A little bit of basic ocular anatomy… What is the eye surrounded by?

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As I wrote in the last post, in this one I am going to briefly explain those structures surrounding the eye; they are as important as the eye itself, because if any of them are not in perfect condition, the visual information can not be adequately processed.

LACRIMAL SYSTEM AND EYELIDS

EYELIDS protect the eye against any element that “wants” to get in. There is a reflex that cause that, when we simply touch the eyelashes, the eyelid closes. This is a “little inconvenience” when we want to position contact lenses onto the cornea (1) or simply when we need to put some drops on the eyes.
Also, they cover the eye when we sleep and, along with the pupil, control the quantity of light that gets into the eye.

If blinkings are not frequent (they are different in each people, but, the average frequency might be 1 blinking for every 5 seconds), the tear is not totally extended by all the cornea (1) and thus the cornea is not correctly lubricated, causing problems of clear vision, reddening and stinging of eye, discomfort with the contact lenses, and so on.
But all these problems are also caused, when the eyelids are not completely closed in each blink, that is, when we blink and the eyelids margins do not touch. Many people blink that way, and they do not know it. In fact, my eyelids blinked wrongly before I started my degree; one day, as I was doing my practice, one colleage let me know it.

People using computers in a frequent basis, usually suffer these problems and in general, everybody that work many hours doing tasks that involve looking at near distance. These people concentrate so much on their tasks, that they “forget” to blink. This paper shows an interesting guide about how to blink consciously the correct way so to automate it and thus to avoid present or future ocular problems.

The TEAR serves to protect the cornea, cleaning and moisturizing our eyes. The Lacrimal Glands (in upper eyelids) produce tears that flow over the cornea (1). The tears drain into two small openings at the inside corner of the upper and lower eyelids called the Lacrimal Puncta. The tears drain into the tear ducts (Canaliculus) and then into the Lacrimal Sac and finally into the back of your nose and throat (Nasolacrimal Duct). Now you can understand why when we cry, “we cry with our nose, too”.


If many tears are produced and they are not correctly drain (Epiphora), the tears will drain down the face rather than through the nasolacrimal system. It is the feeling that the eye is always watery, with many tears.
Sometimes an obstruction is present in any of these ducts owing to a infection, this causes an inflammation of Lacrimal Sac (Dacryocysititis). Some babies suffer this infection (20-30 percent) and some adults, mainly women, because of aging.

Besides the Lacrimal Gland, there are some sebaceous glands in the eyelids, that produce the lipid layer of the tear. If any of them gets blocked, it might cause the following disorders:

- Stye: It is a red lump in the eyelid margin, very painful. It is caused by an infection of the sebaceous glands at the base of the eyelashes, with more or less depth. If it is deep, its treatment is more difficult.
- Blepharitis: It is an inflammation and irritation of the margins of the eyelids, due to an allergic, infectious, seborrheic, irritable or mixed reason. It usually occurs in both eyes at the same time, and it is recurrent.
- Chalazion: It is a hard and painless inflammation of some little sebaceous glands in the eyelid margin. It usually disappears in a few months, but it sometimes remains, develops into a cyst and its size increases. When this occurs, it causes aesthetic problems and, what is worse, might compress the cornea and modify vision. If they are small, they usually just need a corticoids injection, but if they are big, sometimes a little surgery is required to extirpate them.


MUSCLES

In one hand, six EXTRAOCULAR MUSLES (EOM) are surrounding the eyeball and anchor it to the orbit. The extraocular muscles control eye movement and allow to lead them wherever we want (while reading, practicing sports, driving,…).


The Superior (2) (top) and Inferior (3) (bottom) Rectus Muscles control the eye’s vertical movement (up and down).
The Medial Rectus (4) and Lateral Rectus Muscles (5) control the eye’s lateral movement (from side to side).
The Superior Oblique (6) and Inferior Oblique Muscles (8) help rotate the eyes inward and outward in order to balance the sideways tilts of the head (they cause an opposite movement to eye).

All six of these extraocular muscles work together to move the eye. They coordinate so that the eyes are always aligned.

