“Unless you’ve got an optical engineer in your exam chair, reciting names of Zernike polynomials as possible explanations for a patient’s night-time blur is gonna get you nowhere.”
After several years of practice and several thousand patients, you’ll definitely get the hang of how to explain things in an efficient manner so that your patients leave your exam room feeling as though they know just what they have and how you’re going to be treating it. But in those first few months (or years) out of optometry school, it may seem a bit difficult to concisely explain some of the more complex optical terms and diagnoses that we commonly encounter in practice. In school, we’re immersed in technical jargon – we present cases to supervising doctors using (or at least trying our best to use) terms right out of our textbooks. Unless you’ve got an optical engineer in your exam chair, reciting names of Zernike polynomials as possible explanations for a patient’s night-time blur is gonna get you nowhere. You’ll develop some of your own ways to explain things to your patients, but I thought I’d share a few of my explanations to give you a jump start in clinic and in your first year of seeing patients.
1) Astigmatism
Dreaded astigmatism! On many occasions, I’ve had patients come to me with a deathly fear of having been told they have astigmatism! I ask them if they know what it is and they almost always say “no!” It can be frightening to be told you have something wrong with your eyes and not know exactly what it is. Some patients come to me and tell me they were told they have “football-shaped” eyes. When I ask them if they know what that means the answer is typically “not really.” So obviously we’re missing out on effectively describing one of the most common forms of ametropia we see in practice. Roughly 85% of the population has it. So this is how I go about explaining astigmatism – which, after a while may sound like a broken record, but it works: I’ve found that you have astigmatism. Astigmatism essentially has to do with the shape of the front of the eye. Instead of the eye being a perfect sphere, you have one part that is curved more than another part. Each of these curvatures has its own focal point. Without glasses, you basically have 2 focal points entering the eye at the same time and that causes blurriness. With a contact lens or glasses prescription, we can correct for each of those curvatures so that you have a single focal point focused on your retina, creating a clear image. Most folks have astigmatism – about 85% of the population, so there’s no need to worry.
2) Glaucoma
Glaucoma can be tricky to explain, especially in the early stages. Put yourself in the patient’s shoes – how would you feel if you were told that you might have something wrong with you that you’ve heard can cause blindness? Patients will come to you with a fear that they may be getting glaucoma because a family member has it, or they were told in passing on a previous exam that they might have it but no treatment was initiated. Whereas you may toss around differential diagnoses loosely with colleagues or supervising doctors, NEVER loosely toss around terms in front of a patient unless you’re sure of a diagnosis or you can fully explain each term to the patient, as well as how you’re going to determine if they have it or not. Don’t leave them hanging! Because of the complex nature surrounding initiation of treatment in a sometimes multi-faceted disease such as glaucoma, it is important to walk the patient through your thought process carefully. Here’s how I usually bring it up (normal tension glaucoma suspect): Your eyes generally look healthy and during your exam I did some routine tests to check for glaucoma. Glaucoma is usually something that is asymptomatic – it’s typically not something you notice or feel and that’s why we always check for it. Glaucoma is essentially nerve damage within the eye usually secondary to the pressure being high inside the eye. When the pressure gets high, it can push on the optic nerve inside the eye and potentially damage some of the nerves that run from the eye to the brain to allow you to see. Your pressure looks good, but when I look at your nerves, I see that the cupped area of your nerves is a little larger than usual. Usually the cupped area takes up about 30% of the whole nerve – in your eyes it take up about half. It’s possible that your nerves have always looked like that since birth, but I suggest doing a few additional tests to confirm that things are OK. If the other tests show that you might have an early form of glaucoma, the worst case scenario is that we start you on some eye drops to keep the pressure down, but we’ll discuss that after we do a few more tests.
3) Cataracts
Typically patients know a good deal about cataracts. You might find that some of your older patients will be very apprehensive about having to have cataracts removed. Older patients may remember a time when sutures were used and when folks would be left aphakic and had to wear very thick plus lenses after surgery. As you know, the procedure is very much streamlined now. Simply telling patients that no stitches are used gives them peace of mind. They also are surprised by the fact that it’s an outpatient procedure and that it only takes about 15 minutes to perform. Again, put yourself in the patient’s shoes. Knowing all that we know about the eye and the delicate nature of pretty much everything inside the eye, I think we’d all be apprehensive about going under the knife. These folks are typically older, may have health concerns about having any surgery done, and need your reassurance. Here’s my typical introduction to the cataract talk: Even with a change in your glasses prescription, I see that the best I can do is to get your vision to 20/50. The reason why I can’t get it any sharper with just glasses is that you have cataracts that are scattering the light as it enters the eye. Therefore, it is unfortunately impossible for me to put a sharp image on your retina – as the light passes through the cataract or cloudiness inside the lens of your eye, the light gets scattered and causes blur. I’m going to recommend that you see a cataract specialist for a second opinion and to see if removing the cataract would be beneficial for you at this time. I would hate for you to spend a lot of money on new glasses only to experience the same amount of blur. I think you will be very pleased with the clarity of your vision once you have the cataracts removed. In many cases, you may no longer need glasses for distance anymore, but you may still need them for fine print when reading.
So there you have it – some simple words for some of the more common things that patients may find complex if they aren’t properly educated. If you like these tips – let me know! I’d be happy to share how I explain other diagnoses if you’re interested.
Scott Bushinger, O.D., M.S.
ABOUT DR. BUSHINGER – Upon graduating from SUNY Optometry in 2007, I joined a group optometry practice in Utica, NY as an associate optometrist. In 2009, I joined the eye clinic at Lewis County General Hospital in Lowville, NY before taking my current position at Costello Eye Physicians & Surgeons, an ophthalmology group practice with 4 offices throughout Central New York. I also provide patient care with LensCrafters at Destiny USA in Syracuse. I have filled-in for numerous optometrists in several commercial and private practice settings from Rochester to Albany, as well as in Brooklyn and Queens. As an active member of the AOA and NYSOA, I serve as District Leader for the Mohawk Valley Chapter. I also serve on the Advisory Committee for the Health Professions at Utica College and have served as Director of Professional Development at Mohawk Valley Young Professionals. My Masters research in vision science included studies of tactile alphabets designed for low vision patients. As a student at SUNY Optometry, I was a member of the Beta Sigma Kappa International Optometric Honor Society.
