Invitation to treat

Organised by the British Contact Lens Association, the programme of the half-day course and evening meeting included a presentation on managing allergic eye disease by ophthalmologist Melanie Hingorani, and a lecture by John O'Donnell on the management of dry eye. Professor Nathan Efron presented new findings on the incidence and relative risk of keratitis in contact lens wear.
'Ocular therapeutics - where we are now and what we have to do to actually prescribe' was the title for Professor John Lawrenson's timely lecture. There were, he said, several opportunities in prospect for prescribing optometrists: extensions to the lists of drugs that could be used, with and without further training; supplementary prescribing; and independent prescribing
The list of drugs that optometrists could currently use in the course of their professional practice included the prescription-only medicine (POM) chloramphenicol, although it was intended for prophylactic rather than therapeutic use. Optometrists could also supply this drug in an emergency or via a signed order presented to a pharmacist. The antibiotic framycetin sulphate was also available for use within their practices.
The expansion of the optometrist's role, opening the way for therapeutic prescribing, began in 1999 with a change to the referral rules such that it was no longer obligatory to refer all cases of injury or disease of the eye. In 2003, the Department of Health indicated that it would welcome an application to increase the range of drugs available to optometrists.
The General Optical Council recommended an amended list of drugs based on the conditions that could reasonably be managed by community optometrists; these were likely to be common, non-sight threatening diseases, the prevalence of which would be determined by audit. The conditions identified were: infectious conjunctivitis and other superficial infections such as styes, allergic conjunctivitis; blepharitis; dry eye; and superficial injuries.

levels of drugs
Professor Lawrenson explained that two levels of drugs were envisaged. Level 1 represented an update of currently available drugs, which all optometrists would be able to access via entry-level registration without further training. It included the antimicrobial fusidic acid as well as chloramphenicol. Patients would obtain these drugs from the optometrist or from a pharmacist via a signed order. The 'emergency' caveat for the direct supply of pharmacy-only (P) medicines would also be removed.
Access to Level 2 drugs required optometrists to undertake further training at postgraduate level and participation in CET for continued accreditation. This list incorporated some drugs previously designated entry level and included topical antihistamines, mast-cell stabilisers and polymyxin B combinations.
The College of Optometrists and City University had developed Clinical Management Guidelines to inform everyday clinical practice. Training would be by GOC-accredited courses and based on the Competency Framework for Prescribing Optometrists produced jointly by the GOC and National Prescribing Centre. A curriculum had now been developed for Level 2 and supplementary prescribing and, once the changes had been approved, the GOC would set up specialist lists for each category.
For Level 2, prescribing optometrists needed to undertake a combination of theory examinations and practice-based sessions followed by assessment, although previous training in therapeutics would be taken into account. Training for supplementary prescribing would be very similar to Level 2, the only distinction being a larger number of clinical sessions.
Professor Lawrenson said he did not want to be too dismissive of supplementary prescribing which would have a significant role in future, largely in the clinical management of glaucoma. 'There is now enabling legislation - we just have to find the clinical need that will justify optometrists undergoing this training.'
But he added: 'I can't personally see any point in any optometrist signing up for a supplementary prescribing course unless you have developed a prescribing partnership at the end of it, because ultimately you'd spend a lot of money getting a qualification you wouldn't be able to use.'
Commenting on the prospects for optometrists achieving independent prescriber status he said that, from the outset, this had been viewed as the ideal for community-based practice. Independent prescribing was not 'off the agenda' by any means, he said. Consultation was ongoing and training requirements were currently being discussed.
Professor Lawrenson described a proposed three-tier career structure for primary eye care of the future. At the third level, 'ophthalmic primary care practitioners' would include the co-management of stable glaucoma among their responsibilities. Additional ocular conditions to be managed by independent prescribers might include anterior uveitis and viral keratitis.
At the evening meeting that followed, more than 80 BCLA members and guests tested their patient management and referral skills with an interactive session 'Immediate, soon, join the queue or treat', led by Professor Roger Buckley and Jonathan Walker. As the new legislation reaches its final stages in Parliament, it will not be long before 'treat' becomes a very real option for UK optometrists.