Should Opticians Refract - The Poll

Hi Tim,

I teach refraction at our college, and I'm an optician, so I'll take a stab at what you are asking.

Yes, we teach alot of Binocular function during our 1 1/2 year (3 semester) course. And, I should point out, that our students have many semesters of Lens Theory and Design, Ophthalmic Dispensing Theories, Anatomy of the Eye, Contact Lenses, and Geometric, Mechanical and Physical Optics prior to touching the dials. And, because of the volume of Rx's we have worked with, I believe that opticians are very well suited in tuning into the subjective responses.

We also use Optometry text books (Theodore Grosvenor's Primary Care Optometry and Irving Borish's Subjective Binocular Refraction). These are required texts...not just for reference.

Duochrome, Binocular Balance, Range of Clear Vision, Maddox Prism Rod and Vertical and Horizontal Phoria testing is very much a part of my curriculum.

I agree that there must be a medical test performed at some point...however, it may be done by an ophthalmologist next door, or even down the street. Personally, I believe that young children should be excluded from our practice. I believe that young children should only go to a pediatric ophthalmologist or a specialist in orthoptics.

One person here posted an "either/or" scenario, and I completely agree:

Either OD's and MD's stop selling that which they prescribe, and we may not feel the need to move forward with the refraction issue.

Or, the MD's and OD's continue the path (especially the OD's getting more into pathologies here) and we move into the area of refraction. I see this as a normal evolution of ALL of our professions.

: )

Laurie

I have no problem with that, as long as the end point of "refraction" is not regarded entirely as a means to selling someone an optical device but is regarded as an asessment of someone's refractive error and how that affects visual function. Personally I don't care who does it as long as they do it well.

I suppose as an optometrist it feels strange to me to divorce the refraction element from an assessment of ocular health. I understand the aspiration and as long as suitable training is in place all you have to do is fight the entrenched interests of people like me.:D

Hi Tim,

I believe your group has big pockets too!

Here in Florida, the MD's and OD's are too busy fighting about other stuff anyway.

Even though I see opticians refracting as a natural evolution, it is not my political fight, nor is it on the political agenda of our org. I think we need uniform mandatory college education and to move forward from apprenticeship first.

Thanks for sharing your views...I've learned not to say "never" about anything in life!

Laurie

Tim,

As someone who went through Laurie's program (Hi Laurie happy holidays) I can tell you we covered a lot, as someone who deals with a WIDE range of people (I'm wholesale) I see a lot of problems in this thread as well. I think refracting is not as simple as people may think, take the other thread asking about ".25 cylinder should it be there" (something like that) I noticed no OD's on here jumped on to that thread, I was hoping more would explain it further and maybe better than I did.. I think if anyone thinks refracting is just turning a few knobs and saying "one or two" or "better or worse" than they are NOT ready to refract.
I have been lucky I guess since I got to train under an MD (plus phoropter) and work with an OD (minus) as well as a ton of trial framing in low vision work, but it is a lot more complicated than most people think, Oh if you just want to dial it in and flip the JCC around and do a couple of flips and fog etc., etc.. and it is a "simple" refraction sure, but I still think you need to be "over trained" to have a deeper understanding than just the "basics" so when something does pop up you can be able to identify it and move them on to more appropriate care and follow up..
One of the BIGGEST misnomers I see is sending a person to an MD for a refraction, I know probably 30 or so MD's and not ONE of them refracts but has a tech do it... the redo rate is also out of this world compared to OD's I have as accounts...
I still think all optics is like a house of cards and you can't build it up until you have that firm base to build upon.. without the basic theories and anatomy than you are going to miss a lot..
If an optician gets very good at fitting contacts, keratometry,biomicroscopy (which I find harder than refracting) and can grind custom fits,bifocals,PALs etc., etc. than I think they can move to the next level.. You need basic anatomy and physiology to get to that point as well as a fairly good grasp of ocular problems ...
If any OD is worried, I think they can stop, unless we push the extended educational level we would never have a chance to get any thing approved to move to the next step any way.
They did try to have a big push a few years back here in FL. to do something and I told them they were wasting there time because they did not think it through (one of my accounts sits on the State board) They went it with the basic plan of "expanding" everyone's scope..sort of "bumping" them (that was their term not MINE) .. so you a non medical board is going to make changes to the state medical board? Right.. and this bumping thing... where exactly do you bump an OD.PA (physicians assistant) now they are an MD? :rolleyes:
Some states have expanded the scope of OD's allowing them into the field of refractive surgery.. I'm anxious to see if that spreads as well...;)

