Scott A. Edmonds, OD, FAAO, focuses his blog on the role of the optometrist in health care reform – moving from primary eye care to primary health care. He is the chief medical officer of MARCH Vision Care, the co-director of the Low Vision/Contact Lens Service at Wills Eye Institute in Philadelphia and a member of the Primary Care Optometry News Editorial Board. 

Disclosure: Edmonds is a consultant for March Vision.

BLOG: The spectrum of chronic disease

The evolution of the profession of optometry has been a wonderful thing to observe. Like many things in today’s society, this evolution is occurring at such a rapid pace that it can be observed over a relatively short time span.

Living and working in Philadelphia, a stone’s throw from Independence Hall, I often think of changes that have occurred along the very streets that I walk every day. What would Ben Franklin or Thomas Jefferson think if they could again walk along this same path? With their names and pictures plastered everywhere you look, it’s hard not to think of them.

For optometry, the evolution has been from our roots in physics and optics to more biology and pathology. Just as we moved into the diagnosis and management of eye disease in the last half of the 20th century, we move today into a larger role in systemic pathology. This evolution has been largely driven by technology and has followed a logical path.

As technology has made refraction and vision correction easier, we have more time to evaluate, understand and manage the underlying cause of refraction and vision changes. These are often related to cataracts, glaucoma and retina pathology, some that we manage and some that we refer to our colleagues in ophthalmology.

Likewise, as we have leveraged technology to better manage ocular disease, we have found that many ocular diseases have underlining systemic origins. In particular, we have become more involved with diabetes, hypertension and dyslipidemia. Also, like eye pathology, we can manage some of these problems in the early stages with education, lifestyle recommendations and wellness programs, and some we need to refer to our colleagues in medicine.

As we have learned from our management of chronic eye disease, most eye pathology does not start overnight and progress rapidly to blindness. There is a spectrum that starts with risk factors, progresses to signs and symptoms, evolves to structural changes and limitations, and often ends in dysfunction and disability. Identification and intervention can often change the course along this spectrum and prevent or at least delay the end result.

Again, these same principles apply to chronic medical problems. Hypertension, diabetes and dyslipidemia follow this same spectrum, and identification and intervention can also change the course along the spectrum.

The Holy Grail of disease management is patient access. If a health care provider does not have access to the patient, there is no way to identify or intervene, and the spectrum will run its natural course. Unfortunately, the end stages of dysfunction and disability will finally bring the patient into the system for the painful and expensive care that can only hope to minimize the suffering.

Optometrists, like many nontraditional primary care providers, have direct access to patients that may be otherwise lost to the system. Healthy people with refractive errors often visit us in lieu of any other health care professional. We start to see them at a young age and mostly see them every year. We see them when they come home from college and have added that “freshman 15 pounds.” We smell them as they learn how to smoke. We, perhaps more than any other health care profession, have direct access to the front end of the spectrum of chronic disease.

The evolution of a profession happens at the grass roots level. In effect, we cannot evolve unless you evolve. Adoption of electronic health records, measuring vital signs, detailed family health histories, using the Review of Systems and communication with the medical community are all steps in this evolution.

I wonder if Ben Franklin, when inventing the bifocal, knew that he would be inspiring a profession to improve the health of a nation?