By: Claire Day, UMSL Class of 2024

As doctors-in-training, we are tasked with knowing all kinds of signs and symptoms of conditions, with an emphasis on “norms.” Through my own personal binocular vision battles, I have realized that this is a simplistic way of diagnosing and it constrains patients to cookie-cutter molds; real life doesn’t always match up with textbooks. By no means am I belittling the importance of knowing these normative values; however, it is crucial to think outside the box and probe our patients for symptoms they may not even know they are experiencing. I know this sounds silly given that the very definition of “symptom” indicates something out of the ordinary, usually something easily noticed by the patient. Be that as it may, some patients have dealt with their symptoms for so long that it is normal to them.

Prior to beginning optometry school, I was convinced, aside from my hefty myopic prescription, that my eyes and binocular function were completely normal. Quite frankly, I didn’t even understand what binocular and functional vision entailed. First-year students at UMSL are required to have a baseline eye exam to collect values for the Clinical Privileging Examination doctored by second-years during spring semester. I attended my exam and, after some puzzling looks from the student doctor, I was asked to return for a binocular vision evaluation; my base-out vergences had exceeded the “greater than 40” prism diopters the phoropter could afford. At the time, I had no idea what this meant and because I was under the impression that I was not symptomatic, my sole motivation for attending the binocular vision exam was to learn. After falling down the rabbit hole that is my functional vision, the phrase “be careful what you wish for” has never resonated so strongly with me.

The January following my comprehensive examination, I returned to the clinic for my functional vision assessment. Vergences, Von Graefe, Cover Test, among many, many other exams were performed, all with values that fell way outside the norms. At the end of this visit and after multiple trips to the preceptor, the student doctor returned to the exam room and asked me the classically vague “are you symptomatic?” To his, and the preceptor’s dismay, I replied “no.” The student doctor left the room, positively baffled, and returned with the preceptor, Erin Brooks, O.D. I knew this doctor well from having the privilege of taking her courses and spending time with her outside of class discussing academia, so you can imagine the comfortable relationship we developed; she entered the room and asked again, “so, you’re not symptomatic? I don’t believe you.” Now being a cautious, young, borderline hypochondriac, future-healthcare professional, I have had my fair share of doctors not believing me because I know just enough information to get me into trouble. This, however, felt much different. This notion of disbelief came from a place of concern and eagerness to help. Dr. Brooks, speaking from her own personal experience, starting listing symptoms that you will not necessarily find in a textbook:

“Do you have trouble focusing on what you’re reading? Do you frequently skip words or lines while reading? Do you have trouble remembering what you are reading? Is studying difficult for you? How long can you study before you lose focus?”

I was speechless; how did she know exactly what I had been dealing with for 20 years? How did she know that I could only study for about a half an hour before I lost all motivation? More importantly, why did I think these things were normal when clearly, not everyone experiences these symptoms? After a lengthy discussion, I realized that I had been symptomatic. In addition to answering “yes” to all the symptoms she listed, I also realized that when looking in the distance, I was tilting my chin up, looking in the “add” portion of my anti-fatigue spectacles. I was getting one-sided headaches that I blamed on not getting enough sleep and seasonal allergies. I was getting headaches after wearing my contact lenses because they did not have an add in them and I was overworking my already eso-posture-prone eyes. If I had not been given specific symptoms of a binocular dysfunction, I would have been suffering all throughout optometry school and well into studying for boards. I truly do not know if I ever would have known about my dysfunctional vision system if I was not in optometry school—and I have been going to the eye doctor since I was two years old. What does that mean for our patients who are not in optometry school? The patients who have no idea why they have headaches, why they can’t tolerate reading as well as they used to—the list goes on and on.

Throughout my 21 years of routine eye exams, not a single OMD or OD mentioned functional vision or how it could be impacting my quality of life. Twenty-one years I lived, completely unaware of how my vision was affecting my school performance, hobbies and daily life. How can we expect our patients to come to us with symptoms if they do not even know what is normal?

If you take anything away from this article, I hope it is not only the importance of functional vision testing even during routine visits, but also the absolute necessity of asking patients specific questions especially when they have any abnormal values. Trust your data and learn how to ask patients about symptoms. Patients will never answer open-ended inquiries such as “are you symptomatic?” and “any other concerns?” if they are blissfully unaware of what falls under “abnormal.” I still learn new things about my eyes nearly every single day that help me connect more dots and expose my past symptoms. Patients should not have to spend four years in optometry school to realize they have trouble converging or diverging—it is our job as current and future optometrists to educate ourselves now, so we can educate our patients later, on what symptoms look like and how we can help patients improve their quality of life.