into clinic this summer.” In addition to building relationships within her own school, Dr. Crowley reflected on how the program also allowed her to meet and develop relationships with key opinion leaders (KOLs) and CooperVision team members. “At the KOL dinners, I learned from many top contact lens clinicians in the country who fit CooperVision contact lenses on a regular basis. I also learned that CooperVision has an incredibly knowledgeable and fun team who care about their profession,” said Crowley.

Though at different stages in their optometry careers, both women feel strongly that their student ambassador experience gives them an advantage in their approach to their careers and clinical contact lens practice. “I think my experience as a student ambassador will help me in my career,” said Spagnola. “This position has helped me to get a better understanding of contact lenses, particularly CooperVision lenses, so that I can better fit patients in the future.”

Dr. Crowley echoed those sentiments in terms of the perspective it has given her now that she is in her own practice. “It really helped with my approach to patient care,” said Dr. Crowley. “I learned CooperVision’s inventory is enormous. They have a SCL option for all needs, thus streamlining the contact lens fit. That is so important in a busy practice. I do not automatically dismiss a patient with a prescription that is difficult to fit in conventional contact lenses. Many of these patients have been deemed non-contact lens candidates and the mere fact that I do not instantly say ‘no’ is sometimes satisfaction enough. I tell them I will try because I have the resources available to do so.”

Any student interested in future opportunities as a CooperVision student ambassador can speak to their contact lens faculty or click here to learn more about the program.

This blog is part of the ASCO corporate contributor blog series. For more information about the blog series, please contact Christine Armstrong, Director of Development at carmstrong@opted.org.

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Company Name: Diopsys Inc.

Company Description: As the world leader in modern visual electrophysiology, Diopsys, Inc. has done more than any other company to advance the use of electroretinography (ERG) and visual evoked potential (VEP) in the eye care practice. The company’s unique, patented technology provides eye care professionals with objective, functional information about the health of the vision system to aid in the early detection of vision disorders, and post-treatment tracking for enhanced patient management.

Results from these tests are not just for rare diseases, but also for the management of more common disorders like diabetic retinopathyretinal concerns obscured by media opacitiesglaucoma, and optic neuritis. See our “Resources” section for research and articles supporting the many clinical benefits visual electrophysiology can provide.

Author: William Ayliffe, FRCS, PhD

Introduction

Determining the effectiveness of treatment in a patient with suspected retinal pathology can be challenging. While visual acuity can serve as a benchmark, vision gains do not necessarily correlate with improvement in structure or global function. Despite the array of diagnostic modalities available to the eye care expert, very few of them deliver actionable information that is helpful in deciding if treatment is working, when to change course, or perhaps even when to cease treatment because risks outweigh the potential benefits.

The Need for Objective Metrics

In the busy clinical setting, clinicians need access to objective, quantitative information that will allow them to quickly determine whether the intervention they are using is having the intended effect. Because it measures electrical responses within the retina—cone cells in particular— flicker electroretinography (ERG) provides objective information about global retinal function. Flicker ERG tests have demonstrated the ability to detect retinal dysfunction in eyes with diabetic retinopathy (DR),1,2 branch (BRVO) and central retinal vein occlusion (CRVO),3,4 and uveitis,5 among others. Flicker ERG also has prognostic value that is relevant for

– staging diabetic retinopathy6-8

– predicting the development of ischemia secondary to CRVO9

– managing patients with uveitis10,11

Independently, each of the aforementioned applications of flicker ERG help build an impression about the health of the retina that is applicable to a variety of common pathologies seen by eye care experts. Armed with this knowledge, the clinician gains confidence in his or her treatment decision making process. Objective, quantifiable data is an invaluable asset when tracking progression and response to treatment in all types of cases, and especially so when results of other diagnostics and clinical tests are inconclusive.

Tracking Progression and Improvement

Yet, there is a more direct link between flicker ERG and its ability to affect treatment decisions. A multitude of research has shown that flicker ERG detects improvement in global retinal function after treatment, including in eyes with DR.12 Other clinical variables, including visual acuity testing and OCT, are valuable in assessing patients’ status, but they do not provide conclusive evidence about the effect of treatment.

