What is an Optometrist?

An optometrist, or Doctor of Optometry (OD), is an independent, primary eye care provider who diagnoses and treats disorders of the visual system. Independent implies that optometrists are not required to work alongside or report to other professionals in order to provide care to patients. Primary implies that optometrists are essential gate-keepers to higher levels of eye care. If a patient requires a surgical or specialty level of care, the optometrist makes the appropriate referral.

The visual system implies:

• the globe, or eyeball surface.
• the connective tissues and skin around the eyes.
• the inner structures and surfaces of the eyes.
• the optic nerve and the entire visual pathway of the brain.
• the refractive state, or the need for vision correction (glasses, contact lenses, bioptic telescope, etc).

Optometry is ranked #16 in Best Jobs and #11 in Best Healthcare Jobs by US News and World Report. The US Bureau of Labor Statistics forecasts optometry as having a job outlook that is expected to grow faster than the average. The Average net income reported by the American Optometric Association is $144,228.

The Nature of Work in an Optometric Practice

Optometrists are most known for prescribing eyeglasses and contact lenses for common vision problems like nearsightedness (myopia), farsightedness (hyperopia), and astigmatism. Optometrists also prescribe topical and oral medications to treat medical problems like eye infections, glaucoma, ocular inflammation, and dry eye syndrome.

In some states, optometrists are authorized to perform injections to certain eye structures to treat inflammation. A few other states authorize optometrists to use lasers in order to treat patients with certain types of glaucoma and other conditions. Optometrists are not true eye “surgeons”. By this I mean that an optometrist will not perform a procedure on a patient in an operating room or under general anesthesia. However, we do regularly perform what are considered to be minor surgical procedures.

Optometrists often co-manage patients with other health providers. In my practice I manage patients that have diabetes, multiple sclerosis, rheumatoid arthritis, and many other autoimmune conditions daily! This is essential care as many of these patients can potentially lose vision permanently if not monitored by an eye doctor.

Optometrists are often the first health care provider to diagnose patients with certain underlying health conditions.

Optometry vs Ophthalmology

An ophthalmologist is also an eye doctor. Legally, they can do anything an optometrist is authorized to do. In addition to clinical responsibilities, ophthalmologists are eye surgeons. They typically have an undergraduate degree, have completed 4 years of medical school, and 3 years of ophthalmology residency. 1-3 years of fellowship are optional.

Prior to the 1980s, optometry’s state legislatures only authorized optometrists to prescribe glasses, contact lenses, and perform exams on patients.  At that time, optometrists could not even prescribe eye drops!  Due to advances in legislation over time, the scope of optometric practice has expanded vastly to what it is today– a more medically-oriented profession.

The remainder of this lesson will be a more visual representation of my practice and the types of patients I examine and treat everyday. But first, here is a primer on some of the basic equipment and instruments used in optometry which you may recognize from your own past eye exams. 

Equipment

Here are 3 important instruments that are essential to optometry practice. A few others will be included in the patient scenarios down a bit further.

This is a phoropter. This instrument is used to perform a refraction, the determination of whether a patient needs vision correction. Put another way, this is the “which is better, 1 or 2” instrument. Obviously this is used in the process of prescribing glasses and contact lenses. I also use it a lot in my practice for patients with existing eye disease to determine the extent of visual loss a patient has suffered.

This is a slit-lamp. It is essentially a big microscope that sits atop a working table. It is used to magnify and focus different structures of a patient’s eye for the viewer, the optometrist. Additionally, many office procedures and tests are performed at the slit lamp.

This is a binocular indirect ophthalmoscope, or BIO, resting in its charging dock. A BIO is essentially like a headset with binoculars. Using a handheld lens and the bright lights that surround the eyepieces, an optometrist is able to examine the far reaches of the retina, or back surface of the eye.

Now let’s get into the heart of today’s lesson.

Real Patients From My Practice

Every optometry practice is different in terms of the patient population. Some ODs do nearly all routine care. Some do nearly all specialty care. This is my best approximation of the patient population in my practice.

• 100% adults (18 and older)
• 30% routine (annual examinations, glasses, contact lenses.
• 70% ocular disease (mostly emergency eye care, infections, trauma, glaucoma, and diabetes-related eye care).