I think most people tend to think "refracting" as being easier than what it really is .. till then I don't think any OD has much to worry about, except how to get away from all this insurance plans bringing down their earnings :p

Happy holidays

Jeff "make everything as simple as possible..but not simpler"Trail

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Jeff Trail said:
"
One of the BIGGEST misnomers I see is sending a person to an MD for a refraction, I know probably 30 or so MD's and not ONE of them refracts but has a tech do it... the redo rate is also out of this world compared to OD's I have as accounts...

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How right you are. Well said.

I can understand why many of us would like to refract if only to correct the problems that come in the office. I can understand why we would like to be able to make a living without the good wishes of a precriber. I can understand why many of us would like to elevate themselves to what O.D.'s used to be happy with being.

But now that the whole thing can be done by machine as well as many refractionists bother to do. Why not just get refraction de-regulated as a "medical practice" and buy a damn machine without bothering to take a lot of complicated courses and legislation.

Chip

I hope that was a joke.

PAW:

Serious if we want to allow refraction without pathology as a means for spectacle sales (you would be supprised how many O.D. and M.D. situations this is not far from the case now) why not as long as the patient (customer) is given a clear understanding the he has not had an eye exam, just a spectacle exam. If he wants his hypertension, diabetes, cataracs, macular degeneration, etc. checked he needs to see someone other than the guy pushing the button and selling glasses. And of course the guy doing this could't call himself "Doctor" but then , O.D.'s could not legally until recently.

Chip

I am not advocating this but it makes more sense than spending 100+ hrs. or 4 years or whatever to the same end.

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Bradmain said:
Meaning no disrespect for any of the eye care professionals, I look at this as an "either / or" situation. 1. Opticians should be trained to refract while Optometrists and Ophthalmologists are trained to fabricate spectacles, or 2. ODs and MDs should get out of dispensing and Opticians won't refract.

With #1, Opticians should also get access to 3rd party and stay competitive with MDs and ODs. This, unfortunately, will never happen because Opticians will never get that organized. In situation #2, we distinctly draw the line between the 3 O's roles and the public is better served (hopefully).

In my dreams,

Brad

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ODs are trained to fabricate spectacles in Optometry school. As in your #1--if ODs and MDs fabricated spectacles, then there really would be no need opticians, so you wouldn't need 3rd party.

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paw said:
I hope that was a joke.

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Exactly, what kind of statement was that???? Pure ignorance.....

