Primary care optometry in the 21st century
Comprehensive care of the visual system is and will remain the foundation of our profession. However, as medical knowledge has advanced, so has understanding of the eye, vision, ocular disease, and related systemic disease. The definitions of “primary care” and “primary care optometry” include the components visual care, ocular health, and care associated with related systemic disorders.1
As primary care providers representing an entry point into the healthcare system, optometrists are responsible for more than the visual needs of their patients. While optometry has increased its scope of practice, ophthalmology has become increasingly sub-specialized.2 Yet specialization or limiting one’s practice does not relieve a doctor from the duty to ensure that the patient receives appropriate treatment or care consistent with standards, begging the question: Is optometry actually an eye profession with some interest in systemic disease, or will time and technology demonstrate optometry to be a primary care health profession with specialized interest in the visual system?
Symptoms of greater concern
The accepted components of a comprehensive ophthalmic examination demonstrate the systemic nature of modern optometry. Along with the chief complaint and the history of present illness, the review of systems helps the optometrist determine systemic concerns, particularly symptoms relating to eye care. Ocular-related constitutional symptoms may include fever, change in weight, and malaise. Diplopia, ocular pain and redness, subconjunctival hemorrhage, and transient or persistent loss of vision may indicate systemic disorders.
The ears/nose/mouth/throat review might reveal reduced hearing, nasal congestion, dry mouth, mouth sores, or sore throat. Chest pain or reduced exercise tolerance (cardiovascular system) and shortness of breath, cough, or wheezing (respiratory system) relate to optometric care. Snoring could indicate obstructive sleep apnea (OSA), linked to multiple ocular complications including floppy eyelid syndrome and glaucoma.3
Gastrointestinal symptoms such as abdominal pain, polyphagia, nausea, vomiting, or bleeding may be important to patient management with oral nonsteroidal anti-inflammatory drugs, oral corticosteroids, or anterior uveitis cases. Relevant genitourinary system conditions include pregnancy, kidney stones, and polyuria. Musculoskeletal complaints may include joint pain, back, or neck pain, weakness, and jaw claudication. Important integumentary symptoms include scalp tenderness, lumps/bumps, and rash.
Depression, anxiety, and short-term memory loss (psychiatric) may affect ongoing care or be related to diagnosed glaucoma or vision loss.4 Seizure, numbness, tingling, headache, hallucination, aura, syncope (neurological), easy bruising, swollen glands or nodes (hematological/lymphatic), polydipsia, heat/cold intolerance (endocrine), hives/itching (allergic) may all prove useful in relating ocular care to systemic care.
Crucial for comprehensive care of optometric patients:5
• General observation
• Prescription and herbal medications
• Supplements
• Past history (eye diseases, injuries, surgeries, asthma, chronic obstructive pulmonary disease, hypertension, stroke, migraine, autoimmune disorders, OSA, herpes simplex virus [HSV])
• Family history (eye and related systemic diseases, migraine)
• Social history (driving status, living arrangements, occupation, activities, pets, alcohol, tobacco, and illicit drugs)
Related systemic diseases seen in optometric practices are large in number. Conditions may include diabetes mellitus (DM) and other endocrine disorders such as hyperthyroidism, hypothyroidism, pituitary tumor, hyperparathyroidism, hypoparathyroidism, Cushing’s disease, and Addison’s disease. Optometrists are specifically cited as important members of teams caring for patients with diabetes.6 Vascular diseases, such as hypertension, carotid artery disease, coronary artery disease, and vertebral-basilar disease, and blood disorders, such as anemia or sickle cell disease, have ocular manifestations. Immune system disorders, such as Sjögren’s syndrome, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), giant cell arteritis (GCA) and sarcoidosis, frequently have ocular manifestations.
Further examples of systemic conditions with ocular relevance include cancer-melanoma, basal cell carcinoma, breast or lung cancer metastasis-infectious diseases, such as presumed ocular histoplasmosis syndrome (POHS), Lyme disease, toxoplasmosis, HSV, herpes zoster virus (HZV), epidemic keratoconjunctivitis (EKC), sexually transmitted diseases (STDs), and dermatological conditions such as rosacea, and dermatitis.
