A VA residency offers more than meets the eye

It’s 8:15 a.m. on Monday, and we are getting ready for another day of typical patient care while gulping down the last sips of our morning coffee. The first 8:30 a.m. patient arrives, and one of us heads out to greet him in the lobby.

The patient is a 68-year-old veteran with diabetes and glaucoma who has not been seen at our eye clinic in over two years. Simple enough, right? After reviewing the previous chart history, a few more key details are uncovered. The patient’s last eye exam two years ago was for an acute anterior uveitis for which he was prescribed Pred Forte (prednisolone acetate suspension, Allergan) and Cyclogyl (cyclopentolate, Alcon).

The patient did not return for his follow-up exams until today, despite trying to reach him several times. Great. In addition, the patient’s HbA1c is 11.2 percent with a fasting glucose level of 303mg/dL. Oh, and did I forget to mention he is on three glaucoma medications because his pressures are off the chart, and his nerves are close to cupped out?

The patient proceeds to tell me that he lost vision suddenly in his right eye three months ago and is just now coming to see us about it. The prescription must be off in his glasses, he claims. The patient’s right eye has an entering acuity of light perception, his cornea is microcystic and edematous, his iris shows neovascularization, his pressure is 36 mm Hg, and his lens has a mature opaque cataract severely limiting our view of the posterior segment details.

The other eye? The left eye is correctable to 20/25 with a healthy cornea, a pressure of 20 mm Hg, a mildly nuclear sclerotic cataract, and no signs of diabetic retinopathy. Good news, right?

Oh, wait. The patient also has a grossly apparent nasal visual field constriction OS from a cupped-out optic nerve! To most, this patient may sound like a nightmare. But to us, this patient is just another challenge in our daily mix of demanding patients. Happy Monday to us.

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Next: Why we chose residency

Why we chose residency

No one will argue that a four-year optometry program does not prepare you for patient care once you graduate. We learned a lot: how to refract, how to fit contact lenses, and how to perform a comprehensive dilated exam, among other things. However, we decided to pursue a one-year optometric residency to expose ourselves to more complicated patients and build our knowledge diagnosing and managing ocular disease.

Managing patients with various stages of glaucoma, age-related macular degeneration, and diabetic retinopathy, to name a few, have become daily patient encounters that require swift clinical decision-making.

As optometric interns, we were comfortable with running Humphrey visual fields, acquiring OCT images, and gathering data, but we often required the aid of our attending doctors to help interpret the data and manage the patient. As graduation loomed, we desired the chance to refine our skills in patient care and management.

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We chose residency because we wanted to continue learning at a higher level. We wanted to improve our efficiency, master interpretation of ophthalmic imaging, challenge our decision-making, increase our exposure to ocular disease and ocular emergencies, gain exposure with interdisciplinary care, and become more comfortable in our new doctor skins.

We chose residency to take one step closer to practicing at the highest level our profession allows.

As the scope of optometric practice expands into a more medically based role, we wanted to be ready and at the forefront of this exciting time. We knew that a Veterans Affairs (VA)-based residency would help us prepare into becoming some of the best primary eyecare physicians around.

Next: A VA residency offers opportunities

A VA residency offers opportunities

Several reasons led us to choose a VA-based residency over other residency opportunities. The VA healthcare system provides an array of opportunities to refine and elevate one’s optometric skills.

First, we were excited to work with such a challenging and rewarding patient population. The eye clinic at the VA provides a high volume of quality patient encounters. Patient care at the VA requires the diagnosis and management of several ocular conditions and systemic ocular complications, such as glaucoma, macular degeneration, diabetic retinopathy, vascular occlusion, optic neuropathy, traumatic ocular emergencies, among others.

The patient population within the VA is inherently challenging due to a variety of physical and mental conditions that plague many veterans. Whether someone is suffering from Parkinson’s, dementia, or schizophrenia, we often find ourselves thinking unconventionally in order to provide efficient, quality care. The creative necessity of certain exams is most evident when examining patients under nursing home care. These patients are often bedridden, with very limited mobility and cognition.

