January 17, 2018
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Complete eye exams in children could save their lives

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Garineh M. Nersisyan

The optometry school curriculum is a rigorous program preparing highly trained doctors of optometry.

In 4 years of graduate work, we learn about vision, lenses, diseases, medications and much more. We are taught to keep our eyes open for simple conditions as well as complex, life-threatening problems. We hope these devastating conditions are so rare that we never have to experience them.

Each day in class and clinic we are trained on the importance of thorough eye examinations. We learn that vision is not just about seeing 20/20. I distinctly remember one particular professor stating, “Anyone can spin dials, run tests and write down numbers, but what differentiates a doctor from a technician is the ability to analyze the results.”

The human body is a complex system unified by two extremely intricate and delicate organs. These organs not only allow one to see the outside world, but they allow doctors to have a glimpse inside the body’s inner workings. The eyes truly are windows into one’s body and soul. They tell us a very important story about each individual. Diseases, accommodative dysfunction and even stress can manifest in the eyes. Yes, optometry school has equipped me with knowledge; however, optometry practice has made me a doctor.

I never imagined that in just a few years of practice I would diagnose so many different conditions. Just to name a few, on my first day working as a licensed optometrist, an elderly man began to have a stroke in my exam chair. After 3 months of practice, I diagnosed a middle-aged woman with glaucomatocyclitic crisis (Posner-Schlossman syndrome) and a teenager with a sight-threatening corneal dystrophy. A year later another patient had been desperately seeking second and third opinions to solve her health problem. Probing with just a few extra questions, I was able to diagnose her with Vogt-Koyanagi-Harada disease. These experiences have made me a better practitioner, but none of them would have prepared me for what took place on July 11, 2014.

Special interest in pediatrics

I had a strong interest in pediatric examinations early in my optometric career. Each quarter of school clinic I made sure to be scheduled in the pediatric department. I believe a lot of conditions can be prevented and treated if caught early enough in children. As a primary health care professional, I play a critical role in ensuring children are on a healthy path and are given a chance to develop properly.

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My office staff began to notice that I work well with children and that kids truly enjoyed spending time with me. The number of pediatric exams that I performed increased rapidly. With each exam I took time educating parents regarding the importance of annual eye exams. Too often I would hear, “My child has already had a vision test at the doctor’s office.” It became apparent that a large percentage of parents did not realize children needed comprehensive eye examinations.

Most parents are under the assumption that a yearly visit to the pediatrician’s office is sufficient. The American Optometric Association recommends a health check at 6 months of age, the first comprehensive eye examination at 3 years and again every 1 to 2 years after. It is estimated that 86% of children begin the school year without having their eyes checked (AOA).

It is also believed that many children diagnosed with attention disorders are actually suffering from poor eyesight (Davis Vision). Glen Steele, OD, AOA InfantSee and Children’s Vision Committee co-chair, stated that eye and vision disorders can impose a significant burden on patients, parents and the public (Pinkston).

After explaining what a comprehensive eye exam consists of, many parents say they’re taught to visit the dentist every 6 months, but why not visit the eye doctor? This same question was stated by one such dismayed parent who had brought her daughter, EH, in for her very first eye exam.

First eye exam at 14 years

EH is a 14-year-old girl who enjoys school, horses and volleyball. She complained of recent blur when reading and headaches for a year and a half. I thought maybe she needed reading glasses and that it’s common for a girl her age to experience headaches during hormonal changes. After doing entrance testing and a refraction, it was determined that she would, in fact, benefit from a small reading prescription.

The next step was to evaluate her ocular health. I was curious about the headaches, so I asked more questions. I felt it would be unethical to brush them off to hormonal changes alone. She described vomiting once and that her vision “seemed to go dark” while standing up. Upon a thorough fundus examination, I questioned the appearance of the nerves. My heart sank. Was this true bilateral papilledema? I had to take my patient’s headaches seriously considering what I was seeing. I completed the retinal evaluation and referred my patient to a neuro-ophthalmologist for an MRI and further testing. I was careful in wording my explanation to the mother, as the girl was in the room and there was no confirmation as to the cause of the swollen nerves. I knew the family deserved to know what we might be dealing with and asked the mother to call me if she had any questions.

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One week later I received the ophthalmology report. I read the exact words I had hoped to never see. “MRI shows presence of a large midline posterior fossa mass.” I felt horrible. Should I call the parents? I had already left a follow-up message days prior to receiving the letter but hadn’t heard back. I decided to email a colleague and mentor. He congratulated me and told me to never feel bad for saving someone’s life. It was difficult processing that at the moment. Just then my patient’s grandmother came to the office crying and thanking me. Unbeknownst to me, the girl had already had a craniotomy. The tumor had been successfully resected, and she was being kept in the hospital for observation.

I asked the family’s permission to visit her. Being a new mom, it was difficult for me to see a young child in her condition. It took every ounce of strength to keep my composure to not upset the girl or her family any further. As I left, EH blew me a kiss. While driving home I was thankful that the pathology results were favorable. I also thought about the value of my optometric education and my role in the health care delivery system. Some days later, the neurosurgeon called, congratulating me for catching the papilledema and saving the girl’s life just in time. I don’t think anyone can prepare themselves to hear those words, but it’s situations like this that drive people to become doctors.

Annual eye exams crucial

It is my responsibility as a primary eye care professional to provide exceptional care to all of my patients. It is also my duty to provide proper education to my patients and parents of children. My plan is to speak up and urge everyone to get annual eye examinations. I have been struggling to meet with local elementary schools regarding vision and eye health care. I am astonished at the school administrations’ lack of interest to have such information provided to their parents and students.

A change must occur in the medical and school communities, and the public needs to be made aware of the importance of timely exams. If you have children, please take them in for complete eye exams. Life- and sight-threatening conditions can be missed otherwise. Reading an acuity chart at the pediatrician’s office is not enough. Your vision might be 20/20, but the inside of your eyes might tell a different story.

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To my fellow eye care professionals: The words above are a reminder of the optometric oath we pledged to, including providing proper care for all individuals with the highest of standards and ethics. They are a reminder of the importance of thorough examinations and the value of utilizing the knowledge gained from our optometric education. Listen to your patients’ complaints even if they are not always related to the eyes. Be attentive in your exams. Analyze your results. “Listen” to your patients’ eyes. What story are they telling you? -- by Garineh M. Nersisyan, OD

References:

American Optometric Association. Make eye exams part of back-to-school routine. August 25, 2014.

Davis Vision. Health Vision for Success in School. Available at: http://cvw1.davisvision.com/forms/StaticFiles/English/Childrens_Vision.pdf. Accessed January 16, 2018.

Pinkston W. Add a subspecialty to your practice. AOA Focus. 2017;7:22.

For more information:

Garineh M. Nersisyan, OD, practices at Wink Optometry in Calabasas, Calif. She can be reached at Garineh.nersisyan@gmail.com.

Disclosure: Nersisyan reported no relevant financial disclosures.