A holistic metric based analysis of Optometric practice especially in private practice!

"Although optometrists are taught the quantitative science of optics and spend most of their workday taking measurements of visual acuity, most do not invest much time to measure the state of their business. More often they form intuitive impressions about business issues. Then they make decisions without a solid, metrics-based understanding of their actual situation and without any quantitative norms against which to compare their performance."
[Key Metrics: Assessing Optometric Practice performance, 2011 Edition (Introduction).]

The Management & Business Academy™ (MBA) is a metrics-based approach to optometric practice management. Since 2005, MBA has gathered comprehensive information on the characteristics and financial performance of over 1,800 private optometric practices in the U.S. There is this popular narrative, "Whatever you measure improves." This is the primary call to action that presupposes introduction of measurement in growing Optometric practice.
With the heavy reliance of eye care health sector on private practicing optometrist in Nigeria, I decided to point out those metrics with the intention of providing insights as to how to grow our practices, because it is said: "Where the money goes, so goes the authority."- and the power too!

Tagged Total Practice Productivity Metrics, it discusses the overall productivity of a practice and empirically analyze them:

1)Gross Revenue per Exam:  This is defined as the gross revenue per every comprehensive eye examination at any given time. This metric is singled out as, "...perhaps the single most useful measure of practice productivity..."
It is influenced by the internal processes of your practice and can be improved by the actions of the practitioner.
If H represents the gross revenue receipts in a given time frame, X(0,1,2,3,4...) representing comprehensive eye examinations carried out on a patient in the same given time frame... (0,1,2,3,4...) represents what constitutes a "comprehensive" eye examination and the internal processes of practice! The later identified in numerals has the tendency of influencing gross revenue earned and highlighted in note below

Hence, H/X (0,1,2,3,4...)................................................................. (i)
= Gross Revenue per Exam!

Note:
a) Number of eye tests carried out.
b) Types of high end user frames on display.
c) Products on display such a medications, contact lenses, surgical practices, low vision care etc
d) Turn-over of patients
e) New patient flow
f) Size of practice etc
Influences the "Gross Revenue per Exam" metric.


2) Exams per OD hour: This is defined as, "The number of complete eye exams performed during each hour an optometrist works." It is an empirical reproduction of revenue generated per OD hour. The key variables impacting this metric are size of the patient base, recall effectiveness, extent of delegation of testing tasks to staff, exam process efficiency and appointment scheduling efficiency.

If X(0,1,2,3,4,...) represents the comprehensive eye examination on an individual patient, Hx represents the optometrist's work rate in an hour, therefore,

Exams per OD Hour would be stated empirically thus:

X(0,1,2,3,4...)/Hx.................................................................... (ii)

Apart from adding a new OD, the main way solo OD practices can grow is to increase patient traffic per hour! The primary determinant of this metrics is efficiency of the OD in the clinic measured per hour!

3) Gross Revenue per Staff Hour (non-OD Staff): This metric is a ratio of the total revenue gained in a specific period of time divided by the total number of non-lab/non-OD staff hours worked during the same period.
This metric is a measure of how efficiently patients are managed administratively in a given OD clinic. It also determines how under-staffed an OD clinic is and triggers hiring of more non-OD staff or firing as the case maybe!

Lets take H as the gross revenue receipts in a given period of time.
Let Ns represent the non-lab/non-OD staff hours worked in a given period of time.

The Gross Revenue per Staff Hour can hence be mathematically represented thus:

H/Ns................................................................... (iii)

Note: Gross Revenue per Staff Hour is dependent on the following factors:
a) Number of staff members
b) Exams performed per hour
c) Gross revenue generated per exam
d) Patient traffic.

4) Gross Revenue per OD Hour: This is a ratio of the gross revenue in a given OD hour. It is a measure of how productive an OD uses his time in generating revenue in a given time measured per hour. It also correlates with the productivity of the staff members on how they efficiently attend to patients administratively! This metric correlates strongly with the clinical efficiency of the OD measured in hour! It is strongly suggestive of how successful the clinical practice is.
Other parameters that correlate with this metric include:

i) Revenue per OD hour
ii) Practice size
iii) Practice growth
iv) Improved OD time utilization.

If the Gross Revenue generated, often indicated by the gross revenue receipt generated in a given period of time, is H,

Let the OD hour be indicated by Ohr;

Therefore, Gross Revenue per OD hour can be mathematically represented thus:

H/Ohr...................................................................... (iv)

5) Complete Exams per 100 Active Patients: This is a metric that indicates the recall rate success of patients. A patient is said to be active if he had completed at least one circle of complete eye examination in a particular OD clinic within a given period. One circle of complete eye examination includes at least on recall examination. That being said, it should be noted that this metric is not dependent of the size of the clinic. The following factors can influence the recall rate, viz.
a) Recurrent ocular conditions like Vernal conjunctivitis especially in Children, Dry eye syndrome in adults etc
b) Chronic conditions like ocular manifestations of Diabetes, Hypertension etc...
c) Glass prescriptions for pediatric patients and for binocular anomalies etc.

