The definition of the word ‘co-management’ from the Collins Dictionary is ‘the practice of managing something jointly’, writes Margaret Lam.
Over almost two decades, I feel fortunate enough to have seen firsthand a considerable amount of evolutionary growth in our optometric profession, particularly in establishing our credentials in co-managed care working alongside our peers in the medical profession, amonggeneral practitioners and ophthalmologists.
Our profession has undergone a considerable shift in purpose. None would disagree that the early role of an optometrist was simply as a refractionist and spectacle maker. The maturation of our profession has seen us grow into an increasingly vital profession, which today encompasses extensive management of our patients’ ocular health needs. We have always focused on meeting our patients’ visual needs, but in addition, we have grown to appreciate that, in our role, it is also important to focus on the health of our patients and the provision of care beyond refraction.
A good example of co-managed care the case-study of a lovely older gentleman, Mr. R. At 84-years of age, Mr. R is the main carer for his wife who has considerable health and mobility issues. He was referred down for co-managed care from his new corneal ophthalmologist for contact lenses.
In his 20s, while working in mining equipment manufacturing, a metal projectile penetrated Mr. R’s left cornea. This created an iris ‘entry wound’ pupil, and possibly on removal of the projectile, another small pupil from an ‘exit wound’. The result was that Mr. R had no functional vision in his left eye.
In his history, in an attempt to restore vision, Mr. R had undergone posterior chamber intraocular lens surgery. Unfortunately, although the damaged lens was able to be removed, the surgery was complicated by the earlier traumatic injury. The intraocular lens surgery resulted in a superiorly displaced and mislocated pupil in his left eye, and a considerable amount of iridodenesis from a weakened iris and weakened zonular fibres post injury.
Mr. R had earlier trialed a contact lens in his left eye in an attempt to improve his vision, but the polycoria created a situation of monocular diplopia from each separate pupil, resulting in the creation of multiple images that the brain was unable to fuse. Mr. R’s vision remained functional for many years, albeit, only in the right eye which achieved 6/6. However, over time, he began to develop mild nuclear and cortical cataracts, and his habitual vision in the right eye dropped to 6/15 (Correctable VA 6/9-2).
Mr. R came into the care of a new corneal ophthalmologist, who listened to his concern about the need for future cataract surgery in his right eye, given that he didn’t have a ‘working spare eye like everyone else’.
As the sole carer for his wife who has extensive health care needs, the greatest concern Mr. R expressed was: ‘What if something goes wrong? If something goes wrong, I would be left with no vision.’
Mr. R’s new ophthalmologist reassured him that it was worthwhile at least considering specialty contact lenses again, with an optometrist with specialty contact lens expertise.
If the previous rigid gas permeable contact lens generated monocular diplopia there were two potential, possibly even simultaneous, causes:
- Monocular diplopia from each separate pupil resulted in the creation of multiple images that the brain was unable to fuse; or
- The previous fitting in the past of a conventional small diameter rigid contact lens may have caught the edge of the second pupil and created a discomfiting glare or secondary image on the edge of the contact lens, with one image corrected and the other images coming through other pupil(s) uncorrected.
My aim for Mr. R was to avoid this by designing a far larger lens diameter with a larger optic zone diameter to cover the three holes and avoid the creation of multiple images from his polycoria.
Larger lenses can be far more challenging to fit as there can be more parameters to customise. However, there is the opportunity to correct for more complex cases of corneal ectasia or injury. So a general fitting philosophy is to use the smallest lens that can optimise the fit for the patient and employ a stepwise approach with the rationale of increasing lens size as indicated by the characteristics of each individual patient.
Our profession has undergone a considerable shift in purpose
I selected a custom corneal rigid lens in an oversized corneal lens diameter in a RoseK2 Irregular Cornea Lens Design, prescribed to the following specifications, resulted in no monocular diplopia:
LE 7.40/11.20/+15.00/-1.25 X 22 RoseK2 IC CL Light blue handling tint, Boston XO material, standard edge lift in all quadrants.
