eyeglasses and the medical model

When glasses do more than correct routine vision problems

By Allan Barker, OD, and Greg Stockbridge, OD, MBA

Most optometrists agree that the profession's future lies with the medical model. By this we mean that for years optometry focused on a “material model.” The end point of patient encounters was the sale of frames, lenses, and/or contact lenses and related products. In recent years, we have seen a shift occurring from a material to a medical focus.

What does that mean for the future of optometry, and how does it differ from where optometry is today and was in the past? Where do the material aspects of the profession fit into this “medical model” concept? Especially, how do eyeglasses fall into this concept?

NOT COVERED

We have vision insurance, but a patient's medical insurance doesn't cover a complete eye examination and glasses. Medical insurance covers routine physicals from a primary care provider, so how is that different than a routine eye examination? Insurance companies routinely cover various devices that allow a person to function better in life, like crutches, splints, wheelchairs, medications, etc., but they don't think of glasses in this same context—despite the fact that a 7 diopter myope can't function without some sort of visual correction.

Medicare offers coverage on a complete pair of glasses after a patient has cataract surgery, which shows they do see the necessity of proper vision correction. But why is it only for newly pseudophakic patients?

Even if medical insurance companies refuse to cover glasses that were prescribed for visual correction only, they should at least cover glasses recommended for various medical reasons.

MEDICAL JUSTIFICATION

Following are 16 areas where eyeglasses should be thought of as a device to correct or aid in a patient's medical condition.

1. Help While Healing

Cycloplegia. Many forms of ocular disease call for cycloplegia to promote healing, decrease or prevent ciliary body inflammation, improve ocular discomfort/pain, or paralyze accommodation.
Sometimes the therapy can be lengthy, and the increased light sensitivity and decreased accommodative side effects need to be addressed through the use of photochromic lenses and multifocals to improve lifestyle and visual function.
The following are just a few disease conditions that could benefit from cycloplegia therapy:

■ Bacterial/fungal keratitis
■ Corneal ulcers
■ Acute corneal erosions
■ Anterior/posterior uveitis
■ Endophthalmitits
■ Interstial keratitis
■ Hyphemas
■ Neovascular glaucoma
■ Amblyopia therapy

2 Photophobia. There are many ocular disease processes or general disease conditions, like albinism, bullous keratopathy, cone dystrophy, keratitis, uveitis, macular degeneration, recurrent corneal erosions, pseudophakia, and dry eye, that create photophobia. Optometrists have a responsibility to address these symptoms and reduce photophobia with solutions that run the gamut from photochromics to polarized lens materials and standard tints.

3 Unilateral Blindness or Amblyopia. Some conditions like amblyopia, traumatic injuries, and sensory deprivation tropias leave the patient with functional vision in only one eye. When this occurs, it is the responsibility of the optometrist to protect the vision and the health of the good eye.

This can be achieved with impact-resistant materials such as polycarbonate and Trivex lenses that need to be worn all day, regardless of a patient's activities, occupation, or visual correction.

Just the opposite of protecting the good eye, there are conditions like angioid streaks, corneal transplants, high myopia, keratoconus, and peripheral corneal thinning or ulceration where we need to protect the affected eye because of its weakened ocular structure.

Polycarbonate or Trivex lenses provide excellent protection during the day and can be augmented with an eye shield at night if necessary.

When sports are authorized for patients with these conditions one-piece polycarbonate or Trivex safety glasses or goggles should always be utilized to prevent further damage to the already weakened orbital globe. It could only take a minor trauma for someone with angioid streaks to develop a subretinal hemorrhage or a choroidal rupture that could have been prevented with the proper prescription.

4 Moist Environment. In the treatment of ocular cicatricial pemphigoid or severe cases of keratoconjunctivis sicca a moist environment is required. Goggles or glasses with side shields can assist in the treatment of this serious condition.

