All Visual Exams Are Not Created Equal

Should Opticians or Technicians Be Performing Subjective Examinations With Automated Technology?

by: Merrill D. Bowan, O.D.
Neurodevelopmental Optometrist Director, The Learning Clinic

Information without education is meaningless. To have visual exam data at hand without an adequate grounding in how to use it – or even, how to properly acquire it – is either meaningless, or dangerous, or merely entertainment.

There is an inherent assumption buried within the nature of the question about automated or technician-based exams that all any examiner needs to satisfy a patient’s visual needs are the right numbers in the LCD display, in the phoropter windows or in the printer output. Will the day come when we have to tolerate vision kiosks in our malls with a pair of peepholes, a knob, a printer, and an optician in the back?

Were it all that simple! The overall question is a difficult one for a number of reasons.

A professional who is overly focused on maximizing traffic and yet minimizing the time spent in patient contact (or as some have said, “…to use the time more wisely”) is not likely to be persuaded to warmly embrace a counter-point argument to the question being raised here. Yet as we myopically do this, we may fail to realize that automating and minimizing patient chair time tends to justify the trend toward further reduction in fee reimbursement schedules. To be utterly fair to the patient, the question, and ourselves as a profession, we need to soberly consider the problem from a point that takes into account the operational role of vision in human behavior.

Much of the problem may lie within our own optometric family: we are losing sight of what the goals of optometry are, what defines a patient’s needs, and what the point of a patient exam is – the why of an examination. Within that frame of thinking, the examiner must determine his or her own role: are we merely objective data gatherers, data processors, or is there a subjective component to the patient’s responses?

To strictly apply a definition to a complete exam as one that meets the patient’s needs is either inadvertently naïve or, in a worst-case scenario, it is self-serving. Yes, I’m aware of how strong those words are – for sure – but here is why I say that: the patient simply cannot be aware of all of their needs. It is not responsible behavior on our part to wait for a patient to be complaining. They are limited in their observational ability. They are poor reporters because they have an auto-centric experience of their worlds. They are just not aware of how the world is supposed to look. In illustration of this, as he reported in the Journal of Learning Disabilities many years ago, I Love Lucy producer Jess Oppenheimer only discovered his intermittent alternating exotropia when, while shaving in an Army latrine, he asked a fellow soldier how long it took his eyes to come back together after he looked away when he shaved! If we as doctors wait and only respond to patient complaints, then public health will suffer.

Indeed, patient evaluations in all allied medical fields take on two general forms:

1) Problem-focused: The patient brings in a set of symptoms. This follows a pathology-driven mentality; and,

2) Health Screening: The patient is assessed for all aspects of healthy performance. This follows a wellness mentality, an enhancement of health-based thinking.

Arguably, optometry as an institution has been drawn further and further into the first. The latter seems mostly to thrive in a small sector of the realm of private practice as a word-of-mouth, mentored phenomenon, and is now beginning to see greater quantification through post-graduate programs like the OEP/BABO confederation.

The doctor (or for purposes of this topic, the refractionist) must be educated enough to make proper assessment of the patient’s responses. To understand why, we must be willing to consider the human factors. The central concern is that mankind is a visual creature:

  •   Years ago, a physiologist noted that the entire design of the human body appears to be solely to support the eyes and the brain in an upright position.
  •   Between 25% and 50% of human neuro-anatomy is dedicated to vision directly or indirectly.
  •   With the eyes open, two-thirds of the brain’s electrical activity is related to visual processing.
  •   The visual creature in our chair is manifesting his/her adaptations to his world as he/she sits before us. Head torts, slouched posture, bodily motor overflows, visual tics and even language and tone of voice – all reflect ocular, torso, and neck tensions.
    Vision dominates perceptions so greatly that as physiologist Samuel Renshaw demonstrated, strong yoked prisms base right or base left change spatial perceptions so dramatically that vertical edges not only look distinctly curved, but for most people, they actually feel curved. How does the technician integrate this dominance of central visual processing into their results? How can a subjective refractor device know how loose or how tight the patient’s visual system is?Leonard Press, optometric author of a significant visual therapy text,1 illustrated the point this way: if, on the positive relative vergence tests, a patient breaks fusion every two prism diopters but recovers until a final break occurs at 22^, how does the mere recording of that value differ from a patient who broke at 22^ the first time? Both final values read 22^, but it would be an unwise prescriber who treated both with the same treatment plan.