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Jeff Trail said:
Tim,

As someone who went through Laurie's program (Hi Laurie happy holidays) I can tell you we covered a lot, as someone who deals with a WIDE range of people (I'm wholesale) I see a lot of problems in this thread as well. I think refracting is not as simple as people may think, take the other thread asking about ".25 cylinder should it be there" (something like that) I noticed no OD's on here jumped on to that thread, I was hoping more would explain it further and maybe better than I did.. I think if anyone thinks refracting is just turning a few knobs and saying "one or two" or "better or worse" than they are NOT ready to refract.
I have been lucky I guess since I got to train under an MD (plus phoropter) and work with an OD (minus) as well as a ton of trial framing in low vision work, but it is a lot more complicated than most people think, Oh if you just want to dial it in and flip the JCC around and do a couple of flips and fog etc., etc.. and it is a "simple" refraction sure, but I still think you need to be "over trained" to have a deeper understanding than just the "basics" so when something does pop up you can be able to identify it and move them on to more appropriate care and follow up..
One of the BIGGEST misnomers I see is sending a person to an MD for a refraction, I know probably 30 or so MD's and not ONE of them refracts but has a tech do it... the redo rate is also out of this world compared to OD's I have as accounts...
I still think all optics is like a house of cards and you can't build it up until you have that firm base to build upon.. without the basic theories and anatomy than you are going to miss a lot..
If an optician gets very good at fitting contacts, keratometry,biomicroscopy (which I find harder than refracting) and can grind custom fits,bifocals,PALs etc., etc. than I think they can move to the next level.. You need basic anatomy and physiology to get to that point as well as a fairly good grasp of ocular problems ...
If any OD is worried, I think they can stop, unless we push the extended educational level we would never have a chance to get any thing approved to move to the next step any way.
They did try to have a big push a few years back here in FL. to do something and I told them they were wasting there time because they did not think it through (one of my accounts sits on the State board) They went it with the basic plan of "expanding" everyone's scope..sort of "bumping" them (that was their term not MINE) .. so you a non medical board is going to make changes to the state medical board? Right.. and this bumping thing... where exactly do you bump an OD.PA (physicians assistant) now they are an MD? :rolleyes:
Some states have expanded the scope of OD's allowing them into the field of refractive surgery.. I'm anxious to see if that spreads as well...;)

I think most people tend to think "refracting" as being easier than what it really is .. till then I don't think any OD has much to worry about, except how to get away from all this insurance plans bringing down their earnings :p

Happy holidays

Jeff "make everything as simple as possible..but not simpler"Trail

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Jeff,

You are an intelligent person. Lots of opticians out there think refracting is so simple, when in reality, it does take much more than a basic understanding to perfect. Also, what happens when you can't get the patient to 20/20--that is the most important question there is. It is very common...............

Hi Doc,

We would do the same thing you would do if a patient did not manifest to 20/20...

1. Know best corrected VA and apply pin-hole

2. If 20/20 is acheived, procede with a better refraction

3. If 20/20 is not possible (refer to Ophthalmologist...
(treat in-house depending on laws...
(send out to specialist...

...you fill in the blank)

If the patient ends up with good refractive care and medical referrals, aren't they still served by specialists?


Laurie

Laurie I dont wish to have a refraction law anymore..I Just wanna hire one of them to work for me...Why cant we do it ? That is very antiamerican anti anti almost talisbanish. Let the doc refract all he wants just let him do it for me. Please? It would be an honor to hire an OD and call him optometric physician or what ever he want to call himself as long as he works for ME! you Optometric gods. I would love to set his fees, force him to really work arrive early leave late 15 minute morning and afternnon break and 30 minutes lunch....pleaseeee have them change the law. Wanna hire one...I dont want an independent docteur of optometry next to me I wannt a dependent optometric physican under me...when times are slow he can dispense for me...maybe we can share toilet cleaning duties with the optometric pysician.

Dannyboy:D

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Laurie said:
Hi Doc,

We would do the same thing you would do if a patient did not manifest to 20/20...

1. Know best corrected VA and apply pin-hole

2. If 20/20 is acheived, procede with a better refraction

3. If 20/20 is not possible (refer to Ophthalmologist...
(treat in-house depending on laws...
(send out to specialist...

...you fill in the blank)

If the patient ends up with good refractive care and medical referrals, aren't they still served by specialists?


Laurie

---

Yes, Laurie, you are correct and I am impressed by your answer, but what you stated was exactly what an OD does, but we can take care of most of things without referring. I would be honred to practice along side of you, but what worries me is the attitude of the individual in the post immediately following yours. I mean, I paid my dues by going to Optometry school and learned an immense amount of info. and I don't want the quality of eyecare to be degraded by individuals with that type of attitude. But, there are people out there like you that are serious and would be an asset to a practice.

There is a quote going around from Henry Ford, "You can't build a reputation on what you are going to do."