Any trauma in any orbit bone may cause a partial or total paralysis of any of these six muscles:
- If it is a partial paralysis we are before a Paresis or partial loss of movement owing to the weakness of one of them.
- If it is a total paralysis we are before a Paralysis or complete loss of the muscle function that causes restricted movement.
In any of these previous conditions, the eye movements in both eyes are not synchronous and thus cross-eyed or strabismus may appear and, consequently, double vision (but I will explain this later on).


In the other hand, we also have PALPEBRAE MUSCLES, which give eyes their shape and allow to open or close our eyes voluntary or involuntary manner.

If any of the muscles described is altered, it may cause the following conditions:
- The upper eyelid is dropped (Ptosis)
- When the previous condition happens or when there is a recession of the eyeball, the eyes seem smaller (Enophthalmos).
- Or, alternatively, when the eyes are more opened that what is usual or the eyeball bulges anteriorly out of the orbit, they seem bigger (Exophthalmos).
- The lower eyelid folds inward (Entropion), and this causes discomfort because the eyelashes rub against the cornea constantly (Trichiasis).
- Or, alternatively, the lower eyelid folds outward (Ectropion), drying the conjunctiva and the cornea, as the eye can not close totally (Lagophtalmos).


Well, my intention with this post is not for you learn these odd scientific concepts, but that these problems are familiar to you, and as with the previous post, if for whatever reason someone mentions these terms, you have where you can look them up to know what they talked about.


In the upsets of the palpebrae muscles I have preferred not to show directly the pictures just in case they are disgusting to any of you.

RELATED POSTS
A little bit of basic ocular anatomy… Eye or Ocular Globe
A little bit of basic ocular anatomy… The Retina.

A little bit of basic ocular anatomy… Eye or Ocular Globe

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Briefly I am going to explain to you how the eye is and everything surrounds it; really I would need several posts, but I think that the basic knowledge of this post and the two next ones, it will be sufficient to understand others.

A cross section of the eyeball:


(1) CORNEA: It is the outer and front part of the eye and where the contact lenses rest on (not on the iris (2) -where some contact lenses wearers think-, as you can see in the graphic), because of its curved surface. In humans, this structure has a refractive power of approximately plus 43 diopters.
Its transparency is its main feature and it is crucial that this layer keeps this way, since it would be a sign of a pathological upset. This layer does not have any blood vessels but has many nervous endings, that is why it is so sensitive; this is the reason why it is necessary a contact lenses adaptation process. The corneal sensitivity in each people is different and that is why some people feel contact lenses as a little eyelash into the eye, and however, others feel it as a stone, which hampers us from opening the eye.

(2) IRIS: It is the colour ring.

(3) PUPIL: It is the round hole in the center of the iris (2), through which light passes into the eye. Pupil controls the quantity of light that gets in; if much light gets into the eye (we are in a bright or sunny environment), pupil gets smaller (it contracts); and if little light gets into the eye (we are in night or in a dark environment), pupil gets bigger (it expands).

(4) AQUEOUS HUMOR: It is the transparent liquid that resides in the space between the cornea (1) and the iris (2). It is responsible for the value of the INTRAOCULAR PRESSURE (IOP), that is, the Eye Pressure, which, under abnormal values, can be one of element of risk to develop Glaucoma (although this one is not the only element that we have to considered in its diagnostic). The normal value range is around 21mmHg, but depends on many factors.
IOP varies during the day; when we wake up the value is higher, due to the pressure that our eyelids make over the cornea (1) during the sleep hours. The value normalizes during the day, until the night when the value increases again.
Therefore, a good control of IOP requires to assess it at around the same hour of the day and to use the same assessment instrument.

(5) CONJUNCTIVA: It is the outer part of the eye as well (it is a continuation of the cornea (1)). It is a viscous membrane that covers the outer part of the eyeball and the inner part of the eyelid in a continuous way; therefore, when one contact lens moves on the eye, it is impossible that it gets lost behind the eye (as many contact lenses wearers are afraid of).
It is a transparent layer, but it has blood vessels, besides nervous endings.
These blood vessels and this layer become inflamed when the eye becomes irritated (due to an eyelash or some dust that gets into the eye, or because of contact lenses, an allergy, an infection, and so on).

