OD education must keep up with industry changes

In Malcolm Gladwell’s classic book TheTipping Point, we are reminded that critical events bring about outsize change.¹ We are at that point in optometry: poised for momentous professional responsibility and growth. This transformation is due to the convergence of science, technology, economics, communication-and resulting patient needs and expectations.

At this moment, optometric leaders are seemingly wedged between fighting against online refractions and spectacles and fighting for “follow the money/ophthalmologic care.”

Yet, both directions fail miserably at delivering enhanced quality of care to the patient-beyond expediency and treatment of acute emergencies, infections, and surgery.

As Internet-savvy consumers demand more, and as unscrupulous insurance executives bottom feed for simple refractions, academics within our colleges of optometry continue to dismiss all discussion of wellness, prevention, and environmental optometry as irrelevant. As science and multiple stressors bear down on our profession for more than the medical “detect and treat” model, the “ivory tower” has no choice but to teach students what consumers demand, lest they become dinosaurs.

Previously from Dr. Richer: Details matter when prescribing meso-zeaxanthin

Thinking inside out-not outside in

The 2016 American Academy of Optometry Nutrition, Disease Prevention, and Wellness Special Interest Group (held in Anaheim, CA, on November 10, 2016) provided a glimpse of the hidden world of the gastrointestinal system.

The microbiome, a 10-trillion–cell civilization of microbes lives within each of us, impacting our inflammatory, cardiovascular, and neurologic systems that affect eye health and function.²

Caring for the patient now means caring about his gut health and factors that can disrupt it. Factors such as systemic antibiotics, modern farming practices, sugar, gluten, environmental toxins, and GMOs all must be discussed with this in mind.

Photobiology

Modern living has become an indoor phenomenon as humans have moved from full-spectrum outdoor living to incandescent lighting-and further toward modern highly energetic blue light-emitting diode (LED) exposure. Indeed, myopia prevention is correlated with the opposite: outdoor living.³ The shift to (unnatural) blue LED lighting is poised to become a $42.5-billion industry by the year 2020.⁴

Yet optometrists require remedial training on the benefits of several topics: sunlight for vitamin D production, overemphasis of sunblock, maintenance of the circadian rhythm, the mitochondrial benefit of near infrared light, color temperature adjustment on televisions, color index, blue light protection and smartphone-induced pediatric dry eye.

Consumers are looking for actionable advice about which light bulbs to purchase, what tints to use, how to adjust their television color temperature, how to reduce the blue light at night emanating from electronic screens, the color choice for nightlights, and which carotenoids to consume.

This isn’t your grandfathers’ patient-optometrist encounter.

Vitamin D3 testing is important at any age-particularly for housebound elderly patients with age-related macular degeneration (AMD) living in northern, sun-deprived latitudes.

Serum 25-hydroxyvitamin D liver-reserve status is associated with retinal pigment epithelium (RPE) disease, AMD neovascularization, and the geographic extent of post-bleed retinal AMD fibrotic damage-and all chronic diseases.⁵

Related: Insulin resistance is more important than you think

Think insulin resistance, not diabetes

Insulin resistance (IR), short of diabetes mellitus, is an epidemic and the universal foundation of poor health.

IR has an immense contribution to cardiovascular diseases and negatively impacts retinal vessel health early on. Kerry Gelb, OD, and I have shown that multispectral imaging of the retina strongly correlates with pre-diabetic insulin resistance.⁶

In turn, IR responds to a host of interventions, such as exercise, mineral/nutrient/vitamin D repletion, elimination of toxins such as BPA, a healthy microbiome, intermittent fasting, far infrared saunas, sleep quality, circadian rhythm health, and more.

Presbyopic adults with pre-diabetes and needing reading eyeglasses are certainly a vulnerable sub-population of patients who present periodically in their 40s and 50s to the same optometrist.