Is it possible that education degrees of all types are building a reputation on what you are going to do. I just saw the post that "I paid my dues in school." and I used to see so many young opthalmologist just out of school who would get to work late, see a minimum of patients, take a long lunch and leave early at the end of the day. They also where the first to stop working Saturday morning and Wednesday afternoon. This is now being expanded to closeing at noon on Friday. Why: "Because I suffered so much in medical school."

How many college courses do we see that the P.H.D. doesn't teach, in fact seldom shows up at all, and has most of his "teaching" done by underlings. This trend needs to stop, and we need to get compensated for what we do, not for what we prepared to do.

Chip

And no this is not a slam on O.D.'s, or M.D.'s but an observation on our society in general. Nobody really works any more.

Yes, Laurie, you are correct and I am impressed by your answer, but what you stated was exactly what an OD does, but we can take care of most of things without referring.
First, let me say that I am not particularly in favor of having Opticians refract. Not because refraction is such a difficult process, but rather because we already have an over-supply of refractionists in the U.S., so there really isn't a public need.

Second, having managed Optometric Practices for several O.D.s in different states, I would have to disagree with the statement above. The general principle I have observed among O.D.s is: "Never be the last one to see the patient."

Yes, the profession of Optometry is- for the most part- completely capable of co-managing (or even managing) many ocular disorders that go beyond ametropia. However, considering the liability that comes with practicing medicine, I would venture to say it is extremely rare that an OD finding glaucoma, diabetes, ARMD, or even a serious corneal infection is going to proceed with treatment without a referral to an Ophthalmologist.

So, my question would be- "Just what sort of non-refractive conditions are being treated by Optometry without referral?" I have the highest regard for ODs- they are the current gate-keepers of ophthalmics and vision care in the U.S. (a role which was earned through increased education and diligent legislative efforsts). However, I still believe- when a medical condition is found- the safest and sanest course of action is a referral to a medical doctor (at least for an initial confirmation, assessment of the diagnosis made by the OD).

Even that I am now into manufacturing I got actually born into optical retail.

First step:

Optical apprentiship. 4 years of working in lab, learning all steps from hand edging (no automatic edger allowed for the first few month) to repairing solderimg and everything else.
2 full days of theoretical schooling per week
Make final exam and you are a full fledged optician knowing the technical aspects inside out.

Second step:
Learn the ropes of selling, adjusting glasses and customer relation in the store.

Third step:
Take the Master Opticians course, another 3 years of learning. You also learn refracting.
Pass the exams and you become a Master Optician that now has the right to refract. Also gives the right to manage an optical store.

Obviously for an optician to refract should take some serious education and not just a chair, a set of trial lenses and a phoroptor.

If you take it from the other side and look at optometric schools and courses there are also some questionable practises.

Optometrists have a full and complete eductaion on refracting and detecting eye problems. Nearly all optometric schooling is missing out on teaching optometric students the practical optical side of the profession.

Looks like on side would like to do the job of the other side but there seems to be nobody getting together and set some standards. You have standards on the technical side (ANSI) but there seems to be no standards in handling the retail end.

Pete,

90% of ARMD is of the dry variety and an MD is going to do the same thing an OD will do. ODs treat glaucoma daily without referring, we do in my practice anyway. As for the cornea, I only refer if the ulcer/lesion is central cornea in nature. So, we as ODs treat many things without referral, but you are correct in saying that the rule exists about "don't be the last person to see the patient before they go blind", but I take that as refer when you need to. Now, a question to you--just what is the legal definition of a refractionist??

Good ones relating very much to care of the patient/consumer whatever YOU call them. The bad ones relating to economics. Trust me: I've been around a long time and some of the people here as proponents of Opticians refracting, have made many are anti Optometry dispensing statements. Really gang, can't go both ways!:hammer:
I truley feel all three O's have a contribution to make and will be happy to relay them to anyone interested. We all, also, have many cross over skills, but really, vitallogy among others: I don't want an RX written by me and I don't want lenses fabricated by you. (and yes, I have a comprehensive awareness of what's taught in Optometry). This is just one example, so truly I don't mean to single out or pick on anyone. The point being: Many changes need to happen before changing Status Quo.

