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HomemistoryBack to School: Ocular Therapeutics

Back to School: Ocular Therapeutics

Graduating as an optometrist in 1982 meant that providing eye care was all about refraction, binocular vision and contact lenses. Even the use of diagnostic drugs such as tropicamide and benoxinate required a postgraduate course and examination. But things have drastically changed in the world of ocular therapeutics as illustrated by one highly experienced optometrist who has had to go “back to school”.

In 1982, knowledge in eye disease was extremely limited and referral was frequent and often inappropriate. It was 1985 before I attended my first continuing education day and I am embarrassed to admit that the day was a total blur. An American optometrist presented on the use of binocular indirect ophthalmoscopy and scleral indentation – I remember leaving at the end of the day and thinking, “What was all that about?”

In 1986, I trialed a Humphreys AutoRefractor and a Humphreys Visual Field Analyser (HFA). It was an easy choice for me at the time – the AutoRefractor had immediate impact on my every day practice. The HFA was in its infancy and had no relevance.

By 1988, I was ready to drop out of optometry altogether, as computers had captured my interest. In fact, I even enrolled at Tech (TAFE) and did a Computer Programming Course in Basic Computing.

By the time I had finished my first year in programming, my perception of optometry was about to take an amazing turn around

By the time I had finished my first year in programming, my perception of optometry was about to take an amazing turn around. The Optometry School at UNSW in 1989 sent invitations to every optometrist in Sydney (or so I assume) to become a fourth year clinical supervisor. There was a significant proviso – it meant attending an intense four-day course in advanced clinical techniques. This course was given by Boston’s New England College of Optometry and it blew my mind.

Advanced clinical techniques such as gonioscopy, foreign body removal, lacrimal lavage, binocular indirect ophthalmoscopy and scleral indentation at the time were all common in the U.S., yet were all new to us. Interest in eye disease was about to leapfrog to another level. The old saying, “you cannot be a good carpenter using a blunt chisel”, is the same as saying you cannot be a good eye care practitioner without using appropriate instrumentation and techniques.

My first year as a fourth year clinical supervisor was in 1990 and I have to say it turned my perception of optometry right around. There seemed to be a purpose to turning up to work each day, as at last I felt that I was making a contribution to my patients’ eye health. By the end of that year there was word that the first ocular therapeutic course was to be run at the UNSW Optometry School and driven by my renewed interest in eye care, I was quick to sign up.

The Introduction of Ocular Therapeutics to Australia

The inaugural ocular therapeutics course in 1991 was almost exclusively run by The Pennsylvania College of Optometry (USA) and was based on precisely the same content and examination that our American colleagues had to sit to obtain therapeutic accreditation. It is now almost 20 years since that first course, so the content at the time is a little vague, but what I can remember is that my outlook to eye care again took another major leap forward. It certainly was the catalyst to me visiting the U.S. at least yearly from then on. My appetite for ocular therapeutic continuing education was insatiable.

This then led to an American Academy of Optometry Fellowship and a preceptorship at Berkley Optometry School in San Francisco and New England College of Optometry in Boston. I was convinced that prescribing topical therapeutics was imminent, so learning from the Americans who had been treating patients for more than 10 years would keep me up to speed until our legislation was passed.

Unfortunately for me, one year led to the next with no progress, so I decided to do another ocular therapeutic course, but this time in Melbourne (1995). It seemed that Victoria would pass legislation, so my logic was that passing the course in Melbourne, which was being conducted by the Optometry School of SUNY (New York), would get me a head-start in NSW… No such luck. It would not be until 1999 before the first accredited optometrists would write their first prescriptions in Victoria and NSW was as far away as ever.

Not to be undone, I applied for a part-time position as a liaison optometrist at the Eye Institute in 1996. The Eye Institute was the leading laser vision correction clinic and was also performing 10 per cent of all the corneal transplants in the country. At the time I was convinced that my career as an optometrist was going to be extinct as with LASIK being so successful, no doubt everyone would have laser surgery and spectacles and contact lenses would gradually just die.

