This summer I participated in a placement at Aarhus University Hospital in Denmark, an opportunity presented as part of the European Region Action Scheme for the Mobility of University Students (Erasmus+) programme. Erasmus provides support and funding to enable students from across Europe to study or work in different countries and, with help from Dr Rebekka Heitmar (Aston) and Professor Jesper Hjortdal (Aarhus), I was able to undertake a work placement during the summer between the second and third year of my optometry degree.
This article will explore how optometry is conducted in Denmark and review the cases I experienced in the hospital. Although I was only in one city in Denmark, I spoke to a wide range of optical professionals and I gained a good overview of optometry within the country.
Aarhus University Hospital (AUH) is situated in the second city of Denmark and so has the second largest ophthalmology department in Denmark, boasting 35 ophthalmologists, five optometrists and one orthoptist. Particularly well regarded is the corneal team, with patients travelling from all over Denmark to get treatment for disorders of the cornea. AUH was the first hospital in Denmark to employ optometrists. Indeed, optometrists have only made an appearance in Danish hospitals within the past 10 years, but their role has been proving successful.
In AUH, optometrists are only found in the corneal and cataract departments, whereas in the UK they might be involved in most areas of an ophthalmology department. There are also only 17 orthoptists in the whole of Denmark, a country of just under six million people. This is because there is no orthoptic training centre in Denmark, so orthoptists in Denmark have to study abroad – usually in England, Germany and Sweden. Furthermore, optometrists and dispensing opticians do not exist as separate professions in Denmark. It would be optometrists who are relied on to dispense spectacles, with optical assistants supporting them just as in the UK.
Education
Optometric education in Denmark differs from the UK. Denmark only has two optometry schools: one in Copenhagen and the Danish College of Optometry in Randers. The bachelor degree programme takes three-and-a-half years, comprising two years studying at university and an integrated 18-month internship in an optical practice. Since only two years are spent at university in Denmark, a proportion of information has to be condensed and some topics (such as pathology) are not explored to as great a depth as in the UK bachelor’s degree. On the other hand, having internships undertaken during the degree ensures students are successfully able to apply what they have learned in practice to support their studies.
The role of the optometrist
The role of an optometrist differs from the UK in that there is not a key focus on the clinical aspects of eye care. Optometrists in Denmark are unable to legally use diagnostic drugs or to refer directly to the hospital, so diagnosing pathologies and monitoring eye conditions is not a key part of the role. In addition, high street opticians in Denmark do not receive income from the health care system for eye exams and related clinical procedures.
The majority of practices offer free ‘eye tests’, and profit depends solely upon payments from the patient; primarily through spectacles, contact lenses and product sales. Management of eye disease in Denmark is through private ophthalmologists, much like there are dentists in the UK, who manage everyday eye problems and refer directly to the hospital when further care is required. Therefore, in Denmark the hospital is often the tertiary step in eye care as opposed to the secondary step in the UK. Indeed, for clarity, optometrists in the UK could colloquially be described as ‘mini eye doctors’ when compared to optometrists in Denmark.
That said, the role of the optometrist in Denmark is developing, becoming more aligned to that in the UK, with increasingly clinical responsibility. This shift is apparent both through increasing optometrist presence in the hospital and in private ophthalmologist practices, and also in the emergence of a new master’s degree programme in optometry and visual science. This was introduced two years ago, and is currently only available at Aarhus University. The master’s degree takes two years, as opposed to one year in the UK. The aim is to confer to Danish optometrists the knowledge, confidence and practical skills to become more involved in clinical procedures. Prior to this qualification, the only option available for those wishing to extend their clinical role was to from Pennsylvania College of Optometry. The Aarhus qualification is much more accessible and it is proving very popular.
Clinical experience
As is the case working in any hospital environment, it is possible to see a wide range of patients in a short amount of time. Since, as mentioned, hospital attendance in Denmark is often the tertiary step in clinical management, many interesting and specialised cases are seen.
I was granted the opportunity to follow all specialist teams, but spent most time with the corneal team. Many of the patients attend for refractive surgery consultation or management, and AUH is the first hospital in Denmark to offer small incision lenticule extraction (or Smile) surgery. Any individual in Denmark is entitled to state-funded refractive surgery if they have a prescription with a sphere over 6.00DS, a cylinder over 3.00DC, or have anisometropia of greater than 3.00DS.
Working in a university hospital presents opportunities for involvement in a wide range of clinical and research activities. For example, one of the optometrists is helping with the Adverse Immune Signatures and their Prevention in Corneal Transplantation (or Visicort) study, an important Europe-wide study into corneal transplants with the aim of improving the success rate of corneal transplantation.
Another key role of optometrists in AUH is in the diagnosis, monitoring and management of keratoconus patients. One such patient I saw had severe bilateral keratoconus as can be seen in the corneal scarring with Vogt’s striae in figure 1 (pictured left). This 33-year-old female had a best corrected left eye visual acuity (BCVA) of 6/9, and just 1/60 in the right. The severity of their keratoconus sign is clearly exhibited in their topography results (figure 2). The location of the cone is clearly seen with a curvature (‘K max’) of 90D, and the thinnest part of the cornea is just 334 microns. The only management option available for severe keratoconus like this is a corneal transplant. In this particular case, the surgical procedure used was deep anterior lamellar keratoplasty (DALK), where the corneal endothelium of the patient is left intact while the rest of the cornea is replaced with a donor cornea. DALK is the preferred technique due to the low risk of rejection of the donor cornea. Six months after surgery the BCVA of the right eye was at the acceptable level of 6/7.5. The six-month post-surgery topography map can be seen in figure 3. The K max is now reduced to 46.20D and the thinnest section of cornea a more robust 473 microns. This is an example of successful management of keratoconus with no further complications reported.
Figure 2: Topography of severe keratoconus case
Figure 3: Topography of same eye from figure 2 six months after corneal transplant surgery
Experience
Overall, I can most certainly say that the Erasmus programme offered me a unique experience, and one that I would thoroughly recommend to anyone in the future. It is apparent that optometry is undergoing rapid development in Denmark, as is the case in much of Europe. Exploring other eye care services offers a useful perspective for our own profession in the UK. What I am now more aware of than ever, is that eye care is integral to every healthcare service and does change lives.
Benjamin Chandra is a final year optometry student at Aston University.