This is an image of a patient’s upper eyelids. As you can see there is a lot of accumulated debris and dried mucus. This very common condition is called blepharitis, which just means inflammation of the eyelid tissue.

This patient’s condition may be due to Staphylococcus bacteria, or possibly Demodex, which is a mite! I prescribed this patient an antibiotic/steroid ointment, as well as a concentrated form of coconut and tea tree oil wipes to eradicate the infection.

The optic nerve is like a long wire that travels from the back of a patient’s eye all the way back to the occipital lobe of the brain. This is an image of the optic nerve head–imagine looking at a wire at one end, straight-on.

The brighter, yellow area in the center of the optic nerve is called the optic cup. Most normal eyes have optic cups that are smaller than the one you see here. Eyes with larger optic cups, are at risk of glaucoma.

Glaucoma is a neurological condition where the optic nerve tissue deteriorates over time. This often results in slow, progressive, and irreversible damage to one’s peripheral vision. In advanced cases, the central vision can be affected also.

The CDC estimates that 2.7 million Americans are affected by this disease.

Optometrists treat glaucoma with prescription eye drops and oral medications that reduce a patient’s eye pressure in order to resist further nerve deterioration. In some states, optometrists are also authorized to utilize laser procedures to reduce eye pressure. If a patient has severe glaucoma, and his or her eye pressure needs further management beyond eye drops and oral medications, the patient may require referral to a glaucoma surgeon (ophthalmologist) for surgery.

This is an image of a metallic foreign body on a patient’s cornea. The cornea is the clear dome structure that lies over the iris, or color part of the eye. After I removed the metal with a small, sharp surgical tool, I had to scrape away the leftover rust with a small drill, or Algier brush, to decrease the chance of corneal inflammation in the future. 

The public generally has a poor practice of using eye protection when working with hardware and hazardous chemicals. As a result, many patients will have traumatic injuries with foreign material. Optometrists are trained to evaluate and manage these patients.

This is a patient who somehow got paint in his eye.

There are literally hundreds of causes for red eyes. The most common are trauma, a hemorrhage or bruise to the white of the eye, dry eye syndrome, blepharitis (like in the picture earlier), and viral conjunctivitis. This, however, is an image of a patient’s eye that has scleritis.

Scleritis is a form of inflammation that affects the sclera, or the white part of the eye. This patient reported a very intense ache to her right eye for the past week. I prescribed an oral steroid as well as a topical steroid to manage this patient.

Many eye conditions like scleritis tend to occur in patients with weakened immune systems. Patients with scleritis often have a history of inflammatory bowel syndrome, Crohn’s, rheumatoid arthritis, Sjogren’s syndrome, sarcoidosis, and other autoimmune diseases. In addition to treating the eye condition, optometrists may order the necessary bloodwork to find the underlying cause, or they can also refer to a rheumatologist.

Treating red eyes is my favorite thing to do in optometry. I get to play detective, and once the diagnosis is made. I can usually treat the patient and cure their pain/discomfort and other symptoms rather quickly.

The brown mass behind this patient's iris is a uveal cyst. The uvea refers to the middle layer of the eye. Cysts and tumors can occur on any major structure of the eye. Some tumors are associated with cancer, while others are benign. 

Lesions like this, that are suspicious for cancer, are typically referred to an ophthalmologist, specifically one who specializes in ocular oncology. Because of the risk of metastasis and/or death, some patients with high risk tumors must undergo direct radiation to the eye, or even surgical removal of the eyeball (enucleation).

This is an image of the retina. All the blood and cotton-like patches of white represent an area where the vein has burst and is leaking blood. This is called a branch retinal vein occlusion, or BRVO. This patient experienced sudden vision loss of the lower half of his vision within seconds.

Note that the upper part of the retina controls the lower part of the vision and vice-versa. Patients with vein occlusion often have a history of hypertension or diabetes. Other times, longstanding clogging of the carotid arteries in the neck and systemic blood vessel inflammation can cause this.

This patient required referral to a retinal ophthalmologist, who performed a series of injections directly into the back chamber of the eye, to reduce further bleeding and the associated swelling. Optometrists will diagnose and manage a LOT of eye disease that is the result of hypertension and diabetes.

Diabetic eye disease is the number 1 cause of preventable vision loss in patients under 70 years of age. In fact, since so many patients don’t know if they have diabetes, many hear it first from their optometrist.