5 Contraindicated Contact Lenses. Many ocular disease processes like acute bacterial/viral/allergic/vernal conjunctivitis, acanthamoeba keratitis, bacterial or sterile ulcers, CLARE, episcleritis, scleritis, giant papillary conjunctivitis, dry eyes, herpetic keratitis, superior limbic keratoconjunctivitis, and superficial punctate keratopathy require that contact lens wear be discontinued to help prevent further irritation to a diseased eye.

Therefore, glasses—single vision or bifocals—must be worn until the condition has completely resolved. This could take days or weeks to even months. In the case of severe dry eye, the use of glasses could be permanent. Also, contact lenses may not be compatible with certain medications prescribed for the disease process, thus adding another reason why patients need to wear glasses.

6 Prism Correction. Single vision eyeglasses with prismatic correction can be utilized to improve eye alignment in certain disease conditions. Patients with small stable deviations because of third, fourth, and sixth nerve palsy can get diplopic relief with the use of prismatic eyeglasses.

For chronic progressive external ophthalmoplegia, base-down prism in single vision reading glasses is called for when downward gaze is restricted. In nystagmus, a face turn may occur when the patient is in search of their null point. Thus, base-in prism placed in the direction of the face turn may help eliminate this need for the face tilt.

For young patients with convergence insufficiency, vision therapy along with eyeglasses that slightly over-correct myopia or slightly under-correct hyperopia can be used to stimulate accommodative convergence.

For older patients who suffer from this condition, doctors can prescribe reading glasses with base-in prism.

7 Cosmesis. Sometimes single vision or bifocal glasses, with and without tints, can provide coverage for cosmetic defects like chalazions, hordeolums, eyelid tumors, ectropions, entropions, ptosis, or strabismus.

This coverage of or distraction from an embarrassing cosmetic defect can have a tremendous and lasting emotional uplift for the patients dealing with these issues.

8 Covering “Good Eye.” The amblyopic eye may respond positively when the “good eye” is restricted, forcing the patient to utilize the eye with reduced vision.

When it's not feasible to occlude the good eye with an eye patch for amblyopia, eye doctors can utilize dark tinted or frosted polycarbonate lenses. This will optically degrade the better-seeing eye to help aid treatment.

9 Frequent/Transient Refractive Changes. Conditions such as pregnancy, keratoconus, complications from refractive surgery, and uncontrolled diabetes can result in wide swings in refractive changes that require the use of glasses intermittently or interchangeably.

It is not uncommon to find uncontrolled diabetic patients who have figured out on their own that sometimes they see better out of their old glasses and sometimes they prefer their newer glasses.

Patients like this, who for years have claimed they have always had large swings in their blood sugar, could definitely benefit from two or more pair of glasses in different prescriptions.

Regarding pregnancy, some doctors say not to change a prescription until several weeks post partum. However, that does not help pregnant women who need different prescriptions due to changes in their corneal thickness and curvature-related, pregnancy-induced corneal edema.

Therefore, temporary glasses may benefit women who they go through these changes.

10 Ultraviolet Radiation. Patients know the importance of UV protection, but many do not realize that UV protection can be put in non-sunglass eyewear.

Eye doctors should be prescribing UV protection for everyone, especially patients who spend a lot of time outdoors or who live in the southern regions.

Patients need to be informed that UV protection helps reduce the risk of developing cataracts, age-related macular degeneration, herpetic keratitis, pingueculas, and ptyergiums.

11 Double Vision. Eye doctors can utilize eyeglasses by blackening or frosting one spectacle lens to counteract diplopia from a third, fourth, or sixth nerve palsy. This therapy is not, however, for children under age nine due to the possible development of amblyopia.

12 Low Vision. Eye doctors are familiar with elderly patients whose vision has been reduced to the point where they can no longer read with their regular glasses.

Elimination of a person's favorite activity can greatly increase their risk of becoming clinically depressed. Since prescribing medications to improve quality of life is considered a medical necessity, why not think of glasses that improve quality of life as medical? High-powered reading glasses can help as a low vision aid.

Also, regular prescription glasses along with various low vision devices can greatly improve both vision and quality of life. Dry age-related macular degeneration, retinitis pigmentosa, Stargardt diseases, and inherited chorioretinal dystrophies are examples of ocular conditions that may respond positively to the use of low vision aids.

