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It is almost certain that untrained laymen will occupy the void created by the shortage of professional specialists and, gentlemen, that is not the way to improve the Nation's vision.

On the other hand, passage of this bill will go a long way toward insuring a continued flow of able, well-trained optometrists into vision care and into the necessary research connected with vision care. Your support will be appreciated not only by us, the Nation's optometrists, but by the American people as a whole, and in particular by that vast segment of our population which is or will be served by optometry.

Thank you very much for your patience. I shall be happy to answer any questions that any member of this committee may wish to ask.

APPENDIX

Licensed optometrists and certified ophthalmologists related to the population

of the United States of America

[graphic]

15, 222 12, 875 13, 209 11, 709 6, 136 7, 370 7, 634 12,514

7, 289 10, 704 13, 031 9, 733 7, 529 4, 012 8,888 7,068 7, 391 10, 704 11, 938

6, 204 14,923 4, 876 8,877 7,081 15, 833 6, 754 7,085 6, 630 10, 269 6, 575 6, 715 12, 769

7,932 14, 189 8, 822 7,850 8,310 5, 580 6, 733 5, 386 14, 720

6, 382 10, 276 10, 751 9, 562 9, 171 14, 168 7,034 11, 488 7, 602 8, 103

Sources: Blue Book of Optometrists, 1958; Red Book of Eye, Ear, Nose, and Throat Specialists, 1959 Directory of Medical Specialists, 1957; Bureau of the Census, Statistical Abstracts, 1958.

VISION AND SCHOOL ACHIEVEMENT

IMPORTANCE OF VISION

More than 80 percent of all school tasks are based on vision.

Vision is the key to a child's whole development, according to the Gesell Institute of Child Development. Not only school achievement but personality, posture, and adjustment to life are closely integrated with vision development

Many retarded readers have neglected vision problems.

Four out of ten grade school children in the United States are visually handi. capped for adequate school achievement.

ELEMENTS OF GOOD SCHOOL VISION

Near vision-ability to focus and see clearly and comfortably with both eyes and each eye separately at a distance of about 15 inches. This is the distance at which most school desk work is done.

Distant vision-the same as above for a distance of 20 feet or more. This is necessary to see the chalkboard, to enjoy motion pictures and television, and to engage in sports.

Binocular coordination-ability to make the two eyes work together. This is necessary for art work, handicrafts, and play activities, as well as to read efficiently.

Adequate field of vision-ability to see to both sides and up and down while focusing on a small target. This saves unnecessary eye and head movements and is essential for participation in sports and for personal safety.

These and many other requirements for adequate vision must be considered in a complete vision analysis, especially for the schoolchild. Because most school tasks are performed within arm's length, it is not enough to determine whether a child can read the Snellen chart at 20 feet or to prescribe corrective lenses to bring them up to that ability. How well a child's visual capabilities are geared for all of the normal demands made upon him, particularly the need for sustained, nearpoint vision performance, must also be determined.

VISION EXAMINATION Modern optometry is based on the concept of functional vision. This takes into account not only the shape of the eyeball, but also the entire vision process, both physiological and psychological.

Any complete vision examination for a child cannot be done hurriedly. It often takes an hour for all of the necessary tests and sometimes more than one visit.

A case history is an essential part of a child's vision examination. It should include symptoms observed by parents and teachers, general health history, developmental history, and the child's attitude toward school and play activities.

There should be a thorough examination for eye disease.
Both the examination and correction provided should pertain to actual use of

CORRECTION

For refractive errors (such as nearsightedness, farsightedness and astigmatism) either conventional glasses or contact lenses (for the older child) are usually prescribed. Lenses may also be prescribed to enable the child to function with greater ease and efficiency.

Visual training or orthoptics is the answer to many problems of muscle im-. balance, where the two eyes do not work together as they should. It is often the means by which strabismus (crossed eyes) may be corrected. Sometimes a child may be trained to improve the vision of a lazy eye (amblyopia).

The vision specialist's advice should be followed on how to use the eyes, on when to wear glasses (for reading, play, all schoolwork, etc.), and on proper light and proper posture when doing close work. All of these are important in correcting vision problems.

With the aid of modern science all but a few children can have their vision brought up to par. Few health problems respond so completely to proper professional care.

VISION SCREENING

The American Optometric Association recommends a complete, professional visual examination before a child enters kindergarten, and annual checkups thereafter to provide maximum preventive care and early correction. However, the achievement of this ideal for every child is not yet within the foreseeable future.

In the meantime, many schools and parent-teacher groups render a valuable service to the vision conservation of the schoolchild by conducting preventive education and vision screening programs.

