I propose that instead of increasing the number of optometry schools, impose a moratorium on all new optometry schools and freeze current O.D. graduating classes until national licensure reciprocity is a reality.

No New O.D. Schools

Yet another restrictive Sun Belt state using undersupply in rural areas as a reason for a new optometry school in their state (A New O.D. School Coming to Arizona? July 2007). Simply dropping draconian licensure restrictions in these states and allowing national licensure reciprocity would likely help, if not cure, the problem of underserved areas and loss of O.D.s due to retirement.

Graduating 30 to 50 students per year is no guarantee that any of them will set up practices in an undersupplied area. There are undersupplied areas all over the country, and they are undersupplied for a reasonthere isnt enough population density to support a practice. It is very unlikely that a new graduate could afford to practice in an underserved area, but experienced O.D.s with less debt load from other states find it extremely difficult to move into many Sun Belt states because of lack of reciprocity and restrictive and expensive licensure exams.

I propose that instead of increasing the number of optometry schools, impose a moratorium on all new optometry schools and freeze current O.D. graduating classes until national licensure reciprocity is a reality. Since the AOA has been unable to make national licensure a reality, possibly a new optometry advocacy group, guild, or political action committee should be established that would place national licensure/reciprocity at the top of its agenda.

Dana C. Rohleder, O.D.

Port Kent, N.Y.

Dr. Steven H. Eyler Responds:

Dr. Eyler serves on both the National Board of Examiners in Optometry (NBEO) and Association of Regulatory Boards in Optometry (ARBO) Board of Directors and is the ARBO Board Liaison to the Council on Endorsed Licensure Mobility for Optometrists (CELMO) Committee.

Dr. Rohleder makes many good points concerning the new optometry school slated for Arizona.

One assessment made in Dr. Rohleders response that was erroneous was that Sun Belt states are restrictive in regard to licensure. In fact, Arizona boasts one of the most progressive Licensure by Endorsement statutes and state board rules in the nation. Not only is Arizona on the AOA Endorsement Map, but its state board is also a CELMO state. CELMO is the continuing education-based program that utilizes COPE to issue a CELMO Certificate, which is recognized by state boards as the highest standard of COPE CE and a significant credential when evaluating a doctor for Licensure by Endorsement.

ARBOs CELMO program, which is only 2 1/2 years old, has issued eight certificates to optometrists to date, has 12 state boards sign on as CELMO States, and has about 30 O.D.s in the CELMO pipeline. In regard to licensure mobility, it is near the top of priorities for ARBO, and it continues to work with AOA to promote uniformity and commonality of licensure.

Steven H. Eyler, O.D.

Charlotte, N.C.


Is it Angle Attack or RCE?

In Julys Glaucoma Grand Rounds column, From Dry Eye to Closed Angles, it seems to me that recurrent corneal erosion (RCE) is the more likely cause of the patients recurrent pain in her left eye than a subacute angle-closure attack.

The April office visit documents the significant pain and corneal findings to support RCE and her pressures were low. Her pain subsided within one to two days of increased lubrication. She denied increased pain in dark environments and didnt mention halos around lights. The post-dilation pressures were normal.

It would have made sense to have her come back during one of her supposed subabcute narrow angle pain attacks to see if her IOP was high or her angles partially closed, or if in fact she was describing her RCE symptoms once again.

Charles J. Dorland, O.D.

St. Louis Park, Minn.

Dr. Fanelli Responds:

Dr. Dorlands comments highlight the difficulty in diagnosing subacute angle-closure glaucoma.

He is correct about the events described in the April visit. In fact, in the column, I attribute the acute pain in her left eye to epithelial erosions secondary to Fuchs endothelial dystrophy, and not to subacute angle-closure glaucoma.

Furthermore, as Dr. Dorland notes, her pain was gone in follow-up after a few days of epithelial restorative therapy.

However, in the subsequent two years, the patient experienced varying degrees of pain in her left eye at various times of the day (remember, epithelial erosions are usually worse in the morning). More importantly, her symptoms of achiness were out of proportion to her corneal appearance, and in the presence of extremely narrow angles, the diagnosis of subacute angle closure became more relevant.

While it would be nice to see the patient during such an episode, the likelihood of that is rather low, as the discomfort is intermittent, and patients often do not follow through with a visit to the office once the discomfort has subsided, especially when they attribute the pain to something else, such as dry eyes. Patients with subacute angle-closure glaucoma, as I point out, are difficult to diagnose because their angles are closed only partially and intermittently, invariably at times other than when they are in the office. The terminology of sub-clinical to describe these episodes is most appropriate, since the symptoms typically fall under our radar screens. That is why many patients with sub-clinical angle-closure glaucoma are often missed.

James L. Fanelli, O.D.
Wilmington, N.C.

Vol. No: 144:09Issue: 9/15/2007