For instance, there is often a disconnect between reductions in macular thickness on OCT and visual acuity gains, and in some cases, patients may exhibit visual acuity gains despite prolonged edema on the macula. Additionally, progression on OCT images indicates structural loss that is irreversible – once cells are dead, they do not come back to life. On the other hand, flicker ERG can detect improvement in retinal function after injection of anti-VEGF,12 information that is important for determining the next treatment interval, or, if there is no response, whether a switch to a different approach is warranted.

Predicting Progression and Outcomes

A similar paradigm exists in the treatment of CRVO. As noted earlier, flicker ERG can be used to detect and characterize ischemia and predict neovascularization with a greater degree of accuracy than angiography.3,4,9,13 In addition, current analysis of angiographic findings are limited to the doctor’s subjective interpretation; whereas results from electrophysiology tests are objective. Such quantitative metrics may spur a decision to initiate or increase the intensity of treatment to ward off ocular hypertension and potential irreversible vision loss.14 Moreover, flicker ERG strongly correlates with VEGF concentration within the eye, thereby serving as an index for the efficacy of attempted VEGF blockade with intravitreal anti-VEGF agents.15,16

Uveitis is often considered a confusing clinical entity with many intersecting variables to consider. Use of the flicker ERG test can help determine the level of retinal dysfunction,5,10 as well as predict which patients are likely to respond to anti-inflammatory therapy.11,17 In fact, flicker ERG is considered to be a gold standard for monitoring the activity of a posterior uveitis entity, Birdshot Chorioretinopathy.11,17

Current methods of assessing activity in uveitis such as acuity, OCT, fields and assessment of clinical haze are variable across the uveitis spectrum. For example many choroidititides may not cause vitreous haze. A drop in acuity may be the terminal event in the long course of a chronic inflammatory eye disease. Other methods of assessing activity and disease burden are urgently needed.

Because Diopsys increases patient access to electrodiagnostics, several uveitis entities can now be assessed for activity, and indeed treatment response, using flicker. The future for monitoring treatment now looks promising for these sight threatening conditions.

Conclusion

Fundamentally, a determination about whether a given treatment approach is working must consider several variables. Classic diagnostics and evaluations may be additive to the clinical impression; however, the process can be greatly facilitated by the availability of quantifiable, objective data about the function of the retina. As a measure of global retinal function, flicker ERG provides information that helps inform treatment decisions in a number of common pathologies.

This blog is part of the ASCO corporate contributor blog series. For more information about the blog series, please contact Christine Armstrong, Director of Development at carmstrong@opted.org.

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Company Name: Volk Optical

Company Description: Volk Optical is an innovator in the design and manufacture of diagnostic, therapeutic, and surgical ophthalmic lenses, portable imaging devices, surgical systems, and accessories. The company is based in Mentor, Ohio, USA, and has representatives and distributors around the world.

Author: Matt Marzullo, Vice President of Global Sales, Volk Optical

The vision care field is continually evolving, with new technology and techniques being pioneered at a fantastic pace. Continuing education is required of optometrists to keep up with these innovations; why shouldn’t we as industry partners engage in ongoing training in order to serve our ODs better?

Volk has a comprehensive in-house training program for employees. With slit lamps, BIOs, lenses and model eyes, we can get a really great understanding of basic eye anatomy. However, static model eyes, 2D textbooks and videos just can’t effectively simulate the tremendous variety of real patients our ODs see in their practices. In an effort to see what our customers actually see, we were fortunate to partner with Pennsylvania College of Optometry (PCO) at Salus University.

Last fall, our Volk sales team, product managers, engineers, and new employees visited PCO’s campus in Elkins Park, PA. as part of our Global Sales Training. Melissa E. Trego, OD, PhD, Dean of the Pennsylvania College of Optometry, orchestrated a two-day educational program for our team that included classroom lectures and hands-on time in the school’s state-of-the-art virtual reality and skills labs.

On day one, Dr. Trego, Rachel Brackley, OD, FAAO, Alissa Coyne, OD, FAAO, and Stephanie Leburg, OD, presented lectures on the anatomy of the eye and various diseases in all stages of progression. Having a deeper understanding of the conditions optometrists are diagnosing and treating is invaluable not only for our sales staff to help customers select the right product to meet their needs, but also for our product managers and engineers as we develop new products to help improve patient care.

