Top 5 Lessons Learned from my Ocular Disease Residency

For those interested in pursuing optometric residency, you will inevitably refine your clinical skills and hone the techniques you learned as a fourth-year student. Regardless of what residency program you pursue, each will provide similar treatment, management, and follow up strategies to use with your patients.

However, every OD is different; we all have different strengths, weaknesses, backgrounds, and personalities, and those will influence, as we complete our residencies, what lessons we’ve learned — especially the small tips and tricks — that go beyond basic clinical skills and techniques needed for optometric practice today. Aside from performing gonioscopy, scleral depression, or foreign body removal, I learned some amazing lessons from my ocular disease residency that are important for other ODs to hear.

A commitment to lifelong learning

A commitment to lifelong learning is crucial for keeping our clinical knowledge-base up to date while providing the best care for our patients. In addition to clinical experience, a unique opportunity about optometric residency is the built-in time allocated for research, writing, and public speaking. Most programs require the resident to create a project, case report, or CE presentation. For new grads who forgo residency, it’s important to know that most professional opportunities will not pay for perusing PubMed all afternoon.

Research

While you certainly don’t need to write case reports or give CE lectures to be a great optometrist, the academic aspect of residency is something to consider for those interested. When embarking on your initial research for a particular topic or question, start with systematic reviews, meta-analyses, and/or randomized control trials. These sources are likely to provide valid answers to the clinical questions you may have. Since most residency programs are affiliated with academic institutions and optometry schools, residents are able to freely request any and all scientific literature through the institution’s library, if necessary.

Clinical Experience

Another big advantage to a residency program is the unique opportunity for new grads to build their clinical skills and expand their clinical toolbox. Honing your craft in a supervised setting is a great way to boost confidence, but it’s also important to not be overly confident in your abilities and to not be afraid to ask for a second opinion from your colleagues and superiors. “I think this patient may have iris and angle neovascularization, can you come double check?” The old adage we’ve heard since elementary school still holds true during residency – The only dumb question is the one that isn’t asked.

Colleagues

Most residency programs will also enable residents to network with and observe other ophthalmic specialists in both clinical and surgical settings—retina, glaucoma, cornea, and neurology/neuro-ophthalmology, for example. It is important to build your professional network, even just to get second opinions on future patient cases. Learning particular ophthalmic management trends by working with other specialists in your area can be useful in determining who you refer and who you continue to follow on your own.

Sometimes a text message, email, or phone call to a trusted ophthalmologist can be far easier than dealing with the logistical burden that some patients face when making it to their referral appointments. Some patients will absolutely need additional management and care beyond our scope-of-practice, however, obtaining a second opinion beforehand never hurts.

Confirm your diagnosis before treating the patient

While pursuing optometric residency, or various other practice modalities early in your career, being on-call after-hours may be encouraged or required. Optometrists will typically collaborate with other primary care physicians and local emergency room departments in triaging urgent and emergent ocular conditions. For the new grad OD, this is an amazing learning experience and opportunity to further develop your clinical skillset. While most medical personnel will have varying degrees of training in triaging ocular problems, the optimal scenario is to have the patient seen by an optometrist (you) immediately. Get them behind a slit lamp today rather than tomorrow morning.

Sometimes being on-call will involve getting a phone call at 1:30 AM. This is especially true in settings where optometrists are co-managing ocular surgeries or in rural settings where you are one of the only eyecare providers in a large geographic area. The calling physician will sometimes give a brief case history and the results of any testing they’ve done (eg. fluorescein staining with the burton lamp, EOM’s, Pupils).

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Over the course of the year that I spent covering call with Indian Health Services, by far the most common reason for an after-hours call was ocular pain—corneal foreign body, corneal abrasion, or iritis. You’ll be able to tell if a patient truly has eye pain by looking at them from across the room. They’ll likely be holding their eye closed or even be wearing sunglasses indoors. With that in mind, it’s prudent for you to know when to triage calls over the phone and when to examine the patient immediately in-office.

Half asleep one night, I took a call from the emergency room and the calling physician explained they had a patient with acute onset symptoms of pain and light sensitivity in the right eye. Immediately I thought: “Ok, corneal pathology or iritis.” After I was told that the corneas were “unremarkable, without fluorescein staining on burton lamp,” so I agreed to a topical steroid over the phone and told them that I’d see the patient first thing in the morning.

The patient ended up simply having dry eyes. When the senior ODs found out that I’d prescribed a steroid without physically seeing the patient, we had a long discussion on why this was a bad habit to develop. They shared a story with me of a patient who was given topical steroids without being examined. This patient ended up having progressive herpetic keratitis and suffered permanent vision loss due to a lack of diligence on their provider’s part.

We’re the quarterbacks for the healthcare system

Regardless of your practice modality after graduation, this fact will likely become apparent to you very quickly. A past survey by the AOA demonstrates that ODs serve as a first line of defense in disease detection; in 2016 optometrists detected over 300,000 new cases of diabetes on routine eye exams in the United States.2

Patients who haven’t sought medical care in years or even decades come to us for their blurry vision or headaches. Since we’re not going to be giving shots or pulling teeth, our offices are generally seen as a pleasant setting. In most cases, patients are expecting us to improve their vision with glasses or contact lenses. This is true regardless of whether or not they’re at risk for other sight or life-threatening conditions we encounter on examination. Patients are rightfully disarmed when you go to check their blood glucose or blood pressure based on your eye exam, or worse, urgently send them to the nearest emergency room.

Are you still on the fence about starting a residency? Check out this interview with Rebecca Lee, O.D. about declining a job offer and pursuing a residency.