It is noted that the average recall rate of active patients is about 28 months especially in OD clinics with more than 70% revenue generated from glasses especially for presbyopes! Hence, an OD clinic with 50 exams per 100 Active Patient is said to have an above average successful recall rate!

6) Annual Gross Revenue per Active Patient: This is the ratio of the Gross Revenue generated in an annum in relation to every active patient seen within the same period. It measures the recall rate and revenue per exam.

7) Gross Revenue per Square Foot of the Office Space: It represents how efficient clinic space is fully utilized and translated into revenue recouped either traffic of patients and multiple examinations carried out simultaneously in a clinic space to improve the OD hour, thereby increasing the gross revenue earning. It is weakly correlated to increase in practice size. It is a particular relevant consideration when ODs plan to expand their practice size... Like introducing Slit Lamp Bi-microscope, Automated central visual field analyzers, lens fitting lab etc. Again, when an OD clinic is moving to a new location, this metric helps in determining space size of new location.

The metrics described above have helped developed OD clinical practice in the USA especially for private practicing Optometrists. Subsequently, this blog will discuss each metric in details such that local contents will be developed. Because my primary interest is to synergize these growth concepts with what is obtainable in our country such that efficiency in practice could be achieved.

Finally, I want to say a big thank you to the developers of Management & Business Academy™ (MBA), Practice Advancement Associates (PAA), a unit of Jobson Medical information. To reach PAA, contact Al Greco at agreco@jobson.com.
Hope you enjoyed this piece.
Long Live Optometry in Nigeria!
Long Live Nigeria!
Dr Ezebuiroh Victor Okwudiri.
(This is strictly a free blog with no financial obligation anywhere!)

World Sight Day... The dawn of a new era!

Today is world sight day. This year's celebration marks a new road map to actualizing vision 2020. The theme for this year is "Universal Eye Health". The action plan in line with WHO's initiative for vision 2020: the right to sight with a "Call To Action"- Get your eye tested!

What is World Sight Day?
 

World Sight Day (WSD) is an international day of awareness, held annually on the second Thursday of October to focus attention on the global issue of avoidable blindness and visual impairment. It is co-ordinated by the International Agency for the Prevention of Blindness (IAPB) and became an official IAPB event in the year 2000, and has been marked in many different ways in countries around the world each year since then. 
 

World Sight Day is the focal Advocacy and PR event for IAPB and its members and partners each year, highlighting the fact that 80% of blindness is avoidable (i.e. preventable and/or treatable) – 4 out of 5 people have avoidable visual impairment. 

WSD provides a platform for organisations to encourage governments, corporations, institutions and individuals to actively support global blindness prevention efforts.

WSD is co-ordinated by IAPB under the VISION 2020 Global Initiative. The theme, and certain core materials are generated by IAPB. All events are organised independently by members and supporter organisations.

Do you know that on this day IAPB members (of which Nigeria is among) work together to:

• Raise public awareness of blindness & vision impairment as major international public health issues
• Influence Governments/Ministers of Health to participate in and designate funds for national blindness prevention programmes
• Educate target audiences about blindness prevention,  about VISION 2020 and to generate support for VISION 2020 programme activities?

Looking back:
 

In 2007 October 11, the "Call For Action" was "Vision For Children" which targeted causes of blindness and visual handicap in children.

In 2008 October 9, the "Call For Action" was "Eye on the Future: fighting visual impairment in later life" which targeted causes of blindness in the elderly, their causes and approaches to manage them, but above all measures to avoid them was brought to limelight.

In 2009 October 8, the "Call For Action" was "Gender eye health: equal access to eye care" aimed at bridging the gap in access eye care among the sexes. It tend to ensure that women were given equal opportunity at eye care as men!

In 2010 October 14, the "Call For Action" was "Countdown to 2020". A reflection of how far we have gone in our quest to eliminate avoidable blindness and what needs to be done were brought to the fore-front and ironed out!

In 2011 October 13, the "Call For Action" was "Working together to eliminate avoidable blindness" were Optometrists, Ophthalmologists and other health care professionals were called up to work together such that avoidable causes of blindness can be eliminated. It put into cognizance the strained relationship between us and other eye care professionals and health care professionals towards the issue of  blindness or visual  impairment.

In 2012 October 11, there was no "Call For Action", it was aimed at allowing eye care professionals to develop priority areas aimed at putting words into actions such that the birth of the next Road map towards achieving the primary goals of World Sight day celebration can be crafted.

This brings us to 2013!
 

2013 is a special year in that a new road map for 2014-2019 is put forward with an overall theme of "Universal Eye health." The intention is to find a way to universally include primary eye care into universal primary health care service. Visual impairment is on the increase and primary eye care is the easiest way to bring it down to a very low level.

The key message of this new road map are as follows:

• Approximately 285 million people worldwide live with low vision and blindness
• Of these, 39 million people are blind and 246 million have moderate or severe visual impairment
• 90% of blind people live in low-income countries
• Yet 80% of visual impairment is avoidable - i.e. readily treatable and/or preventable
• Restorations of sight, and blindness prevention strategies are among the most cost-effective interventions in heath care.
• The number of people blind from infectious causes has greatly reduced in the past 20 years
• An estimated 19 million children are visually impaired
• About 65 % of all people who are visually impaired are aged 50 and older, while this age group comprises only 20% of the world's population
• Increasing elderly populations in many countries mean that more people will be at risk of age-related visual impairment.