Our team was treated to a comprehensive lesson on glaucoma–what it is, the different types, how it’s diagnosed, and what Volk products each doctor uses. It was fascinating to hear from each doctor which lens they preferred and the reasoning behind it – each liked something different, often for different reasons to suit their personal preferences. Lectures also covered diabetic retinopathy and AMD. The common thread that ran through all the lectures was what an important role our products play in helping to save people’s sight. It was a great reminder of how our products directly improve lives and why we all love what we do.

The second day was a hands-on day in PCO’s newly renovated Clinical Procedures Lab; it was time to put our classroom education to the test! The world class lab has 34 fully-equipped optometric bays, video/camera slit lamps for demonstration, and mounted live feed video cameras for integrated instruction. Our team experienced two different interactive sessions, one in the virtual reality lab, and a second in exam lanes with actual subjects (PCO students graciously and generously volunteered to sit in as our ‘patients’).

In the VR lab, we were equipped with a virtual BIO headset, virtual lens, and virtual patient. In one exercise, we searched for various shapes hidden in different parts of the eye, another offered the opportunity to diagnose pathologies. The simulated real-life experience helped us build confidence in our BIO exam skills.

In the exam lanes, each Volk employee was paired up with a PCO optometry student or faculty member and given one-on-one instruction. We practiced our slit lamp exam techniques with a range of lens types from a 90D, to a Digital Wide Field® lens, to the 3-Mirror Gonio. Having the opportunity to see how each lens performs on real-life subjects, where individual anatomy can vary greatly, was dramatically more instructional than studying a diagram or model eye. To know the definition of an open angle versus a closed angle is one thing, to see both with our own eyes took our understanding to the next level. We came away with a new appreciation of what doctors are trying to view as they administer exams and diagnose various disease states.

Our professional education went even deeper when we were taught the proper techniques of applying a contact (gonio) lens at the slit lamp. For those who were up to the challenge, instruction was also given on how to perform a BIO exam.

For me as a relatively new Volk employee, I found this weekend to be invaluable. In speaking to my Volk colleagues, even those who have been with the company for years felt they were seeing the products from a whole new perspective.

As Ezequiel Lukin, our veteran Global Sales Manager, explained “You can understand the specifications of the different lenses and know logically that a 100° field of view is wider than a 60° field of view or that a 1.0x magnification is less than a 1.3x. Using the lenses on real subjects let me experience the nuanced differences and understand from the doctor’s point of view what can be visualized through the different lenses. From listening to the faculty, lens selection is very user-dependent and not one size fits all. Factors beyond technical specs – ease of handling, exam time, contact versus non-contact, etc. – all play a role in preference. Now I’m even better equipped to ask the right questions and understand what each doctor might need in a lens.”

Lena Zhuk, Regional Sales Representative, agreed, “I feel like I have a more personal connection with the doctors now that I’ve experienced what they actually see in their offices every day. The virtual lab was also a really nice opportunity to practice before working on an actual subject. At the end of the training, I have a much better understanding of how to guide the doctor to the best product for them.”

For Sales Manager Paul Koopman, it was the detailed training in anatomy that struck him. “The lectures went into so much detail of the pathology of various disease states and what our lenses were used for. The hands-on was amazing to then literally see into the eye and see all the structures we’d learned about in the classroom. All of the insight gained will be great to take back to distributors and help in training.”

Dan Nelson, our Senior Product Manager, found the training to be valuable to the work he does on Volk’s software and imaging products. “The experience of actually looking into a real eye, getting past the pupil into the retina really gave me a feel for just how complex the eye is. I got to see the lens, see the anterior segment, and look around the retina. Experiencing what can be seen with our current imaging products naturally got me thinking about what we can do to expand and improve those capabilities and see even more anatomy at once. The visit really brought home the importance of what we do and why we keep striving to develop new products.”

The students and faculty at PCO provided a highly educational weekend and everyone we met was extremely gracious and patient. We feel so fortunate that we could experience this small glimpse into the intensive education and training future ODs undergo. Every Volk team member that attended was left with a new appreciation of the eye and the practice of optometry.

