Download Submission to the Ministry of Health Services, Province of British

Submission to the Ministry of Health Services, Province
of British Columbia, in Response to a Request for
Consultation on New Eye Care Regulations
Submitted by the Opticians Association of Canada
June 11, 2004
“It is the belief of the Opticians Association of Canada that
visionary leadership identifies innovative pathways to good public
policy that result in better results and greater choice for
consumers. The new regulations for optometrists and opticians
announced by the BC government are reflective of this concept.”
1
TABLE OF CONTENTS
1. 0
2.0
Executive Summary
Background:
2.1 Stand Alone Sight Testing is Safe
2.2 Automated Sight Testing is Accurate
2.3 Improved Health Outcomes
2.4 Public Education
2.5 Appropriate Referral
2.6 Regulation/Legislation Enables Safe Choices
2.7 Historical Perspective
3.0 Specific Commentary: Optician’s Regulation
3.1 Definitions
3.2 Reserved Titles
3.3 Reserved Acts
3.4 Limitations on Practice
3.5 Auto-refraction or Automated Sight Test
3.6 Schedule – Limitations on the Use of ‘Auto-Refractors’
4.0 Overview of Key Public Issues
4.1 The Basic Training of an Optician Provides the Appropriate
Underpinning
4.2 Sight Testing Opticians Must Be Required to Have
Specialty Training to Perform This Service
4.3 Opticians Have Demonstrated the Reliability of the Results
of the Sight Testing They Perform
4.4 There Is a Consumer Need for Optician Performed Sight
Tests
4.5 There Has Been No Injury to Consumers as a Consequence
of Optician Performed Sight Tests
5.0 Conclusion
2
1.0
EXECUTIVE SUMMARY
The Opticians Association of Canada has a mandate to advocate on behalf of the
profession of opticianry, particularly as it relates to the provision of safe and effective
services to vision care consumers. Public safety is at the forefront of our thoughts as we
provide the following comments to the British Columbia government regarding new
regulations governing automated sight testing by opticians.
Scientific and experiential evidence concludes sight-testing service as provided by
opticians using automated suites of equipment is a safe procedure that will result in
positive vision health outcomes for British Columbians. Although sight testing is not a
reserved activity, opticians have recognized that as vision care professionals they must
ensure the public understands the limitations of the process and have requested regulation
to enforce common standards and guidelines. Further, opticians believe this service will
provide a unique opportunity to provide general education about eye health to consumers.
These four factors – safety and accuracy of using the technology, improved health
outcomes for consumers, opportunities for public education, and enforcement of
standards – have been adequately considered and allowed for by the British Columbia
government.
2.0
BACKGROUND:
2.1
Standalone Sight Testing is Safe
Some would suggest that a sight test cannot be safely performed apart from an eye health
examination. The Canadian Ophthalmological Society (COS) has defined sight testing as
a non-medical procedure that can be performed by non-medical personnel separate and
apart from an eye health examination.1 Although the recommended frequency of eye
health examination differs from one professional group to another, the American
Academy of Ophthalmology (AAO) standard2 is widely recognized as being a benchmark
and is supported by the Canadian Ophthalmological Society (COS). According to the
AAO schedule, whether they wear eyeglasses/contact lenses or not, adults between the
ages of 20-39 need a comprehensive eye examination once throughout those years while
those between the ages of 40-64 need be examined every two to four years. The
recommendation is based on age and not on refractive errors. In other words, the AAO
does not recommend a greater frequency of eye health examination for eyeglass wearers
than it does for other adults. They make no connection between eye disease and the need
for refractive correction.
In reality, individuals in these age categories who do wear eyeglasses/contact lenses will
need to replace their lenses or refurbish their appliance with much greater frequency than
the schedule suggests. Ophthalmology recognizes this truth. The COS policy statement
on eye examination states:
“For the ultimate benefit of the public, a clear distinction should be made between a
diagnostic eye examination and an examination for the purpose of refraction. A
1
2
Canadian Ophthalmological Society-Policy Statements and Guidelines “The Role of Ophthalmology”
American Academy of Ophthalmology-Health Tips on How Often to Have an Eye Exam
3
diagnostic eye examination involves the practice of medicine and requires the highly
specialized training of a physician. A refractive examination involves the taking of
measurements from the visual system, which is simply a data-gathering procedure and
involves no medical expertise.”3
Optometrists have taken the position that a sight test must be provided concurrent with an
eye health examination. The majority of people seeking optometric services do so
because they need new glasses or contact lenses and merely want to make sure they will
not be spending money on lens powers that are too weak (see figure 23).