Kidney disease may produce ophthalmic findings including band-shaped keratopathy, posterior subcapsular cataract, renal retinopathy, Elschnig’s spots, nonrhegmatogenous retinal detachment, and Seigert’s streaks.7 Gastrointestinal disorders such as Crohn’s disease and psychiatric disorders are also significant systemic conditions with multiple associations to primary eye care. Neurological conditions such as cardiovascular accident (CVA), traumatic brain injury (TBI), multiple sclerosis (MS), pseudotumor cerebri, tumor, Horner’s syndrome, and cranial nerve palsies are familiar to optometrists. Obesity is linked to ocular complications.8 Sudden illnesses can occur in any optometric office, including fainting, choking (particularly infants), seizure, CVA, diabetic emergencies, anaphylaxis, and acute myocardial infarction.9
Next: Diagnostics and testing
Diagnostics and testing
Optometrists routinely order laboratory testing for systemic disease with ocular manifestations (sickle cell disease, GCA, DM, thyroid disorders, etc.). In-office testing for EKC is readily available.10 Improved technology should allow easy in-office testing for other etiologies of systemic/ocular disease.11 Genetic testing will increasingly provide optometrists the abilityto diagnose and educate patients regarding risks of multiple conditions.12 Imaging studies ordered by ODs allow for the diagnosis of diseases such as Grave’s disease, CVA, and tumor. Existing office instrumentation, such as sphygmomanometry, perimetry, color vision testing, optical coherence tomography, and visual evoked potential, often aid in the diagnosis of related systemic conditions.
Oral pharmaceuticals used for systemic treatment often produce adverse ocular effects. Tamoxifen, hydroxychloroquine, amiodarone, bisphosphonates, cetirizine, retinoids, and topiramate are well known to eyecare providers (ECPs). Oral fluoroquinolones have recently been considered to increase the risk of retinal detachment.13 In addition, ODs write prescriptions for oral pharmaceuticals, including antibiotics, antivirals, steroids, and opiate analgesics in multiple jurisdictions. This privilege necessitates a thorough and ongoing understanding of pharmacology and organ systems.
Nutrition research is an ongoing concern for ECPs.While generally safe, adverse effects from the supplements used in the Age-Related Eye Disease Study include urinary tract problems.There are additional concerns regarding possible risks of prostate cancer and lung cancer.14 Illicit drug use is also responsible for multiple adverse ocular events.15
As experts in care of the visual system, optometrists frequently encounter and manage disorders of the central nervous system (CNS) or their manifestations, including MS, cranial nerve palsies, TBI, pupil anomalies, CVA, Parkinson’s disease, Alzheimer’s disease, and more.
Next: Anterior, posterior segments
Anterior, posterior segments
The examination of the posterior segment often reveals conditions relevant to systemic care. Congenital hypertrophy of the retinal pigment epithelium is associated with familial colorectal cancer.16 Age-related macular degeneration (AMD) may be associated with increased risk of CVA as well as depression.17 Infectious diseases, including toxoplasmosis, toxocariasis, and POHS, are posterior segment diagnoses of systemic relevance.18 Retinopathy may indicate diminished cognitive ability and vascular changes in the brain.19
The anterior segment also provides opportunities for the OD to diagnose, suspect, or manage related systemic disease. The tear film, lids, and lacrimal system are frequently affected by dermatological, endocrine, infectious, or autoimmune disorders.20 Corneal disorders may be associated with collagen vascular disease, Wilson’s disease, Fabry disease, obvious infection (HSV, HZV), and many others.21,22 Uveitis is a relatively common condition with multiple systemic etiologies.23 Crystalline lens abnormalities may be associated with effects of medications, DM, tobacco, or ultraviolet radiation (UVR).24
Because optometrists co-manage or perform surgical procedures, expertise of related systemic diseases is required. Knowledge of pharmacology, adverse effects of medications, and potential operative and post-operative complications can be crucial to outcomes. Immunodeficient, autoimmune disease, and pregnant patients may be poor refractive surgery candidates.25 Alpha-1 blockers used for treatment of benign prostatic hyperplasia are linked to intraoperative floppy iris syndrome.26 Intravitreal injections of vascular endothelial growth factor inhibitors for the treatment of AMD have been linked to non-fatal myocardial infarction, CVA, and vascular death.27
