Since the redesign last week, you may have noticed that the phone apps haven’t worked properly. We’re releasing updated versions of the apps to go with the redesigned site.
The Android version has already been released, and the iPhone version should be available shortly.
Let me know if you have any problems!
— adam
Should Opticians or Technicians Be Performing Subjective Examinations With Automated Technology?
by: Merrill D. Bowan, O.D.
Neurodevelopmental Optometrist Director, The Learning Clinic
Information without education is meaningless. To have visual exam data at hand without an adequate grounding in how to use it – or even, how to properly acquire it – is either meaningless, or dangerous, or merely entertainment.
There is an inherent assumption buried within the nature of the question about automated or technician-based exams that all any examiner needs to satisfy a patient’s visual needs are the right numbers in the LCD display, in the phoropter windows or in the printer output. Will the day come when we have to tolerate vision kiosks in our malls with a pair of peepholes, a knob, a printer, and an optician in the back?
Were it all that simple! The overall question is a difficult one for a number of reasons.
A professional who is overly focused on maximizing traffic and yet minimizing the time spent in patient contact (or as some have said, “…to use the time more wisely”) is not likely to be persuaded to warmly embrace a counter-point argument to the question being raised here. Yet as we myopically do this, we may fail to realize that automating and minimizing patient chair time tends to justify the trend toward further reduction in fee reimbursement schedules. To be utterly fair to the patient, the question, and ourselves as a profession, we need to soberly consider the problem from a point that takes into account the operational role of vision in human behavior.
Much of the problem may lie within our own optometric family: we are losing sight of what the goals of optometry are, what defines a patient’s needs, and what the point of a patient exam is – the why of an examination. Within that frame of thinking, the examiner must determine his or her own role: are we merely objective data gatherers, data processors, or is there a subjective component to the patient’s responses?
To strictly apply a definition to a complete exam as one that meets the patient’s needs is either inadvertently naïve or, in a worst-case scenario, it is self-serving. Yes, I’m aware of how strong those words are – for sure – but here is why I say that: the patient simply cannot be aware of all of their needs. It is not responsible behavior on our part to wait for a patient to be complaining. They are limited in their observational ability. They are poor reporters because they have an auto-centric experience of their worlds. They are just not aware of how the world is supposed to look. In illustration of this, as he reported in the Journal of Learning Disabilities many years ago, I Love Lucy producer Jess Oppenheimer only discovered his intermittent alternating exotropia when, while shaving in an Army latrine, he asked a fellow soldier how long it took his eyes to come back together after he looked away when he shaved! If we as doctors wait and only respond to patient complaints, then public health will suffer.
Indeed, patient evaluations in all allied medical fields take on two general forms:
1) Problem-focused: The patient brings in a set of symptoms. This follows a pathology-driven mentality; and,
2) Health Screening: The patient is assessed for all aspects of healthy performance. This follows a wellness mentality, an enhancement of health-based thinking.
Arguably, optometry as an institution has been drawn further and further into the first. The latter seems mostly to thrive in a small sector of the realm of private practice as a word-of-mouth, mentored phenomenon, and is now beginning to see greater quantification through post-graduate programs like the OEP/BABO confederation.
The doctor (or for purposes of this topic, the refractionist) must be educated enough to make proper assessment of the patient’s responses. To understand why, we must be willing to consider the human factors. The central concern is that mankind is a visual creature:
Does the question of delegated or automatic refraction boil down to patient- centered care versus something less? Is not pathology/medically-oriented optometry more important? The question is somewhat moot. No one would argue that we should abandon our medico-legal responsibilities to identify, refer, or treat ocular medical conditions. Yet would we ignore our accountability to identify, refer, or treat the up to 30% of the population who manifest binocular or developmental visual dysfunctioning?
To think of the refraction/visual analysis process as just “another piece of data” is to risk second-rate care to our patients. Are all refractions the same? Perhaps the more important question is looked at a bit differently, in this way:
What is the nature of ametropia? If ametropias are strictly genetic in origin, or perhaps merely idiopathic, then we have no choice as care-givers but to follow and palliate the patient. However, if there is ever any functional component to ametropia, or any medical condition that can alter the refraction, then our focus, even our responsibility, to our patient is altered. We then ethically owe it to our patient to apply our scientific ministrations to either correct or prophyllactically intervene and interrupt the process.
This brings up an extremely important question: does stress ever manifest itself in the refraction? Do medical conditions ever alter a refraction? Will a patient in emotional distress respond in a usual and customary way and render a valid prescription? How do black and white numbers or cryptic notes from a technician reflect the picture that the prescriber would see if they were personally involved in monitoring the quality of responses from the patient?
In a nutshell, it may be said that there is a lack of understanding of what vision represents to the organism, what it really is. This is the endpoint of much of the very confusion in optometry, as to what we are as a called profession. Are we:
There is a saying that those who want more theory often need more clinical practice. Those who want only clinical results usually need more theory. Extending this thinking, we might say that those who want only refractive data need more clinical observation, and that those who want only clinical observation need more data.
What we can’t do, because of the moral, ethical and medico-legal ramifications of the question being posed, is to ignore the problem. It must be resolved within optometry, for the public’s welfare.
A further dimension to this discussion is that many patients expect optometrists to be the experts to deal with school-related vision problems. This covers the whole behavioral spectrum from ADD/ADHD to visual processing-based learning disabilities to autism. Only the examiner can understand the numbers before him in relation to the patient’s needs, the patient’s performance, the patient’s responses. To equate the results of a refraction with those of an EKG as some have done – with technicians performing each – is to discount the objective versus subjective nature of the two tests. The qualities of the responses of a refraction are revealing – they can be as important to an artful examiner as are the actual findings.