We have not gotten there, we should not relent because we will certainly get there.
for more information go to www.iapb.org.
Thank you World Health Organization and International Agency For Blindness Prevention for not relenting in ensuring the actualization of Vision 2020.

An after thought:

I am currently organizing school children for eye examination to find out those in need of glasses. New Eyes for the Needy International donated about 1080 free frames for distribution to those in need of glasses. I will give out 300 glasses to children in schools within Bonny Island and provide reading glasses for school teachers. It is a week-long event!
 Do you know that World Teachers Day fell on this same day?
You can call it co-incidence, but I call it a reward to our teachers who made us who we are today! Happy Teachers Day! Happy World Sight Day!


GET YOUR EYES TESTED TODAY!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Optometric practice in Nigeria and quackery in eye care profession!

"We must not let anyone else write our future.” 

(Dr. Ronald Hopping, President, American Optometric Association, June 2012.)

The practice of Optometry in Nigeria is without doubt improving into a medical care service especially in private health care setting and in eye hospitals despite the host of challenges that confronts us.

For instance the average MBBs physician keeps flinching at any association of Optometrist as "Doctors"! It is not only those MBBs members that gets all goose-pimpled at associating the Optometrist with "doctor"! Some ignorant nurses and allied health workers find it very difficult refer us as such.

 

But who is a "Doctor"?

1) A licensed medical practitioner who administers treatment for the benefit of ameliorating symptoms, managing signs by applying "professional" judgement.

2) A PhD holder in any academic field.

Does it matter whether we are called a Doctor? Or does it benefit more to develop in proficiency? Do we claim what we are not? That is by the way.

In a bid to checkmate the influx of Optometrists into the health care mainstream, efforts have been on top gear to discredit our role via propaganda and systematic cutting off of funding (the "call duty" phenomenon) by the government and our "Head of Departments". But do we really need the government before we stick to our ethics? Do we really need mainstream government to have a reviewable, current & water-tight code of conduct that mirrors professional practices internationally?

In other to play dirty, some Optometrists in Nigeria are gripping hard on each others jugular veins in a vice-like manner. Like two elephant in a brawl, the helpless grass (the at-risk populace) have been left to bear the blunt providing quacks the opportunity to operate with ease!

It is no longer news that most ophthalmic nurses are today parading themselves as "eye doctors" to fleece victims of money and dishing out blindness. Also on record are so many of these "orthodox" eye doctors, diploma Ophthalmologists etc who junket the country doing the opposite of vision 2020!
Quackery is when we do not adhere to what we profess!

a) A matured cataract patient was recently "couched" by such doctors and this man's eye today is worse off with pigmentary glaucoma and NLP (No Light Perception).

b) A bifocal reading glass given to a child of 16 years with myopia and against the rule astigmatism.

c) A topical steroid prescribed by a nurse for a "red eye" secondary to angle closure glaucoma.

d) Practicing without a license.

f) Poor adherence to ethics of practice.
g) Lack of compliance to Optometric code of conduct
h) Poor acquisition of professional continuing education & competency
i) Snail-speed update of our current school curricular, scope of practices etc...

They are but few of the travesty orchestrated by quacks in the practice.

I have not seen any health care profession than the eye care sector that has been so infested by quackery courtesy of the "silent" imbroglio between Optometrists and Opticians on one hand and the entire NMA (Nigerian Medical Association) & Ophthalmologists on the other hand.
In a bid to get at the primary eye care practitioners, NMA, Ophthalmologists have variously cooked up spurious and fabricated propaganda aimed at slandering us or belittling us. They go to such low levels as to blocking our growth in area of competency! Why is residency in Optometry as seen in MBBs here in Nigeria not been approved? They are everywhere, at the National Assembly, in health Ministries, in politics as politicians painting us as parasites (as recently portrayed by a medical doctor in my place of practice!)...  Did the recent strike embarked by Nigerian health workers ring a bell? The manner in which they were frustrated? The ease in which those super human "NMA" board disgraced their efforts to make it look like they are not supposed to have a say! Until their bubble is burst, we will be seeing these actions repeat itself over and again in the coming days and in the future.
In the Nigerian health care system they call the shots because they are always elected head of health ministry, from the minister of health to even health departments in local hospitals! They command the money, as we all know where the money goes so too does authority! They are on course to asphyxiate Optometry at all cost, hence the few Ophthalmologists in their folds are doing their dirty jobs for them.
They spew out half-baked Ophthalmic nurses, ship them off to practically all state and federal hospitals in every location in Nigeria to replace Optometrists as primary eye care providers! It may sound incredible, but it happens right in front of us! When we (Optometrists) started agitating especially through our serving corps members, they gave us few slots and ensured that many of us are disgraced out of the milk cow! They came with the rebellious call duty allowance, then with other flimsiness that includes our lack of surgery skills etc As if that was not enough, they have encouraged all sorts of impunity in eye care profession such that today, eye care examinations are equated as freebies by politicians to win elections!
And you know what? We follow those crumbs were ever it takes us to the detriment of our profession. Indirectly, shop owners have seen the "illegality" as an avenue to sale their over the counter reading glasses & the "patient" or "victim" sees little difference in patronizing the "quack", who often gives out their product for much lower prices than the professionals! By the way, they will say: "Is it not that same glass they gave me when so & so politician or philanthropist organized "free eye test" for us & even without even testing my eyes I was given a reading glasses?" "Therefore I can easily get a reading glass like that one in a shop!"" They conclude.
"Quacks" have gone ahead to indulge in harmful ocular surgery practices because of the overwhelming number of persons blind as a result of cataract and other conditions like Glaucoma, retinopathies etc
Why won't it be like that, on record in Borno state Specialist Eye centre are some Ophthalmic nurses who perform cataract extraction without license to do so, just because Ophthalmologists are using them to get at us! Ophthalmologists prefer "training" them to help them (the Ophthalmologists) in the theaters while undermining our position in pre- & post-cataract co-management of such patients! Little wonder most victims do not know they are going to slaughter like lambs and like sheep they do not complain until their eyes get compromised!
On the part of Optometrists, we do not strictly adhere to our codes of conduct! We practice often times without understanding our oath of practice. Ethics? Even fewer commit to them. We need to become stricter and more serious in combating such criminality, as well as build ourselves into the colossus our founding fathers dreamed for us!

