Applicant's Guide to the North Carolina Optometry Board's Examination for Licensure
Over the past 30 years the medical eye responsibilities of primary eye care have been embraced in the optometrists' expanded primary care scope. While North Carolina expects full scope primary eye and vision care competence with all of its optometry practitioners, it takes this opportunity to alert applicants to some important concepts and responsibilities expected in the medical eye care aspects of those full scope primary care expectations.
When looking at today's optometrist and the changes that have occurred in their education, training and expanded scope of practice over the past three decades one would conclude that the overlap and differences of skill sets required of the optometrist and the ophthalmologist would be analogous to those of the neurologist and the neurosurgeon. Diagnostic and medical skills should be the same while surgical skills are unique to their respective surgical specialties. Outside of surgery, the privileges of a North Carolina optometrist are the same as those of an ophthalmologist. The North Carolina State Board of Examiners in Optometry is convinced that the knowledge and understanding of ophthalmic disease should be commensurate with the responsibility of today's practicing optometrist in this state. The Board believes that the foundation upon which continued competency must rest is the practitioner's initial competency reflected by a comprehensive and thorough knowledge and understanding of the ophthalmic medical challenges that face all practitioners. What follows is meant to serve as a knowledge guide (not to be confused with a study guide) and as an indicator of the Board's expectations of candidates applying for licensure to practice optometry in North Carolina.
• Knowledge of the structures of the eye and adnexa is critical. For example, distinguishing between the layers of the retina is especially important when evaluating hemorrhages, exudates and differentiating between retinal schisis a retinal detachment.
• Neuro-anatomy is a major challenge, especially that of the afferent and efferent systems. It is crucial for the optometrist to be able to recognize anomalies which may be indicative of sight or life threatening conditions.
• The anatomy of the visual pathway (both neural and vascular) and detailed knowledge of the origin and course of the relevant cranial nerves are all important.
• The vascular anatomy of the visual system and the brain are both challenging and important
A solid understanding of the infectious and inflammatory processes is requisite as well as is the mechanics of the autoimmune diseases. Apoptosis, angiogenesis and nerve transmission are just a few of the physiological processes that must to be clearly understood.
• Understanding the anatomy and physiology of the cornea has been critically important in the optometric community since the advent of contact lenses nearly 60 years ago. Therefore, candidates are expected to not only understand but to be able to diagnose and treat those diseases and conditions involving the cornea that commonly present in optometrists' offices
• Recent advances in refractive surgery necessitate additional knowledge, especially of complications.
• Knowledge of new technologies in corneal and refractive evaluation (topography, and a basic understanding of wavefront analysis) is important for management of postoperative refractive and cataract surgery patients, as well as enhancing and/or improving communication with the surgeon.
• Corneal dystrophies, though challenging, need to be understood.
• Dry eye has become an optometric disease. Tear chemistry and treatments need to be fully understood.
• Candidates must be thoroughly familiar with sight threatening mechanical and chemical injuries of the cornea.
• The diagnosis, treatment and management of glaucoma is fast becoming the responsibility of the primary eye care provider, the optometrist. This disease encompasses many different forms, all of which need to be thoroughly understood.
• New technologies aiding in the diagnosis of ocular conditions and disease are important and require a basic understanding of the principals upon which they operate as well as the diagnostic data they provide. With analysis of the optic nerve (and retina) utilizing modern imaging technologies becoming today's 'standard of care' (thus playing an integral role in the diagnosis and management of diseases of the posterior segment) OCT, GDX or HRT (or instruments based upon similar technologies) findings (printouts) may be presented for interpretation.
• Medications are constantly evolving and all need to be understood. Because North Carolina optometrists are obligated to practice evidence based medicine they need to be familiar with the most recent clinical trials and studies. Nationally recognized glaucoma educators are no longer limited to the ophthalmologic ranks, since there are a number of optometrists among those who are currently recognized at the national level as glaucoma educators.
