Monday, April 21, 2008

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.


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.


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.


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.

Friday, April 04, 2008

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:


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.


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.