An after thought...

Earlier today in our, "Optometrists Lounge" Facebook page an update drew my attention to some major issues hitting us directly in our faces:
1) Discrimination in payment parity with members of the NMA (Nigerian Medical Authority) in Hospitals- Government and Private.
2) Headship disparity especially as in departmental heads in hospital, private or public with the consequence of favoring their group more than others.
3) Finally, the contentious CAP 463 Act establishing the "University Teaching Hospital Act" which overtly skews in favor of the medical doctors, for instance in the provision for the members that make up the "Board" in Cap 463 LFN Section 2, Sub (1) a-j; unduly favored the members of NMA than other post-graduate trainable professionals like Optometrists as in (a), (d), (g)!
 Could it be the reason why residency in optometry in Nigeria is still an uphill 4-year task in isolated universities without the backing of Government?
Just a morally laden rhetoric question though...
4) The term "Consultant" as an exclusive right of the NMA members as put forth in their recommendations to the FG in health care reform number (1.20).
5) In number (1.23) of their (NMA) recommendations in the FG's Health reform act, they pointed out the lack of need for post-graduate programs akin to Residency in medicine to Optometrist!

Definitely a pattern is being perfected here and we cannot afford to just fold hand and let the implosion gets complete.
We need to curtail such impunity because it is doing the health care arena no good.
Optometrists are primary health care providers and as such should not be lumped together as mere dispensable or collateral damage in the health care community. They need that degree of "freedom" to practice whether in the private or public sector such that they can perform efficiently.

 We have a choice to make...

1) That as a body-ODORBN- ,we, should get our acts right by infusing confidence in our students through re-visitation of our academic curricular to embrace the realities of 21st century Primary eye care providers.

2) We should buy over the at-risk populace over with our people-oriented eye care services such that "quacks" will not find a safe haven to operate.

3) We need to research, form very strong advocacy groups, encourage international Optometric bodies to partner locally with us and invest deeply in eye care if we want this rape of our collective efforts in the eye care sector not become a spite to our individual abilities.

4) We should revisit our code of conducts, add vigor to our ethics and bridge the gap with other health care practitioners such that the second fiddle rating we are subjected to is recanted. We can do better.

A stitch in time save nine!

Nigerian Optometry introduces a residency program!

I got the information below from this website: http://www.medicalworldnigeria.com
This is to inform all qualified Doctors of Optometry, wishing to undergo a 4-year post-graduate training, leading to the award of Fellowship of the College in any of the specialties, that the primary examinations for admission into any of the faculties has been scheduled as follows:
DATE: October 12th 2013
VENUE: Department of Optometry, University of Benin, Benin City.
TIME:  11:00am.
QUALIFICATION: Any intending applicant should possess the following
qualifications:
a) A degree of O.D (Doctor of Optometry) from an institution accredited by the Optometrists and Dispensing Opticians Registration Board of Nigeria (ODORBN)
b) A3year Post NYSC clinical experience
c) Must be in good standing with ODORBN
EXAMINATIONS WILL BE TAKEN FOR THE FOLLOWING FACULTIES/SPECIALTIES
a. Primary Care Optometry  b. Public Health Optometry  c. Cornea and Contact Lens Practice
d. Rehabilitative Optometry and Low Vision Care  e. Paediatric Optometry  f. Ocular Health
e. Orthoptics
METHOD OF APPLICATION: Pay an Exam fee of N30,000 (Thirty Thousand Naira) only into:
Account Name: -Nigerian College of optometrists
Account No.  1000957051
Keystone Bank (formerly bank PHB) Asaba Branch.
COLLECT APPLICATION FORM ON PRESENTATION OF YOUR BANK TELLER AT ANY OF THE UNDER-LISTED ADDRESSES:
1. Dr. Mrs. O.U.Amaechi
Department of Optometry
Abia State University Uturu
2. Prof. F.O Iwuagwu
Department of Optometry
Imo State university Owerri
3. Dr. Emma Esenwa
Department of Optometry
Federal University ofTechnology Owerri
4. Dr. E.lyamu
Department of Optometry
University of Benin
5. Dr. (Mrs.) N. Aruotu
Department of Ophthalmology
University of Port-Harcourt Teaching Hospital
6. The Registrar
Optometrist and Dispensing opticians
Registration Board of Nigeria
No.8, Harvey Road, Yaba, Lagos.
7. Dr. Damian Echendu
Optometry unit
State House Medical Centre Aso Rock,Abuja.
CLOSING DATE:All completed forms must be returned to the point of collection not later than 5th october, 2013
Prof. Uche Ikonne
Registrar.

