The Reverend Robert J. Fox of the Catholic Charities of the Archdiocese of New York, in a letter to Dr. Haffner said: "Repeatedly our workers here in the family service division have spoken of the outstanding service accorded to clients referred to your center. "In expressing the respect and gratitude of the agency, I should like to indicate that this service has greatly helped us in our work of helping families and individuals regain or develop their sense of dignity and their adjustment to society. The significant aspect of your service has been your sensitivity to the person's need not only for visual care but also for acceptance and considerate attention. This is a truly professional service." The insinuation that optometrists are not well educated is utterly unfounded. Approximately 30 percent of the students entering optometry schools already have a bachelor's degree and those who do not must successfully complete a minimum of 2 to 3 years of college training before enrolling in the optometry courses. Optometry performs a unique and distinct vision care service. Its uniqueness stems from its extensive education not only in the sciences of physiology, anatomy, and pathology, in the training offered of the health care professions but in addition, the exclusively formal education in physiological optics. The only courses in graduate studies leading to the Ph. D. degree in physiological optics are found on campuses where schools of optometry exist. The hard core of their faculty teaching this subject is composed almost exclusively of optometrists. In Maryland, the provisions of section 43, title “Health," subtitle “Optometry,” section 259, reads as follows: "Diseased conditions ***. It shall be unlawful for any person to knowingly sell or prescribe glasses for persons with diseased eyes except it be with their knowledge and consent or on an order or advice from a registered physician." This law was passed in 1914 and there has never been an optometrist who lost his license for failure to comply with this provision of the law. The medical witness sought to confuse the words "diagnosis" and "detec tion." Webster defined detection as "the act of detecting, discovering," and the word "diagnosis" as "scientific determination; critical scrutiny or its resulting judgment." Optometry's premise, published by the American Optometric Association states: "The treatment of pathological conditions and eye surgery is acknowledged by optometry to be in the field of medicine. However, for the protection of the public and in order to make proper referrals to other practicioners and specialists, optometrists must continue to be well trained in the detection and recognition of ocular signs of pathology." [Italic supplied.] The medical diagnosis and treatment of eye diseases is clearly a function of the physician. We trust that the committee will not fall prey to the misleading argument that when an optometrist searches a patient's eyes to detect signs of pathology that he is thereby indulging in medical diagnosis which is the exclusive province of the physician. In 1954 a book was published entitled "The Optometrist's Handbook of Eye Diseases" by Joseph I. Pascal, M.D., and Harold G. Noyes, M.D. The following quotation is taken from the preface of that book: "The purpose of this book is to bring to the optometrist, student, and praetitioner the salient facts regarding dieases of the eye, including congenital and acquired deformities. The authors have been teaching diseases of the eye to optometrists for a great many years and have incorporated here the results of their experiences in this field. "The importance of the subject can be appreciated from the fact that the optometrist in the course of his professional work is bound to come in contact with eyes which may be diseased. In fact, he may be the first to come across diseases of the eye which, because of their unobtrusive nature, that is, lack of startling objective or subjective symptoms, may send the patient to the optometrist first, e.g., glaucoma simplex, diabetic retinopathy. Sometimes the eyes he sees may be in a stage of active inflammation, or they may present the sequelae of some previous disease which has already run its course. "Thus the optometrist is sometimes the most important member of the healing profession with regard to the patient getting the quickest medical or surgical service. To perform this service successfully he need only know, sometimes merely suspect, pathological deviations from the normal. This is his principal concern. Of course he must also be sufficiently familiar with the physiological deviations from the normal so as to know when a referral to the medical practitioner is necessary and when it is not. Differential (pathological) diagnosis is only of secondary interest to him. "Differential diagnosis is a large and difficult field. A medical specialist, with all his training in this direction, with many facilities for making all kinds of auxiliary tests, is sometimes unable to make a differential diagnosis. What good is it for the optometrist to involve himself in such work? "The various State and local standards of blindness, the courses and facilities for rehabilitation of the blind in the various institutes, the special visual aids available for the blind