As reproduced from the Health Canada Statistical Report on the Health of Canadians 1996-1997
Health Canada’s report on the Health of Canadians for the years 1996-1997 revealed the
majority of Canadians over 12 years of age who sought eye examinations did so not
because of job requirements (2%), or cataracts (3%), or Glaucoma (4%), or eye
conditions (5%) or declining sight (6%). Reassurance – not complaint – was the main
reason people went for an eye examination (50%) and the need for a prescription change
was a close second (47%). (Some respondents answered in multiple categories.)4
For purposes of refreshing the lens powers or purchasing new product, individuals falling
into those age categories and who require optical appliances should not be required to
undergo and pay for an eye examination that is bundled with a sight test. To repeat a
crucial point, a standalone sight test can be performed affordably without risk to
consumer eye health.
2.2
Automated Sight Testing is Accurate
Accuracy is not an issue with automated sight testing. The technology currently being
used in Canada underwent a year of field-testing and has since been used successfully in
Canada for eight years. With approximately over ½ million tests having been provided in
that time frame, the margin for error was slightly less than ¼ dioptre, which is totally
3
4
Canadian Ophthalmological Society-Policy Statements and Guidelines “The Role of Ophthalmology”
Statistical Report on the Health of Canadians /Determinants of Health /Health Services/Eye Examinations
4
within industry standard tolerances and comparable to sight tests performed by optometry
and ophthalmology.5
2.3 Improved Health Outcomes
The sight testing service offered by opticians has a limited and narrow purpose, and it is
vital that consumers understand this. It provides consumers with an easy, affordable
method of upgrading or fine-tuning their visual acuity. In a model where sight tests and
eye health tests are bundled and the burden of payment is not borne by the health care
system, consumers often delay visits to a eye care professionals in order to save money.
Many times, this results in gradually reduced visual acuity. This introduces to the debate
a facet of the safety issue far different from the risk of eye disease focused upon by
stakeholders opposing optician sight testing services. Compromised visual acuity
represents danger on the job, at home and on the roads.
It is difficult to assess the impact of de-insurance on the frequency with which consumers
will seek sight tests and eye health examinations. We can only draw inference from
researching a variety of statistical reports.
In Health Canada’s 1996-1997 Report Statistical Report on the Health of Canadians6,
29% of British Columbians (1,036,650) stated they had had an eye examination 3+ years
ago or never. There is no data to break that number into age groups or to determine how
many fall into the ‘never’ category. It is, nonetheless, an alarming statistic.
The Health Canada figures were developed prior to the de-listing in B.C. of eye
examinations as an insured service. The British Columbia MSP Information Resource
Manual for 2002-20037 (compiled after de-insurance) indicates that for that year
optometrists billed for 334,991 fewer services than they had in years when the service
was insured. In other words, 334,991 fewer people attended optometric offices for
Medicare-covered eye examinations. The average for the four years preceding de-listing
was 887,206 services. (Ophthalmology services actually increased by 40,676 in the
reporting period 2002-2003.) We have no method of determining whether those 334,991
citizens were forced into the optometric marketplace and paid for their own eye
examinations, or delayed getting their eyeglass/contact lenses upgraded or if they need to
be added to the ‘3+ years or never’ category in the next Health Canada study.
Optician-performed sight testing services would definitely be a safer option than the
latter.
Subsequent to government de-listing of optometric services, the price of an optometristperformed eye examination was revealed in a survey commissioned by the OAC to be an
5
Journal of Telemedicine and Telecare Vol.6 Supplement 2-A Fully Automated Remote Refraction System
Statistical Report on the Health of Canadians-Determinants of Health/Health Services/Eye Examinations
7
MSP For Medical and Health Care Practitioners/Billing Procedures for Physicians/MSC Payment
Schedule/Ophthalmology
6
5
average of $70 with a high of $1008 as compared with the $48.909 that is paid to an
ophthalmologist for a basic eye examination under the current B.C. government payment
schedule. When a consumer needs to purchase a new pair of glasses or contact lenses,
the price of an optometric eye examination clearly acts as a deterrent to updating the lens
powers with the only recourse being to duplicate a previous pair of lenses or put up with
reduced visual acuity. As previously mentioned the latter choice represents a risk of
harm both to the individual requiring correction and to others.