I think the job of an OD is terribly boring. Refracting is terribly boring. How many Ods actually enjoy this part of their jobs? How many times they dilate patients to affirm yep another .0 c/d ratio
a/v 2/3 macula WNL...lets face it most exciting diseases are always treated by Mds not ODs.

As far as opticians being qualified to refract it seems obvious that we can. The reasoning that we cannot comes from the fact that 80% of all patients seen are refractive errors...not pathology. afraid..you should be because ones we have the step in the refracting door we are going to kick it open as wide as we can...we are already doing so even without licensed to do it...MDS have a several thousand certified assistants doing it. They only sign the pad anyway. Other times the tech just signs the his name and spell the name of the doctor.

Who is to stop us at refracting? Think about it. We as opticians can learn to detect disease as well. At the very least we can be trained to know what is normal...and what is abnormal must go the friendly MD (or Od).

Even if it was legal to do it independently I would hire someone to do because I feel it is boring...Now would I hire a refracting optician for 50 k or continue with the optometric pysician next to us that is another good question.


:bbg:

Dannyboy

Are optometrists that treat glaucoma really giving the patient all the options available.? Do they offer LTPs etc to their patients? or only rely in the prescribing authority that they have on certain drugs?

In the old days optometrists used to wait to the last minute to refer patients who had cataracts to the MDs..why...but now that they comanage the surgery patients get send right away. Some even get gutsy and send the patient with the A scan results under the arm to the Mds office... why...

A few years ago I went to Georgia to learn to do retinal angiography and to our surprise there were some Ods in the course. Scary not to say the least...that they actually feel competent to try doing it independently from MDS ..I guess they can interpret it but what can they do with the info results....are they going to do retinal surgery next? Maybe they can actually bill medicare for this too.



:eek:

Dannyboy

If opticianry is the fabricating and dispensing of lenses, why is optician learning how to do a medical procedure like retinal angiography? Playing doctor? Scary...

PAW have you seen what CRA make at ophthalmology offices?
They make big bucks...and yes under the care and supervision of an opto opps ophthalmologists. The course was the start of another life...we all have pasts some with secret lovers others with secret desires..I have had other lifes that required more education than CRA or optician but opticianry is still the most enjoyable one..that is why I came back to this field.

Scary yes.. they actually teach how to do the flourecein injection and all...but always under supervision... do you know some offices hire EMTs to do the injection because they legally can do it.


Just in case CRA is a Certified Retinal Angiographer....
Nothing wrong with a little education...Independent optician with a few laps around in the eyecare field.


Dannyboy:eek:

Now, a question to you--just what is the legal definition of a refractionist??
Well, since the term "refractionist" isn't to be found in Merriam-Webster, I'm going to assume there exists no legal definition.

However, I think I can supply a definition that will serve as a point of reference for this discussion. A refractionist is someone who is permitted by law to provide a prescription for eyewear based upon an assessment of the refrative condition of the ocular system. Under this definition, in the United States Optometrists, Ophthalmologists, and General Practitioners (I believe) are refractionists. This is not to imply that this is the sum of the capabilities / medical responsibilities of these professionals- it is simply one function.

To the point I was making when using the term "refractionist;" however, there is currently an over-supply of refractionists in the U.S. in most markets. Look in the phone book and there are literally dozens of Optometric and Ophthalmological offices in your area. Therefore, adding Opticians to the body of refractionists out there would only serve to place patients at greater risk (will anyone argue that- all things being equal- a patient is likely to receive better total eye care at an OD office than in the chair of an LDO?).

Further complicating the point is the inconsistency in education/skill level in Opticianry. Unfortunately, it remains a largely non-formally educated profession which is not even regulated in about 1/2 of the states. It will be very difficult to ever gain refraction privileges if this remains the case. The only argument I agree with for LDOs refracting is in the case of the independent Optician who provides eyewear only. In this case, I could see some value to having the ability to correct a recent prescription that fails to meet the patient's requirements (e.g., a refractionist that over-adds a patient who does mainly intermediate work, an over-minused patient who shows classic symptoms of over-correction).

