Optometry’s Bubble
The past decade saw economic bubbles in the dot-com and housing markets, each collapsing spectacularly. Is our optometric profession following a similar path? (“Two New Optometry Schools Announced,” January 2011.)

In just the past few years, the number of optometry schools in the U.S. has risen from 17 to 20, a 15% increase. The dogma is that more optometry graduates are needed because the aging population requires more eye care services. That makes intuitive sense, with 78 million baby boomers getting older. Furthermore, the Harkin Amendment promises optometrists greater access to patients starting in 2014.

In the lay media, optometry is cited as one of the best professions to go into. For example, U.S. News & World Report lists optometry as one of the top 50 professions. The same high ranking for optometry is echoed by Money magazine and Payscale.com. Many of these reports cite the increasing need for eye care by the aging population.

Yet if there really is such high demand for eye care services, then why has the the number of accredited ophthalmology residency programs decreased from 122 to 118 over the past decade? Why do I get resumes from O.D.s looking for a job almost every month? Why are there 25 unemployed O.D.s in my hometown of San Diego looking for positions? Why are more optometrists moving into cosmetic services with lash extension and color contacts?

The stark reality is that there is no huge brewing demand for eye care services requiring a dramatic increased number of optometry graduates.

Turns out, the manpower projections are ignoring how new technology allows optometrists to see more patients. In the next decade, our profession will likely see the introduction of disruptive technology that will delegate refraction to a technician, or even be self-administered. Take for example, the refraction system based on point-spread function by VMaxVision and the do-it-yourself refraction using a smartphone with NETRA technology by the MIT Media Lab.

Of course, optometry isn’t just about refraction. There are also incredible technological advances underway for evaluating eye health. Take for example the DRS retinal camera, distributed by Ellex, which is almost self administrable.

Surely, even if optometrists are no longer needed to perform various measurements, optometrists are still valuable for making diagnosis and treatment plans, along with offering recommendations. The trend is that optometry is becoming a more cerebral profession as we perform fewer measurements, but spend a greater proportion of our time analyzing the clinical data, patient needs, and offering treatment. That’s great, but in so doing, fewer optometrists are needed.

The day of reckoning for optometry graduates comes when they try joining the workforce. I shudder to think how many of them will have that “stunned-by-the-headlights” look, wondering why there isn’t available employment. Still, the executives of big box and retail chains are probably cheering on the opening of new optometry schools which will generate for them a steady supply of newly minted O.D.s willing to work at their locations for less. Indeed, a large number of new graduates work in those places out of school because they offer the most plentiful positions and pay well compared to starting out in private practice. Income out of school is a major consideration for optometry graduates leaving with an average indebtedness of $114,367 in the 2008-2009 academic year according the Association of Schools and Colleges of Optometry.

So with plans of new optometry schools opening in Massachusetts and Virginia, I wonder if this bubble is only further inflating with an impending collapse in the coming years.

As a profession, we should not sit by idly without concern.
—Brian Chou, O.D.
San Diego, Calif.

More Tips for Tots
I really enjoyed Dr. DiLibero’s, “Where We Fall Short in Pediatric Optometry” (November 2010). I would like to share a few insights that came to mind while reading it.

When reviewing if a patient has a chronic head turn or eye turn that has been previously undiagnosed, Dr. DiLibero suggested the patient bring in photos. I have found it to be much faster and easier to let the patient log into Facebook or MySpace and look at the photos there. This has been surprisingly successful if Internet access is available.

With drop installation, I have found that use of the Gate Theory of Pain most helpful and fun with small children. (http://health.howstuffworks.com/human-body/systems/nervous-system/pain4.htm) I always show the patient what I am about to do. I have the child sit tall with a very straight back and move to the front of the exam chair. I then ask them to bend their necks all the way back and, without drops in my hand, I have them close their eyes and I touch the lids where I will be placing the drops. They next open their eyes and then I ask them to say their ABCs fairly loudly. If they don’t know the ABCs, I ask them to say their name over and over, while I put an opened tissue over their eyes with my hand over that. I always tell them that Mom will think this is really funny and so will they. At this point they are fairly dubious of what is going to happen, but are generally compliant.

With my left hand supporting their back and the heel of my right hand under their chin, I then place the two anesthetic drops on the lash margin of their closed eyes. I have them keep their head back and eyes closed while I set the drops down and get an unfolded tissue out of my pocket. Then I ask them to open their eyes, at the same time I am moving the tissue and my right hand over their eyes and I move my left hand to the back of their head. Now this is where it gets strange, scientific and fun! They start to feel a slight burn, but you urge them to sing or say their ABCs and then quickly but gently shake their head in a mild rattling motion. It makes their voice and speech irregular and funny sounding while also employing the Gate Theory of Pain and preventing the stinging of the eyes to be reported to the brain. Mom laughs, the patient laughs and a prudent doctor would also laugh and tell the patient how silly they sounded. It’s a big party atmosphere. The routine is repeated with a different song and with cyclopentolate.

This is the “no drama” method of drop installation that I have been using for years. Because it is a “no tears and no fighting” method, the drops are fully effective and I have personally never seen the need to repeat the cycloplegic drops. I encourage doctors to put a drop of anesthetic in an eye and shake your head immediately after. It works surprisingly well.

I would also add sleepy or sudden onset naps as another common post-cycloplegic side effect. I have had more than one parent jokingly ask for the drops prior to long car trips!
In ruling out amblyopia, be aware that crowding effects and field confusion only occur with amblyopia. This is an excellent positive test. Another test is a simple red cap desaturation test to rule out optic nerve conduction problems. This will not be present in amblyopia. These are offered in addition to Dr. DiLibero’s excellent examples.

I have always found microstrabismus challenging to pick up clinically; however, the use of a pair of polarized glasses while looking at a wall or hand mirror, over the current or proposed prescription, can give an excellent indication as to the suppression status of the patient. I have seen many times when a hyperopic child was under-corrected and the proposed correction was of equal acuity, but allowed for much less suppression than the previous Rx. Essentially, if an eye goes black when viewed in the mirror, it is suppressed.
—Dan Bowersox, O.D.
Shelbyville, Ky.