At the completion of this article, the reader should be able to…
- Recognise the common misconceptions about experience and therapeutic knowledge in clinical optometry.
- Learn how clinical optometrists assist in therapeutic co-management of ocular conditions.
- Appreciate the importance of collaboration within the multidisciplinary ophthalmology team.
Cassy Versteeg
MOptom, BVisSci
Clinical Optometrist
Queensland Eye Institute, Brisbane, QLD
For CASSY VERSTEEG, working as a clinical optometrist within a private ophthalmology practice has offered a unique and fulfilling career path. She shares valuable insights about her role, essential skills, and the growing importance of collaborative care with ophthalmologists.
Modern clinical optometry is a dynamic and interesting area within the broader scope of optometry. As a clinical optometrist, one has the opportunity to work closely alongside ophthalmologists, assisting in the diagnosis, treatment, and ongoing management of various ocular conditions.
This article aims to provide optometrists with an understanding of the role of clinical optometrists in a private ophthalmology setting, with practical insights on therapeutic co-management and postoperative care.
Role of a clinical optometrist
Clinical optometrists working in ophthalmology practices work closely with ophthalmologists, often assisting in pre-surgical testing, post-surgical management, and therapeutic co-management of ocular conditions. Pre-surgical testing involves assessing visual acuity, intraocular pressure, refraction and various scans dependent on the patient’s needs. Post-surgical management often involves post-operative ocular assessments and evaluation of surgical outcomes.
Depending on the workplace, some clinical optometrists will review and manage their own patients. In my role working alongside corneal and refractive specialists, I primarily care for patients with keratoconus, glaucoma, and dry eye, as well as those undergoing refractive treatment or recovering from surgery.
Clinical optometrists can assist with some procedures including corneal cross-linking, and can provide dry eye treatments such as intense pulsed light therapy (IPL) and Rexon. There is scope to select intraocular lenses for cataract and refractive lens exchange surgeries, and to plan laser treatments like LASIK, photorefractive keratectomy (PRK), phototherapeutic keratectomy (PTK) and corneal cross-linking.
Debunking myths
There are several common misconceptions about clinical optometry, and it’s important to address them to provide a clearer picture of what to expect in this role.
• Experience requirement: A common myth is that clinical optometry positions require many years of experience. In reality, optometrists can obtain clinical optometry positions at any stage in their career, with some optometrists starting in a clinical optometry role soon after graduating. In my case, I had two years of experience as an optometrist before moving into a clinical optometry role within an ophthalmology practice.
• Therapeutic management expertise: Another misconception is that clinical optometrists need to have an in-depth knowledge of therapeutic management and ocular diseases prior to starting in a clinical optometry role. While this is certainly beneficial, therapeutic management skills will be strengthened in this workplace setting. You are also working in a team environment and have guidance from colleagues.
• High patient load: There is sometimes the belief that clinical optometrists have overwhelming patient loads. Ophthalmologists do have high patient loads and although clinical optometrists will do the workups for these patients, you will likely have one or two colleagues assisting alongside you which makes the workload manageable. Additionally, there can be some degree of flexibility with my own appointment book, which aids in maintaining a manageable workload.
• Pre- and post-operative management: It’s often assumed that clinical optometrists must already know how to manage pre- and post-operative patients. In fact, this is a skill that will be refined as you work alongside ophthalmologists, as different clinics and doctors may have differing approaches. With time and experience, you become familiar with the specific protocols and management of various types of surgery.
Case studies
Below are some case studies that offer an idea as to what conditions clinical optometrists may encounter.
Case One
Patient One presented to the clinic six weeks after undergoing unilateral cataract surgery. The patient reported blurry vision in the operated eye, adding that vision was initially recovering well but had deteriorated in the last two weeks. There was no history of pain, discomfort or photophobia, and the patient had finished their course of post-operative drops.
Clinical assessment revealed that the patient had reduced visual acuity in the operated eye (6/12 PHNI) and unremarkable IOP (14 mmHg). Slit lamp assessment revealed clear conjunctiva and cornea, with no sign of posterior capsular opacification or anterior chamber reaction.
These findings would indicate an issue with posterior ocular health. Fundoscopy and OCT scans revealed unremarkable optic nerves and retinas, but cystoid macular oedema (CMO) was confirmed.
Based on this diagnosis, the surgeon would be notified and a management plan would be discussed. CMO is managed with the use of steroid eye drops,1 and the patient would be reviewed in three to four weeks. By one month after regular use of steroid drops it would be expected that the CMO had resolved. Conditions such as epiretinal membranes, previous retinal vein occlusion and diabetes should be flagged when patients are referred for cataract surgery, as these conditions increase risk of CMO development.2
Differential diagnoses for a patient with reduced visual acuity following cataract surgery include dry eye, CMO, posterior capsular opacification (PCO), corneal oedema, residual lens fragment and residual refractive error. This highlights the importance of patient education as drop compliance assists in managing some of the above diagnoses, and results in overall improved patient satisfaction.
Case Two
Patient Two presented with a three-day history of cloudy vision, mild ocular redness and discomfort affecting the left eye, which has previous history of Descemet membrane endothelial keratoplasty (DMEK). There was no reported change in photophobia, and the patient was using regular lubricants. The right eye was unaffected.