and near blind are all matters of concern to the optometrist and are therefore included." The following quotations are taken from pages 19 and 20 of the same book: "In any survey of the care of the eyes in civilized communities it will be found that the great majority of citizens depend for the relief of their common visual disturbances on refracting opticians, ophthalmic opticians, and, in America, optometrists. This means that the first line in detecting early disease processes and frequently in preventing blindness is held by these practioners. Hence, the great importance of learning to detect signs which point to derangements of the eyes or to the body in general. The following is a brief outline of what is required. Emphasis is placed on the borderline cases so that the optometrist can distinguish between those lying within his province and those lying within the province of other practitioners; e.g., family physicians, and specialists (including ophthalmologists, neurologists, pediatricians, dentists, etc.). "The signs and symptoms of disease are phenomena which are deviations from the normal. But the normal is not an absolutely fixed entity. There are many deviations from the normal which are physiological variations and fall into the realm of normalcy. It is important for the optometrists to learn to recognize these physiological variations." Attached as an exhibit is a copy of the topical outline of the National Board of Examiners in Optometry dealing with the subject of diseases of the eye. In the light of what Dr. Jaeckle said about the education of all medical students in ophthalmology, it seems appropriate to call to the attention of the committee a statement by the late Dr. E. F. Tait, M.D., an ophthalmologist active in the affairs of the National Medical Foundation for Eye Care, as it appears on page 824 of the "Transactions of the American Academy of Ophthalmology and Otolaryngology," November-December 1955. "We have occasion, Mr. President, to discuss at times the undergraduate training of our medical students in ophthalmology, and we had last Sunday a very excellent presentation which I enjoyed very much. However, there is one factor which embarrasses a great deal those of us who have to do, unfortunately, with the legislative aspects of these things. "We have thrust under our noses continually statements by physicians that the medical school training in ophthalmology is limited to anywhere between 26 and 60 hours. That may be true as far as the courses which are labeled ophthalmology in the medical school catalog are concerned. But, Mr. President, it is not true if we take into consideration the fact that these courses in the third and fourth years of medical school would be incomprehensive if it were not for the preceding work, some of it specifically in anatomy and physiology and pathology of the eye, and also in general anatomy, physiology, pathology, biochemistry, and other subjects which are included. "So I would like at this time to present a motion which does not constrict the council in any way and should not in any way be construed as an attempt to dictate in this matter. It is just simply so that we who have to deal, as I say unfortunately, with these legislative situations may be aided; that is, that when these matters are discussed before the council or before this body we may be honest about them and say that the 26 to 60 hours in the medical school catalog does not mean that is all of the instruction a physician gets in opthalmology. "So I move you, sir, that it is the sense of the academy that it is inadvisable that any paper or other communication be published in the transactions of this organization (that does not mean that the academy cannot publish, but it does mean that we feel that care should be exercised in this regard) that would describe the training of medical students in ophthalmologic subjects in terms of courses specifically labeled "ophthalmology" in medical school catalogs, without adequate reference relating that training to the specific eye instruction in preclinical subjects, as well as to the general instruction given in anatomic, physiologic, and pathologic subjects which underlie all studies of special systems and without which instruction in special systems would be incomprehensible and without value." [Italic supplied.] In January of this year, Mary C. Mulvey, administrator of the Rhode Island State Division on Aging, wrote a paper entitled "Optometry's Significant Role in the Total Approach to the Challenge of Aging." Dr. Mulvey received her B.A. degree from the University of Maine, her M.A. from Brown University, and Ed.D. from Harvard University. We submit the following quotations from this paper: "The optometrist might be considered the key practioner of the health disciplines for his primary responsibility for advising the patient to seek further treatment in accordance with his possible needs and/or refer him to a praetitioner in another discipline. "I am quite knowledgeable of your excellent work and achievements and am deeply impressed with the dedication to work of the Committee on Vision Care of the Aging of the American Optometric Association." We respectfully submit that during the 12 years that have elapsed since the Doughton amendment was incorporated into title X of the social security law, the optometric profession has rendered a needed service which should be continued and expanded under the terms of H.R. 10032, Public Welfare Amendments of 1962. EXHIBIT 1 NATIONAL BOARD OF EXAMINERS IN OPTOMETRY TOPICAL OUTLINE1 Anatomy of the eye (pt. 1, sec. III) 1. The bones of the orbit and accessory nasal sinuses.