As mentioned in my June commentary (“Insulin resistance is more important than you think”), many Americans have become sedentary “screen huggers,” stress-induced overeaters, sweetened-beverage and processed-food consumers, poor quality-manufactured/restaurant-food aficionados, and multiple-pharmaceutical takers that further reduce the nutrients needed to process banquets of ubiquitous sugar and protein.

How long is academic optometry going to ignore these facts and merely address ophthalmologic end-stage disease?

Here is an opportunity for the OD to perform primary care and not just talk about it. Why not become a pre-diabetes, diabetes educator and certified nutrition specialist, helping to reduce this public health burden? How long are colleges of optometry going focus on detection rather than prevention?

Related: How diet and nutrition affect disease

Brain health plays role in eye health

Brain health is intimately related to ocular health and vice versa.

Reading, visual-spatial perception, saccadic eye movements, hyperacuity perimetry, useful field of vision (UFOV) deficits, as well as contrast sensitivity loss are a handful of abnormalities encountered in early Alzheimer’s disease.⁷ 

The pupil’s response to mydriatics, the presence of thinning skin, thinning corneas, thinning superior optic nerve fiber layer, peripheral lenticular amyloid beta protein, and apoptotic cells in the retina, are important objective clues to declining brain function.^8,9

Particularly exciting is the recent discovery of the dietary ocular carotenoids (lutein and zeaxanthin) as the dominant carotenoids of the brain as well as the retina. With a simple macular pigment optical density (MPOD) measurement, the optometrist is informed about the functional health of both the eye and brain.¹⁰

That is, MPOD is related to cognitive function. It is not unusual to attend a CE event where few optometrists know the numerical value of their own macular pigment optical density.

Our educators are not at the top of their games.

Related: Why ODs should care about sugar

References

1.Gladwell M. The Tipping Point. Black Bay Books. 2002. Print.

2.Lu LJ, Liu J. Review: Human Microbiota and Ophthalmic Disease. Yale J Biol Med. 2016 Sep 30;89(3):325-330.

3.Lagrèze WA, Joachimsen L, Schaeffel F. Current recommendations for deceleration of myopia progression. Ophthalmologe. 2017 Jan; 114 (1): 24-29.

4.Market Research Store. Global led lighting market worth USD 42.5 billion by 2020: industry size, share, trends and segments – market research store. ABNewswire. 2016 Oct. Available at: http://www.abnewswire.com/pressreleases/global-led-lighting-market-worth-usd-425-billion-by-2020-industry-size-share-trends-and-segments-market-research-store_83341.html. Accessed 1/23/17.

5.Yanoff M, Ackert J, Aronow M, Crandall A, Freman P, Lieberman R, Ortiz J, et al. Advances in Ophthalmology and Optometry. Elsevier Press. 2016. Print.

6.Gelb, K, Richer, S, Zimmer, C, Sherman, J, Gold, J. 2016. Retinal multispectral imaging of “sub-clinical” capillary micro-aneurysms in non-diabetics correlates with insulin resistance. Diabesity. 2016 Jul;2(3):19-25.

7.Armstrong R, Kergoat H. Oculo-visual changes and clinical considerations affecting older patients with dementia. Ophthalmic Physiol Opt. 2015 Jul;35(4):352-76.

8.Normando EM, Dehabadi MH, Guo L, Turner LA, Pollorsi G, Cordeiro MF. Real-time imaging of retinal cell apoptosis by confocal scanning laser ophthalmoscopy. Methods Mol Biol. 2015;1254:227-37.

9.Kerbage C, Sadowsky CH, Tariot PN, Agronin M, Alva G, Turner FD, Nilan D, Cameron A, Cagle GD, Hartung PD. Detection of Amyloid β Signature in the Lens and its Correlation in the Brain to aid in the Diagnosis of Alzheimer’s Disease. Am J Alzheimer’s Dis Other Demen. 2015 Dec;30(8):738-745.

10.Vishwanathan R, Schalch W, Johnson EJ. Macular pigment carotenoids in the retina and occipital cortex are related in humans. Nutr Neurosci. 2016;19(3):95-101.

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