(6) SCLERA: It is a tough and white layer under the conjunctiva (5) (in the outer part of the eye) and it covers the almost all the eyeball from the cornea (1) until the Optic Nerve (11). When the eye becomes very irritated, you can see much better its inflamed blood vessels.

(7) CHOROID: It is the next opaque concentric layer under the sclera (6).

(8) LENS: It is the biconvex “lens” (you can see in the graphic how its outer and inner face are convex surfaces), flexible and transparent that we have inside the eye, directly behind the pupil. Owing to this flexibility the lens changes both surfaces curvatures constantly and thereby, the light, getting into the eye through the cornea (1), focuses on the retina (10); that is, this structure allows us to focus on objects in different distances due to these changes of curvature.
This is the part of the eye where the Cataract occurs, because the lens loses its transparency. In humans, this lens has a refractive power of approximately plus 18 diopters, which is why, when the damaged lens is removed, doctors put a new lens in the eye to replace it. Its refractive power can vary according to the patient refraction and his visual needs.

(9) VITREOUS HUMOR: It is a jelly-like and transparent liquid that fills a big part of the eye between the lens (8) and the retina (10). It allows to maintain the shape of the eye and absorbs any knock. This liquid is mainly made up of water. So, when it loses its transparency, it is necessary to extract it and to fill with salt solution; but this surgery involves many risks. This part is responsible for the “floaters” which are perceived in the visual field as spots or fibrous strands. We can see them mainly when we look at a plain background (as white walls, sky,…). Floaters are generally harmless, but the sudden onset of recurring floaters may signify a disease of the eye.

It is crucial that the four transparent surfaces of eye (cornea (1), aqueous humor (4), lens (8) and vitreous humor (9)), maintain the transparency, in order for the light not to find any obstacles in its way.

(10) RETINA: It is the last concentric layer under the choroid (7) and surrounding the vitreous humor (9). It is the most important and complex eye layer, because it is made up of six kinds of nervous cells and it is wherein the visual information that gets in the eye is received, and wherein the image is created and processed by the brain later on. Therefore, it is the first part of Visual Process.
But this layer deserves one blog post just for it.

(11) OPTIC NERVE: All axons of ganglionar cells at the retina (10) (the last layer of nervous cells of the retina) get out the eye setting up this nerve and taking all information received in the retina, through the visual path.

(12) BLIND SPOT: It is an area in the rear part of eyeball, and it is the orifice where the optic nerve (11) goes through the sclera (6), the choroid (7) and the retina (10). There is no vision in this orifice because there are not photoreceptor cells - the first cells with the responsibility of receiving the visual information that get into the eye-.
In order to see it, let us do a little demonstration: Close one eye (for example, the left one) and stare at one target. Then, put your forefinger over that target and move it slowly out (on the right in this case and on the left if you stare at with your left eye); keep on staring at that initial target and maintain the horizontal height. Doing this, one certain moment, the forefinger tip will disappear, and will come back if we keep on moving your finger out.
This little area without vision in the retina is named “blind spot” and it is what we named Physiological Scotoma in the space. But the brain manages to fill this spatial gap, basing on what we see in the surrounding areas.

(13) FOVEA: It is the point of highest vision of the retina (10), since it contains the largest concentration of cone cells in the eye and is responsible for Central Vision. In the example above, it is the point wherein we focus on what we want to stare, the target (with the exception of strabismic people or people with “lazy eye”).

(14) MACULA: It is a little area in the retina without blood vessels and that surrounds the fovea (13). We see the things that we want to see within this area and perceive all its details (e.g. reading); besides it is the area responsible for seeing the colours and the vision under well-light conditions as well.
The rest of the retina (peripheral retina) is responsible for the vision under low-light conditions or at night, and it is very helpful when we move in the space to avoid being hit with the surrounding objects that we do not see directly.


These are some of most important structures of eye, or at least the ones that you can hear more often, and some concepts that I am sure someone, some time, has told you or will tell you about them.
I hope that you have now a better idea what part of the eye they were or will be talking about.


In the next post, I will briefly write about all structures surrounding the ocular globe, which are also very important for a correct visual functioning.

RELATED POSTS
A little bit of basic ocular anatomy… What is the eye surrounded by?
A little bit of basic ocular anatomy… The Retina.

