Turning through the history books, the origins of optometry and ophthalmology as professions in the UK have little common ground: they are separated by centuries. Optometry can be traced back to the 17th century with the charter of the Worshipful Company of Spectacle Makers, but it was not until the beginning of the 19th century that ophthalmology began to be recognised as a speciality in its own right with the foundation of the first specialist eye hospital in London – later to become known as Moorfields.
Since then, both professions have seen rapid expansion largely in isolation from each other despite sharing a common denominator in the mid to late 19th century: the ophthalmoscope, arguably the greatest singular invention in eye care.
Fast forward to more recent times, and the combination of the scope of optometry becoming much more focused on eye health and the well-reported challenges facing ophthalmology around capacity and timely review of patients, has meant that we have the potential to work alongside each other more than ever in our history.
If the last two decades are anything to go by, this is set to continue and intensify. Our common denominator now is the patient – and quite rightly so. It simply makes sense for optometrists to work more closely with ophthalmologists in the medical care of our patients, as well as the enhancement that both professions working alongside each other brings.
Within the NHS, the development of shared care or co-management models have proliferated since this type of model was first rigorously studied in the mid-1990s with the Bristol Shared-Care glaucoma scheme. This study demonstrated that suitably trained optometrists can monitor glaucoma patients as effectively as their secondary care counterparts.
Crucially though, the Bristol study and other subsequent similar studies since have failed to demonstrate clear all-important cost savings. This, combined with the reticence of some ophthalmologists to discharge their patients and even a feeling in traditional ophthalmology that community optometrists as a whole are ill-equipped to deal with these patients, has meant that rather than monitor patients with diagnosed eye disease, the community schemes are leaning more towards refining and improving the accuracy of the initial referral into secondary care, and to a lesser degree monitoring low-risk patients such as ocular hypertensives. This is certainly the case where I practice and is most welcome.
What we have seen instead is growing numbers of optometrists involved in secondary care units to deliver services – largely in glaucoma and macular degeneration – under the guidance of ophthalmologists. Evolving technology has enabled virtual glaucoma clinics, whereby the entire work-up of patients is done through technicians and reviewed remotely by ophthalmologists or indeed specialist optometrists.
In my experience, this has led to three or four times as many patients being reviewed as with face to face consultations. What you lose in personal interaction with patients is more than offset by huge improvements in efficiency. The widespread adoption of these clinics will I think further oust developments of community monitoring schemes.
So where does that leave the collaboration of community optometrists and ophthalmologists?
Interestingly another shift is taking place which provides another avenue to strengthen our association: a shift from secondary to primary care ophthalmology. The clear majority of patient appointments in ophthalmology departments are outpatient-based and require fairly standard equipment in modern day terms, making the secondary care base for these visits unnecessary.
Thus, ophthalmology care is very amenable to being in a primary care setting. Cost is perhaps the major driver, but better access to patient care is a distinct advantage. Set free from the shackles of large, expensive and at times inefficient hospital-based services, ophthalmology has been embraced by non-NHS care providers who see non-medical ophthalmic professionals as a major resource for patient care.
Optometrists should put their collective hand up and demonstrate they are willing and able to become more clinically focused to work in these environments. Perhaps unsurprisingly, these clinics probably have more in common with optometry practices than traditional ophthalmology settings. They are often based in easy access locations, have fewer than half a dozen consulting rooms adjoining a common reception area and employ clinical assistants to perform pre-tests such as visual fields, fundus photography and OCT. Electronic-based appointments and patient records are standard and many are even open at weekends.
So for many optometrists, in particular those who enjoy engaging in post-graduate learning, primary care ophthalmology represents an accessible opportunity to work collaboratively with ophthalmologists, allowing for meaningful (and potentially transferable) skills to be developed and most importantly implemented, in this rapidly expanding area of eye care.
Mr Jeremy Diamond, consultant ophthalmologist and Newmedica Ophthalmology Joint Venture Partner, Bristol