This blog is part of the ASCO corporate contributor blog series. For more information about the blog series, please contact Christine Armstrong, Director of Development at carmstrong@opted.org.

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Company Name: Rev360

Company Description: Rev360 is the eye care software and business services company that serves practices centered on RevolutionEHR. Rev360 delivers the RevolutionEHR software platform and a growing suite of optional business services to RevolutionEHR users.

Author:  Kelly Kerksick, OD, Rev360 Director of Professional Relations

Along with the excitement of going into business for yourself, there’s often a bit of apprehension.  Sound guidance and tips from someone who’s already successfully traveled the journey of business start-up and ownership can be an invaluable resource.  In this brief article, I share my own experience to answer some of the most common questions asked by doctors just starting out in practice. I hope you find this information helpful and I wish you the best in your new endeavor!

1. How much space will I need?

I recommend starting with a smaller amount of space.  It doesn’t make sense to pay for a bunch of space that you aren’t using or haven’t grown into. I opted to start small with my practice (900 sq ft) and then, four years later, I bought a building that provided 3600 sq ft of space.  As a result of starting small, I was able to get out of the red faster and set aside some money.  My small nest egg quickly grew and gave me 20% cash to put down on my new building.

2.  Where should I open a new practice?

Open a practice in a community that you want to be a part of.  The second point of consideration should be whether or not there is a good business opportunity in the community.  If you can answer yes to both of those factors, you have a winner!

3.  What equipment do I need?

Start out with one or maybe two pieces of equipment such as a visual field analyzer and a retinal camera.  As the practice grows, it is wise to reinvest any profits back into the practice by purchasing more equipment.  Each year, consider adding one new instrument from profits.

4.  What, if any, insurance plans should I take?

Early on, it can be advantageous to take a large variety of insurance plans.  These plans, even if less desirable due to lower reimbursements, etc., can be very beneficial in growing the practice.  This is a great way to attract new patients to the practice and establish a rapport with them.  As you become busier, it makes sense to drop those lower paying plans.

5.  How do I get credentialed?

Credentialing can be tricky.  It can take months getting appropriately credentialed which is why I recommend outsourcing this.  My advice is to hire a company to do this piece for you that knows what questions to ask.

6.  How do I hire and train employees?

I always preferred to hire for attitude and train for skill rather than hire someone highly skilled that didn’t have a great personality.  Early in your practice, you will have the time to devote to training and teaching new employees how to do various tasks within the practice.  Some of my best employees were those who came to the table with no experience.  While it can be time consuming to train these kinds of individuals, you also have the ability to train them correctly.

7.  How do I market my new practice?

Get heavily involved in your community.  Volunteer and participate in local civic organizations.  This shows your commitment to the community and is a way that you can give back.  These opportunities always pay themselves off in dividends.  I found limited success with advertising.  My best marketing came from me.  Giving the community the opportunity to see my commitment to the community and its people was such an important part of my practice’s growth early on.

8.  How do I learn billing and coding?

Many times, the software within your electronic health record can assist you with billing and coding.  If it doesn’t, I would recommend that you attend classes to help to bring you up to speed.  Always remember, just because you get paid by the insurance company does not mean what you filed was correct.  I’ve seen too many practitioners code and bill incorrectly and while unintentional, it can be a very costly mistake as most insurance companies will demand recoupment of claims filed incorrectly.

9.  Should I start off with an EHR and Practice Management software program right away?

Absolutely!  One of the best advantages you have as a new start up practice is the ability to start from day 1 with an electronic health record system.  Often you can begin implementation and training while you are building out your practice so you are ready to go the first day you open your doors. Also, if chosen wisely, the system can also provide you with much more than just a way to schedule patients and document eye exams.  Often times, your EHR will serve as an indispensable employee.

10.  What advice do you have regarding choosing the best vendors for my new practice?

Choose a partner rather than a vendor.  Choose the company that wants to work with you and help your practice grow rather than choose a company solely on their product offering.  You want the whole package.

This blog is part of the ASCO corporate contributor blog series. For more information about the blog series, please contact Christine Armstrong, Director of Development at carmstrong@opted.org.