2.4 Public Education
Whether out of curiosity, need, or budgetary restraints, consumers take advantage of
standalone sight testing services. The first benefit for them is improved visual acuity to
perform daily functions such as driving and work requirements. As well, the standardized
and regulated process of interview and selection that takes place prior to an optician
providing the sight test acts as a means of providing vision health care education and
referral as appropriate.
The College of Opticians of British Columbia has consulted with stakeholders on the
development of their Standards of Practice document and the required interview protocol.
The OAC has been part of that dialogue. The OAC believes the resulting College
documents are not only effective tools for eliminating those individuals who are not
appropriate candidates for an optician-performed sight test, but will serve as triggers for
discussion through which the optician can answer questions and provide direction.
2.5 Appropriate Referral
Opticians are frequently the first professionals selected by consumers when information
about vision care is required. Opticians are accessible and approachable in widely spread
retail settings. As regulated professionals, opticians routinely recognize questions and
complaints that lead them to suggest specialized attention to clients.
A study that was reported in The International Journal of Pharmacy Practice (2001)10 is
instructive. Most customers in the study were found to consult for advice on managing
their eye complaint rather than asking for a product. Difficulty in accessing the GP was
the main driver for customers to consult a pharmacist. Others considered the complaint
too trivial to trouble their doctor with. This parallels the experience of opticians whose
clients are often unsure if their complaint is minor or serious.
In the same study, 34% of consumers were conditionally referred to another health
professional and 15% were directly referred, usually to a GP. It was concluded that the
referrals were appropriate as all but one customer received a prescription from the GP.
The College of Opticians Guidelines for Referral are clear in not only requiring opticians
to retrieve health history from clients but also to recognize articulated complaints that are
typical to symptoms of eye disease or other eye-related conditions. Front-line health care
8
OAC Survey of Cost of Eye Examination in British Columbia Optometric Practices 2003
B.C. Medical Services Commission-Ophthalmology/Guidelines for Billing Eye Examinations 2003
10
International Journal of Pharmacy Sept. 2001-Responding to Red Eye
9
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service providers are without question effective in serving as a conduit to both
information and referral.
The Ontario government has recently de-listed optometric services. Ontario Health
Minister George Smitherman has stated that a Family Physician referral may eventually
become necessary to access OHIP-covered eye exams.11 A Family Practitioner-centred
vision care model is consistent with the AAO guidelines for frequency of eye
examination as well as with the conclusions drawn by Dr. Steven R. Shields, assistant
professor of ophthalmology, Saint Louis University School of Medicine, and director,
Glaucoma Service, Saint Louis University Eye Institute. In his paper, which appeared in
the peer-reviewed journal Postgraduate Medicine Dr. Shields found, “Periodic visual
acuity testing is adequate screening for persons up to age 40 who are at low risk for
occult eye disease.”12 Dr. Shields further suggests that a Snellen test (an ordinary eye
chart) is adequate testing for low risk individuals between the ages of 6 and 40 years.
Once opticians have been formally integrated into the vision-screening network, Family
Practitioners can more effectively and economically triage patient needs by referring for
standalone sight tests when required.
2.6 Regulation/Legislation Enables Safe Choices
It is clear that all governments recognize the need for change in existing eye care models
to support the Canadian universal health care concept. Studies have been done both in the
United States and Canada, reflecting on ways to contain costs while respecting the need
for continued high standards of care. British Columbia’s Seaton Royal Commission
Report (1991) parallels the recommendations of all. The considered advice evolving
from these several commissions and task forces is to discover methods of maximizing
existing human resources. In other words, before engaging in additional expenditures,
make the most of what you have.