On lens delivery, the lens was unstable; swinging around inconsistently for mislocation. This was fixed on the next iteration with increasing base down prism, thus increasing the prism ballast in the lens to improve stabilisation.
My patient, as a first time, full time contact lens wearer, with a stable fitting, and no adverse events at the two-week, one-month, three-month, and six-month aftercare visits.
Mr. R was incredibly grateful for the co-management from his corneal ophthalmologist and his optometrist who brought back vision to an eye that was considered long ago to be functionally blind. He said “he has peace of mind because he can retain a full driver’s licence with his spare eye working and can drive his wife to any doctor’s visits”.
I saw Mr. R for a consultation on my last birthday and as a token of appreciation I received lovely flowers and a birthday card.
In the future he may possibly benefit from an iris cerclage procedure to reposition the pupil. If this is the case, it will still be necessary for Mr. R to be fitted with a specialty rigid contact lens afterwards to correct the irregular corneal surface. This is where I would defer to the expertise of the ophthalmologist.
Although this is an interesting case study, which emphasises the benefits of customised care and an individualised approach, the take home message is the mutual benefit for all from co-management.
The role of an optometrist now encompasses a considerable breadth of general and holistic health care. Optometrists have always provided patients with the precious gift of sight, and we have established our area of expertise in prescribing practical solutions in the form of visual devices to optimise functional vision to our patients.
Additionally, inroads in therapeutic and pathology management in ocular health and specialty contact lens management in our profession over this time have certainly evolved. There is now mutual respect for our unique skill set to co-manage patients together for improved health outcomes for our patients.
As our profession continues to evolve at this considerable pace, the future beckons faster than we can imagine. With some modesty, the best way to serve our patients is to remain humble in the knowledge that we do not know it all… to continue to learn about frames, spectacle lenses, contact lenses, therapeutic medication, ocular and general pathology… and to invest in ourselves so that we can be well versed in treating our patients along best practice principles.
This approach will enable us to continue to provide optimal management for our patients, to drive a future that pursues continual excellence in our profession. Co-management creates synergy, particularly with our general practitioners and ophthalmology colleagues, as all our patients stand to benefit when we all act in their best interests from mutual recognition for our complementary areas of expertise.
Case History Summary
Traumatic metallic penetrating foreign body LE in his 20s resulting in polycoria and monocular vision and a displaced pupil LE
Entering Habitual (Uncorrected) VA RE 6/15 LE 6/60 OU 6/15
RE +3.00/-2.75 x 114 6/9-2
LE +9.75/-2.25 x 16 6/30+1 with eccentric fixation OU 6/12
Previous RGP CL generated monocular diplopia and was unsuccessful.a
Margaret Lam graduated from the University of NSW in 2001 and started theeyecarecompany in 2005 and today has practices in greater Sydney and Sydney CBD. Margaret practises full scope optometry, but with a passionate interest in contact lenses, retail aspects of optometry and successful patient communication. She has extensive experience in specialty contact lens fitting in corneal ectasia, kerato-conus and orthokeratology, and is a past recipient of the Neville Fulthorpe Award for Clinical Excellence.
Margaret is a guest lecturer at UNSW and works in several advisory roles with leading contact lens companies. She currently serves as the NSW President of the Cornea and Contact Lens Society of Australia and is a regular public speaker on topics spanning business building, retail aspects of optometry, contact lenses, specialty contact lenses, and patient communication.
Margaret writes ‘mipatient’ on alternate months wth Jessica Chi.
Cornea and Contact Lens Society of Australia, Orthokeratology Society of Oceania and other CL bodies exist to share knowledge and develop expertise in the CL field. For more information visit www.cclsa.org.au
A reference for the fitting guide for RoseK2 fitting is www.roseklens.com/page/105-rose-k2-video-fitting-guides
Thanks and appreciation to corneal subspecialty ophthalmologist Dr. Doug Parker who referred this patient for co-managed care to my practice.