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Interest in a health professions career such as optometry can spring from a variety of motivations, but a desire to help people is a common inspiration. Sight is such a precious human sense, the care optometrists provide is of immense value to the patients they serve. As shown in the international Barometer of Global Eye Health survey, most people would rather lose a limb or 10 years of their life than lose their vision. The care optometrists provide can be life-changing, and the following stories are just a few examples of how. The stories highlight some of the many different areas in which optometrists can specialize, the expertise available at private practices as well as in the eyecare centers of schools and colleges of optometry, and the dedication optometrists apply to delivering the solutions their patients need.

If you missed Part 1, click here to read it, and read Part 2 below.

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As a student working toward her Doctor of Optometry degree, Brittney Schieber looked forward to the time when she could start applying everything she had been learning to real-world patient care. In August 2017, during her third year at the University of Missouri-St. Louis College of Optometry, she began her rotations through different types of eyecare clinics, seeing patients alongside supervising optometrists. Her very first contact lens case turned out to be, pardon the pun, an eye-opener.

The patient was a 23-year-old male who had been diagnosed with an eye condition called keratoconus in 2011. Keratoconus is characterized by thinning and bulging of the cornea and therefore blurry, distorted vision. It can progress to the point that cornea transplant surgery is required to restore usable vision. This patient had come to the University Eye Center after being told by other doctors that a transplant was likely necessary for him.

Regular soft contact lenses are usually ineffective for patients with keratoconus, but a different type, gas permeable contact lenses (GPs), can enable satisfactory vision, sometimes for years. The patient had tried GPs in 2012, one year after his diagnosis, but they were of no help. They were also uncomfortable because they moved around on his eye. He opted to wear glasses instead, which weren’t much better. In the intervening five years or so, even while wearing glasses, he couldn’t see well enough to drive or to comfortably read. He also suffered from headaches, possibly because he was always squinting, and simply didn’t do many of the things a young man would normally do.

Brittney spoke with the patient to obtain his medical and ocular history and was surprised to hear he was still struggling even though he had just gotten a new pair of glasses two weeks ago. Going through the routine tests of an eye exam, she determined that his vision was correctable. This was curious as well because it meant properly prescribed glasses or properly fit GP contact lenses, or perhaps a third option of scleral contact lenses, should be helpful. Scleral contact lenses are larger than standard GPs, extending to the white part (sclera) of the eye, and tend to be more stable. They’re custom fit to the individual eye based on sophisticated imaging and measurements.

Brittney and the supervising optometrist ran the tests necessary to prescribe scleral contact lenses and placed a trial pair in the patient’s eyes. Brittney describes what happened next: “As soon as the lenses were in, his eyes got really wide, not squinty, and he started looking around at everything in the room. He scrolled through messages on his cell phone without needing to have it right up to his face. He was looking at his hands, too, and saying how he hadn’t seen them so clearly in years. His mom was in the exam room and he told her how clearly he could see the details of her face, which he hadn’t noticed in quite a while.” With his vision much improved, the patient went back to driving and was thrilled to be able to read and play video games without straining and headaches. With functional vision restored with the scleral lenses, a corneal transplant wouldn’t be necessary right now. In addition, it was explained to the patient that if his keratoconus continues to worsen, he may be a candidate for a new non-surgical treatment called corneal crosslinking, approved by the FDA in 2016, which can stabilize or slow progression of the disease.

While it was a great day for this patient, Brittney says it was also quite amazing for her. While she was knowledgeable about keratoconus in a textbook sense, this was the first time she saw for herself the effects it could have on someone’s life. Better yet, she says, “I have to admit I actually got goosebumps realizing how frustrated they were when they came in and how apprehensive they were about surgery and how what we did helped so much. It made me feel really good about my decision to become an optometrist.”

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Diabetes can take a toll on the entire body, including the eyes. “Joyce,” who has type 1 diabetes, the type that manifests at an early age, knows this all too well. Now 34, she has experienced many diabetes-related ocular complications and undergone multiple types of treatments, all of which have reduced her vision over the years. It was a more sudden worsening of her eyesight over several months, however, that led her to the William Feinbloom Vision Rehabilitation Center at Salus University. Patients come to the Feinbloom Center to learn how to live with decreased vision and to be prescribed and taught to use devices for what’s known as low vision: poor eyesight that is no longer correctable with glasses, contact lenses, medicine or surgery.