Because the VA ensures that these patients are provided with appropriate specialty care, we are given an opportunity to provide eye care in a technically challenging and emotionally rewarding environment. In this setting, the nursing staff’s expertise and knowledge about the patient is a valuable part of the comprehensive eye exam. The nurses often provide pertinent patient history and specific patient needs that they have gathered through their daily interaction with these patients.  

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Second, we were drawn to working in a hospital-based setting in which interdisciplinary care thrives and academia flourishes. The collaboration we have with nurses, primary care physicians, pharmacists, ophthalmologists, and other specialty providers is invaluable to our learning experience.

The electronic health records maintained by the VA allow an integrative approach to patient care. A patient’s medical and ocular history is available for immediate and comprehensive review, which is particularly helpful because many patients are not always the greatest historians when it comes to specifics about their health.

A patient’s specific medical problems, medications, allergies, and lab work are immediately available and provide you with a blueprint for your comprehensive eye exam.

If you have a patient presenting with neurological symptoms, a suspicious visual field defect, a swollen optic nerve, a recurring red eye, or unexplained retinal hemorrhaging, it is easy and convenient to order specific imaging and lab work to rule out serious or potentially life-threatening systemic concerns. As the referring doctor, you will be notified when these tests have been performed and interpreted by the appropriate specialist.

In addition to collaborating with other specialties, consulting with other optometrists, opticians, and ophthalmologists within the eyecare facility is an integral part of our residency experience. Being able to discuss a challenging case with colleagues, review a patient’s OCT with your peers, and obtain the opinion of an ophthalmologist regarding a patient’s specific treatment options creates an atmosphere of learning and growth.

Working closely with other specialties not only allows us to teach other healthcare providers about the importance of routine eye care, it reminds us to look beyond a patient’s two eyeballs and consider the patient as a whole. As primary eye care providers, we may not have the tools and knowledge to diagnose every ailment; however, we can be valuable assets in directing a patient’s concerns to the correct specialist and providing pertinent patient education.  

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Finally, we were attracted to the prestige that the VA health care system offers. In our experience, the VA has some of the most up-to-date ophthalmic instrumentation, which provides us-and our patients-with the best tools to aid in diagnosis and management of complex ocular conditions.

Because the VA is such a large, nationwide healthcare network, many companies are eager to have their instrumentation integrated into VA patient care. This past year at VA Sepulveda, we were able to operate and trial the AdaptDx instrument from MacuLogix. The AdaptDx is a dark adaptometer used to evaluate dark adaptation abilities in macular degeneration patients and suspects.

It was an exciting addition to our clinic and we knew that we were a part of cutting edge technology that could potentially help shape future optometric care.

In addition to new technology, we were able to gain experience in advanced optometric techniques and care. We became skilled in fluorescein angiography and foreign body removals, to name a few. Other VA facilities also offer additional experience with low vision rehabilitation and specialty contact lens fitting.

Next: Closing our our typical Monday

Closing out our typical Monday

We could not be happier with our decision to pursue a VA-based residency in primary care and geriatrics. Every reason for seeking additional residency training has been validated, and we emerge from this experience as more confident primary eyecare physicians.

And with that, I bring you back to our typical Monday in direct patient care. As Monday afternoon comes to a close, we get one last walk-in patient (as if we weren’t busy enough). He’s coming straight from work as a contractor and tells us he feels as if something is embedded in his right eye. His eye is shut upon arrival, and the patient winces in pain as I pry his lids open to take a look. His conjunctiva is bright red and there is a metallic foreign body waving hello from his peripheral cornea.

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I educate the patient on the findings and how we plan to proceed as I anesthetize the eye and grab my needle to pluck out the tiny metal piece. The patient remains relatively calm as I Alger away the rust that came along for the ride.

The patient immediately expresses relief when I tell him he will be fine and that his cornea will be back to new in a few days. The patient leaves our clinic so thankful we could see him and so happy with the care he received.

The three of us, on the other hand, leave our workday fulfilled and grateful for the opportunity to help care for America’s veterans.

Why did we decide to pursue a VA-based optometric residency?

Because we desire to practice at the highest level possible within our scope of practice and be on the forefront of our profession as we expand into a more medically based role.