An Open Letter to Future Graduates of Optometry ~Malaysia~

Assalamualaikum wbt and hi everyone!!


Time  is flying past, and you're already in your final year as university students.  In a month's time, you'll be off, free from the constraints of lecturers and clinical supervisors, free from thoughts of clinics and assignments, released from the clutches of midterms and final exams.  You are coming out as adults, working adults, finally.  After years of being lectured, scolded, days of sleepless nights... you are finally qualified as professional optometrists.

Yet... what will you face out there in the real world?  How will everything work out?  Will you be happy out there?


Dear juniors,
This, is what this letter is going to be about.  Not that I've worked long enough.  Nor that I can claim to have long enough experience in the field.  No.  But because I have had just started working not more than a year ago that I still remember those hope, expectations, and fears that my friends and I share.  Also because I see how some of my ex-course mates and friends, and myself, fare in different places and situations, Malays, Chinese, and Indians alike. I hope, this letter can serve as a guide to you, so that you make your decisions wisely in deciding where you will be in the near future.


First and foremost, before you decide 'where' to work, think carefully of why you become an optometrist, if you have not done so yet.  Decide what really drive you on.  Is it the thirst of knowledge, the moneymaking aspects of the business world, the humanitarian aspects, the clinical pearls... and the list goes on.   For the reasons, had it been strong enough, will let you go on and stand strong, no matter what challenges lie ahead.


Secondly, what do you want in your job? Experience? Less working hours? A large pay check? Location? A five-day per week work?  Know that you can't have all that you want in one go.  If you wish for experience, you might not earn as much as others, but you get to learn a lot more.  If you want less working hours, you might have a smaller pay check.  And the list goes on.  It all boils down to, are you going to be happy with what you have, albeit some compromise.  Inquire through all this in your job interview with your prospective employer.  Also, you should be clear whether you are supposed to make sales or not, and personal target sales, or are you free to focus on your refraction and clinic only.


A word of advice from me, know that although you've earned your degree, it doesn't mean you know everything.  As my employer points out, as soon as you step out of the university, you are back to square one again.  There will be so much more to learn, clinical-wise, dispensing-wise, and most of all, patient management.  The people you meet in the optometry clinic does not represent the whole general population, and people of different background and race tend to react and treat things in different ways.  All this, are matters you will slowly learn through your senior optometrist, your sale assistant, and your boss, if you are willing to.


Personally, for me, I love clinical part of optometry.   If you like them too, make sure that you try to find a store with not only equipment such as slit lamp, but also with a senior optometrist to guide you.  Yes, I know that it is not as easy to come by, along with a good pay.  But it's a worthy sacrifice on the pay.  For it will be valuable experience in years to come.


Even if you are more interested in business and sales, just be sure that you carry out your role as optometrists to the best of your ability, not just your role as a salesperson in order to earn higher income.  Be sure to consider the customers as a whole, and address their needs and issues, professionally.  Listen to your conscience, and weigh options which will fully benefit the customer, not just yourself.  Provide them with options, give them proper advice, and keep yourself updated so that you can find out more ways to manage your customers.  You can be good at both, sales and clinical, although you might be inclined more to one direction.  Just try to balance between the two as best as you can, and you'll be fine, insyaAllah.

Last but not least, remember that the job you are about to choose is not just a way to earn money.  But as a way to gain valuable experience and increase your skills by leaps and bound, should you allow them to.  And make sure that you will be happy in carrying out your role as an optometrist where you are, with the carrier itself, not just the money that you earn.  Hence, choose wisely and do not hesitate to talk to your seniors for advice, and ask your future employer all the questions you have regarding his or her practice when you come for the interview.


May you find fruitful years ahead of you and enjoy being in this field more so when you start working!


_Humayra'_

26 July: Cerebral Palsy

Cerebral palsy.  Are you familiar with the term?  CP is a motor anomaly which results from injury to motor centers of the brain.  The damage occurs before, during, or after birth, and is usually non-progressing.  The severity of the motor impairment differ greatly between individuals, according to where the damage lies.  Damage to the motor centers of the brain may occur concurrently with other parts as well, which may result in mental retardation, perceptual deficits, sensory problems, and/or behavioral disturbances.  The severity of CP patients may vary from mild to severe.  CP may be divided depending on time of onset, neuro-muscular characteristics or parts of body affected.  This will not be discussed in detail here, but may be read further in other articles such as this one.