These conditions require the understanding of 'ocular manifestations' of systemic diseases. They also require an understanding of autoimmune conditions even though uveitis in a particular patient may be infectious or traumatic in origin. A thorough understanding of a full battery of laboratory tests (i.e., PPD, ACE, RPR, FTA-ABS, etc.) available to the practitioner is absolutely necessary to the understanding of these types of diseases. A clear understanding of the granulomatous and non-granulomatous forms of this disease is essential.
Even though most tumors encountered in a vision care practice are dermatological, it is imperative that candidates understand the diagnosis and treatment of the sight and life threatening tumors that may be present in the globe, orbit or brain.
Neuro-ocular conditions are probably the most challenging conditions in the vision care world. Understanding them as previously stated, requires a thorough knowledge of anatomy (neuro and vascular). With the exception of neurologists and ophthalmologists, optometrists deal with more cranial nerves than any other medical discipline. The six relevant cranial nerves must be thoroughly understood. The anatomy of the visual pathway is obviously of absolute importance. The late Larry Gray, an optometrist on the faculty of the Pennsylvania College of Optometry (as well as the faculties of several of the Medical Schools in the Philadelphia area) demonstrated that neuro-anatomy and neurological eye disease can be taught and learned at the highest level in an optometric academic environment. The recently edited Text, 'Walsh and Hoyt's Clinical Neuro-Ophthalmology The Essentials', is a wonderful source for any serious student of this challenging field of ophthalmic science.
• This represents a broad class of ophthalmic conditions, but clearly the most important are the vascular conditions, especially diabetes. For a large segment of the population optometrists have become the primary care providers for the management of diabetic eye disease.
• The maculapathies with their evolving treatment modalities are obviously very important.
• Knowledge of the instrumentation and the ability to interpret findings from fundus photographs, OCT (and similar instruments) and fluorescein angiography is essential.
• An understanding of the various types of retinal tears and detachments is critical, requiring a lucid understanding of retinal anatomy.
• Some of the less common conditions such as Stargartt's, AMPEE need to be generally understood. Again, many of the systemic vascular diseases manifest in the retina.
Many of these conditions have already been referenced in the corneal section though they occasionally involve areas beyond the anterior segment. Since these are all potentially sight-threatening conditions, a complete trauma workup should become second nature to a properly trained clinician.
OCULAR MANIFESTATIONS OF SYSTEMIC DISEASE
Of this group, clearly diabetes is the most common presentation in an optometric office. An optometrist's status as a primary eye care provider is largely determined by his or her ability to manage the visual consequences of this disease. Even though their role is largely diagnostic, a thorough understanding of treatment modalities is required. Many of the uveitic diseases also fall under this category.
Injuries, infections and inflammations of these tissues are very straightforward.
Besides the neoplasm's already mentioned (both benign and cancerous) a moderate range of conditions, infectious, inflammatory and neurological affect these tissues.
Even though there are many different types with different etiologies their diagnosis is straightforward (but need to be clearly understood).
Headaches are a separate category that could have been included under neuro-ocular. These can range from mild asthenopia to serious and life threatening conditions. Since as many as half of optometric patients mention some type of headache as the clinician takes their history and reviews their symptoms, this class of conditions needs to be clearly understood. Knowledge as to how the clinician obtains a proper headache history as well as adequate interpretation of the patient's responses is expected.
There are always miscellaneous conditions that do not fall neatly under any one category, therefore no attempt is made here to create such a list..
EVIDIENCE BASED MEDICINE
Every North Carolina licensed optometrist is obliged to utilize procedures and protocols that are supported by the well-accepted studies that demonstrate treatment efficacy. The Early Treatment Diabetic Retinopathy Study along with the Ocular Hypertensive Treatment Study and the Temporal Arteritis Treatment Study are just a few of a number of studies that an entry level optometrist should be familiar with.
Approved February 13, 2009
Amended March 29, 2009
Applicant's Guide to the North Carolina Optometry Board's Examination for Licensure