essary for maximum operation in confined quarters. For example, the chinrest of the opthalmometer can be designed from aluminum eliminating the up-anddown adjustment, which can be compensated by a more easily adjusted traverse mechanism of the illuminated section itself. The base of the instrument could also be of lightweight case aluminum or a plastic material. The projector chart could be made with a stand of much lighter material that would be as durable as cast iron. The stand beside the chair can be made much lighter because of the reduced weight of the opthalmometer. If the stand is lighter, then the chair could be of a clinical variety for the purposes of demonstrating the layout of this type of self-propelled vehicle. All instrument tables could be of lightweight construction with adjustable stools to vary the heights for proper adjustment and alining of instruments. PORTABLE EQUIPMENT For bedside vision examinations, an armpiece of equipment upon which to hang the refractor is necessary so that the bed may be straddled from one side (such as a bed table) and operation can be done from the other. The projector could be on a lightweight three-legged folding tripod stand as could be the projector screen. A headrest to attach to the bed could be arranged to assist bed patients and backrest. Such a headrest arrangement could be prepared for wheelchair patients also. GLAUCOMA SCREENING The electric tonometer screening would be conducted in conjunction with this project for the purposes of detecting glaucoma. Glaucoma, being a disease of the eye in which the internal pressure of the eyeball exceeds normal limits, would necessitate referral of cases that exceeds the norms for medical consultation and care. The prevalence of this disease is known but the screening of the multitudes is the only method of finding those afflicted with this disease in time to afford them remedial medical treatment. The use of a self-propelled vehicle and portable bedside equipment would eliminate the use of ambulance transportability for bedridden patients thereby eliminating an expensive transportation problem. PSYCHOLOGICAL BARRIERS TO SERVICE OUTSIDE USUAL OFFICE The cost of optometric service to the chronically ill and aged has been a barrier, monetarily, in the minds of these patients; thereby keeping them from seeing properly. Reading and television are two sources that could while away the many long hours for those thusly afflicted as well as using vision to see rehabilitation projects that may be proposed. There are hundreds of our aged population that inhabit institutions that do not have facilities for vision testing. Those institutions that do provide this service are not now set up on a basis to service all the patients that require attention either due to lack of sufficient funds, lack of adequate equipment to do a professional examination or due to the lack of cooperation that exists under the present contractual arrangements between the professional vision specialist and the particular institution. REVIEW OF FILM "VIGIL OF JENNY FAY" Rarely do optometrists own portable optometric equipment and the cost of a home examination is high. Proper examination cannot be done without proper equipment. Kansas City health and welfare organizations and churches supplied names of chronically ill and aged. Also lay and professional groups validating chronically ill and aged. 1. Administrator 2. Dentist 3. Dental assistant 4. Dental hygienist 5. Social worker 6. Secretary 7. Driver of car Eligibility established by local dental board of 4,000 examined; 75 percent brought to clinic by car; 15 percent brought by ambulance to clinic; 10 percent treated at home. The project consists of various steps concerning patients chosen for the project. (a) Find them. (b) Treat them. (c) Followup treatment and train others to continue the work. Various nursing homes and persons chosen for use of project cooperated very willingly. Development of lighter weight and portability of equipment outcome of project. Dental hygienist visits patients for followup and education of dental care. Of 4,000 patients examined, 12 percent didn't need care, 50 percent or half of the 12 percent, had lost all of their teeth, 90 percent of those examined with teeth suffered from diseases of the gums. Dr. EXFORD. In January 1961, the Public Health Service of the Department of Health, Education, and Welfare published a pamphlet of some 40 pages in which it listed the activities of the National Institutes