    Does the question of delegated or automatic refraction boil down to patient- centered care versus something less? Is not pathology/medically-oriented optometry more important? The question is somewhat moot. No one would argue that we should abandon our medico-legal responsibilities to identify, refer, or treat ocular medical conditions. Yet would we ignore our accountability to identify, refer, or treat the up to 30% of the population who manifest binocular or developmental visual dysfunctioning?

    To think of the refraction/visual analysis process as just “another piece of data” is to risk second-rate care to our patients. Are all refractions the same? Perhaps the more important question is looked at a bit differently, in this way:

    What is the nature of ametropia? If ametropias are strictly genetic in origin, or perhaps merely idiopathic, then we have no choice as care-givers but to follow and palliate the patient. However, if there is ever any functional component to ametropia, or any medical condition that can alter the refraction, then our focus, even our responsibility, to our patient is altered. We then ethically owe it to our patient to apply our scientific ministrations to either correct or prophyllactically intervene and interrupt the process.

    This brings up an extremely important question: does stress ever manifest itself in the refraction? Do medical conditions ever alter a refraction? Will a patient in emotional distress respond in a usual and customary way and render a valid prescription? How do black and white numbers or cryptic notes from a technician reflect the picture that the prescriber would see if they were personally involved in monitoring the quality of responses from the patient?

In a nutshell, it may be said that there is a lack of understanding of what vision represents to the organism, what it really is. This is the endpoint of much of the very confusion in optometry, as to what we are as a called profession. Are we:

  1. Medical optometrists?
  2. Refraction jockeys?
  3. Visual researchers?
  4. Behaviorists?
  5. Visual rehabilitationists?
  6. Alternative care providers? Or, are we;
  7. All of the above?

There is a saying that those who want more theory often need more clinical practice. Those who want only clinical results usually need more theory. Extending this thinking, we might say that those who want only refractive data need more clinical observation, and that those who want only clinical observation need more data.

What we can’t do, because of the moral, ethical and medico-legal ramifications of the question being posed, is to ignore the problem. It must be resolved within optometry, for the public’s welfare.

A further dimension to this discussion is that many patients expect optometrists to be the experts to deal with school-related vision problems. This covers the whole behavioral spectrum from ADD/ADHD to visual processing-based learning disabilities to autism. Only the examiner can understand the numbers before him in relation to the patient’s needs, the patient’s performance, the patient’s responses. To equate the results of a refraction with those of an EKG as some have done – with technicians performing each – is to discount the objective versus subjective nature of the two tests. The qualities of the responses of a refraction are revealing – they can be as important to an artful examiner as are the actual findings.

The refraction is a road test of the visual system under controlled conditions. Has the visual system the resources to cope (as measured by the duction tests)? Is it distorting due to performance stresses (as reflected by the phorias)? Has it begun to collapse (as in Streff Syndrome)?

Vision is an operation that involves the total organism.

Optometry is the only profession capable of bridging visual perceptual processing with the manifestation of any external distortions. AM Skeffington, the father of modern developmental visual science, said many times that refractive error is the last stage of a visual problem and that a visual problem is an outer manifestation of an inner problem. These platitudes are far from philosophical only; they are seen daily in all of our exam rooms. They have proven themselves true hundreds of thousands of times: they just need a proper examiner to observe and evaluate them.

To restate the initial postulation of this discussion, information with education is highly meaningful. To have data at hand with adequate grounding in knowing what to do with it is not only meaningful, but it is healing and it enhances the quality of life of the recipient. A visual exam requires the observation of a trained professional, a doctor, and the patients will be benefit from and be grateful for it.

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