Residency in Optometry in Nigeria is a welcome development. But we need to understand the following:



1) NOA website has been suspended, I do not know for how long now. I went to look up the information circulating around on residency in Optometry in Nigeria, but came up with nothing! Why should we not know what is going on? ODORBN website does not have such information too! Then why hastily publishing it to the outside world without communicating in-house first of all? We are in Information Age and ignorance has no place here.
2) If this is residency, why does it take 4 years here while it takes a max of 2 years in the USA to attain fellowship and one year for residency?
3) What is the salary allowance for the residents, just as it is done in MBBs and in American Optometry residency program?
4) How will this program be funded? By who? How will it be sustained?
5) Examinations should be conducted by an independent body made up of technocrats without any partisan sentimentality and whose primary priority is hinged on objectivity!
6) Why is the information so wrapped-up in secrecy to so many of us and only leaked in National newspapers and in the conferences?
We need inclusiveness in this bold step the profession has decided to take into the future. But for christ's sake, we need to understand what is happening. I so believe in Nigerian Optometry that am willing to join hands with all and sundry to make this program work... For it to work though, need more than mere wishful thinking and grandiosity. Long live Nigerian Optometry!

The continuing euphoria of Nigerian Optometry in Residency!

In my last blog, "Nigeria Optometry and the Euphoria of Residency", I ruffled hats, stepped on big toes and even went as far as opening cans of festering worms on which the foundation of this noble profession has been standing on since its inception in this country!

But what is residency in Optometry? Where is it currently practiced? What need is residency to an Optometrist?

Optometry has functionally developed into a medical eye care, with some Optometrists designated as Optometric physicians. In some states in the USA, Optometrists are allowed to perform surgeries! (See my blog: "Optometry and were the future of eye care lies..."). 

Historically, Optometry introduced its first residency program in 1975 and Dr Thomas Stelmack became the first post-graduate resident of Optometry in 1976 at the Kansas city VA hospital. (History of Optometry in the VA. Robert D. Newcomb, OD, MPH).

It all started in the USA, the Veteran Administration hospitals. Before 1972, optometry schools had virtually no interface with medical hospitals and clinics and teaching clinics were in the schools or clinics serving the poor, blind or homeless. Founded in 1930, the Department of Veterans Affairs was swamped with returning WWII veterans in 1946 and first given congressional mandates to affiliate with medical, dental and nursing schools and tie into their student and residency training programs. This was a boon to the medical schools, giving them access to large inpatient populations and funds to support faculty and residency training programs while the VA gained skilled, board certified physician specialists and medical students and residents who rendered considerable patient care as part of their training.  In effect, in 1946 the Congress directed the VA to reorganize its hospitals as “teaching hospitals”. Soon almost every medical school was affiliated with a VA hospital and most medical students and residents rotated through them.  VA physicians were required to be board certified in a specialty. 

Congress,in 1973, enacted legislation (PL 93-82) requiring the VA to establish an optometry program.  An expanded mandate was given in 1976 (PL 94-581) which was the equivalent of the 1946 mandate for medical and dental care by calling for the VA to increase its number of ODs and establish teaching affiliations with optometry schools. A pilot student Optometry training program begun in 1973.  The development and growth of VA Optometry training programs were the result of policy arising with the congressional committees with VA oversight that determined an optometry service within VA hospitals with students and affiliated schools were the best means to meet unmet needs for eye care. This integration continued to accelerate while VA worked to define areas of residency training within its hospitals in cooperation with the Association of Schools and Colleges of Optometry and to create an accrediting process for the new optometry residency programs in cooperation with the American Council on Optometric Education.
(Culled from "ABCMO - Overview of ABCMO and History of Board Certification.")

The current pattern of Optometry residency in the USA, requires:
a) American Council on Optometric Education (ACOE) to accredit the candidate's Residency
program.

b) National Board of  Examiners in Optometry (NBEO) to administer the candidate's specialty examination.

c) American Board of  Certification in Medical Optometry (ABCMO) to give recognition to granted specialized "board certification".