Optometrists manage glaucoma at some level in 49 United States jurisdictions. Interestingly, primary open-angle glaucoma may represent a neurological disease rather than an ocular disease.28 In addition, pseudoexfoliation and pseudoexfoliation glaucoma are ocular manifestations of a systemic condition.29 The medications used to manage glaucoma have significant systemic adverse effects.30 Examination of the patient’s fingers may reveal ulnar deviation and joint swelling, limiting the ability to instill drops, or nail bed hemorrhages linked to disc hemorrhage and glaucoma.31 The diagnosis of glaucoma has been linked to a broad range of patient co-morbidities, emotions, and concerns.32
Next: Specialized patient populations
Specialized patient populations
As primary care providers, optometrists often deliver care to specific patient populations-nursing homes, residential care facilities, assisted living facilities, prisons, Veterans Administration, the Indian Health Service, vision care missions, and many more communities. In addition, public health aspects may include environmental optometry, occupational vision, and infection control, all with systemic ramifications. Ultraviolet radiation has been linked to skin and eye cancers.33 Computer vision syndrome includes associated symptoms such as headache, pain in the back, neck, shoulders, arms, or wrists, tension, fatigue, irritability, nervousness, and drowsiness.34
ODs involved primarily with refractive or visual system care are responsible for significant related systemic care. Sports vision, including specialty contact lenses to enhance athletic performance and concussion testing, is essentially systemic in nature.35 Contact lenses have also been shown to have a positive effect of vision-related quality of life in pediatric patients.36 Keratoconus has been associated with atopy, connective tissue disorders, and genetics.37 Pediatric care offers many challenges, including an understanding of human development and congenital disease.38 While relatively uncommon in pediatric care, the ocular/systemic conditions associated with childhood may be very serious, including retinoblastoma and juvenile rheumatoid arthritis. Early signs of adverse changes to the retinal microvascular structure have been documented in sedentary 6-year-olds.39 ECPs are mandatory reporters and have been urged to be vigilant for signs of abuse.40 InfantSEE, a volunteer optometric program, brings infants to the primary care office setting, allowing for early diagnosis of potentially serious disorders.41
Vision rehabilitation and neuro-optometric rehabilitation involve multiple systemic aspects including orientation, mobility, and perception.42 While currently lacking a large amount of supporting literature, behavioral optometry also appears to positively affect optometric patients in complex situations beyond refractive or ocular care.43 In addition, many low vision patients have diseases with multiple systemic complications requiring understanding. Unusual refractive changes may signal diabetes44 (hyperopic or myopic) or be related to autoimmune disease (often myopic).45 Special populations (Down’s syndrome, cerebral palsy, autism spectrum disorder, TBI, attention deficit hyperactivity disorder, etc.) often have complicated ocular and systemic histories and needs.
Geriatric care presents multiple conditions for optometrists including vision loss, associated depression, elder abuse, and systemic diseases associated with aging.46 Lee et al found significant numbers of geriatric patients with depression, functional disabilities, and possible dementia via screening techniques in an eye clinic.47 One recent study demonstrated reduced falls in unfamiliar outdoor locations with single-vision lenses as compared to multifocal lenses.48 Neurological conditions are linked to visual complaints. Parkinson’s disease may result in ocular tremor or convergence insufficiency.49 Alzheimer’s disease may be associated with varied visual symptoms or the lack of proper eye care and visual correction.50
While the basis of optometry remains optimizing and maintaining patients’ vision, the importance of viewing the profession as part of the realm of primary health care is increasingly clear. This evolution of optometry not only allows comprehensive eye care for our patients, but also requires our ongoing dedication and commitment to professional development.ODT
References
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4. Popescu ML, Boisjoly H, Schmaltz H, Kergoat MJ, Rousseau J, Moghadaszadeh S et al. Explaining the relationship between three eye diseases and depressive symptoms in older adults. Invest Ophthalmol Vis Sci 2012;53:2308-13.