While even the best school vision screening programs fail to detect all children who are in need of professional care and sometimes refer those whose vision is adequate, the value of such programs is unquestionable. Every school should offer the best screening program possible within the limits of available resources.

The limitations of the Snellen chart at 20 feet as a sole criterion for vision screening are now well known. Numerous other tests have been developed and are readily available for school use of help determine which children need professional care.

An important part of any screening program is the observant parent or teacher who watches for symptoms of vision problems particularly while the child is reading.

SYMPTOMS TO WATCH FOR

Losing place while reading.
Avoiding close work.
Body rigidity while looking at distant objects.
Holding reading material closer than normal.
Excessive head movements.

Poor sitting posture and position, or facial distortions while reading such as frowning, excessive blinking, scowling, or squinting.

Tilting head to one side.
Tending to rub eyes.
Thrusting head forward.
Headache.
Tension during close work.
Little or no voluntary reading at home.

In general, any child in the lower third of the class should have a complete eye examination, particularly if he seems to have ability to achieve at a higher level. Any child who is not working up to within reasonable limits of his own capacity should also have a complete vision examination.

HOMEWORK CORNER

The schoolchild should have a suitable place for homework-a corner, if not a room, that is his or her own.

Such a place should be evenly lighted, without glare and without large dark areas. If possible, the room should be painted in light pastel colors that reflect rather than absorb light. It should be comfortable and attractive. It should be a place the child likes.

Chair and table should be of the right size for proper posture.

Small children should have reading matter of large type-the smaller the child, the larger the type.

Children below the third grade should not concentrate for more than 15 or 20 minutes on close work without looking up to relax their eye muscles and whole bodies.

NOTE.This pamphlet, prepared by the American Optometric Association, St. Louis, Mo., is published in the interest of furthering he visua we are

American people; 12,000 licensed professional optometrists, members of the American Optometric Association, serve the vision needs of 60 million Americans.

[From the American Journal of Public Health, vol. 51, No. 11, November 1961)

OPTOMETRY'S ROLE IN HEALTH MAINTENANCE-A STUDY OF REFERRALS

(Galen F. Kintner, O.D.')
Optometrists see large numbers of people, some of whom require
re al to other health personnel. This study reports on
ferrals made by optometrists to ophthalmologists, general physicians
and others, and suggests means for making more effective use of
optometrists referrals in health care.

re

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 deviations 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-diagnosis (2) 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.

FORM OF REFERRALS

Referrals (3) 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.

1 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., Nov. 2, 1960.

In general, referrals can be divided into two groups: the desirable but electire 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, obesity, 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.

The present study is concerned with the more formal or specific type of referral, characterized by the fact that the optometrist not only undertakes to motivate the patient to seek the services of others but also initiates the communications with the essential third party to whom the patient is referred. In this type of referral the optometrist not only determines that the patient needs the services of others but that these services are required at an early date and with more certainty than the product of casual conversation or direction. These referrals are generally made to a specific practitioner or office always consulting the patient on his choice. Communication is between principals and typically generates more return discussion between them in the patient's interest.

To date, no information with an authoritative background was available on this subject of optometric referrals. In the development of their activities, several committees of the American Optometric Association felt that such a study would be desirable for several reasons: to provide information essential to proper development of the profession in a changing world; to provide information for the optimum development of interprofessional relations; and to develop information which could be used to improve the educational preparation of optometrists.

TUE QUESTIONNAIRE In order to provide a source of material for the current study on optometric referrals, a questionnaire was designed. It was mailed to a random sampling of 1,350 optometrists who were asked to return one copy each month for 6 consecutive months. Of the 306 who responded by returning the first month's questionnaire, 133 completed the entire series. A total of 1,360 monthly questionnaires were returned.

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California:

Rural.

Urban. Florida:

Rural.

Urban Illinois:

Rural,

Urban Massachusetts:

Rural..

Urban Michigan:

Rural

Urban Pennsylvania:

Rural.

Urban Texas:

222

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Rural.

Urban
Other States:

Rural..
Urban.

25
94

3, 972 14, 392

57 194

1. 44 -1.35

103
193

16, 184
36, 135

403
924

2. 49 2. 56

Total of all States:

Rural.
Urban.

513
847

80, 257
155, 055

1.890 3, 256

2.35 2.10

Grand total.

1,360

235, 312

5, 146

2. 19

It is estimated that the

1 The term "patient visit” means visits to the optometrist for any reason. refracted patient uses 244 visits in connection with one refraction.

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