Note: 

ACOE is the only accrediting body for professional optometric degree (O.D.) programs, optometric residency programs and optometric technician programs in the United States and Canada. ACOE, formerly referred to as Council on Optometric Education, was first established in the 1930 Boston AOA. In 1934 it was ratified. In May 2001, it became recognized by Council for Higher Education Accreditation (CHEA).

NBEO is a body required by the American Optometric Association (AOA) to administer board certification examinations for licensure, license renewal and for specialty examination to enter into residency program. It was formed in 1951 by Association of Regulatory Boards of Optometry (ARBO) and Association of schools and colleges of Optometry (ASCO).

ABCMO is a body created to provide practitioners, medical facilities, government and state agencies and  the general  public a uniform national standard to identify optometrists with advanced competence in the medical diagnosis, treatment and management of primary and secondary disease and dysfunctions of the human eye, adnexa and visual tracts. It was established in 2009.

Residency in Optometry is a one year program designed for Optometrists who have graduated with an OD. A residency allows the doctor to gain specialized skills and information in a specific area of Optometry.
Residency in Optometry is a teaching hospital based program aimed at providing the OD physician with advanced skills and knowledge in medical eye care. We are living in times of advanced medical care, technologically, ethically and ideologically. It behoves of the profession to take the bull by the horn with the aim of advancing eye care to embrace the realities of 21st century.

Do not forget this:

Residencies have many benefits. To start with, a residency is known to increase the knowledge, skills, clinical experience and self-confidence in the O.D. physician. On top of that, the O.D. practitioner should be able to build relationships with professors, mentors, other residents and students, Optometric legislators, industries, clinicians, as well as other healthcare professionals.

(Residency Programs Grow: Amber Hirley, ASCO NL, UAB)

Truth is that the Optometrist is trained to become a general eye care practitioner, but specialization in eye care community has shown to hugely benefit us especially in area of competence and actualization of vision 2020: The right to sight.
Nigerian Optometrists are called on today to put it out to our law makers within the profession and in our state and National houses of Assembly to develop a residency program which has been shown to help in research and advanced competency in the profession, but above all, it has shown to have a tremendous effect in main stream eye medical care sector!

Nigeria Optometry and the euphoria of residency...

After 6 years of studying Optometry in Nigeria, one sets out into the job market tagging a Doctor of Optometry (OD) along. Then comes the unending quest to find a good place to do the compulsory 1 year internship, just like our Medicine and Surgery counterpart! By chance, you may be fortunate to do it in a federal establishment but in most cases the scenario depicts a sorry state of of our internship program (I will discuss that in a subsequent blog). The young Optometrist intern is left in the cold, either used as a marketer by senior Optometrists or used as a money bag by other more sinister senior colleagues of ours. Imagine a situation were a young Optometrist intern, devoid of the necessary clinical experience been thrown into the hordes of darkness, in the market square to scout for customers and make glass sales without recourse to our ethics!
Then he/she finishes the internship and zooms off for the compulsory 1 year NYSC (National Youth Service Corp) to serve their father's land! Just like our Medicine and Surgery colleagues, we all go to serve our father's land. We suffer, we sweat, we put our lives on the line to serve the nation patriotically. Yours sincerely even have to face the threat of Boko Haram while providing eye care services in rural Bama, Jere, Munguno etc all in the name of vision 2020! What came out that? We had to escape via the whiskers when Boko Haram's threat became viscous. Then NYSC finishes.
The job market keeps toying with us, we have to live on the benevolence of the health ministry to get us job in federal establishment. As if that is not enough, some colleagues go practically begging for food or live by the harsh reality of underemployment!
Then our Medicine and surgery colleagues, enjoying a better pay and the plum jobs out there and truly living out the Doctor title. They prepare to go into various specialties in our various institutions to do their residencies... But the Optometrist colleague? We are left to wait for 10 years post NYSC before we can embark on post graduate studies in university of Benin! Is it a residency program? I doubt it. But all the same we do not have a residency scheme for NYSC Optometrists neither do we have an internship scheme befitting this beautiful profession in Nigeria.
Oh what a lost cause! No wonder the medical doctor, a colleague of mine in a hospital were we co-practice, preparing to go into residency in internal medicine asked me if we do not take post-Med school exams. I was thrown aback but that is life for you! Oh Optometry were goeth thou?
Hope you got the message. Pass it on...
Dr Ezebuiroh Victor Okwudiri
N/B: This article has no financial interest!

Bi-Temporal Hemianopia- a clinical finding!

Hello, welcome to yet another exiting blog... Read on!