Clinical assessment revealed reduced visual acuity (L 6/12-1 PHNI) and normal IOP (9 mmHg). Slit lamp assessment revealed mild conjunctival hyperaemia, mild endothelial folds and corneal oedema inferiorly. Keratic precipitates were present on the posterior cornea (Figure 1), as was diffuse punctate epithelial erosions (PEE) on the corneal surface. A mild cellular response was present in the anterior chamber. These clinical findings are suggestive of DMEK graft rejection.3
In cases of graft rejection the immediate course of action would be to contact the patient’s ophthalmologist to discuss further management. Intensive topical steroids are used to treat this condition in conjunction with close monitoring.3 Anterior OCT may be helpful to assess the integrity of the graft and image corneal oedema (Figure 2) or graft detachment.
Case Three
Patient Three presented with a four-day history of a red, painful and photophobic right eye. There was no history of discharge. Vision was mildly reduced (R 6/9), and intraocular pressure was normal (R 19 mmHg). On slit lamp examination, there was a moderate anterior chamber reaction. There were iris vessels approaching the pupil margin, with multiple synechiae present (Figures 3A and 3B).
These clinical findings point to a diagnosis of acute anterior uveitis (AAU). Management required frequent topical steroids and cycloplegics, which break the synechiae and manage ocular discomfort.4 Topical steroids should be tapered when inflammation settles. If the synechiae cannot be broken, it’s worthwhile sending the patient to an ophthalmologist.
Before diagnosing anterior uveitis, it is essential to evaluate the posterior health of the eye. A patient with AAU will need to be reviewed closely to ensure inflammation is controlled and symptoms are improving. For recurrent cases, a systemic investigation may be necessary.4
Post-operative care in clinical optometry
Post-surgical care is a crucial aspect of clinical optometry. Common surgeries such as cataract surgery, pterygium excision, refractive surgery and corneal cross-linking require careful follow-up to ensure optimal outcomes. It’s helpful to know what to expect following some of these procedures.
After pterygium surgery, patients can expect discomfort, redness and irritation for the first couple of weeks. Diplopia can occur but should resolve within one to two weeks. By four to six weeks, most of the redness should subside and the graft should look flat and healthy. Compliance with regular lubricants and steroid eye drops is critical for optimal healing and cosmetic outcome. Glasses should not be dispensed until at least two to three months following surgery.
For LASIK and implantable collamer lens (ICL) patients, visual recovery is rapid, with most patients seeing around 6/7.5 to 6/6 in the days following surgery. PRK patients will experience significant ocular discomfort for approximately three days while the epithelium heals. As a result, the vision for PRK patients takes longer to recover, stabilising at 6/6 by one month. Common complications like dryness should be managed with lubricants. Annual follow-ups are essential to monitor for changes in refraction, ocular surface health and potential signs of complications like ectasia in laser patients, and pigment dispersion syndrome for ICL patients.5
After corneal cross-linking, the corneal epithelium may still be disrupted for several weeks. Follow-up visits focus on ensuring proper healing and monitoring for any epithelial defects or haze. Refractive management is delayed until the epithelium stabilises, which typically takes three months.
The importance of collaborative care
One of the key benefits of working as a clinical optometrist within an ophthalmology practice is the collaborative nature of the role. The ability to consult with ophthalmologists on complex cases, ask questions and benefit from your colleagues’ expertise is invaluable. In my experience, working in a team has made me feel less isolated as an optometrist. It has provided a rich learning environment and has fostered my professional growth.
Like all optometrists, clinical optometrists play a vital role in patient education. As a point of contact between the patient and the surgical team, optometrists ensure that patients understand their conditions, treatment options and post-operative care plans, ultimately contributing to better patient outcomes.
Conclusion
Clinical optometry within an ophthalmology practice offers a unique and fulfilling career path, with opportunities to expand one’s clinical knowledge and skills. From cataract management to refractive surgery assessments and post-operative care, clinical optometrists are integral to the multidisciplinary care team, working alongside ophthalmologists to provide optimal care for patients.
Whether you’re new to clinical optometry or considering this type of role, there are abundant opportunities for growth and learning, and the collaborative environment fosters both professional and personal satisfaction.
More reading
Best-practice management of topical ciclosporin in dry eye
Exploring geographic atrophy: Managing patients and progress in treatments
The emerging role of light therapy in myopia
References
1.Erikitola, OO., Siempis, T., Foot, B. et al. The incidence and management of persistent cystoid macular oedema following uncomplicated cataract surgery—a Scottish Ophthalmological Surveillance Unit study. Eye. 6 May 2020; 35:584-591. doi:10.1038/s41433-020-0908-y
2. Chu CJ., Johnston RL., Buscombe C. et al. Risk Factors and Incidence of Macular Edema after Cataract Surgery. Ophthalmology. Feb 2016; 123(2):316-323. https://www.aaojournal.org/article/S0161-6420(15)01146-X/fulltext
3. Gurnani B., Kaur K., Lalgudi VG., Tripathy K. Risk Factors for Descemet Membrane Endothelial Keratoplasty Rejection: Current Perspectives- Systematic Review. Clin Ophthalmol. Feb 2023; 1(17):421-440. doi: 10.2147/OPTH.S398418
4. Duplechain A., Conrady CD., Patel BC., Baker S. Uveitis. StatPearls [Internet]. Updated Aug 8, 2023. https://www.ncbi.nlm.nih.gov/books/NBK540993/
5. Ramesh PV., Parthasarathi S., Azad A. et al. Managing pigment dispersion glaucoma postbilateral ICL implantation in high myopia: A case report on the crucial role of gonioscopy in correcting a misdiagnosis. J Curr Glaucoma Pract. Jan-Mar 2024; 18(1):31-66. doi:10.5005/jp-journals-10078-1433
