Challenges and Opportunities – The Road Ahead for Optometry

Most young optometrists have little interest in the history of the profession, and that’s entirely understandable. However, to appreciate what has been achieved, it is important to realise that the privileges now afforded have been gained through the dedication and persistence of those before us.

Rivalry between optometry and ophthalmology is not new; in fact, incidents worldwide date back almost a century. The grandfather of Alan Saks (optometrist and mivision contributor) was convicted during the 1930s for performing an eye examination without a medical qualification. The case was later rejected by the Supreme Court. Similar situations arose in other countries including the United States of America. It is important to recognise that even now, in many parts of the world, including Europe, the scope of optometric practice remains extremely limited.

WORKING IN AN UNREGULATED PROFESSION

My journey in optometry commenced in South Africa in the late 1960s, when optometry was a rudimentary profession, with optometrists being largely considered as spectacle sellers. As it was unregulated, many ‘opticians’ were simply ‘testing eyes’ and selling spectacles with no qualifications. Back then, most formally trained optometrists did not possess a slit lamp unless they practised as contact lens practitioners. In common with most countries, including the United States, Australian optometrists were not permitted to use diagnostic drugs. Indeed, because of the latter, it wasn’t until Dr Bernie Grolman developed the non-contact tonometer, that we were able to determine an accurate intraocular pressure. I recall, as a student, seeing a Zeiss fundus camera in the clinic – but we were not permitted to use the required mydriatic, so it lay in a corner collecting dust.

It was only through the persistent efforts of Brian Layland and others that suitably trained optometrists in New South Wales were permitted to use diagnostic drugs in 1970.

The group I trained with did receive formal training in both general and ocular physiology and pathology. However, as optometrists we were officially restricted from making a diagnosis of ocular pathology. Instead, we were expected to classify the condition as ‘normal’ or ‘abnormal’ and if it was the latter, to refer to an  ophthalmologist! Obviously, this never transpired in practice.

IN PURSUIT OF RECOGNITION

It was in this environment that we, as a group of students, developed a strong desire to achieve professional recognition with an emphasis on our clinical abilities.

In my first year of study, Dr Robert Morrison, a renowned American contact lens practitioner, delivered a lunchtime lecture that inspired many of us to elevate the status of our profession. His comment that “there could be no greater satisfaction than driving home at night knowing that you had restored someone’s vision”, had a profound effect on my lifelong view of optometry. The comment must have had a similar effect on at least one other fellow student, Dennis Levi, who ultimately became Dean of Optometry at the University of California, Los Angeles.

The foundation for my therapeutic journey began in the 1980s, when a number of optometrists started the quest to expand the scope of optometry. At a conference in Fiji, the pioneering American optometrist Dr Lou Catania inspired optometrists from NSW, including John Davis, to set the goal to expand the scope of optometry to include therapeutics.

This journey was, of course, fraught with many difficulties and hurdles. Understandably, RANZCO was resistant and was believed to have strongly discouraged Australian ophthalmologists from lecturing to optometrists on therapeutics. But this was just the beginning – there were many legal barriers to be overcome as well.

I attended the second course in ocular therapeutics at the Cornea and Contact Lens Research Unit (CCLRU) within the School of Optometry and Vision Science, at the University of New South Wales in 1992. The course was delivered by an all-American team of optometrists, and the hope was that legal barriers to treating eye diseases would be removed shortly thereafter. However, this did not eventuate.

Nevertheless, having gained an enhanced understanding of pathology, and been given a ‘sneak preview’ of the increased job satisfaction that would come with therapeutic prescribing rights, I continued to expand my skills, completing more courses in 1993 and 2004.

Having gained the knowledge, it was frustrating to be unable to put therapeutics into practice, especially as GPs with extremely limited training in ocular conditions were permitted. However, in 2008, with the legislation finally changed and having completed yet another course, I was able to do so.

BARRIERS CAME DOWN

It was only through the tireless dedication of many optometrists in different states that the various barriers to practising therapeutics were overcome. While it is impossible to recognise all those involved, Optometry Australia certainly played a pivotal role in coordinating strategy. In New South Wales, John Davis, Keith Masnick, Andrew McKinnon, and Dr Phil Anderton were among those who made a major contribution, with the latter playing a significant role in negotiating with ophthalmology to overcome objections.

These optometric pioneers have not only enabled optometrists to have a more fulfilling professional life, but have improved the quality of eye care, particularly in remote areas.

COOPERATION AND COLLABORATION

Ophthalmology and optometry have had a long history of rivalry over the scope of practice for optometry. However, my experience has always been that at the ‘coalface’ there has been excellent cooperation. In fact, I have been privileged to work closely with ophthalmology over a lengthy period, including completing a Master of Science in Medicine degree in the Department of Ophthalmology at University of Witwatersrand, South Africa. Furthermore, I have found that since becoming therapeutically endorsed, my interaction with ophthalmologists has been enhanced.

Inevitably, caution is necessary when expanding into a previously ‘uncharted territory’, however the ophthalmologists in my area have provided great support, both during mandatory training and thereafter.

One time, when discussing the challenges I had experienced contacting the local ‘on call’ ophthalmologist, one of the ophthalmologists I worked with on a regular basis, invited me to call him at any time on his mobile. This facility was obviously used with discretion, and on occasions he responded from various locations in the world.

One Friday night, as is typical, a patient presented with symptoms highly suggestive of giant cell arteritis (GCA). I called the ophthalmologist to discuss the case and was initially surprised when he did not respond as usual. Soon after, I remembered that he was going overseas and realised he would have been airborne at the time.

