Why is optometry school 4 years long?

Merry Christmas,

If you ask a toy factory tech how to make a ball, he'll say he presses the green button on the console and a ball rolls out of the conveyor belt in 2 minutes. If you ask the engineer or manager, they'll probably know exactly what the inputs, outputs, and mechanism of what goes into toy production as well as how to troubleshoot anything going wrong with the system.

You would expect a primary eye care professional to understand how the eyeball works so that you have some idea for the underlying reasons when problems occur:

Anatomy and physiology , and circulatory and neurological pathways of the eye. How vision/perception occurs. How the eye/visual system develops with age so you know age-related normative data to consider what is normal or abnormal testing. One would argue that it is important to have this as a background (and more importantly what is clinically relevant) rather than having no concept of it at all. This alone is a mountain of information.

Because we do have prescribing privileges for oral and topical, law mandates we know drug interaction, drug mechanism, current therapeutic management from evidence based medicine, pharmacology. Familiarity of other systemic drugs needs to be known to understand any possible ocular toxicity or understand the systemic health of a patient (mostly hypertension, diabetes). Because optometrists are primary eye care professionals with a health component required to constitute an eye exam, it would make sense that understanding what is going on in the overall health of the patient is important. For that matter, optometrists can also order blood work based on their findings or suspicions and need to be familiar with what's normal and abnormal and related to what they are suspicious for. Optometrists are more often than not (especially when lower income classes refuse to see their pcp) the first professional to diagnose something going wrong systemically [whether uncontrolled diabetes, malignant hypertension, or even a referral to be checked out for colon cancer which has increased to be positive based on retinal presentation]. Optometrists do save lives occasionally along with other health care professionals, and to do that, you need understanding of what is going on.

It would also make sense if we have prescribing privileges that we understand the nature of ocular diseases and even systemic diseases. That in itself is a huge as you would know. Incidence/signs/symptoms/treatment/risk factors/mechanism. If there is a central corneal ulcer, standard of care is that it must be cultured and the pathogen identified, so some understanding of what eye-bugs are out there and microbiology is needed and what meds work for it. While this can and should be sent to a OMD immediately, especially based on state laws, again sometimes you are the first responder (especially in rural areas of the country) and you may have an obligation to get the ball rolling as a corneal melt can occur within tens of hours.

Sure 95% of cases in a normal eye exam are straightforward refractive error and normal binocularity and ocular health, but when things go wrong you need to be able to help them. How do you prescribe for the pediatric patient with one good eye and one bad eye? How do you prescribe for the pediatric patient with an eye turn? How do you prescribe for the adult patient with an eye turn? How do you prescribe for the adult patient with an eye turn that is new in 2 months? He still has a job and life where he needs to see and now some unknown cause of an eye turn that you must refer to the proper professional? Send that to an OMD and you just wasted the OMD's time as he sends it to the neurologist for imaging. Do you even prescribe prism or do you consider vision therapy? How do you perform vision therapy? If you prescribe prism, are you prescribing for someone with normal correspondence or abnormal correspoondence? If you are prescribing for someone with normal correspondence how do you know how much relieving prism they need? Did you even think to consider measuring fixation disparity?

What if your patient is legally blind but wants to be a productive member of society and still read and interact with what limited vision they have left? What role do you have in helping them or managing their cause of legal blindness.

How do you even figure out what to prescribe or detect what's going on? You need to learn how to do and become proficient at these skills.

To conclude: A tech can run tests and get outputs, and while they may or may not know how it fits in the big picture of the case, by law a licensed doctor needs to have interpreted the results and run the case. An OMD is a surgeon, and unless it is moderate/severe primary glaucoma or any secondary glaucoma, if they can't cut it, sew it, or inject into it, they generally don't want to see it because it is a waste of their time. They'll just refer it to the OD who should have the expertise and responsibility REQUIRED in their license to manage the condition. And that expertise does involve a lot of education. Refraction can be learned in 10 hours. Everything else I mentioned takes a ton of patience to LEARN. And it is learned in 3 years of time, as the 4th year is just clinical rotation.

As a side note: even though the pre-req "rehashing" part of curriculum is in one part intended to get everyone in the class up to speed on the same page, it should weave in relevant information related to the eye. Such as understanding the biochemistry of aqueous production (salts, gradients, protein channels, etc) that by the time you get to glaucoma, you already repeated that information at least three other times in ocular anatomy and ocular physiology. And that repetition is usually a good thing to reinforce what is important and things that you need to know for clinic and boards.

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Why is optometry school 4 years long?