of Health in the field of gerontology. There are hundreds of projects listed, only one of which could I identify as being connected with vision. It appears on page 7 of the pamphlet, and is entitled, "The Influence of Age on the Control of Accommodation (B-1922)," as being conducted by Dr. Merrill J. Allen, an optometrist on the staff of the University of Indiana, Department of Optometry, Bloomington, Ind. Please do not misunderstand me; I am not saying that any of these projects should be abandoned, but it would appear that the importance of vision to the aged had been sadly overlooked, notwithstanding the recommendations and guidelines issued by the White House Conference on Aging held last year. Permit me to call your attention to the statements which appear on pages 32, 33, 34, and 35 of the pamphlet entitled "Rehabilitation and Aging," Series No. 11. I would like to quote a few statements from those pages. It was the consensus that to promote the well-being of persons suffering visual loss and maintain their integration as members of society, there are available a very considerable array of valid processes. These are under legitimate disciplines which require support and promotion from society, the professions, legislatures, and executives in Government as well as private organizations. These processes consist of two major kinds-(a) means of sight preservation and restoration, including visual aids; and (b) means of self-management talents of medicine, optometry, and social work require special facilities and training under the aegis of properly constituted public health programs. There are two major aspects of visual loss which are of concern to the community: Preservation and use of sight. Living effectively without sight. These two aspects are often diametrically opposed with respect to motivation and must be managed accordingly. The first two and last two recommendations in the booklet on the White House Conference are as follows: 1. That there be established in each major population center of each State a visual aids rehabilitation center that would be health oriented, making complete use of all experts in all phases of eye care, including opthalmological, optometric, social work, medical, and psychological specialties. 2. In sparsely populated areas it is suggested that the State medical society and the State optometric society take the lead in providing a panel of available experts to foster the use of optical aids. 22. Although research moneys have been available for the study of visual loss and of blindness and also for areas of geriatrics and gerontology, a considerable amount of research must be done on the areas where these overlap. It is therefore recommended that further research and demonstration grants be made to study the effects of blindness on an aging population and the effects of advancing years on persons already blind. In this connection separate attempts should be made to correlate this study with all research on sensory deficit in the aging. Mr. BAILEY. May I interrupt there? Does the proposed bill that we have been giving attention to make provision for this? Or are you suggesting that as an item the committee should consider in the form of amendment? Dr. EXFORD. We would recommend that it come under the bill. Mr. BAILEY. Go ahead. Dr. EXFORD (reading): 23. It is the opinion of the group that for the sake of increasing the number and quality of professional personnel in this specific field of working with persons who, in addition to age, suffer a visual loss there be made available scholarships, fellowships, grants in aid, and that, in addition, a recruitment program be instituted which would reach back to lower grades of school to interest young people in these growing problems. Only about 25 percent of the population who are rated as legally blind have no sight. Of the remaining 75 percent, our experience has shown that approximately 70 percent of them are able to obtain a marked improvement in their visual acuity through the use of visual aids, most of which have been designed and prescribed by members of our profession. There appeared in the November 1961 issue of "Ohio's Health" an article by Leslie M. Knott, M.D., entitled "Research in Aging; Implications for Public Health." In this article the author lays particular stress on the effect of aging upon the sense of sight. I quote: Vision starts to be affected in the late twenties or early thirties. Among the various impairments which appear or increase