It was a normal clinic day, on a week day to be precise; I was expecting patients that morning, as was the usual norm in a medium scale Optometric practice. This man walked in that I should help him work on his glasses( I also fit and mount lenses for my patients; not forgetting other optical works like frames adjustments, repairs etc to increase eye care services and hence reduce all forms of health care duplicity as encouraged by the health care terrain of our country!) I put up discussion with him and in no long time he opened up to me about his eye condition that has been on for 3 years now.
The man, 46 years, has a progressive bilateral distant blur that increases with peripheral gaze. He has associated near blur, feels disoriented sometimes which he attributed to the persistent "eye problem"! His Optometrist in Lagos gave him glasses for sight and for reading, gutt: Voltaren i tds x1/12 and eye antioxidants that he has been using for 3 years on! The problem is that the eyes does not seem to be improving and this patient is preparing to go to "Ijebu" to go and find out from a spiritist who was responsible for his eye condition.
The present glass was already 3 years worn habitually by the patient so I asked him to run some tests to enable me renew his glass prescription.
His visual acuity @ 6 meters:
RE: 6/9
LE:6/9-3
&
Visual acuity @40 cm
BE: N8
He used his habitual prescription to read the visual acuity chart (+0.75 DS add 2.25)
Refraction
RE: +1.00 DS 6/9
LE: +1.25 DS 6/12 (It turned out that the retinoscope light probably dazzled his eyes!; after 10 minutes, he read 6/9-2 with the same power ipsilaterally.)
At near +2.50 DS was added on his distant retinoscope finding to give him N6 OU! ( Do you understand anything unusual here?)
No meaningful improvement with the new retinoscope finding, objectively and subjectively! Again, this man's age and the near add shows an underlying condition that seems to be suppressing his near acuity! Or else why will a 46-year old man use a combined +3.50 DS readers and still cannot use it to see N5! Hmmm...
Funduscopy was carried out and the bilateral temporal- peripheral retina of each eye showed haziness and choroidal vascular degenerations, more prominent on the left eye than on the right eye!
His cup-to-disc ratio is OD 0.3, OS 0.3 an associated pallor not consistent with glaucoma nor optic nerve atrophy was seen. The diagnosis was blurring around its edges, the symptoms greying out such that subtle and sublime dynamic skills was required to arrive at a tentative diagnosis with sketchy information available. So what could be the cause? Was I getting confused? Should I leave him with his habitual management regimen or do I explore other options?
Plan: IOP (intra ocular pressure) measurement with Handheld Goldmann Applanation Tonometer, central visual field examination and dilated funduscopy of both eyes!
His intra ocular pressure on OD=14.5 mmHg, OS=14 mmHg @ 4pm! Central visual field result showed a bi-temporal scotoma, prominent on his OS than OD with macular sparing of both eyes, dilated funduscopy of both eyes showed choroidal vascular degenerations probably extending to the Ora serrata area (Do not judge me cos there was no indirect Ophthalmoscope to view the Ora serrata proper!)
Still not very convinced, I did some digging into the symptoms of bi-temporal hemianopia and came up with a subtle, but clinically relevant symptom- mental confusion is associated with many cases of Bi-temporal hemianopia! I called his primary eye care specialist in Lagos to inform him of the development and asked the man to run an MRI scan to find out the underlying cause of his condition or to rule out compression of the chiasma by an obstructing tumor and to take the results to his primary eye care physician!
Two weeks later, he returned to thank me generously and even made me feel like a chief priest of Ogun!
He has since been flown to India for removal of the tumor and I feel so satisfied to have been of help!
Note: "Bitemporal Hemianopia is a type of partial blindness where vision is missing in the outer half of both the right and left visual fields. Usually associated with the lesions of the optic chiasms, bitemporal hemianopia causes patients to experience difficulty seeing in both eyes." (www.hemianopiasociety.com/what-is-bitemporal-hemianopia)
Bitemporal hemianopia can be caused by the following:
a) Pituitary adenomas,
b) Craniopharyngiomas, or
c) neoplastic menangiomas
d) aneurysm of the anterior communicating artery which arise superior to the chiasm.
(en.wikipedia.org/wiki/Bitemporal_hemianopsia)
Again, Bitemporal hemianopia causes a damage to the crossing fibers of the optic chiasm which interrupts fibers from the nasal hemi retina of both eyes. The nasal hemi retina relays information that originated from the outer visual field. (http://www.csus.edu/indiv/m/mckeoughd/learningmodules/CtrVisualPathModule.pps)
Hope we started on a positive note? More to come on On same topic soonest! Thank God it is weekend!
Dr Victor Ezebuiroh
We are not doing this for financial rewards, hence no financial attachment! Feel free to share and comment!

Hypertension and the Eye... Pathogenesis?

In my last article on "Hypertension and the Eye... What the primary Eye care Optometrist Should know.", I pointed out some ocular consequences of this systemic condition viz: Retinopathies, changes in refractive status as the eye of the chronic hypertension patient, choroidal degenerative changes and general changes in ocular vascular supplies with an increasing affinity for low vision in subjects.
The ocular effect of hypertension, especially on the collagen matrix making up the most vulnerable portions of the eyes, is not really new to eye care. The ocular blood vessels, the choroidal and retinal surfaces, the crystalline lens, even the jelly vitreous humor are all kept in shape by the collagen matrix that gives structural rigidity to this delicate organ-the eye- and ironically becomes the main connecting tissue to be weakened by hypertension or so I think.
Can the pathogenesis of ocular manifestation of hypertension be explainable by the weakening of the collagen matrix of the eyes? What is the relationship between hypertension disease degenerative condition and collagen matrix weakening effect? Are we saying that maintaining the integrity of the ocular collagen connective tissue matrix is one of the means to manage ocular manifestation of hypertension? What does it mean to have a weakened collagen matrix?
Lets take a detour.
Elastin and collagen are the most important components of blood vessels extra-cellular matrix, giving the necessary strength and elasticity to blood vessels, including the capillaries. The blood vessels- veins, venules, capillaries, arterioles and arteries-characteristically presents with the tunica adventitia, tunica media and tunica intima with their modifications based on function and location.
The capillaries contain no tunica media (the structure the reinforces vascular tensile strength) but has modified endothelium (tunica intima) and oftentimes its tunica adventitia is modified into a base membrane.