Because we can offer early detection and prevention, it’s important for us to relay any and all pertinent exam findings not only to our patients but also to their other healthcare providers. If we’re dealing with a patient who is not currently plugged in with a primary care physician, it is our duty to refer them and help them to establish care based on their geography and health insurance.

A plethora of medical specialists rely on us to rule out the ocular side effects of systemic disease and/or medication. These can include neurologists (headaches/diplopia), rheumatologists (plaquenil/uveitis), cardiologists (retinopathy), endocrinologists (retinopathy), and primary care physicians.

Depending on your practice setting, other healthcare specialists may be referring their patients far away for routine eye care when you’re right down the street; make other providers in your area aware of your scope of practice. Writing summary letters to schools, employers, and other medical providers is a great way to convey your clinical knowledge and presence within the community!

Improved time management – from student to doctor

In your final year of optometry school, you’re still learning the proper flow for patient care while adjusting to a variety of teaching styles and preferences of your preceptors. Depending on the externship site, students may have more time in between patients – half hour slots to conduct entrance testing and tonometry. As you become more comfortable and confident, your flow will become faster and more efficient.

During residency there will be significant demands on your time, forcing you to refine your patient flow and avoid falling behind schedule. This process happens differently for everyone. As ODs we must become proficient at juggling patients back and forth between dilation checks, finishing charts, and/or writing referral letters.

Patients that are being followed closely by a retina specialist for diabetic retinopathy or macular degeneration do not necessarily need to be dilated again when they see you. With these patients, you can instead focus more on helping them see better with glasses or contact lenses. If you know they have decreased BCVA from an ocular pathology, and you won’t be dilating them, consider spending some extra time on a trial frame refraction. You can even try a higher than expected add power to help them with their near tasks.

Are you finishing up your residency and ready to kickstart your career? Check out our Complete Guide to Your Transition from student to optometrist!

With the growing epidemic of type 2 diabetes, ODs will continue to see more patients for their annual diabetic exam. In cases where these patients do not have any visual complaints, it’s perfectly acceptable to dilate their eyes prior to refraction. I’ve found this can save a significant amount of time and avoid the back and forth of shuffling patients around.

For example, I had a 55-year-old male with type 2 diabetes come in for his annual dilated exam, his autorefractor is +0.25 sphere in both eyes and he only wears OTC readers for the computer. In his case, I’d check his uncorrected VA, pressures, pupils, angles, then dilate. Typically an exam with him will take less than 5 minutes. By the time his charting is caught up, and I answer any questions he may have about his eyes, it’s been 15 minutes, mydriasis has set in, and we can wrap up the dilated portion of the exam!

Learning from mistakes and becoming more thorough

Early in my residency training, I swore that I had induced spontaneous bilateral iritis with topical phenylephrine. I remember calling the patient back to finish their DFE, and when I got them back to the slit lamp I noticed what appeared to be a 3+ anterior chamber reaction in both eyes that I had missed!

Come to find out, patients with pigment dispersion syndrome (or those with pigmented irides) will occasionally have what appears to be a spontaneous onset anterior chamber reaction after phenylephrine is used to dilate their eyes. Phenylephrine-induced mydriasis has been shown liberate pigment from the posterior iris epithelial cells.

In some cases, this will cause a transient increase in IOP (this is more common in patients with pigment dispersion syndrome or pigmentary glaucoma).4 Rest assured, if you didn’t see anterior chamber cells or flare prior to dilating their eyes with phenylephrine, you’re likely seeing pigment cells from the iris and can forgo a uveitis workup.

Regardless of your robust clinical experiences as fourth-year optometry students, you can count on facing additional clinical challenges and learning opportunities during your optometric residency. Despite our practice modality and professional aspirations, it’s important to keep an open mind, value our training as optometrists, and always strive to provide the best care for our patients.

Resources

  1. Kalezic, Tanja, et al. “Herpetic Eye Disease Study.” Current Opinion in Ophthalmology, 1 July 2018, insights.ovid.com/pubmed?pmid=29846207
  2. Middleton, Deirdre. “American Optometric Association Survey Reveals Misconceptions about Diagnosing Diabetes and Its Related Eye Diseases.” American Optometric Association, 31 Oct. 2017, www.aoa.org/newsroom/november-2017-diabetes-awareness-month.
  3. Epstein, David, et al. “Phenylephrine Provocative Testing In The Pigmentary Dispersion Syndrome.” Science Direct, American Journal of Ophthalmology, 1 Jan. 1978, www.sciencedirect.com/science/article/pii/S0002939414766632
  4. Stamper, Robert, et al. “The Adrenergic System and Adrenergic Agonists.” ScienceDirect, Mosby, 30 Oct. 2009, www.sciencedirect.com/science/article/pii/B9780323023948000243

About Kevin Cornwell

Kevin Cornwell
Dr. Kevin Cornwell graduated from The New England College of Optometry in 2015. He went on to complete a residency in ocular and systemic disease with Indian Health Services in Zuni, New Mexico. He now works with MACT Health Board, Inc in Northern California, a nonprofit organization that provides healthcare for Native Americans. He is enthusiastic about bringing eye care to populations in need, both domestically and abroad. He has been involved with several humanitarian outreach projects, in various parts of California, New Mexico, Nicaragua and Mexico. He is passionate about managing the ocular manifestations of systemic disease, and monitoring ocular pathology through retinal imaging with spectral domain optical coherence tomography. He’s also an avid health crusader and enjoys educating and encouraging patients to better manage metabolic disease. Dr. Cornwell enjoys hiking in the Sierras and recording music as a guitarist for Cornwell Studios' youtube channel.

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