The next morning, I called the patient’s GP and advised him of my suspicion. I requested that he order Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tests and initiate steroid therapy as a  precaution.

Fortunately, although the GP doubted the diagnosis, he agreed. Later in the day I received a call from the ophthalmologist who had, by then, arrived in Canada. He approved of the management. The patient did test positive and was treated accordingly, potentially averting a serious loss of vision.

On another occasion, I had an overt case of GCA late on a Friday afternoon after all practices had closed. I contacted the ophthalmologist who arrived at my practice 15 minutes later. The patient was hospitalised for treatment that evening.

The ability to treat eye diseases has greatly enhanced my job satisfaction and enabled me to expedite treatment of serious conditions such as corneal ulcers, thereby preventing more complex management with a less positive outcome.

Nevertheless, there are cases in which involvement of ophthalmology is essential, both to confirm the course of action and provide backup, especially when treatment is unlikely to result in an optimal outcome. An example of this is advanced glaucoma, where inevitably there will be significant loss of vision. I have found that the willingness of ophthalmologists to assist in these cases has been exemplary.

A patient I had not examined for five years, recently presented for a driver’s vision assessment. When I checked the pressures, I was amazed to find that the right was 14 and the left 59mmHg. I contacted the ophthalmologist who took my call between surgical cases. As the angle was open, it was decided to treat with maximal topical medications initially. Surprisingly, the pressure dropped spectacularly to 7mmHg in the left eye within two days.

An interesting by-product of this expanded scope of practice has been to free ophthalmologists’ time. By managing a broad spectrum of eye conditions, I am better able to streamline ophthalmology referrals, allowing ophthalmologists to concentrate on their primary area of expertise.

When, in 2013, the Optometry Board enabled optometrists to treat glaucoma autonomously, RANZCO launched a challenge in the courts. Fortunately, through mediation, a compromise was reached whereby optometrists can treat provided they issue the patient with a referral to visit an ophthalmologist. It is at the patient’s discretion whether to exercise this referral. Colin Waldron, President of the Optometry Board at the time, greatly assisted in achieving this outcome.

Obviously, it is essential that optometrists practise within the bounds of their competence. However, it has been my experience that most patients are happy to be treated by an experienced optometrist and referred if necessary. Over time, several ophthalmologists have indicated a similar preference for optometric management where possible, to allow them to concentrate on areas where their skills are required. Some ophthalmologists encourage GPs to refer to optometry for similar reasons, and hospital accident and emergency departments will often refer patients to optometry for foreign body removal.

RELATIONSHIPS ARE EVERYTHING, BUT… In daily practice, my most important relationship is with ophthalmology. It is imperative that this relationship be preserved. However, as technology evolves, it is important that optometrists are able to take advantage of opportunities to expand their scope of practice.

It is understandable that every profession strives to protect privileges that have been gained through many years of study and sacrifice. However, legislation is designed to provide an efficient, safe, effective, and affordable service to the public rather than protect professions.

As a result, it is inevitable that as change takes place, tensions between optometry and ophthalmology will arise. In these circumstances, Optometry Australia will continue to play a pivotal role, as in the past, in furthering the scope of optometry while preserving our most important relationship with ophthalmology.

One of the immediate goals is for Australian optometrists to join colleagues from the United States, Canada, the United Kingdom and New Zealand in being permitted to prescribe oral medications for ocular conditions.

Optometrists wishing to play a meaningful role in treating ocular disease in this way will inevitably have to free themselves from the ‘shackles’ of bulk billing. Optometry has traditionally relied on cross subsidisation from appliance sales. Management of pathology can be time-consuming and is completely uneconomical with current Medicare rebates. It has been said that “predictions are incredibly difficult to make, especially when they involve the future”.

One such widespread prediction in the 1990s was that by 2020 spectacles would become a ‘relic of the past’. Clearly this prediction was way off the mark. However, if an effective accommodating intraocular lens were developed, this would have a dramatic impact on optometric practice. With the current rate of technological development, occur within the next 15 to 20 years.

THE FUTURE IS IN OUR HANDS

If optometry is to survive into the future, it is essential that it is able to adapt to circumstances and take advantage of opportunities as they arise. Young optometrists should be aware that the profession will face many challenges and, as such, it will be essential for Optometry Australia to be strong when charting a course to the future. Over the years, I have frequently reflected on the statement by Dr Robert Morrison about the satisfaction of restoring patients’ sight. That statement was made before optometrists in any part of the world were able to treat eye diseases. How much more relevant is that statement now that we have expanded our role to not only improving vision but, in some cases, preventing blindness or serious systemic disease, and in others, saving a life?

I acknowledge Andrew McKinnon and Joe Chakman for providing background information and images.

Dr Alan Burrow DipOptom FBOA (Hd) FBCO DOrth DCLP MSc(Med) GCOT MOptom Grad Cert Glaucoma is an optometrist who did his original training in South Africa followed by three years of study in the United Kingdom, where he was awarded postgraduate qualifications in contact lenses, eye diseases and binocular vision and orthoptics. He subsequently completed a Masters degree in Medical Research through the University of Witswatersrand Johannesburg. He has a Graduate Certificate in Ocular Therapeutics from UNSW, which enables him to prescribe scheduled drugs in the treatment of eye diseases. In 2012 he was awarded a Master of Optometry degree by the University of New South Wales. He was awarded an advanced certificate in glaucoma in 2017. Dr Burrow practises in Coffs Harbour, New South Wales.