Joyce conveyed the problems she was having to Erin Kenny, OD, FAAO, chief of the Feinbloom Center and assistant professor at Salus University Pennsylvania College of Optometry. While she felt comfortable in her own home because every room was so familiar, Joyce avoided going out at night and into new environments because she was having so much trouble seeing. Moving around felt unsafe in those situations. Stairs and curbs posed big dangers. She frequently bumped into things. Even her ability to do the crucial task of reading her insulin pump could no longer be taken for granted. Joyce was forced to drop out of graduate school, just two semesters short of earning her degree. Her biggest concern was how her vision made it difficult to care for her 1-year-old daughter. Reading food labels was impossible, and spotting the little girl as she crawled around the house was problematic. She worried what the future would bring.

With Dr. Kenny and the rest of the rehabilitation team, Joyce was in good hands. Dr. Kenny prescribed several low vision devices designed to make Joyce’s remaining vision more functional. For example, telescope-like devices, both handheld and mounted on a glasses frame, enable her to see far away, and different types of magnifiers allow her to read labels and her class materials. She did, by the way, return to school. With orientation and mobility training, Joyce also learned techniques for getting around safely and confidently. And she was able to take advantage of aids around the house such as special stickers to make the numbers and buttons on the stove identifiable by touch. She was happy to be referred to a state agency that could assist her in an employment search when she was ready.

Joyce moved to another state a few years ago, but she sticks in Dr. Kenny’s mind. One of the things she likes about providing low vision care is the relationships that are formed with patients. They’re seen at multiple visits over time as they tackle new goals along the way. “Joyce was very motivated. She worked hard and did very well,” Dr. Kenny says. “She was also very appreciative of what we were able to do for her.” The appreciation goes both ways. “I love my job,” Dr. Kenny says. “I love coming to work. Joyce is an example of what we’re able to do as optometrists. How we can change somebody’s life for the better by helping them to live more independently.”

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Babies aren’t born with fully developed vision. Their eyes and eyesight, working very closely with the brain, continue to mature for several years. This being the case, infants and toddlers are particularly sensitive to a number of eye conditions that can potentially emerge and interfere with this process. If not properly addressed by an eyecare professional, such conditions can negatively affect not only the child’s vision, into adulthood, but also his or her overall development.

It’s usually not a concern if shortly after birth a baby’s eyes occasionally seem to not be working together. For example, one eye may sometimes point more inward or outward. However, when little Finn was about 18 months old, his mom noticed something more than that. She noticed that both of his eyes were tending to drift outward frequently. Wisely, she brought him to see pediatric vision specialists Elizabeth Knighton, OD, FAAO, and Nathan Bonilla-Warford, OD, FAAO, FCOVD, who have two offices in Florida, one dedicated to family vision care and one just for kids. With a thorough initial exam, Dr. Knighton (“Dr. Beth” to her patients) determined that Finn had exotropia ― an outward drifting of the eyes. She also found that he had significant hyperopia (farsightedness) as well as astigmatism. All three cause blurry vision, a definite threat to proper vision development.

The solution Finn needed was a pair of glasses. His glasses are designed to provide the clearest vision to each of his eyes so that his brain finds it easier to keep them aligned and provide good depth perception. Finn needs to wear his glasses as much as possible, and will likely need glasses or contact lenses for the rest of his life, but his prognosis is excellent. Dr. Bonilla-Warford describes the little guy’s progress: “He has gotten much more visually responsive. His spatial awareness is better, and because he can see the world around him better, he is more active. Because he can see his mother and others better, he is more interactive and expressive.”

Finn’s mom has been excited about how far he’s come. She shares in an online video how giving Finn glasses “gave him … a whole new him!” It goes to show, says Dr. Bonilla-Warford, “just how much a single pair of glasses can benefit a person.”