5. Fraunfelder FW. Ocular side effects from herbal medicines and nutritional supplements. Am J Ophthalmol 2004;138:639-647.
6. National Diabetes Education Program. Redesigning the Health Care Team: Diabetes Prevention and Lifelong Management. Available at: http://www.ndep.nih.gov/media/TeamCare.pdf. Accessed August 31, 2012.
7. Muchnick B. Clinical Medicine in Optometric Practice. St. Louis, Mosby;2008:98-99,236.
8. Bohlman H. Communicating the ocular and systemic complications of obesity to patients. Optometry 2005;76:701-712.
9. Heinberger MH, Madonna RJ, Nehmad L. Emergency Care in the Optometric Setting. New York, McGraw-Hill;2004:27-49.
10. Kaufman HE. Adenovirus advances: new diagnostic and therapeutic options. Curr Opin Ophthalmol 2011;22:290-293.
11. Leyden MR, Messinger RJ, Schuman C, Sharf T, Remcho VT,Squires TM et al. Increasing the detection speed of an all-electronic real-time biosensor. Lab Chip 2012;12:954-959.
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13. Etminan M, Forooghlan F, Brophy JM, Bird ST, Maberly D. Oral fluoroquinolones and the risk of retinal detachment. JAMA 2012;307:1414-1419.
14. The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group. The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. N Engl J Med 1994;330:1029-1035.
15. French DD, Margo CE, Harman LE. Substance use disorder and the risk of open-angle glaucoma. J Glaucoma 2011;20:452-457.
16. Chen CS, Phillips KD, Grist S, Bennet G, Craig JE, Muecke JS et al. Congenital hypertrophy of the retinal pigment epithelium (CHRPE) in familial colorectal cancer. Fam Cancer 2006;5:397-404.
17. Ikram MK, Mitchell P, Klein R, Sharrett AR, Couper DJ, Wong TY. Age-related macular degeneration and long-term risk of stroke subtypes. Stroke 2012 Jun;43(6):1681.
18. Mcleod R, Boyer KM, Lee D, Mui E, Wroblewski K, Karrison T et al. Prematurity and severity are associated with toxoplasma gondii alleles (NCCCTS, 1981-2009). Clin Infect Dis 2012 Jun;54(11):1595-605.
19. Haan M, Espeland MA, Klein BE, Casanova R, Gaussoin SA, Jackson RD et al. Cognitive function and retinal ischemic brain changes: The Women’s Health Initiative. Neurology 2012;78:942-949.
20. Karns K, Herr AE. Human tear protein analysis enabled by an alkaline microfluidic homogeneous immunoassay. Anal Chem 2011;83:8115-8122.
21. Garmizo G, Fraens BJ. Corneal copper deposition secondary to oral contraceptives. Optom Vis Sci 2008;85:E802-807.
22. Samily N. Ocular features of Fabry disease: diagnosis of a treatable life-threatening disorder. Surv Ophthalmol 2008;53:416-423.
23. American Optometric Association. Optometric Clinical Practice Guideline. Care of the Patient with Anterior Uveitis. Revised 2004.
24. Roberts JE. Ultraviolet radiation as a risk factor for cataract and macular degeneration. Eye Contact Lens 2011;37:246-249.
25. Barbazzetto IA, Pizzarello LD. Ocular changes during pregnancy. Compr Ophthalmol Update 2007;8:155-167.
26. Chatzirialli IP, Sergentanis TN. Risk factors for intraoperative floppy iris syndrome: a meta-analysis. Ophthalmol 2011;188:730-735.
27. Stewart MW. The expanding role of vascular endothelial growth factor inhibitors in ophthalmology. Mayo Clin Proc 2012;87:77-88.
28. Chang EE, Goldberg JL. Glaucoma 2.0: neuroprotection, neuroregeneration, neuroenhancement. Ophthalmology 2012;119:979-986.
