Moneo writes: Silo mentality
How good are we at treating our patients holistically? I ask this question because I have recently been helping out with a young child born with bilateral congenital ptosis. The ptosis is mild and he seems to be developing normal vision in both eyes but it means he permanently needs to lift his chin up in order to see straight ahead. The young lad was referred to ascertain what the cause might have been and to rule out underlying pathology.
The good news from the eye clinic was that there was no underlying pathology but the outcome was an interesting one. It was felt that, after assessing his vision and the visual development being normal, no action should be taken but he should be monitored in six months’ time with a view to possible surgery when about five years old. He has now had the six months follow up where it was again decided his visual development seemed okay and therefore warranted another routine review in six months. However, it occurred to me that this young child had developed a marked backward head tilt to overcome his ptosis and was at risk of a permanent abnormal neck growth development that could significantly affect the rest of his life. I therefore suggested that when he was seen for this last follow up in the eye clinic that he be assessed by a paediatric orthopaedic specialist to see if there were risks attached to this monitoring strategy. Only after this suggestion was made was any consideration given to this line of action.
The reason I raise this is that, as in so many situations, the eye clinic seemed to be working in isolation from any other factors and just considering the visual development of the child rather than the wider determinants of his development. I do not say this to criticise that clinic, but more to point out how easy it is to become obsessed with just one factor rather than viewing the patient holistically. With this in mind, maybe we should all reflect on how we approach our patients.
It has been known for a long while now how smoking can have serious detrimental effects on vision but how many practices today have trained stop smoking advisers within their ranks? How many practices offer any form of stop smoking services at all? We also know the impact of poor diet and lifestyle on long term visual welfare but how many practitioners take time to talk to their patients about good diet and exercise? Not only patients, but parents of their patients as well. When was the last time you saw an obese child for a sight test and omitted to even think about, let alone discuss with the parents the detrimental impacts obesity may well have on their child’s vision later in life?
Much is spoken about the myopia epidemic within the younger population, and how we as optometrists should get involved in myopia treatment, but how much is spoken about the massive increase in childhood type 2 diabetes? Next to nothing is said. We all know the devastating impact diabetic retinopathy can have on an individual, we all know the horrendous figures for permanent sight impairment from this avoidable eye disease but how often do we stop to consider our role in preventing it in our everyday lives?
There is no denying we are very good at what we do when it comes to deciding if a patient needs an appliance of some sort to correct their focusing errors, but it would seem that when it comes to looking outside our narrow sphere, we are not very good at all. When was the last time you requested a visit from an occupational therapist to a patient’s home for an assessment of their needs because of poor vision? When was the last time you suggested that a lighting assessment be carried out in an elderly person’s home to ensure their lighting was safe for them, in particular in stairwells where it can be notoriously poor? When did any of us last have a discussion with family members of an elderly patient about checking carpet edges and stair carpets to check they are not loose? Is there anyone in your practice that could help a person with failing sight to learn to use a Kindle or iPad for reading, be able to show them how to order books and increase the font size to facilitate reading?
All of these things, and so many more, should be within our daily remit. They are not the usual refract and dispense things, but are just as vital and possibly more so. They are evidence that we are treating our patients properly. That we are considering all aspects of their ability to live their life to the full and not guilty of a silo mentality where all we do is look at their eyes and vision in isolation from all other aspects of their life.