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Optometry, as a profession, is becoming a network of highly specialized practitioners. In the near future, the primary care optometrist will continue to serve the primary role in patient management, but our paradigm is shifting to a “village” model for the management of patients with specialized vision needs. It is becoming more commonplace for a primary care optometrist to comanage patients with another optometrist who has a particular specialty, whether that is low vision, vision therapy, contact lenses, or any of the other niches that are increasing in prevalence.
Optometrists are regularly involved in comanagement with ophthalmologists for LASIK and refractive surgery care, the management of glaucoma, and for following patients with cataracts, macular degeneration, and diabetic eye disease. Less common is the practice of optometrists comanaging patients with fellow optometrists, although this is slowly becoming more common, and it may ultimately become the norm for our profession as optometric subspecialties continue to grow in popularity. Optometric associations and schools and colleges of optometry are strongly encouraging graduates to seek out residencies, which serve to strengthen subspecialty training in contact lenses, binocular vision, pediatrics, ocular disease, and low vision services.
A CONTINUUM OF CARE
Although all optometrists receive some low vision training in optometry school, and many receive more intensive training during clinical rotations, the vast majority of optometrists are not comfortable or appropriately equipped with assistive technology and low vision devices to provide comprehensive care, especially in cases of moderate to severe visual impairment.
In the ideal care model, management of the low vision patient would be a continuum of care—a village of optometrists and ophthalmologists (Figure). It would begin with the primary care optometrist recognizing the problem and would continue as the patient’s disease progresses. Along the way, it would include referrals for advanced low vision care and comanagement of the pathology with an ophthalmologist, as well as the consideration of programs such as state services for the blind and visually impaired.
Many optometrists refer directly to retina, glaucoma, or other ophthalmologic subspecialists, who then take on the responsibility of ensuring that the patient ends up back with his or her optometrist for primary eye care and glasses prescriptions. Generally, in the current model, the ophthalmologist makes the referral for low vision services.
IDENTIFYING BARRIERS TO COMANAGEMENT
There may be several barriers that prevent optometrists from referring patients to low vision optometrists. Included among these are the concern about losing a patient to another optometric practice and the fear that referring to another optometrist will make the patient question the abilities of his or her own optometrist. Additionally, primary care optometrists may refer to an ophthalmologist with the assumption that the patient will be referred on to low vision services at an appropriate point in the treatment; however, that referral does not always take place. Therefore, the best way to ensure that patients get the referrals and the care that they need is for optometrists to take owner ship of that comanagement themselves.
Overcoming these barriers will be successful if the optometrist-to-optometrist referral relationship functions as a comanagement relationship. The primary optometrist is in a unique position to truly understand the patient’s needs and to initiate low vision rehabilitation. Even after a referral to a specialist, the primary care optometrist can follow up with the patient to ensure that he or she fully understands the disease process and what to expect both in terms of the progression of whatever pathology is affecting the eye, as well as reasonable expectations about therapy. At the same time, the optometrist can begin to ask the patient questions about his or her daily functioning and can make initial recommendations for glasses changes. This may be as simple as a computer prescription, glasses for walking (distance vision only rather than a progressive-addition lens), or it may be bifocals with a higher add.
As the patient’s needs become more complex and move beyond the spectacle plane, comanagement with a low vision optometrist would be beneficial. Low vision optometrists can evaluate patients and make recommendations that will help improve patients’ daily functioning. This could include additional changes to glasses prescriptions, which patients can continue to fill in the the primary optometrist’s optical shop. The low vision optometrist can also explore additional technology, community resources such as rehabilitation services, and the potential for a modified or restricted driver’s licenses.
Often, the low vision optometrist conducts functional vision assessments for workplace accommodations, individualized education plans, and disability services. Many low vision optometrists have relationships with vision rehabilitation teachers, low vision occupational therapists, and orientation and mobility instructors. The low vision evaluation is in some ways no different from what any optometrist can do—prescribing glasses and evaluating magnifiers. On a larger level, though, it is an ongoing dialogue to educate patients about the various community resources he or she can take advantage of to maintain independence while providing recommendations for nonoptical interventions, such as orientation and mobility training, contrast enhancement, and environmental modifications.
As the optometric profession continues to move forward and become more subspecialized, I hope that we redouble our efforts to form strong relationships and comanage patients as specialists within a specialty. Low vision optometrists will benefit by having solid relationships with their local optometrists. In this scenario, primary care optometrists will benefit from the additional knowledge base of community resources that the low vision optometrist has, in addition to the ability of the low vision optometrist to spend the valuable chair time educating patients and prescribing specific devices to maximize their independence. This type of comanagement is ideal for the patient, as well as for the primary care optometrist, the low vision specialist, and the profession of optometry as a whole.
Alexis Malkin, OD, is a low vision optometrist at Low Vision Services, PLC, in the Washington, DC/metropolitan area, and is a part-time clinical instructor in ophthalmology, vision rehabilitation service at Wilmer Eye Institute, Johns Hopkins University, Baltimore. Dr. Malkin may be reached at firstname.lastname@example.org.