as the years go by are: Loss of ability to see objects at lowered illumination; increase in time needed for focusing; changes in near-point vision; decrease in ability to distinguish between colors, particularly closely related colors; increase in time needed for adaptation to darkness. Visual impairments in the elderly are an important consideration in accident prevention programs. For example, a darkened stairway can be a serious threat for the elderly and proper precautions must be taken through proper illumination, both in industry and in the home. Also, loss of ability to see at lowered illumination and lessened adaptation to the dark, are factors in highway accidents, particularly at dusk or at night. Our association has a standing committee concerned with the subject of motorist vision and highway safety, and our profession has financed the first research project in dealing with the visual problems connected with automobile driving between sunset and sunrise. estimated that approximately one-third of the automobile mileage is driven during this period, and yet two-thirds of the accidents occur in night driving. The American Optometric Association is an affiliation of the State associations in each of the 50 States and the District of Columbia. Every one of these affiliated organizations has a standing committee known as the Committee on Vision Care of the Aging, the functions and duties of which are similar to those carried on at the national level. It occurred to me that it might be of some assistance to the members of this committee and to your colleagues if, as part of the hearing, there could be published the names and addresses of persons to be contacted in the various jurisdictions who are particularly interested in this subject. Such a list is submitted herewith. (List referred to and reprint follow :) COMMITTEES OF VISION CARE OF THE AGING NAMES AND ADDRESSES OF PERSONS TO BE CONTACTED Dr. Arnold Opengart, 8056 North 57th Street, Phoenix, Ariz. Dr. Myron E. Shofner, 213 North Jefferson Street, El Dorado, Ark. Dr. Richard L. Haney, 258 University Boulevard, Denver, Colo. Dr. Richard People, Selbyville, Del. Dr. David M. Dantzic, 6125 Georgia Avenue NW., Washington, D.C. Dr. Bernard Kahn, 12 Peachtree Street, Atlanta, Ga. Dr. Jack Salle, Snow Building, Burley, Idaho. Dr. John M. DeMoure, 607 First National Bank Building, Peoria, Ill. Dr. Dale L. Nielsen, Box 212, Sibley, Iowa. Dr. M. D. Reynolds, 617 Second Street, Dodge City, Kans. Dr. E. M. Sheridan, 503 South Third Street, Louisville, Ky. Dr. Robert D. Sandefur, Post Office Box 66, Ruston, La. Dr. Francis P. Pakulski, 32 Main Street, Livermore Falls, Maine. Dr. Bernard E. Rothman, 8246 Georgia Avenue, Silver Spring, Md. Dr. Donald C. Exford, 74 North Street, Pittsfield, Mass. Dr. G. D. Rowe, 22057 Garrison, Dearborn, Mich. Dr. R. H. Ehrenberg, Granite Falls, Minn. Dr. Walter C. Simpson, Jr., Box 284, Booneville, Miss. Dr. Bernard C. Jander, 315 West Lockwood Avenue, Webster Groves, Mo. Dr. John Howard, Box 884, Helena, Mont. Dr. W. J. Higgins, 1276 South 44th Street, Lincoln, Nebr. Dr. John R. Uglum, Robeson Building, 475 South Arlington Avenue, Reno, Nev. Dr. Lionel Desmarais, 130 Franklin Street, Somersworth, N.H. Dr. A. J. Shack, 107 Broadway, Newark, N.J. Dr. Claise C. McDougal, Box 486, Belen, N. Mex. Dr. I. Irving Vics, 610 Western Avenue, Albany, N.Y. Dr. Belle A. Palmer, 401 North Church Street, Charlotte, N.C. Dr. Bernon Duntley, Corrington, N. Dak. Dr. Edward Gould, 437 Spitzer Building, Toledo, Ohio. Dr. J. M. Winchester, Box 176, Clinton, Okla. Dr. Byron E. Woodruff, 616 Southeast Jackson Street, Roseburg, Oreg. Dr. Harry Kaplan, 1550 Pratt Street, Philadelphia, Pa. Dr. Clement Powsner, 248 Weybosset Street, Providence, R.I. Dr. H. B. Odom, 503-504 Hodges Building, Greenwood, S.C., chairman. Dr. David C. Lewis, Post Office Box 477, Abbeville, S.C., cochairman. Dr. Donald D. Slater, Evans Hotel Building, Hot Springs, S. Dak. Dr. Ralph E. Wick, Box 3006, Rapid City, S. Dak. Dr. Merrill S. Wise, Jr., 33 Harmony Lane, Jackson, Tenn. Dr. E. T. Jennison, 809-811 Maverick, San Antonio, Tex. Dr. H. V. Marsell, 48 East Gentile Street, Layton, Utah. Dr. Walter I. Auber, Bank Block, Springfield, Vt. Dr. Herbert E. Cross, 202 Doniphan Building, Alexandria, Va. Dr. Alan J. Johnson, 2 North 55th Avenue, Yakima, Wash. Dr. Harry George, Wilt Building, Elkins, W. Va. Dr. Phillip G. Jacobson, 6113 West Capitol Drive, Milwaukee, Wis. Dr. J. A. Greenlee, Box 109, Thermopolis, Wyo. Dr. Robert