The refraction is a road test of the visual system under controlled conditions. Has the visual system the resources to cope (as measured by the duction tests)? Is it distorting due to performance stresses (as reflected by the phorias)? Has it begun to collapse (as in Streff Syndrome)?
Vision is an operation that involves the total organism.
Optometry is the only profession capable of bridging visual perceptual processing with the manifestation of any external distortions. AM Skeffington, the father of modern developmental visual science, said many times that refractive error is the last stage of a visual problem and that a visual problem is an outer manifestation of an inner problem. These platitudes are far from philosophical only; they are seen daily in all of our exam rooms. They have proven themselves true hundreds of thousands of times: they just need a proper examiner to observe and evaluate them.
To restate the initial postulation of this discussion, information with education is highly meaningful. To have data at hand with adequate grounding in knowing what to do with it is not only meaningful, but it is healing and it enhances the quality of life of the recipient. A visual exam requires the observation of a trained professional, a doctor, and the patients will be benefit from and be grateful for it.
The Acuvue Vita is a new monthly replacement lens by Johnson & Johnson Vision Care, Inc.
In this interview, I spoke with @Jeffrey Sonsino and @Cristina Schnider OD MSc MBA at AOA Boston about the new lens and how it fits into practice.
(Interestingly, Jeff was the very first person to place a commercial order for the lens, so as of now, he knows more than anyone about its long-term performance in the field.)
About Jeff & Cris:
Jeff Sonsino, OD, FAAO is the Chairman of the AOA’s Contact Lens and Cornea Section. He graduated from the New England College of Optometry with research honors, was a Faculty member at Vanderbilt Eye Institute for 12 years, and now is a partner in a multi-specialty private practice in Nashville, TN. Additionally, Dr. Sonsino consults for nine industry companies, including Johnson & Johnson Vision Care, Inc.
Cristina Schnider, OD, MBA, FAAO is a Global Professional Affairs Director with Johnson & Johnson Vision Care, Inc. She received her Doctor of Optometry from Pacific University College of Optometry, a Master of Science from the University of New South Wales, and she spent 14 years as a contact lens educator and researcher at Pacific University College of Optometry, the University of New South Wales in Sydney, and at the State University of New York (SUNY) College of Optometry. Dr. Schnider has worked with Johnson & Johnson Vision Care, Inc. for 17 years.
If you have any questions, post ’em here!
Welcome to the latest iteration of the site.
We’re in the midst of upgrading the place & adding some cool new features.
Help us stomp out the bugs!
Visit this thread & shape the site over the next several days!
The SpecialEyes 54 Multifocal is a custom soft contact lens option for your presbyopic patients. It is unique in that you can custom tailor the optics to each patient’s individual pupil size via the SpecialEyes Multifocal Simulator.
In this fun ODwire.org Radio show, Drs. Matthew Lampa and Moshe Schwartz discuss both the clinical and practice-building aspects of this lens.
We get into:
Thanks again to SpecialEyes for being a site sponsor — their support is appreciated!
Fewer than 5% of optometric practices ever get past the $1 million dollar a year revenue landmark.
Indeed, according to Dr. Jerry Hayes in his book, getting past the $900k barrier is one of the most daunting challenges a practitioner faces.
The Challenge:
How can a solo practitioner, in practice for 30 years with mostly static growth, ramp up his practice to crack the $1MM barrier?
In this on-the-road episode of ODwire.org Radio, we take a trip to Jacksonville, FL to speak with Dr. Kevin Henne and Dr. Tim Petito.
We first talk to Dr. Henne about how he’s transformed his “mature” practice to accelerate its growth in an attempt to crack the million-dollar revenue barrier.
We specifically cover:
Dr. Petito also tells us about his practice which is demographically very different from Dr. Henne’s (ie, more elderly), but still benefitted from new technology.
Dr. Henne and Dr. Petito can take your questions in this thread.
(Thanks to Marco for inviting me into their corporate HQ and providing us with a nice quiet space for us to record the interview! I confess that I totally littered their place with cables, microphones, etc… and I didn’t even have Paul around to blame!)
You may not think a lot about where contact lenses come from, but ponder this: a daily disposable needs 30x the number of lenses that a monthly does.
How does one scale up to consistently produce a new product like this? In a wide parameter range, no less? (Acuvue Oasys 1-Day will cover +8 to -12 at launch, and nearly 20,000 fit sets will be produced within the first several months, so all fitters that want to will have a crack at it.)
I got a tour of the production facility and was able to interview Tim Ryan, JJVC’s Plant Manager, and Mike Alleva, World Wide VP of Operations to talk about this new production lines & how they have been able to produce the lens in the quantities that will be needed right out of the chute.
Dr. Dave Turner, Senior Director of World Wide R&D at JJVC, and Bart Johnson, Senior Manager R&D at JJVC Jacksonville discuss the science behind the lens, its design, and comparison to other products such as DT1.
In this first interview with Laura Angelini, President, Johnson & Johnson Vision Care, Inc. and Dr. Millicent Knight, Head of Professional Affairs, JJVC we talk about Acuvue Oasys 1-Day, what makes this product launch different from all others, and what it will mean to clinicians and patients.
In this ODwire.org Radio Show, we interview Dr. Faive Kovalis, the founder of SmartOD.com.
The company provides an online site for eye care professionals to directly order frames and lenses WITHOUT the need for sales rep visits or ‘boots on the ground’. This removes a great deal of cost.
Using Zappos as a model, docs can go to the SmartOD.com web site, order product that they want to evaluate, and return any product they don’t want in a pre-paid box.
We get into:
If you have any questions for Dr. Kovalis, please post them here!