Free prescriptions!!!

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As I wrote in my last post, in Spain, the optician’s shops that belong to the big optical chains and also many little optician’s shops, nowadays, do not still charge when they perform an eye refraction examination. These professionals of vision do not value their services, but what service are they going to charge? Would they charge a refraction test executed in 5 minutes? Would they charge for something that anyone who might have not studied the Optometry degree and who might learn easily because it can be done monotonously or can do it mechanically? That has no value. That is not testing the vision.


The worst of all is that with that, we ourselves have been spoiling to the patient for many years. Optician’s shops that do not already offer this limited service, suffer the consequences.

So when people come into the optician’s shop, they believe they have all the rights for asking for and demanding many “complements” when they buy just some glasses, many times they are on offer.

When they pick the glasses up, after:

• having tested the patient’s eye vision (better or worse, let me skip that for now),
• having been advised about what glasses fit them better,
• having recommended one or another lens according the patient’s need,
• having requested their lenses to the manufacturer,
• having fitted and fixed the glasses,

the customer might pay just 55 euros or might have a 50 percent discount in some of the glasses and by all the time and work that involves that sale, that is, all of those services that are done free. But that is not all, the customer, believes that has all right to demand “added values”: a hard case, a soft dustcloth, a cord, a lenses cleaner, and absolutely, the prescription.

Within an optician’s shop many opticians do not charge for their services but just for the products they sell. When we study the degree, teachers do not teach us how to sell, but how to be Optometrists. However, many people complain because the glasses are very expensive.

Now that in many optician’s, the opticians are beginning to charge the prescriptions, many people are complaining about that, and they are surprised because “this was not done before”. Maybe the service and the knowledge has improved. When the people visit a medical doctor, they pay for that, don’t they? And even worse, don’t people pay whatever is required to go to the ophthalmologist office that might actually test their vision the same fast an ineffcient way that the optician’s that I talked about above? If you pay for this service, why should not you pay for the one offered by an optician, or optometrist one, whose work is more qualified and that is going to offer you much more quality time?

My web site

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In order to have access to both blogs (in English and in Spanish), I have created one modest web site, where you will find a little introduction about Vision Therapy, my profile, reference to other related blogs,…

But better that keeping on reading, go take a look!

Where to go if we notice any alteration in the vision?

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Optician’s Shops, Optometrist Offices, Ophthalmologist Offices.

From a point of sanitary view, and in Spain, an Optician-Optometrist can work in any of these places and his occupation in each one is different.

Besides these ones, he can work in ophthalmic lenses factories, contact lenses factories, workshops for fitting eyeglasses, physics laboratories, etc., but I will just write here about the sectors that might concern the reader, since they are the places that you may need access to.

In Spain, the term “Optometrist” did not exit in the past, and people just knew about two types of professionals: in one hand ophthalmologists who were and are the medical doctors and in the other, the opticians, who were those that sold the glasses.
But this has changed. Our functions have increased and though our degree does not allow to pursue Doctorates in Spain, our profession grows day by day and each one of us specializes in whatever we like or perform better. Just like any profession.


OPTICIAN'S (SHOP)

Some Opticians-Optometrists work in Optician’s. This group is the most plentiful one. But although, in the past our functions were basically the performance of eye exams and selling in an optician’s, nowadays things are changing (little by little, unfortunately).

According to the Spanish law, an Optician's is not a shop, but a health center. As such, the most important thing is the visual health of the people that come in. But unfortunately I have to admit that this is not always the actual aim. The big optical chains and many little optician's shops, as in any business, lead their aims to earn as much money as possible and obviously that is attained by selling eyeglasses, sunglasses, contact lenses, and so on. The correction “must be obtained quickly”, forgetting the quality of the service and the deontological code that every optician should have engraved in his forehead. In these optician's shops an optician can not “dally” about one person who tells him his “visual problem”. “Do you see or not? Do you see with this one? You need some eyeglasses, follow me to the point of sale”. So sad... They are just sales-oriented opticians.