The space of the inner eyeball is mostly a fluid called vitreous. This patient has a vitreous hemorrhage, which means an abnormal blood vessel on the retina had burst. Unlike a BRVO, the blood didn’t seep into the retina tissue, but instead into the vitreous fluid cavity that surrounds it.

As a result, this patient suddenly lost vision. In fact, the amount of blood in her vitreous was so extensive that it actually blocked my view of the retina behind it.

The image above is called a B-scan. It is an ultrasound that images the major structures of an eyeball, viewed from the side.  This test allowed me to essentially image through all the blood debris, where I noticed the hump-shaped irregularity on the back surface of the eye. You can clearly see it in the image.

This was concerning as it almost looked as if there was a tumor growing on the back of the eye. A melanoma on the retina could in-theory rupture a blood vessel and cause a vitreous hemorrhage in the eye. I wasn’t sure exactly what that irregularity was. B-scan can give an idea, but the only way to know for sure is to actually examine the area. 

I referred this patient to a retinal ophthalmologist, where he underwent vitrectomy surgery, which removes and replaces the blood and vitreous fluid with either oil or gas. After the surgery was performed, the surgeon could actually view the back of the eye and see that there was no tumor.  This patient had a macroaneurysm to one of his retinal blood vessels. Basically, one of his blood vessels developed a large and abnormal shape. This vessel eventually grew so large that it burst and leaked into the vitreous.

This is an image of a patient’s optic nerve in the right eye. It is swollen. You can compare the appearance to the other images above.  This patient had swollen optic nerves in both eyes. He complained of “the worst headaches imaginable” and progressive blurred vision for the past 4 months.

This report is from an advanced diagnostic instrument called optical coherence tomography, or OCT.  It can measure the thickness of individual structures on/in an eye down to a micrometer, which is 1,000th of a mm! 

In the case of the swollen optic nerves, it allowed me to quantify how much swelling was present. This can be repeated and compared to earlier or later scans. Swollen optic nerves can be a sign of systemic infection, cancer, trauma, thyroid disease, brain tumor, multiple-sclerosis, stroke, and a long list of other systemic conditions.  

Many of these patients will present for an eye exam with a variety of eye problems and systemic problems. The role of the optometrist is to ensure that the patient gets the appropriate systemic care needed. Swollen optic nerves, sudden double vision, and other neurologic eye problems can be a sign of a potentially life-threatening underlying disease. 

For this patient, I ordered a CT scan of the patient’s head, lumbar puncture (or spinal tap), and MRI of the patient’s brain and orbit (or eye socket). I sent the patient to the emergency room so that the tests could be performed on the same day.

She has idiopathic intracranial hypertension, or IIH. This patient is severely overweight. Sometimes the body will compensate for increased body-mass-index by producing too much cerebrospinal fluid, which normally cushions the brain and spinal cord.

This can lead to compression of the brain, and surrounding structures like the optic nerves. Common symptoms are intense headaches, blurred vision, double vision, and swollen optic nerves. This patient required a weight loss program and oral medication.  Other patients with IIH may require neurosurgery.  

Summary

Optometry is such a diverse profession. There are several clinical specialties and modes of practice for an optometrist to find their niche that suits their abilities and interests. The patients above represent the types of patients I see every day. Other optometrists may see mostly pediatric cases. Others may see mostly traditional and specialty contact lens patients.

INVEST IN YOUR FUTURE

If you still have an interest in optometry, I strongly encourage you to purchase the rest of the Pre-Optometry Bootcamp Course today for $99. Even though I am a full-fledged OD now, I wish I had an advocate who shared this perspective and resources with me before I started optometry school. In addition to specific cost-cutting and success-driven strategies, I have included a statistics data sheet, which shows all recent enrollment and financial data from all 23 US schools of optometry. This will make your assessment of each optometry school much easier when it comes time to select a school to apply to.

Also, I included an optometry school cost comparison calculator, which will show you how the cost of your education varies among institutions and how it will affect future student loan payments. A simple change in how you approach the finances of your optometric education can potentially save you literally HUNDREDS OF THOUSANDS OF DOLLARS.

I wish you the best in your future professional endeavors.

Eric Harris, OD, FAAO