13. Eyeglasses as Treatment

Eyeglasses as Method of Treatment. Minus and plus lenses can be used to treat conditions that prevent ocular alignment and commonly result in asthenopia.
Accommodative esotropia is treated with a wide-segment bifocal that has an add power of +2.50 or +3.00 to help maintain proper ocular alignment when reading. For some exodeviations the full distance vision correction along with prism is sometimes recommended.
In mild keratoconus, eyeglasses may be the selected mode of vision correction and supersede the utilization of contact lenses or other treatment regimens.
Also, eyeglasses can be utilized in addition to contacts in keratoconus therapy.

14 Tints. Visual acuity is not the only thing needed to enhance various visual impairments.

Contrast sensitivity can be just as important. A perfect example of this is when a person has 20/40 vision secondary to macular degeneration and cataracts. That individual then gets cataract surgery, and though their vision does not improve beyond 20/40, they are happy. This is because colors are more vivid and contract sensitivity has been enhanced.

Retinitis pigmentosa, macular degeneration, rod/cone dystrophy, and various forms of inherited chorioretinal dystrophies are some examples of conditions that can benefit from the enhanced visual comfort and improvement of contrast sensitivity from single vision or bifocal glasses with various color tinted lenses.

15 Glare Reduction. Anti-reflective coating is one of today's popular lens enhancements that doctors recommend to most patients for improved visual comfort and acuity.

Eyecare practitioners also need to think of this as a medical device that will help improve the visual function of patients with ocular diseases that scatter light and/or don't process light at a normal rate.

Cataracts, corneal abrasions or scars, corneal dystrophies and degenerations, superficial punctate keratopathy, age-related macular degeneration, and retinitis pigmentosa are just a few of the conditions that could greatly benefit from the vision-improving effects of no-glare lenses.

16. Easing Abnormal Accommodation

Accommodation. Accommodative spasms, insufficiency, infacility, and excess all are conditions that result in an abnormal accommodative process. Patients with these conditions, especially in today's modern computer-oriented era, can benefit from vision therapy, prism, or near-add prescriptions.
Patients with ocular albinism could have a reduced applitude of accommodation associated with their condition and its related nystagmus, high-refractive error, and amblyopia. These patients could benefit from a progressive bifocal for near-point work as the added plus power could help magnify lettering.
Children who have ADHD/ADD, and take medications for these disorders, may have a reduction in their accommodation. Was this reduction in their accommodation present before the medication treatment or was it induced secondary to the treatment?
Regardless of that answer, we are still dealing with many children with ADHD/ADD who have near vision complaints. By prescribing a near prescription for them, we may be able to improve their reading performance and academic success.
Adults on psychiatric drugs may also experience a reduction in their accommodation. These patients also need to have their visual complaints addressed.
Physicians prescribe medications to reduce the side effect of other medications. Prescribing reading glasses or progressive bifocals to those that have a reduction in their accommodative system produced by medications is no different.

TRANSITIONING POINT

The medical model may hold the future for optometry. However, the place that eyeglasses have taken in optometric education, as well as state and National Board testing, has continually diminished.

Optometry is faced with the process of often having to file for vision insurance that does not cover medical conditions and then file separately for medical care. This occurs despite the fact that eyeglasses can be considered a medical device for the eye in addition to a device to help a patient see better.

Eyeglasses are an integral part of the medical model and should be prescribed and reimbursed by medical insurance in the same way a physician gives a splint for a sprained ankle or a medication for a headache.

We hope that this article represents a transitioning point of where eyeglasses and their different properties will also be thought of as a medical device—one designed to improve the comfort, vision, and quality of life for individuals with ocular conditions. EB

Greg Stockbridge, OD, MBA, graduated from New England College of Optometry and received his MBA from Duke University.

Allan Barker, OD, is president of Eyecarecenter, OD, PA , and serves as president of the North Carolina State Optometric Society.

Both Stockbridge and Barker are practicing optometrists.