Finally, I'm still not ready to accept your statement that a patient with ARMD (even dry) would not be referred by at least 9 out of 10 Optometrists in this country. Saying that "the MD would do what the OD would do" is the exact same argument the Optician would make for refracting privileges- and the exact same counter argument applies, IMHO. Namely, there is an over-abundance of MDs out there to manage things like ARMD and glaucoma, adding additional capacity simply isn't necessary.

These are only my opinions. If an OD can build a medical practice, more power to him or her. For myself, were I to find myself in an Optometric practice I would focus (pun intended) on what is- without a doubt- the single most profitable aspect of Optometry (providing prescriptions and Ophthalmic goods). Show me almost any OD practice, and I can clearly demonstrate that the profit center is the dispensary (with a few exceptions).

Now, if I was really interested in the provision of medical services, I would either go to medical school or gain employment in an Ophthalmological practice (my wife worked as an Ophthalmological Tech for a few years, and I always envied the OD there- he had a great situation).

In australia this is a relatively new debate, and also in New Zealand. New Zealand has had this debate become much more relavant as their optometrists have been given the clearance to prescribe drugs, but only limited amounts.. also Victoria Australia has had a similiar legislation introduced

Optoms wishing to prescribe drugs will need to sit the relavant exams and are only limited in the drugs they prescribe, but makes sense. a Px with eye problems 90% of the time goes straight to an Optometrist. the optometrist then refers onn to a GP or an opthalmologist to write an Rx, which is a nuisance for a px, but could potentialy be quite risky, as they put off treatment.

Optometrist prescribing drugs is a natural progression really.........
so why wouldn't Optical dispensers/ opticians refract?? I beleive that opticans do the refractions in france, and some other European countries, so why limit it? With the proper training it would be quite sensible, and very handy to a patient. BUT one has to go with the other, if a dispenser can refract, an optometrist should be able to prescribe drugs, other wise the position of an optometrist becomes redundant.

Then Opthalmologist will complain, but it must be realised that optoms are limited in what drugs they can prescribe.. but opthals would still complain. In Australia MEdicare/HIC(National Health service) pays for these services (similar to canada i think) and also sets the price, its not legal to charge more than the set benefit, only less, so what would a dispenser be paid? would this be covered by the HIC? An optometrist gets $48.75 for a full test, 17.85 for a short test... is 17.85 worth it?

i belive that an optometrist needs to be on duty to even allow a refracting dispenser to preactice, but this would work out very good, as optometrist would get standard bookings, and then RODs would just pick up any walkins in the second room (assuming you have one) any questions/ queries would need to be directed straight to the optometrist, as well as contact lens fittings.

but would we get lazy? i know several optometrists who just use the humphries for testing auto-refract, or would optometrists get lazy? make it a two part test dispenser does the initial check, and the optometrist checks the general health... are we really that busy?


i guess its going to come down to whats practical, if your in a large practice churning through customers, then maybe having 2 optometrists on 4-6 dispensers for testing and grindings, as well as selling, and possibly a receptionist helping to book the 3-4 testing rooms available.... but now it sounds like K-Mart, and not a medical practice....

I would get trained to refract, not so much to sell, but only to see a patient from start to finish...

so when can i start dispensing contacts? :p
if i did wouldn't an optometrist want more drugs?, wouldn't an opthalmologist want to do more? (can they??) an optometrist would want to do surgery...

while i support the drugs in optometry, and would love to refract, their are boundaries, these are called job titles, if you want to refract, would in the rich time and become an optometrist, i'm not going to fight to refract, i'll happily embrace but if i really wanted to refract i'll go back to university




good moral/ethical question:-

are we in it for money or job satisfaction, when you go home do you think, "sweet i made a $400 sale today" or is it "wow i made someones life easier by giving them the correct product"..



James


if any of those details are incorrect in any way let me know... David Wilson, i'm sure you will be the first to tell me