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.

Who can be interested on my blog?.

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As I said in the previous post, this blog is not for other optometrist colleagues who are specialized in the same area as me. It is for the rest of the people, a broad group of people worried about their own eyes or about other people’s eyes, and how the vision works.

Specifically, this blog can be interesting for:

- As I said, any person that, suffering visual upsets, has visited an optician’s or an ophthalmologist office and they have said she sees 100 percent and she does not have any visual problem; or in another case, they offered some glasses and following the “professional advice”, she thinks that it is the only solution. But she keeps on noticing she does not perform well in her job or in her studies; she can not concentrate many hours; it is difficult for her to change the focusing on different papers-computer over the table, or to do near-to-far and/or far-to-near fixation changes; the letters “dance” when she reads, her eyes get tired when she does it; she can not take many hours reading, sewing or doing handicrafts; she has headaches or eye stinging; she is not able to enjoy reading a book, in fact, she has never liked to do it, … a vast number of symptoms that some simple glasses or contact lenses, used to only improve the “quantity” of vision, are not enough to improve the “quality” of vision.

As we will see later, sometimes glasses can relieve that symptomatology, but it is not always enough. A specialized optometrist could offer more variety of options to relieve her upsets.


- Any father, mother, grandmother, uncle, friend, neighbour, nanny,… being in contact with a child and they want to make sure that the child has an efficient visual system that allows him to develop a good learning at school and to avoid any problems at sports, social contact with other children or adults, and so on.

In everyday life, parents, better than anybody, can observe whether their children are using some compensatory method of any visual problem that their parents do not know that their children have. For example: getting too closer to the TV; getting to closer the paper when they are drawing, writing or reading; rubbing their eyes a lot; tilting their head very much or even resting it in their arm when they do any homework at near, in order to use only one eye; avoiding any of that homework at near; missing the line when they read; needing the help of their finger to do it; reversing letters or numbers; changing the position of some letters within a word; being very sensitive to the light; etc. Everything indicates the existence of a visual problem, that discovered on time, it would not affect their learning or their general life.


- Any education professional, from nursery schools, all the way up to the elementary school and finishing in high school (teachers, assistant, nurse, psychologist, …)
Just as their parents, these professionals spend much time of the day in contact with children/teenagers. It is not the same case, because for each father his child is “his child” and teachers have many “children” to worry about. Many times the signs are too obvious; other times, not so much.
Fortunately, the concept “learning of disabilities” is better known and recognized each time. There is more and more information about this subject in many professions, not only in education.

Do not go so far, in my generation, if a child got bad grades at school, he was simply a bad student and he “did not want to” study or he “was not good” to study. Nowadays any professional looks at this subject in depth and looks for the cause why the child suffers from school failure. But fortunately you, education professionals, already know it. But, what I want to remind you is that most information that a child receives is visual, and almost all information that is not directly visual, is related to it. That’s why, it is very important that you always make sure that if a child “fails” at school, the cause is not related to any visual reason. Your observation along with those of their parents is crucial to detect these visual problems.
I do not believe in the concept that a child is “lazy” or that he is more “stupid” than the rest. Everybody had potential when we were born, and we “learn to see” with our experiences. The problem is that while some people have known or have had the opportunity to develop this ability, others have not.

Signs like these: not obtaining the main idea of a text or not knowing how to summarize; moving his head when the child is reading or doing it in a monotonous way; not remembering or understanding what he has read; being a restless child on the chair; winking his eyes, covering one of them; copying from his classmate’s notebook; being bad at sports; having bad handwriting… these and more are indications of masked visual and perceptive problems, which people do not think enough about. Providing a correct treatment, the child improves his school performance, improving his visual performance.


- Any another professional specializing in children: pediatricians, psychologists, pedagogues, speech therapists, neurologists, ophthalmologists, otorhinolaryngologists, occupational therapists, physiotherapist, osteopaths... Well, I am sure I forget someone, I am sorry. We, optometrists and visual therapists, belong to all that huge group of professionals that take care of the health of the child, each one from our own speciality.

The next fragment expresses what I think VERY WELL. This belongs to a post of Rosina Uriarte’s blog (in Spanish language) (specialist in Early Stimulation). She expresses the ten things she more “detests”. I just want to show the seventh one because it talks about what I am writing:

(Excuses, I have tried to translate it the best way I could :-))

“…I detest the war of rivalry among the professionals: "Don’t go to the optometrist office, they aren’t medical doctors”; “The psychologist doesn’t know anything about this…”; the neurologist, the psychologist, the speech therapist, the physiotherapist… Each one of them just looks at their own subject, they do not look beyond that, and parents have to put up the puzzle by joining all pieces… But the child is a whole, is not a pile of single pieces… THE MULTIDISCIPLINARITY IS VITAL TO TREAT ALL MANIFESTATIONS OF THE PROBLEM IN THE CHILD AND TO ATTAIN A SOLUTION. The child is a unit; it is not enough putting a patch here and other there…”

I think I would not have expressed it better. The child would be better treated if ALL OF US WOULD WORK TOGETHER, if all of us would know about other professionals’ existence too and if each one would work within our own specialty, without trampling on the work of other professionals.

I know that some parents think: “Well, so I have to visit many offices for my child to be fine and I do not have any time to do it. I have a job…” This is a thorny issue that only depends on the parents and what they want for their child. The perfect thing would be for parents that all these professionals were working in just one center, so the families would only visit one place; but unfortunately that does not exist. A good job is achieved, if each professional helps within his area the best way he knows, but is able to send him to another professional, thus helping the child as a whole. His problem would be solved sooner.


- Neurologists specializing in illness or traumatism which symptomatology or drugs necessary for the treatment, disturb the visual function (like Multiple Sclerosis or some brain injury, etc). In many of these cases, that visual function can be improved, and thus, at least we improve their quality of life a little bit.


- And not less important, any optician not specializing in this area who wants to know what the visual therapy is; how a neurological problem, development problem or learning disability affect the vision; knowing that there are more options besides conventional glasses or contact lenses; and sometimes, that those same options can be used to achieve another goal. And of course, the same as other professionals, they can send their patients to specialized colleagues, when the patient’s visual problems do not fall within their area.