Fortunately not all optician's work with this way, and the quality of service is much better. Maybe the patient will finish buying some glasses, but at least he will go to home convinced that the manner has been much better and more qualified, and that he has not been just a customer number, but the patient “Mr. Smith”.

Some optician's (very few) have even increased some services in the last decade. They are not just responsible for advising and selling some glasses or adjusting some contact lenses or fitting a pair of ophthalmic lenses in a frame that the patient chose. Their work is more specialized. The glasses are part of their work but it is not the ONLY job.
The visual evaluation is more specific to each problem and so is its treatment. This is the reason why many opticians are beginnnig to charge this service. Really this is our work and it is fair to charge for carrying it out. It is a qualified service, which as any other, has its price (but I will write about this subject in another post, possibly the next one). These optician's shops offer more treatments through contact lenses or eyeglasses and some of them even offer vision therapy.

Although nowadays in Spain, our 3 year “Opticians-Optometrist” degree is the only training available (in Spanish), there are many seniors opticians that do not have the knowledge of an Optometrist. In reality, there should be a differentiation between an commercial Optician (who will advice on the glasses or contact lenses-buying process and its maintenance, or fit /fix your glasses, and so on) and an Optometrist (who will be able to carry out all of these tasks but also, he will be able to offer you a more complete visual evaluation and more treatment options for different non-pathologic visual problems). In USA this difference is much more defined legally , since the studies are different, the each one’s responsibilities are different too, and although an optometrist can work as an optician, an optician can not act as an optometrist , since it is considered that he does not have enough knowledge.


OPHTHALMOLOGY OFFICES

The optometrist can work in two kinds of offices. In one hand, people can find optometrists working in an ophthalmologist office. Generally, these are offices in private refractive clinics. In them, optometrists help ophthalmologists in ALL optometric-related examinations which are necessary to perform to any patient who will undergo refractive surgery (myopia, astigmatism, and so on). Only recently have optometrists started to work so closely with ophthalmologists.


OPTOMETRY OFFICES

On the other hand, and for me it is the most important thing, optometrists can already set up our own optometry offices legally. We previously required an ophthalmologist to do it and therefore, it was considered as an ophthalmologist office.

Generally, in these offices there is not selling of glasses, and if so, the room for it is so small, that is almost symbolic.

In any offices, the “customer” does not exist, everybody is considered a “patient”.

If you want to receive a visual examination, you need to make an appointment (some optician’s shops do it too).

These visual examinations are complete and sometimes they require one or even two hours depending on the patient’s symptoms and visual problem (I will explain this examination more later on, in another post).

Usually, people, who go to an optometric office, do not arrive complaining because they can not see at distance and so they need some glasses to see better. They are usually people who come with a visual problem that goes beyond seeing or not seeing clearly:
- “I can not read for many hours because I get tired very fast.”
- “When I am working with the computer I have eyestrain, burning and itching eyes.”
- “Sometimes I see blurred or double.”
- “My child has difficulty for reading, he always loses the line and he reads very slowly.”
- “Is there any way to avoid my child’s increasing myopia?”
- “My child has performance problems at school.”
- “My child has lazy eye and he has been wearing a patch all last year and he has not gotten any improvement.”
- “It looks like my one-year-old baby has a squint in one eye, but we are not very sure.”
- “I have undergone a skull-encephalic trauma after a car crash and I have visual consequences.”
- “I have Multiple Sclerosis and since I started my medical treatment I have many visual upsets.”
- “I do not feel safe when I am driving.”
- “I feel sick when I am a car passenger but not when I am the one driving the car.”
- …

With many problems people have, they do not relate them to vision, and many times it is the base problem of everything. And when the visual problem is treated, rest of associated upsets, that they did not know that were related, disappear.

In that visual examination so comprehensive, we can find where the problem is and how to solve it.

For that, we have different treatments or solutions in the office:
- Some glasses for seeing better at distance or at near.
- Some glasses to performing better.
- Some glasses to avoid eye deviation.
- Some glasses to prevent the head from tilting…

As you can see, there are many options for using glasses and the first one is just one more.
It happens the same thing with the contact lenses, but I will explain later how we use each one of our work “instruments”.