D. Y. Chang, Box 1074, Kailua, Hawaii. [Reprinted from American Journal of Public Health, vol. 51, No. 11, November 1961] OPTOMETRY'S ROLE IN HEALTH MAINTENANCE-A STUDY OF REFERRALS (By Galen F. Kintner, O.D.) OPTOMETRIC REFERRALS Most patients seeking the services of an optometrist have, or presume to have, symptoms of disorders connected with the eyes or their use. The optometrist, in taking a careful case history, observing the patient, making various tests and in evaluating his findings, must decide if solution of the patient's problem lies within his circumscribed field. This is a differentiating activity requiring skill and understanding since many symptoms of visual disorder are similar to those manifest by a patient with general disease, dental or eye health problems. If other than optometric services are required, the optometrist refers his patient to other health professions or agencies for further attention. Thus the optometrist in his routine practice regularly originates referrals to other professions as part of his responsibility to his patients. This report is concerned with various aspects of these referrals. The visual system is a generous window to a number of the patient's health problems. While the optometrist's area of service includes refraction and coordination problems (with lenses, orthoptics, subnormal visual aids, and the like), his field of investigation includes much more in determining the state of health of the patient and his visual system. Case histories are revealing; the reflexes of the eyes and adnexa are rich sources of neurological information; the appearance of blood vessels, tissue structure, and pigmentation are prime indicators of both general disease and localized diseases of the eye. The normal physiology and anatomy of the eyes is so well understood that any deviation from it is readily recognized by the observant optometrist. As the optometrist originates many referrals his activities often partake of the nature of the general practitioner,1 rather than that of a specialist. Even though the public is becoming more sophisticated in its self-diagnosis2 and hence its choice of health specialists, the fact is that a great number of people with vague symptoms come first to the optometrist. In serving these patients the optometrist frequently consults with the general practitioner to insure correct referral. Conditions requiring medical or surgical treatment of the eyes are generally referred directly to an ophthalmologist. Close cooperation between the optometrist and the consultant contributes to more efficient use of community health resources. 3 FORM OF REFERRALS Referrals of patients by optometrists take many forms, depending upon the factors that the patient's problem and degree of urgency may present. On the one hand it may be such an acute situation that he actually accompanies the patient to the physician, conferring with him on the signs and symptoms that actuated the referral. At the other end of the scale, the optometrist may decide that the patient need only be given the recommendation that he see his physician or dentist at his early convenience. Between these two extremes are all gradations, with all types of communication between the optometrist and the other members of the health care professions to whom he sends his patient. In general, referrals can be divided into two groups: the desirable but elective, and the more formal or specific referral. The former presents the larger portion of the direction of optometrists to their patients to seek the service of others. These referrals are for conditions of less than an acute nature. Dental caries, periodic health examinations, obseity, general hygiene, and such subjects of health management are examples of the matters that an optometrist typically calls to the patient's attention. Rare indeed is the older patient that does not need some encouragement for better health management. 1 Howe, Henry F., "Procedures in Consultation and Referrals," General Practice 20: 218-227 (November), 1959. 2 Means, J. H., "Profession or Business," New England J. Med. 261: 791-797 (Oct. 15), 1959. 3 Bornmeier, W. C., "Referral and Consultation," J.A.M.A. 154: 440 (Jan. 30), 1954. NOTE. Dr. Kintner is an optometrist, and a member of the district board of health, Lynden, Wash. This paper was presented before the medical care section of the American Public Health Association at the 88th annual meeting in San Francisco, Calif., November 2, 1960. |