Street Smarts

Beyond the Classroom

Here are some examples of the priceless pieces of wisdom that come only from daily clinical practice.

As a third-year student at the Pennsylvania College of Optometry, I recently began my clinical externship, where I discovered that being a successful optometrist involves handling cases that don’t show up in textbooks. Here are just a few pearls of knowledge I’ve gained thus far.

“Blue-core” Cataracts
The first week of my externship, one of the O.D.s was remarking on a patient’s cataracts, noting that the nuclear sclerosis (NS) had a “blue-core” component. I couldn’t recall learning about such a thing. The optometrist told me she’d coined the term “blue-core” to describe a unique type of NS cataract that she saw frequently in the clinic. She said she recognized a variant of the typical NS cataract and decided to give it a specific name to help distinguish it. “Blue-core” cataracts progress more quickly and are associated with a more dramatic myopic shift than typical NS cataracts. The O.D. extracted these certain key diagnostic features and managed her cataract patients accordingly.
Any well-rounded O.D. must be willing to think outside the textbook and have an open mind when diagnosing patients.

The +0.12 Test
A 9-year-old child presented with a chief complaint of decreased vision at distance and near. All of my objective findings were unremarkable. I struggled through the refraction, finally finding a small prescription through which the patient read 20/20.
When I told my preceptor the refraction likely wasn’t accurate due to unreliable patient responses, he suggested the +0.12 test. Seeing my puzzled expression, he offered to demonstrate this mysterious procedure. He asked the 9-year-old to read the 20/20 line without correction. The patient said he couldn’t. Then the O.D. held two +0.12 trial lenses in front of the patient’s eyes, saying that this is how the chart would look if glasses were prescribed. Without any hesitation, the patient recited the 20/20 line perfectly.
Do you suspect a malingerer? The +0.12 test can confirm your suspicion.

Keep an Open Mind
An optometrist at my externship was following a patient who had facial nerve disturbance and lagophthalmos. Most O.D.s probably would recommend artificial tears, taping the lid or perhaps punctal occlusion. But lid weights? I’d learned about lid weights in school, but I didn’t think many O.D.s actually used them. To my surprise, the O.D. suggested lid weights to the patient, who eagerly agreed to try them.
We applied the weight quickly and easily and instructed the patient on proper usage. The weight brought the patient immediate relief. He was able to blink fully much more easily.
Sometimes treatment options that seem inconvenient aren’t troublesome at all. Don’t let your lack of experience with a treatment keep you from trying it. You may find that it’s perfect for your patient.

Real-world Learning Is Priceless
While my clinical rotation has provided a welcome respite from endless studying and exams, it hasn’t put a stop to my learning. Thanks to my externship, I’ll join the world of optometry armed with a potent combination of education and real-world experience that not even a deceptive 9-year-old can challenge.

Erin McCabe, a third-year student at Pennsylvania College of Optometry, is on the lookout for clinical pearls during her externship with mentor and regular columnist, Dan Beck, O.D.