Besides using glasses and contact lenses for helping in the treatment of a visual problem, many times patients need to know some little guideline in order to use their visual system in an optimal way, and therefore, to remove their upsets and prevent them for appearing again. For that, we resort to the Vision Therapy. It is a treatment that might need more or less time to automate all what the patient learns in the office and put it into practice daily.

Some offices also are specialized sport vision or low vision; in any of them, optometrists use specific visual tests and procedures of vision therapy.


THEREFORE, after reading all this, I guess it is a little bit more clear where you have to go depending on your visual problem, and the service and/or the manner that you would like to receive.

Who examines the Vision? Differences between Optometrists and Ophthalmologists.

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The professionals responsible for evaluating everything related to Vision are the Ophtalmologists and the Optometrists.

Ophtalmologists and optometrists, in many parts of the world, have always had “difference of opinions”, as I guess there is between architects and quantity surveyors. The difference is that Optometry is not the technical career of Ophthalmology and the optometrists’ work does not depend on ophthalmologists’. They are independent careers, with different aims and fields of evaluation.

For many ophthalmologists, we, optometrists, are just those who sell the glasses that they prescribe to their patients after they test them, or who test when the medical doctors have a very long waiting-list (as in the Social Security in Spain). Surely, many of them have always considered us “their little sister” with inferiority of knowledge. And we have always considered them the “bad people”, because many of them do not respect our work.

Simply said, each one has different vision models, with different knowledge. Each one covers distinct vision areas; therefore we all should respect each other and should not work in areas that we do not know.

In just a few words, ophthalmologists evaluate the sanity of vision and we, optometrists, evaluate the functions of vision.

I explain:

Ophthalmologists

The Ophthalmologist, as a medical doctor, is specialized in checking whether the eyes and the visual path are sane. And if any disease exists, they can prescribe the drug that is in need or perform a surgery to achieve the best cure.

It is true that they can prescribe graduated glasses. But although I do not want to generalize, many of them spend the same time testing that the time that many of my colleagues do at the optician’s. That is, their only goal is checking with what correction the patient sees better, and do not worry about anything else; for example whether it will be comfortable every day, whether it will create other different upsets, whether it really covers the patient’s initial upset,…
It is true too, that there are some ophthalmologists who have a broader vision model, they respect there are other ways to analyze the vision more complete and that a simply pair of glasses is not always the cure against a problem of wrong vision or uncomfortable vision.

Optometrists


The optometrist receives little notions at the University about possible pathologies that the visual system can suffer. But we are light- years behind the knowledge that an ophthalmologist has on the matter.
After graduating, some optometrists attend some courses of specialization where they can learn more about these pathologies, but my opinion is that as much as they can learn in one year of specialization or attending small courses, ophthalmologists study ocular medicine for 4 years specializing in them. Their pathological knowledge easily overtakes us. This is their field and not ours.


So, an optometrist is not a medical doctor and thus, in Spain:
- He can not diagnose any pathology, although we can see it and we know that a patient has a cataract, for example, we can not tell it to him; we must simply send him to an ophthalmologist, with more or less rush depending on what we see. Many times the optician or the optometrist can be the first one detecting a problem like that, and we must know to detect it and send him to a qualified professional.
- He can not prescribe any medicine: Neither any eye drops nor anything that contains a drug. We can advise artificial teardrops, vitamins or homeopathic products.

- He can not use any medicine in his office, and with that I refer to pupil dilator. The medical doctor has all responsibility for it. Sometimes, if a child does not collaborate and we can not get him to read a test while we perform an objective test - which allows to obtain the exact correction of eyes-, and we need this piece of data, using the dilator eye drops can be the only way, in these cases, to achieve it (I will explain how this works later). Then, the patient should be refered to an ophthalmologist to obtain this piece of information. In some US states, optometrists, even without being medical doctors, can use pupil dilator in their offices.


All right, I have described what the optometrist is not educated for, or what he should or should not do in those situations. But now, let me define what our functions are.

The Optometrist’s field of action is different and broader. An optometrist can find a “machine” that physically is fine, but does not work well.