—Orbital foramina and structures transmitted. 2. Fibreous tunic.-Cornea: General description, minute anatomy, physiology, nerve and blood supply, function; limbus; sclera; canal of sclemn, pectinate ligament, scleral spur. 3. Vascular tunic.—Choroid; ciliary body; iris; general description, minute anatomy, nerve and blood supply function. 4. Neural tunic.-Retina: General description, location, histological structure, blood supply, function. 5. Anterior and posterior chambers.—Aqueous formation, circulation and drainage. 6. The lens-General description, location, histological structure, function physiology of the lens; zonule of Zinn. 7. Vitreous humor. 8. The appendages of the eye.-Eyelids: General description, location, histological structure, blood and nerve supply, function, medial, lateral; eyebrows: Conjunctiva: Histology and gross anatomy, glands, blood and nerve supply caruncle, plica semi lunaris; lacrimol apparatus. 9. The extrinsic muscles.—Origin, insertion, primary action, secondary action. nerve and blood supply, reciprocal innervation, synergistic and antagonistie actions, yoke muscles, detection of impaired muscle actions; levator palpebrae superioris, tenon's capsule, check ligaments, orbital fat. 10. Cranial nerves, II, III, IV, V, VI, VII nerves.-Nucleus of origin, course. components, consequences of its impairment, ciliary ganglion. 11. Automatic nervous system.-Path of the light reflex, near reflex, ArgyllRobertson pupil. 12. Visual pathway, minute anatomy, fiber distribution. 13. Vessels of the eye. 14. Development of the eye.-Organogeny of the nervous system, differentiation of the component parts of the eyeball. 1 The topical outlines provided by the national board are intended merely as a guide. not as a rigorous plan of examination. The individual topics and subtopics serve only to suggest the general coverage and possible areas of emphasis in each examination. In the design of the examination. attempts are made to word the questions, and to allow sufficient choice of questions to be answered, so as to compensate for differences in curriculum emphasis and recognized differences in doctrines prevailing in the different schools and colleges. Theory and methods of optometry (pt. II, sec. II) 1. Refractive status.-Hyperopa, myopia, astigmatism; causes, classification, prevalence, hereditary influences, eye changes, etc. 2. Functional status.-Accommodation, convergence, anisometropia, aniseikonia, presbyopia; norms, relationships, classifications, prevalence, etc.; test procedures and significance. 3. Examination procedures.-History, external ocular, ophthalmoscopy, field charting. Norms, significance, relation to systemic, occupational and aging influences. Specific techniques and instrumentation. Ophthalmometry, retinoscopy, static and dynamic, subjective routines, phorometry. Techniques and instrumentation; evaluation, significance, and comparisons. Analysis and prescription. Specific case applications, comparisons; isolated procedures and significance; problems of prescription, such as prism problems, etc.; lenses and multifocal selection. Strabismus, orthoptics, visual training. Training procedures; diagnostic and differentiating techniques and implications. (a) Paralytics from functional cases. (b) Correctable functional indications from noncorrectable indications, etc. Fitting of contact lenses. Aids to subnormal vision. Occupational and industrial vision problems. Diseases of the eye (pt. II, sec. IV) 1. The eyelids.-Congenital defects; diseases of the lid margin; diseases of the glands of the lid; diseases of the skin of the lid; diseases of the cilia of the lid; tumors of the lid; injuries of the eyelid. 2. The orbit. -Congenital anomalies, displacement of the eyeball, periostitis, celluitis, thrombosis of the cavernous sinus, ocular manifestations of accessory sinus diseases. 3. The lacrimal apparatus.-Diseases of the lacrimal gland and ducts. 4. The conjunctive.-Pinguecula, concretions, subconjunctival hemorrhage, chemosis, dry catarrh, anomalies of circulation. Types of conjunctivitis: Catarrhal, purulent, membranous, inclusion, trachoma, phlyctenular, vernal, allergic, angular; symblepharon, pterygium; differential diagnoses; tumors; injuries of conjunctiva. 5. The cornea.-Congenital anomalies; degenerative processes-arcus senilis, dystrophies, keratoconus, etc. Inflammation of the cornea-ulcers, superficial keratitis, deep keratitis; foreign bodies on cornea; wounds of the cornea. 6. The sclera.-Pigmentation; ectasia and staphyloma. Inflammations: Scleritis, episcleritis; injuries. 7. The iris, ciliary body, and pupil.-Congenital anomalies; reactions of iris and ciliary body. Inflamations of iris and ciliary body; types of endogenous uveitis; diagnosis of specific types of iridocyclitis; tumors; sympathetic ophthalmia; disturbances in pupillary reaction. 8. The choroid and vitreous body.