So... how did I find a CP patient?

on 26th July, a guy walked  into our optical shop at around 8 p.m, along with his mother, and an invalid in a wheelchair, pushed in by an assistant.  He searches for my boss, who's out for some errands.  Apparently, the invalid is his brother, who requires a routine eye examination.  Well... as my boss is out, it is my duty to carry out the eye examination.   I had to admit, I was nervous.  Especially when his brother whispers to me that the invalid has cerebral palsy.

This is not my first time dealing with people with cerebral palsy.  I had previously encountered another case in UKM clinic.  However, it is different this time, as I was on my own. With no friends or supervisors to help me out, only the brother.  I took a deep breath, and attempted it anyway.

So... what should I do? Hm...  of course, first of, as in anyone else's visit, I attempted to take down his VA (visual  acuity with the Snellen Chart).  I was lucky that he did know his alphabets, but halfway through, maybe due to fatigue, or that he cannot see the letters any more.  I couldn't verify which is which, as he responds an 'S' to all letters I showed him afterwards.  After a few more tries, I stopped taking the acuity, and did an over-refraction with him wearing his glasses.  This is done simply using my retinoscope.  Thankfully, his current refractive error did not change much with his glasses, hence I did not prescribe any new lenses.  I attempted ophthalmoscopy, whereby I manage to view some of the fundus (the retina- where light is received by our eyes to be transmitted to the brain), but not the cup and disc as the eyes are not fixating well (especially the left eye).  Under the slit lamp, no abnormality was found.

For this visit, the patient was not given any new pairs of glasses.  His current one is still good for distance, and he had made another previously for reading [the patient is in his 60s].  His brother reported that he has been seen wearing his reading pair for daily use and vice versa at his care-center often.  Hence, to make it easier for his carers to identify and differentiate the two, I marked the current one with tape.

-----

Well... so that is how I handled the patient at the time.  However at the back of my mind, i kept wondering on what visual problems people with cerebral palsies usually have, and how should we really manage them?  Hence, I did some reading and research.  I found many interesting facts regarding vision conditions of people with cerebral palsy and the ways to manage them.

First and foremost, the biggest question that looms over my head when the patient arrived (other than how well will he be able to respond to my questions) is regarding the visual problems that the CP patients might face.  Identifying their common visual problem makes it easier to focus one's examination and assist in any particular problem they might face.  According to the Ettinger, who complied numerous studies regarding CP, the most common problems for a CP patient are strabismus (30-60%), amblyopia (, significant refractive errors, accommodative deficits (100% accommodative insufficiency) and visual perceptual problems (78%).  Nystagmus and optic atrophy have also been reported, but less frequently (18-19% and 4-10% respectively).

Strabismus [picture courtesy of Google search]

Now that we had identified some of the problems the patients commonly face, we should examine the patients best as we can.  The first thing to do is, of course, to take a detailed history, in order to identify the extension and type of CP, the medical practitioners involved, past operations and treatments, education, etc.   During this time, one should attempt to gain the patient's trust, as well as the trust of the person who cares for him.  Next is to attempt to take the visual acuity as best as we can.  There is a limitation in the accuracy, as the patient may not be able to communicate that well, and often have reduced mental capacity.  Some tools that may help are Tumbling E chart, Forced Preferencial Looking, and optokinetic nystagmus (OKN).  A precise and reliable, yet seldom available visual acuity test is the sweep-VEP.

Various test charts [picture courtesy of google search]

VEPs [picture courtesy of google search]

Oculomotor assesment may be made using bright, attractive target via cover test, Hirschberg test, pursuit, saccades and near point of convergence.  Refractive status may be determined by refraction and keratometry reading, when possible.  The use of subjective refraction depends on the patient's ability to respond and participate.  Accommodation status may be tested by testing monocular estimation method via dynamic retinoscopy.  Ocular health testing is also very important, hence direct or indirect ophthalmolscope is important.  If possible, dialation of the pupil may be used.

The next question that pops up, after the examination, is how to treat these conditions on a CP patient?  Will treatment help improve their vision?  According to Ettinger, there are four different aspects in addressing this issue, which are:

1. Communication with caregiver, parents and other medical professionals;
2. Binocular dysfunctions impact to the patient, whether it reduces the patient's functionality or not, especially in doing prolonged near work such as rading and writing.  There are vision therapies which the patient may undergo in order to improve their binocular vision condition.  Articles regarding the types of vision therapy available may be found in the bottom of this article.
3. When to prescribe glasses, some suggest that refractive error of myopia, hyperopia or astigmatism of 1.50D or more should be prescribed (Ettinger, 1991), whether the condition is symptomatic or asymptomatic.  Taub (2006) suggests that myopia more than 8.00D, hyperopia and astigmatism more than 4.00D should be corrected.
4. Decision regarding strabismus surgery. As the strabismus incident is very high in this population, parents would likely discuss the option of surgical intervention with optometrist, who needs to weight out the option carefully, regarding the risk posed by the vulnerable population,  neurological basis of the strabismus, and the guarded success rate of strabismus surgery among CP patients.

