Common Goals, New Directions

In my experience, the relationship between the ophthalmologist and the optometrist has evolved over the years. Since I began working in an NHS practice at the Manchester Royal Eye Hospital in 2008, specializing in cataract and vitreoretinal surgery, I have noticed that the care of the patient is seen very much as being in the hands of both: a shared care. Prior to this, the ophthalmologist would manage almost everything, from the pathology to the post-operative visits, before discharging them back to the optometrist. Now, I feel there is a much stronger relationship – more of a team approach.

Frequently, patients who have had cataract surgery might see me for an initial appointment, but then further appointments will be with the optometrist. Today’s optometrist does not simply dispense spectacles, but is wholly concerned with the health of the patient. And that’s reflected in the range and sophistication of the comprehensive list of equipment you now find in a typical independent community optometrist’s practice. To illustrate this, one of the most common examination tools we have for investigating retinal health and glaucoma is an optical coherence tomography (OCT) scanner. Until relatively recently, OCT scanners were only ever to be found in hospital environments. Now, most small independent optometrists have access. The use of OCT and imaging has enabled optometrists to extend services, from purely the visual field into other diseases areas; for example, diabetic screening.

This transition has had a very positive impact on the ophthalmologist. Most importantly, the increased involvement of the optometrist has eased our workload – especially true for patients with glaucoma, where the optometrist has become very involved in the provision of their care. With the increased involvement and greater access to specialist equipment, the quality of referrals and accuracy of diagnosis has become extremely high. Previously, without access to imaging technology, a patient complaining of distorted or reduced vision could have suffered a wide range of diagnoses. Now, with an OCT scan at the point of care, the optometrist is able to correctly identify the underlying condition and refer on immediately to the correct person. This shift naturally leads to an acceleration in the delivery of appropriate care to the patient and a reduction in unnecessary referrals or referrals to the wrong service. I believe that, in the future, there are even more activities that optometrists can take on.

By way of example, we are particularly worried about post-operative retinal detachment. During a post-operative follow-up, clinicians are primarily concerned with ensuring the operation itself has been a success, for example, that the epiretinal membrane has been completely removed or the macula has closed. Checking for retinal detachment is a secondary consideration. As optometrists are now routinely examining and imaging the central macula and peripheral retina, they may well be able to take some of this workload away from the ophthalmologist in the future. It’s not happening right now simply because there is not yet adequate additional training available to the optometrist; ophthalmologists are not yet sufficiently comfortable with discharging such patients back to the optometrist’s care at an earlier stage. We may need some form of education, training and validation program that is accredited in a similar way to those currently available for glaucoma.

We should recognize that transferring these services to an optometrist also transfers additional responsibility. A reality that may deter some optometrists from taking on these additional duties – especially within an environment of increasing litigation. The optometrist will need training, continual support, and an ability to return the patient back to the hospital service should there be any inkling of a problem. Technology and access to specialist equipment is not just improving for the optometrist of course. Artificial intelligence (AI) and advanced technologies are anticipated to reduce workload and improve patient care. It’s another change that we will have to embrace in clinical practice. For me, AI is primarily a diagnostic tool, leaving the actual surgery in the hands of people – at least until robotics become sufficiently sophisticated! Algorithms are superior to individual skill after all and, if this benefits the patient, it should be encouraged.

The other question regarding the extent of an optometrist’s remit is whether or not they could become prescribers of postoperative medicines, or broader medicines that would normally fall under the control of the ophthalmologist. I believe that while this may be another way of reducing workload for the consultant, many of these drugs would be inappropriate for prescribing by the optometrist as they are tightly connected with post-operative management. Obviously, there are also the formalities associated with being a registered prescriber, and this would require further training and monitoring. Today we have a much more cooperative relationship between the ophthalmologist and optometrist than existed 10 or 20 years ago. There is no longer a feeling of “them” and “us.” We do a much better job for the patient when we work together and, ultimately, we are both concerned with bringing better eye care to our patients.