-Congenital anomalies of the choroid; degenerations of the choroid; inflammations of the choroid; tumors and injuries; fluidity, opacities, muscle volitantes, hemorrhages, abscess, foreign bodies in vitreous. 9. The lens. Congenital anomalies. Cataract: Symptoms, types, differential diagnoses, secondary involvements; dislocation of the lens. 10. Glaucoma.-Intraocular pressure. Types of glaucoma: Primary, secondary, open-angle glaucoma, congenital; visual field changes; differential diagnoses. 11. The retina.-Congenital anomalies, injury, inflammations, circulatory disturbances, degenerations, detachment of the retina; tumors; retroletal fibroplasi. 12. The optic nerve.-Inflammatory changes, hyperemia, papilledema, toxic amblyopias, optic atrophy, tumors of nerve and sheaths, injuries, visual field defects. 13. Ocular manifestations of general disease.-Syphilis, tuberculosis, rheumatism, nephritis, diabetes, arteriosclerosis, cardiac affections, diseases of metabolism, chronic intoxications, infective diseases, diseases of the central nervous system, head injuries. 14. Disturbances of ocular motility.-Paralysis of ocular movements-supramuscular paralysis, of individual ocular muscles, paralysis of the III nerve: The ophthalmoplegias. 15. Ocular therapeutics.-Local anesthetics, antiseptics, mydriatics, cyclopligics, miotics, staining agents, eyewashes, use of ACTH. Mr. KING. I would now like to place in the record a letter and statement from Dr. George I. Deane, Jr., Director of the Department of Public Affairs, California Optometric Association. CALIFORNIA OPTOMETRIC ASSOCIATION, Hon. CECIL R. KING, House Office Building, Washington, D.C. DEAR CONGRESSMAN KING: It is the understanding of the California Optometric Association that H.R. 10032, a bill introduced on February 1 by Congressman Mills, of Arkansas, which among other provisions would add a new title to the social security law to be known as title XVI, “Grants to States To Aid for the Aged, Blind, or Disabled, and for Medical Assistance for the Aged." As introduced it provides that for a State plan to be approved it must “(12) provide that: In determining whether an individual is blind, there shall be an examination by a physician skilled in the diseases of the eye or by an optometrist, whichever the individual may select." It is our further understanding that a representative for the National Medical Foundation for Eye Care recently appeared before your committee requesting the elimination of the words "or by an optometrist, whichever the individual may select." He also asked that the existing law as it pertains to certification of the blind entitled to benefits under title X be amended so as to eliminate the utilization of optometrists and expressly require a certification be made by a physician skilled in diseases of the eye. We understand that oral testimony has been completed but the record will remain open until February 23 for the inclusion of any written statements which may be submitted. Therefore, on behalf of the California Optometric Association, I would deeply appreciate your kindness in requesting the inclusion of this letter and its enclosures as written statements for the record of the committee. During February of 1958, the then director of the Department of Social Welfare, State of California, George K. Wyman, prepared a statement entitled “Use of the Services of Optometrists." A copy of this statement is attached. While president of the California Optometric Asociation, I wrote a letter dated November 2, 1959, to John M. Wedemeyer, who was and is the current director of the California Department of Social Welfare; a copy of this letter is enclosed. At the close of the calendar year 1961, the records of the State department of social welfare show that there were 303 optometrists serving as authorized examiners rendering professional service under the State aid to the blind program. This is an increase of 36 over the previous year. During the year 1961, 848 applicants were examined by optometrists. The proponents of the amendment to delete optometric participation from this program have stated that as a consequence to the present inclusion of optometrists in the program the States have commonly, having accepted the optometrist's report, nevertheless found it necessary to call for an examination by an eye physician. The official records of the Department of Social Welfare, State of California, will show that this is a gross misrepresentation inasmuch as only 1 percent of the reports submitted by optometrists were considered by the State ophthalmologists who reviews all reports of optometrists and physicians and surgeons, to be in need of further clarification, requesting further information from the examining optometrist or requiring an additional examination of the applicant. Thus we can say that it is rare indeed that the department has found it necessary to call for an additional examination. We believe that the record of optometry is proof of its importance and contribution to the program and urge the defeat of any amendments that would remove the services satisfactorily rendered during the past 11 years by members of the optometric profession in California and, of course, other States. Sincerely yours, GEORGE L. DEANE, JR., O.D., Director, Department of Public Affairs, California Optometric Association. |