29. Praveen MR, Shah SK, Vasavada AR, Diwan RP, Shah SM, Zumkhawala BR et al. Pseudoexfoliation as a risk factor for peripheral vascular disease: a case-controlled study. Eye (Lond.) 2011;25:174-179.
30. Detry-Morel M. Side effects of glaucoma medications. Bull Soc belge Ophthalmol 2006;299:27-40.
31. Park HY, Park SH, Oh YS, Park CK. Nail bed hemorrhage: a clinical marker of optic disc hemorrhage in patients with glaucoma. Arch Ophthalmol 2011;129:1299-1304.
32. Wu PX, Guo WY, Xia HO, Lu HJ, Xi SX. Patients’ experience of living with glaucoma: a phenomenological study. J Adv Nurs 2011;67:800-810.
33. Gallagher RP, Lee TK, Bajdik CD, Borugian M. Ultraviolet radiation. Chronic Dis Can 2010;29 Suppl 1:51-68.
34. Sheedy JE, Shaw-McMinn PG. Diagnosing and Treating Computer-Related Vision Problems. Burlington, MA, Butterworth Heinemann;2003:40-43.
35. Erickson GB, Horn FC, Barney T, Pexton B, Baird RY. Visual performance with sport-tinted contact lenses in natural sunlight. Optom Vis Sci 2009;86:509-516.
36. Rah MJ, Walline JJ, Jones-Jordan LA, Sinnott LT, Jackson JM, Manny RE et al. Vision-specific quality of life of pediatric contact lens wearers. Optom Vis Sci 2010;87:560-566.
37. Bennett ES, Barr JT, Szczotka Flynn L. Keratoconus. In: Bennett ES, Henry VA, ed. Clinical Manual of Contact Lenses. Philadelphia, Lippincott Williams & Wilkins;2009:468-470.
38. Bremond-Gignac D, Copin H, Lapillonne A, Milazzo S. Visual development in infants: physiological and pathological mechanisms. Curr Opin Ophthalmol 2011;22:Suppl:S1-8.
39. Gopinath B, Baur LA, Wang JJ, Hardy LL, Teber E, Kifley A et al. Influence of physical activity and screen time on the retinal microvasculature in young children. Arterioscler Thronmb Vasc Biol 2011;31:1233-1239.
40. Moore DB, Herlihy EP, Weiss AH. Chronic keratoconjunctivitis with dermatitis as a presenting sign of child abuse. J AAPOS 2012;16:193-195.
41. InfantSEE. Available at: http://www.infantsee.org/. Accessed September 1, 2012.
42. Hayes A, Chen CS, Clarke G, Thompson A. Functional improvements following the use of the NVT Vision Rehabilitation program for patients with hemianopia following stroke. NeuroRehabilitation 2012;31:1-12.
43. Barrett BT. A critical evaluation of the evidence supporting the practice of behavioural vision therapy. Ophthal Physiol Opt 2009;29:4-25.
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45. Arellanes-Garcia L, Preciado-Delgadillo M, Garza-Leon M. Refractive changes in patients with autoimmune scleritis. J Ophthal Inflamm Infect 2011;1:173-175.
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Dr. Ohlson is in private practice in rural Iowa, has been awarded Diplomate status in the American Academy of Optometry Primary Care Section and the American Board of Certification in Medical Optometry, and currently serves as president of the Association of Regulatory Boards of Optometry (ARBO). Reach him at mutineer@qwestoffice.net.
Existing office instrumentation often aids in the diagnosis of related systemic conditions.
• Sphygmomanometry
• Perimetry
• Color vision testing
• Optical coherence tomography
• Visual evoked potential
Crucial for comprehensive care of optometric patients:5
• General observation
• Prescription and herbal medications
• Supplements
• Past history (eye diseases, injuries, surgeries, asthma, chronic obstructive pulmonary disease, hypertension, stroke, migraine, autoimmune disorders, OSA, herpes simplex virus [HSV])
• Family history (eye and related systemic diseases, migraine)
• Social history (driving status, living arrangements, occupation, activities, pets, alcohol, tobacco, and illicit drugs)