An optometrist is able to test a patient in objective and subjective ways. He is the most capable professional to do it. In Spain, while an ophthalmologist studies for 4 years (besides other four previous years of general medicine) about ocular and refractive pathologies and their medical treatments (drugs and surgeries), in those four years they study very little about the optometric side, basically learning to perform sight tests, in the simplest way. But optometrists study, in the three undergraduate years, the way for testing and treating a problem of wrong visual functioning with different options.
One sample of that Optometrists finish our degree more qualified in this field than Ophthalmologists, is the “Letter to Publisher” in the Spanish Society of Ophthalmologist journal, that Dr Colome Campos (ophthalmologist) published in 2005. “The optometry: A challenge for the ophthalmologist in 21st century” (in Spanish). In this letter, he explained that he designed a study evaluating and comparing the refraction knowledge between MIR Ophthalomologist and 3rd year Optic-Optometry students. For it, they had to answer 40 questions test, about Optometry, Binocular Vision and Contactology. Result: Any ophthalmologist appeared at the test. “Only one intern was very kind, my gratitude from here, of excusing because his chief of Internal Medicine
prohibited him the collaboration owing to the questionnaire was excessively difficult.” (Dr. Colomé Campos).

All opticians-optometrists leave the University with the same taught knowledge. But later, some of us, as those opticians that works in some optician’s, whose only goal is to sell as many glasses as possible, will make a visual test similar to the one made by an ophthalmologist, and his treatment will simply be to order some glasses or contact lenses “for seeing better” (in the next post I will explain the different models of work that there is within my profession). However, some of us have specialized and updated our knowledge year after year, we know better how vision works and how its functioning can change; that is why, we can find out from the patient’s symptoms, how the visual problem is affecting the person’s life, what parts of vision we should test to find the problem and the best treatment. Many, many, many times glasses are not the solution, or not as the solution that many people know. And the optometrist knows how to use glasses, contact lenses or prisms the best possible way for removing all patient’s symptoms and for giving him other options that can help him. Not only his loose vision.

In later posts, I will explain little by little, the treatments or solutions that an optometrist can offer and what the best is in each situation. One of these possible solutions is the Vision Therapy. This treatment is necessary when the upsets are not solved with some simple glasses, can be or:

- because a disruption has taken place in the patient’s visual system owing to some cause in his life. In one moment a change occurred (e.g due to work stress, a divorce, parent’s separation, …) and the person began to use his visual system in a different way, the incorrect one; he modified the base, creating a wrong one, from which he has developed his visual skills. But as it is not the right way, the symptoms and upsets come up after some time;
- or because the development bases (visual and motor) were not created right when he was a baby.


Well, maybe this is a little bit abstract, but when I describe in another post what the Vision Therapy consists of, you will surely understand it much better. For now, what I want you to understand is that in vision there are more problems besides seeing 20/20 and optometrists are the ones meant to solve those problems. When the “eyes” do not work very well, you do not perform well too. Not only we have to see right, but we have to process right what we see, and our visual system has to be able to answer and perform the optimum way in all situations. A specialized optometrist in Vision Therapy can re-educate the visual system in order for it to have right visual bases or to establish them from the beginning if the person has never had them (strabismus, lazy eye, retained reflexes, …). He can teach the patient to use his vision the optimum way for getting the greater quality and performance in his daily visual task.

Therefore, the optometrist has different options of alternative treatments before resorting surgery.

I hope that with all this explanation, now the function of each professional of vision is clearer.

Finally, I would like to make use of this post to expose a demand: a little bit of respect by both professions. Each one has a work to do, so, we must not neither diagnose or treat what we do not know, nor underestimate or undervalue the qualified work of the other professionals if we do not know the field that we criticize. As well as ophthalmologists master pathologies and we, optometrists just “know” them; we master visual functioning and they just “know” it.

What each one of us must to do is to work as well as we know, and if both sides collaborate together, the patient will be the most favoured.

What is the Optometry? History

Enlace a entrada en español


Optometry is the science that studies how vision works and its mission is preventing, detecting and solving the non-pathological visual upsets that a patient may present.
From refractive upsets (myopia, astigmatism, hyperopia…), all the way up to functional upsets (wrong focusing, visual system under visual stress, double vision sometimes,…), up to upsets happened during the development and the visual learning, not related to the fact of seeing in a clear and stable way, but to receive, understand, identify, discriminate size, shape and color, calculate distances and speed of objects, wrong eye-hand coordination, memorize,… I mean, any upset that impedes the achievement of the maximum visual performance with the minimum fatigue.