In hypertension, arteriolosclerosis and arteriosclerosis collagen, back bone of the vascular connective tissue, is always the victim and the much hyped degenerations associated with this condition (Hypertension) becomes the consequence. Insult on the surrounding vascular endothelium leads to increasing production of collagen in the process of fibrogenesis. Suddenly there is increased proliferation of fibrocytes and subsequent formation of fibroblasts resulting in increase in connective tissue activity, perhaps to ameliorate the insult of the arterial blood pressure/resistance on the vessel! The proliferated formation of new collagen connective tissues in this instance does not follow the normal pattern and hence a less structurally similar network of collagen bundle results to a vulnerable and weakened structure.

Connective tissue (CT) is a kind of biological tissue that supports, connects, or separates different types of tissues and organs of the body. (Wikipedia). Collagen and its extra cellular matrix provides such function in the blood vessels and in short could be seen as a bag or container of less "rigid" body tissues. In supporting the tissues and organs of the body, the connective tissue is known to provide some kind of defense to its content. Eg Fibrosis (a kind of supporting function of the connective tissue) is caused by a series of events, triggered by chronic injury. These events include:
1) immediate damage to the epithelial/endothelial barrier;
2) release of TGF-b1, the major fibrogenic cytokine;
3) recruitment of inflammatory cells;
4) induction of reactive oxygen species (ROS);
5) activation of collagen producing cells;
6) matrix activation of myofibroblasts; and,
7) in the absence of continuous injury, reversal of fibrosis.
(TATIANA KISSELEVA AND DAVID A. BRENNER. Mechanism of Fibrogenesis.Experimental Biology and Medicine 2008, 233:109-122.).

The fibrosis process as outlined above is similar in almost all the structures having collagenous connective tissues but different organs' connective tissues effect different structural adjustments leading to compromised intra-tissue coherence and hence the disintegration/degenerations in the susceptible vessels, tissues, organs etc!

In rats, AKIRA OOSHIMA et al in "Increased Collagen Synthesis in Blood Vessels of Hypertensive Rats and Its Reversal by Antihypertensive Agents. Vol.71,No.8,pp.3019-3023,August1974.", observed increased collagen synthesis and thickening in the aorta, mensentric arteries and to a lesser extent in the heart. They observed that the increased synthesis of collagen is a direct result of the effect of hypertension on these structures.
In end vessels and in very tiny blood capillaries, arteriolosclerosis is induced and its many consequence like vascular rupture in advanced retinopathies, choroidopathies, maculopathies, aneurysms and even breakdown in collagen type ll of the vitreous humor, the collapse of the lamina cribosa, and many more such sclerosis in the vulnerable eye, kidney,heart, distal part of the arms, limbs or cerebral contents!

Little wonder we are faced with multiple ocular signs of ocular manifestations of hypertension, not only that the eyes are reinforced by the collagen network- the cornea has type l collagen, collagen present in the vitreous are types II,XI,VI and IX; the sclera is composed of type l and type lll collagen, the retina is composed of types I, ll, lll, lV, V, VI and XVIII, the retinal vessel is composed of collagen types I, III, IV, V, VI, and XVIII, the choroid is composed of type l, lV and type XVlll, lens capsule collagen consisted mainly of type IV collagen etc- it is almost exclusively held in place by this connective tissue. Varying degrees of injuries are inflicted to these connective tissues in chronic hypertension.

As primary eye care practitioners we are therefore expected to be in the fore-front of promoting preventive health care maneuvers that will reduce the incidence of this, often irreversible, structural changes- anatomically and physiologically- in the ocular plexus. We must ensure that our patients susceptible to chronic and/or acute insult cum injury are kept from harms way by ensuring any of the underlying causes are addressed as early as possible and we should work closely with GPs to ensure that the patients adhere strictly to their medications and check ups! Ones their underlying systemic cause is removed normalcy returns in collagen synthesis and other tissue functions ameliorated. Even if the underlying cause is not the entire system, it is advised that the condition be isolated, if it is within our scope of practice, or referred to a specialist in a co-managed process.
Finally, chronic effect of hypertension can be sight threatening and early detection and management is the best option, we are therefore required to always remind our hypertensive patients of this with the aim of healthy vision of the subjects.
Long live Naija Optometry.
We can do better.
Thanks.
Dr Ezebuiroh Okwudiri Victor.
This article is exclusively my opinion.