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The new glasses recently prescribed for “André” don’t provide X-ray vision or shoot laser beams ― that’s the stuff of James Bond movies and comic books, for now anyway ― but they’re pretty special nonetheless. The glasses lenses are called prism lenses, and they solved André’s double vision problem.

A patient at the New England College of Optometry (NECO) Center for Eye Care – Roslindale, André had been experiencing bouts of double vision for about four years. After reading or using the computer for 5 or 10 minutes, whatever he was looking at would split into two images. The situation was annoying but didn’t happen very often, so he hadn’t wanted to take any steps to fix it. That changed when it started happening more frequently. It reached a point where it was adversely affecting his work as a quantitative analyst, which relies heavily on close-up work like reading and online research, which was precisely when his issues occurred. He was making errors and his performance reviews at his Boston financial firm were slipping. The 44-year-old decided it was time to seek a solution.

During André’s visit to the NECO clinic, Jennifer Williams, OD, MS, clinical assistant professor of optometry and attending optometrist, performed the tests necessary to determine the cause of the double vision. Double vision (technical name: diplopia) can be a diagnostic challenge because there are many potential causes, such as corneal irregularities or cranial nerve palsies, to be confirmed or ruled out. Proper treatment, which in some cases may be surgery, hinges on knowing the specific cause. The fact that André’s problem didn’t come on suddenly eliminated some of the potential causes that would have constituted an emergency. Dr. Williams was able to determine that esotropia, an inward eye turn, was the culprit. An eye muscle problem, esotropia prevents the eyes from working together properly, hence the double vision. It can become harder to control as time goes on, which is what was happening for André.

Prism eyeglass lenses were the logical treatment option to try first. They’re based on optical science, i.e., how the prism shape added to a lens bends light. The effect is to “move” the image in a patient’s view to the spot where the brain thinks the eyes are working together. But fitting them is also somewhat of an art. “It’s challenging to find just the right amount, the right power, of prism to incorporate into the lenses,” Dr. Williams explains. “It’s all about what is comfortable for the patient, and you rarely end up prescribing the amount your tests have measured.”

André and Dr. Williams worked through the prescribing process, prism was added to the glasses prescription he was already wearing, and the result was a slam dunk. No more double vision. The prescription will likely have to be adjusted from time to time to keep the problem at bay, but for now, André is happily back to crunching the numbers, one set at a time rather than two.

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As a Los Angeles-area optometrist who works in a private practice and serves as an adjunct faculty member with the Southern California College of Optometry at Marshall B. Ketchum University, Brett Nagatani, OD, treats all types of patients. He finds that providing care for those with low vision ― poor eyesight due to ocular disease or injury that can’t be corrected with glasses, contact lenses, medicine or surgery ― can be especially rewarding. “Many people feel that without perfect vision they can’t do anything,” he says. “However, in reality, they can still work, travel, date, use the computer, and do most things sighted people do. Low vision optometrists and the devices they prescribe open up that world of possibilities.”

By the time Dr. Nagatani met Mr. Garcia at the University Eye Center, it had been 19 years since Mr. Garcia suffered a traumatic head injury from falling off a bike. The injury permanently damaged his optic nerve, making him legally blind. Despite having to give up his construction job as well as the sports and marathons he had loved so much, he had been getting along OK. The more time that passed, however, the more he realized there were quite a few things that used to be simple that now he really missed. He became increasingly frustrated with not being able to comfortably read small print, walk around in unfamiliar areas (especially at night), use the computer, or watch television. Finally, he decided to seek help and called the University Eye Center to schedule a low vision evaluation.

Dr. Nagatani and the low vision team demonstrated for Mr. Garcia various devices, such as telescopes and magnifiers with LED lights, that could make his distance and near vision more functional. He was able to find several that addressed his needs and fit his lifestyle. He was particularly excited about an electronic video magnifier that enlarges reading material up to 100 times yet still enables the user to move through the lines and pages efficiently. In addition, the team referred Mr. Garcia to the California Department of Rehabilitation, which could connect him with other services related to independent living and potentially help with job placement. According to Dr. Nagatani, Mr. Garcia’s time with the low vision team gave him new motivation, and he was “looking forward to all of the possibilities his low vision devices would provide.”

 

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