But really, in Spain my degree is known as Optic-Optometry; that is why I must point out that it has two inter-related fields of action.
• One physics side related to the study of the light in the vision, the lenses, the instruments used in Low Vision (they are optic aids for those people that have usually undergone a pathology or surgery, which has sufficiently reduced the clarity of the vision; those aids improve a little bit the quality of life), the optic materials and instruments, the manufacture of ophthalmic lenses (for glasses) and contact lenses, and so on.
• And another side related to the one above (because of the lenses that we use to correct a myopia or astigmatism, or the prisms for the strabismus), is the health side and it belongs to the area known as “Science of Health” (not Medicine); personally, I feel more identified with this side. This part studies:
- In one hand, how the light gets into the eye (creating myopias, hyperopias and astigmatisms). It is the part most related to physics.
- In another hand, how each eye works separately and together (whether they see clear, they focus right, they fuse well, …) to allow an optimum visual performance.
- At the end, how that light that gets in across the eyes, as visual information along with all information around it (auditory, tactile, vestibular,…), is integrated and processed neurologically to allow a good learning and an optimum general performance.


In Spain, this degree, is a three years “bachelor’s degree” that covers the following areas of knowledge: anatomy, biology, neurology, pharmacology, pathology, physiology, ergonomics, etc.; areas that for many people are in second place before the great field of the Optics (physics, chemistry, mathematics, geometric optics, instrumental optics, physic optics, etc.). When you graduate, and in order to be allowed to work lawfully, you need to sign on the Optics-Optometrist National Association (Colegio Nacional de Ópticos-Optometristas –CNOO-) compulsorily.
But in each country the educational period, the professional functions and the rules to execute the profession are slightly different. This creates a problem when you want to work in a different country than yours, since each one has its own “conditions”.

An optician-optometrist can specialize in diverse fields: Clinic Optometry, Contact Lenses, Child Vision, Geriatric Vision, Low Vision, Vision Therapy, Sports Vision, Neuro-optometry, Optometric instruments and Physic Optics.

In one hand, the History of Optics is very extensive. The ancient optics notions are unknown, but in the remains of Egyptian tombs, pieces of metallic mirrors were found, that probably came in useful for deflecting the sun rays. The Optics history narrates the history of the lenses, the discovery of the laws of reflection and refraction, and the formation of the images. It is interesting to know how the first optics instruments, like the telescope and the microscope, were invented, since most of the later optics instruments are modifications of these ones. If you are interested, the history is quite well explained chronologically in this link.

In the other hand, the History of Clinic Optometry and Vision Therapy in Spain has evolved along with the years (quite slower than in the US):

- In the University, the old curriculum (until 1995), we learnt a classic vision model, where most causes of visual problems are attributed to the genetics and the only solution to these problems are glasses or contact lenses, and surgery. This approach is a “victim model”, in which the patient is victim of the genetic, development or age-related changes, among others.

- Before the change of the curriculum occurred, a functional model came up approximately in 1985, where it was not just important seeing 20/20, but also that other visual problems can exist and where the solutions for these problems increase; checking that the visual skills can be developed through the use of techniques related to the oculomotor control, the improvement of focusing and the increase of fusional range from both eyes in a sequential and incremental way. Vision Therapy begins to arise. This approach is a “modified victim model”: the patient is victim of stress at near.

- In the new millennium the vision begins to be related to the rest of senses, integrated as a whole. A behavioral model comes up, where many visual and perceptual problems are related to a poor motor and neurological development. The visual problem is not caused due to the stress at near, but because people respond to that stress. The therapy is much more individualized because it depends on the individual needs, skills and goals of each person. It is not a procedure for improving the vision, but the conscience and the person, making internal changes in the individual that creates the improvement. The approach is a “no-victim model”: The patient knows what he does wrong and can modify his behaviour consciously, in order to, through those internal changes, improve his visual and general performance.

This last vision model is not so novel in USA; it is being developed since 1970 and it is the model that I have come to study right to its birthplace.