To my surprise, even though over the years I have seen thousands of happy laser patients, the penetration of this great technology has never penetrated past two per cent. So here we still are in 2010 with optometry as strong as ever – and people are still too scared to have their eyes lasered. I have heard that this is because “it is too expensive”. I have heard that the technology is “still set to improve”. I have heard that “long-term effects are not known,” but the reality when you drill deep into it is most people choose not to have laser surgery because the fear of lying down on the surgical table is overwhelming.

This position was invaluable in experiencing ocular therapeutics first hand and with the help of the surgeons I designed and ran what I think was the first practical course in laser co-management in Australia.

In 2007 the first group of therapeutic optometrists started writing prescriptions but like optometrists in other states their prescriptions were not recognised under the very important Pharmaceutical Benefits Scheme (PBS). I investigated my rights as a potential prescriber, but was told that the two previous courses I did in 1991 and 1995 would not count – I would have to repeat the whole process again. Because there was not PBS authority I decided to wait.

Finally in 2008 therapeutics prescribed by optometrists was recognised in the PBS so it was time to do the course again.

The Benefit to Independent Optoms

Ocular therapeutics for independent optometrists is very important. There are a number of reasons such as:

  1. It will differentiate your practice from the corporates.
  2. It will invigorate your day at work.
  3. It will provide a new source of patients, who believe eye health management is important.
  4. It will help you to safely and conveniently service the eye health of the Australian public

With these thoughts I started the course again in July last year. To my amazement there were more than 70 candidates who had enrolled and from day one it was obvious that this course was superior and more complex than the previous courses I had completed. Not only was the didactic component more involved, but the assessment process has also proven to be challenging, but fair so far.

The examination consisted of 120 multiple choice questions plus six in-depth written questions all to be completed in three hours. Previous exams were just 120 multiple choice questions in the same time frame and even though I believe my knowledge in ocular therapeutics is quite reasonable, I was pushed to the limit to finish on time… In other words, this is no “Mickey Mouse” exam. Currently, we are still waiting for our marks and a pass means achieving at least 65 per cent.

Once the written exam is passed, the next stage is a 50 hour preceptorship at Hobart Eye Hospital and a local ophthalmologist. Having already worked in an ophthalmological environment I can attest to the importance of this. Using this experience, the therapeutic candidate will then write up three case reports that are referenced and are at a level that could be published in a peer reviewed journal.

If that is not enough, just as you think you have finished, you then have to front up for a 30 minute oral exam where anything that has been taught to date is fair game!

I have not experienced other courses conducted in other States, but I can say with certainty that Professor Fiona Stapleton and crew at the University of NSW have done a magnificent job in designing and delivering a course that will do optometry proud going into the future.

Just as importantly, this level of graduate will be able to safely and conveniently service the eye health of the Australian public. Just think of how the system used to work:

  • A patient would turn up with a red eye that needed treatment
  • Patient is referred to a GP
  • The GP in many cases was not confident in treating
  • Patient is then referred to the local ophthalmologist, who has to somehow squeeze the patient into their full schedule
  • Not only was this a waste of time for both the GP and the ophthalmologist, it was also a waste of time for the optometrist to write up and organise the referral and most importantly for the patient.

I’m thankful that times have changed. Everyone involved, including the taxpayer and more importantly the patient, will be better off with optometrists finally achieving therapeutic status.

If you are an optometrist considering ocular therapeutics; do yourself and your local community a favour and pounce on this opportunity.

Jim Kokkinakis BOptom FAAO ISCLS is a partner in The Eye Practice, a Sydney-based optometry practice specialising in the use of cutting-edge diagnostic technology including Retinal Digital Photography, Optical Coherence Tomography and Corneal Topography. To receive regular business tips, clinical pearls in ocular therapeutics, implementation of computers in an optometric setting and new product reviews subscribe to his monthly complimentary newsletter at www.kokkinakis.com.au.