In a nutshell, optometrist play an important role in ensuring visual functioning of patients with CP.  Optometrist need to realize that this population must obtain proper eye care in order to ensure that they may function better and not be limited by visual capabilities.

Resources:

http://www.optometry.co.uk/uploads/articles/c6292bb74eab99ac77dac5d0f67594c4_Taub-10206.pdf
http://www.oepf.org/jbo/journals/2-5%20ettinger.pdf
http://www.oepf.org/ICBOFlash/Posters/Scheulke.pdf
http://www.drjoelwarshowsky.com/Principles_of_Optometric_Rehabilitation.pdf
http://www.nature.com/eye/journal/v9/n1/pdf/eye199523a.pdf

25 July: Ortho-K Follow-up

In the shop I work at, we don't prescribe Ortho-K.  Nor do we have its trial lenses set.  However my boss had gone to a few ortho-K courses previously.  When we received a phone call from a customer, who was referred from another optical shop in Melaka, my boss and I were a bit worried, wondering what the case is.  As we had suspected, it was a case of Ortho-K.  but luckily, not a fitting session, only a follow-up.  The customer had worn the current ortho-K for 3 months, and we wanted to know how effective the ortho-K is for him, and if the lenses cause any adverse effect in his eyes.

Firstly... what is Ortho-K?  It is a non-surgical procedure with the purpose of reducing the refractive errors of nearsightedness (myopia), farsightedness (hyperopia) and astigmatism.  How does it work?  The cornea is flattened by a hard contact lens (as shown below).  The hard lenses are worn for a few hours, commonly at night. These lenses flatten the cornea, and thus reducing the refractive power of the cornea.

So anyway... we carried out the follow-up.  We checked his visual acuity (how well he can read the Snellen chart), do refraction (check his eye's current refractive error, better known as 'power') and also do a slit lamp evaluation.  The subjective refraction done by retinoscopy shows confusing reflections, which my sifu (a.k.a. my boss) tells me is quite typical in Ortho-K patients as well as post-lasik patients.  There are Fleischer's-like brown ring which could be observed under the slit lamp.  This is not an unusual occurrence, however, as several journals have also reported of the same ring.  There are also some neovascularization on his eyes, but very minor ones.

All in all.... it is the first time I ever observed and attempted to do follow-up on Ortho-K patient (though with a lot of help from my sifu).  I learnt that their refraction with retinoscope tends to be a bit different, and of the brownish-rings which will sometimes appear on the cornea.

Well... I guess, that's all for now... you can find more regarding ortho-K in some of the links I share bellow (which I also did take some info from).

Sources:
http://www.ortho-k.net/
http://www.ncbi.nlm.nih.gov/pubmed/12322926
http://www.allaboutvision.com/contacts/orthok.htm

Pictures courtesy of Google search engine.

Welcome, Ahlan wasahlan!

In the name of Allah, most Gracious, most Merciful...

This blog is a new one.. Not that I am closing the old one, but this one is more focused on sharing what I gained training as an optometrist here in Johor Bahru.

A bit of a rewind....
I am a fresh graduate who had just started working less than a month ago here in an optical shop in a mall in JB.  I had not even officially received my transcript yet.  Yup... Just started working life after four arduous years as an optometry student.

Anyway... back to the present.  Working here, alongside a boss who is also an optometrist (and a good one at that!) had given me the opportunity to observe many cases, some of which I have only heard of before.  Of course, there are some others which I had seen, but also still not so familiar with.

As I found one case after another, I realize that I had to write them down!  Otherwise, I might forget them sooner or later.  Writing them down is also a great way to do some reading and research on whatever stuff that I had discovered as well.  

Now, this blog might be a bit more academic and filled with jargons, but I hope to write them so that non-medical/optom background might also understand them.  But again, this is my first attempt at writing academically via a blog, so if you have any comments, questions, or things to discuss, feel free to do so.

I guess that's all for now.
Do wait for my update... (which will be soon, I hope!)

Till next time...
Assalamualaikum n have a great day!