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Professions in Eyecare
- Oct 21, 2024
- Latest Journal
There is a lot of confusion between the various professions involved in eye care in the UK. This is not helped by the postcode lottery that prevails in the ‘National’ Health Service. I will attempt to explain the responsibilities of the professions as I have seen them over my almost fifty years in the profession.
Orthoptists used to train for two years at college, but now a degree is given at the end of training. They then work primarily in the N H S, often with children, getting their eyes to work together, thus hopefully avoiding double vision and ‘lazy’ eyes in the future. They usually work under ophthalmologists.
Ophthalmologists are qualified in medicine and undertake at least nine years post university training before applying for consultant roles. It is very unlikely that a patient will see a fully qualified ophthalmologist unless there is something seriously wrong with their eyes. Most work in hospitals, but many are now in the private sector, lasering eyes to change the need for other eye correction, or removing cataracts. The best of them perform very delicate operations such as a friend of mine who removed a tumour the same size as the eye from the eye socket, taking seven hours to do it!
Many ophthalmologists supervise clinics, making sure that glaucoma patients are controlling their eye pressures, checking whether cataracts are impairing patients’ lives sufficiently to justify their removal, injecting eyes to slow the progression of macular degeneration, checking flashes and floaters for retinal detachments and advising on any other eye problems which patients report. They are assisted by ophthalmic nurses.
Some ophthalmologists work in high street locations performing eye examinations, these doctors are referred to as ophthalmic medical practitioners but these are a rarity these days.
Now things get more complicated, so a history lesson! Please excuse any errors, some of this was before even I was born!
In 1948, when the N H S was started, anybody who had a shop premises with ‘Optician’ over the door, became a qualified optician. I met a man many years ago whose father had taken out leases on five such premises in the sixteen year old son’s name, and thus he ran a surprisingly successful business for many years! Thankfully these ‘opticians’ are all no longer practicing.
In 1958, the title ‘optician’ became a protected title, those who were already registered remained ‘qualified’, but new registrants needed a college diploma (In the 1960’s this qualification became a university degree) and to pass post graduate viva examinations.
The unfortunate thing about this was that there were three different types of ‘optician’. There were manufacturing opticians, who made glasses, dispensing opticians (DO’s), who translated prescriptions into orders for the manufacturers, and ophthalmic opticians (OO’s) who generated prescriptions from eye examinations whilst also checking for disease of the eyes. I should mention that some DO’s have taken an extra course so that they can fit contact lenses after an OO or optometrist has checked the eye for disease and issued a prescription. During the 1980’s, OO’s increasingly started to be referred to as optometrists, and this became the new protected title, nowadays anybody can call themselves an optician.
The duties of optometrists are hard to define; when I qualified in 1975 I believed that it was obvious that the scope of optometrists (or ophthalmic opticians as I was then titled) would expand to taking over routine checks on stable patients, and to the issuing of simple prescriptions for dry eye and eye infections. This is only slowly and patchily coming in, almost fifty years later!
The optometrist that most people meet will be working in the high street. Their duty is to refract, that is, find the correct prescription for glasses or contact lenses to get the clearest vision for the patient at whatever distance the patient wants. Whilst doing this, they are obliged to check the eyes for abnormalities and if any are found, to refer the patient to secondary care, usually a hospital, for further investigation.
Whereas refraction has stayed much the same now as when I qualified, checking the eyes for disease has changed massively. Checking the eye pressure has become the norm, with increasingly accurate non-invasive techniques. Because the regulations have not kept up with the technology, any abnormalities seen on the new Ocular Coherence Topographers (OCT’s) have to be referred, resulting in more referrals to hospitals. This causes bad feeling between the primary and secondary care systems. More bad feeling is generated when hospitals do not reply to referrals. A few years ago the NHS decided that optometrists could only get paid for eye examinations at certain intervals, except under certain conditions, so unless there are local schemes, all flashes and floaters, or post cataract problems, or dry eyes, have to be referred to the hospital, or treated privately, causing more bad feeling.
Some optometrists work in hospitals, accepting lower pay in return for the more interesting cases and the ophthalmologists’ acceptance of responsibility for the patient. I worked in a hospital briefly, but wanted to look after my patient, and not be just part of a system, so I have spent most of my working life in the high street.
Some optometrists can be found in laser clinics, I have a biased view of such clinics because I usually see the patients where things have gone wrong.
Some optometrists practice ‘behavioural optometry’ or prescribe tinted glasses as a treatment for dyslexia. In the absence of controlled experiments to prove that such treatments work, I am reluctant to practice in either of these ways, but I have seen some very impressive results.
Increasingly, optometrists are prescribing contact lenses to children for myopia control, once again, I have seen some impressive results, but I am not sure about the effect such treatment has once the child reaches adulthood.
Luckily, a few areas of the NHS are accepting prescriptions written by suitably qualified optometrists, I can only hope that this expands to the rest of the country.
Author
Richard Manns
I have been working as an optometrist across southern England and Wales since 1975.
I opened my first practice in 1984, and eventually owned, with my wife, 6 practices. As such I dealt with many queries about optometry and ophthalmology. We sold the last practices in 2016, and since then I have worked as a locum, mainly as holiday and sickness cover for friends. I have been an adjudicator for the Optical Consumer Complaints Service, the Association of Optical practitioners’ council, and have been a member and chair of the Local Optical Committee.
I thus have dealt with refraction, glaucoma, cataracts, retinal detachments, tumours of the eye, squints, orthoptics and trauma in patients in all age groups from paediatric to geriatric.
During the last few years I have studied how optometry is performed in China, India, Vietnam, Peru, Sri Lanka and Japan. I have done some charity work in an orphanage in Darjeeling, India, and at present am engaged in training Optical Clinical Officers in Uganda so that they can refract.
As a high street optometrist, I believe that I can comment on the expected practice by a high street optometrist more accurately than an ophthalmologist or a hospital optometrist.
Tel: 01179 422 537