The Pew Commission Report on Reforming Health Care Workforce Regulation13 is well
respected and often quoted with reference to the re-shaping of health professions. The
Commission produced 10 recommendations (attached) all of which are captured by
B.C.’s Health Professions legislation. In summary, these recommendations promote
competency standards, regulatory oversight including public representation, public
education about the profession, professional mobility, safety of performance, enabling
mechanisms to allow professions to evolve their scope of practice and requirements for
practitioners to demonstrate their competence throughout their careers.
It is for this reason that new legislation for health care professionals focuses on regulatory
governance structures that ensure uniform public accountability and allow for flexibility
11
Toronto Sun Newspaper-May 29, 2004 They Just Don’t See Eye To Eye
Post Graduate Medicine Oct 2000-Managing Eye Disease in Primary Care/How to Screen for Occult
Disease
13
Pew Health Professions Commission-Considering the Future of Health Care Workforce Regulation
(1997)
12
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in assignment of reserved activities. These legislative principles are mirrored in the
Ministry’s decision to regulate opticians who perform sight tests.
It is always a challenge for government, professions and members of the public to shift to
new models of health care delivery, particularly when there are overlapping scopes of
practice. The dilemma has been aptly put by Barbara Safriet, a member of the Pew
Commission, speaking to the National Summit on State Regulation of Health
Professionals in the 21st Century.14 “The real issue is we have an increasing disjunction
between legal authority and clinical ability. The law says who is allowed, but it has not
kept up very well with the question of who is able.” And she further stated, “The law
always drags behind developments.” This is particularly true in the matter at hand since
emerging technology and professional education have outstripped the commitment of
legislators to implement the fundamental spirit of umbrella legislation that has already
been enacted.
It is the belief of the OAC that visionary leadership identifies innovative pathways that
make good public policy and result in greater choices and better results for consumers.
The new regulations for optometrists and opticians announced by the BC government are
reflective of this concept.
2.7 Historical Perspective
British Columbia opticians have earned the confidence the BC government has placed in
them. They have historically demonstrated their commitment to serve the public interest
and to be responsible members of the vision care community. Opticians in British
Columbia have taken a deliberate path toward higher standards of education, uniformity
of service and career progression. There has been provincial opticians legislation in
Canada for 50 years, the earliest being Manitoba in 1954. B.C. was the last provincial
government to create optician regulations. As vision care professionals working almost
entirely in a retail environment, and realizing the importance to their clients of a strong
professional responsibility quotient, B.C. opticians organized themselves and joined with
the Canadian community of opticians to voluntarily train themselves through educational
and examination programmes accredited by other provincial regulatory bodies. The OAC
and its predecessor (the Canadian Guild), have been involved in delivering opticians
education programs through those early years and can note that B.C. had the highest
enrollment of students in any opticians program in any province.
B.C. opticians petitioned the government for many years before being granted a
regulation in 1996. They participated actively in developing the College structure and
by-laws, and endorsed the requirement that every optician practicing in B.C. prior to
regulation regardless of length of service must successfully challenge a qualifying
examination.
Automated refracting devices were introduced to vision care professionals at least a
decade before B.C. opticians started sight testing. Shortly after being granted regulation
14
CLEAR (Council on Licensure, Enforcement And Regulation)-National Summit on State Regulation of
Health Professionals in the 21st Century-May 1999
8
B.C., opticians became aware of new automated technology that incorporated all the
components of objective and subjective sight testing and that produced highly accurate
and repeatable results. This equipment blends a combination of assessment modules and
produces data that can reliably be used to produce optical products.
B.C. opticians began offering sight-testing services to clients using the automated sight
testing suite and a telehealth concept of sending the resulting data to a physician for
review. Responding to complaints from optometrists the College of Opticians of British
Columbia followed its regulatory duty by challenging its sight testing members through
the B.C. Courts. The Supreme Court of British Columbia in the case of The College of
Opticians of British Columbia v. the Moss brothers15, found in favour of the respondent
affirming the right of opticians to offer this service to consumers.
Both the College and sight testing opticians acknowledged the necessity for consumer
education and careful selection of appropriate candidates for this new sight testing
service. Consequently the College established, in consultation with physicians, Standards
of Practice for sight testing opticians. These standards continue to be enforced by the
College until the consultation period has been completed and revised standards come into
effect.
3.0 SPECIFIC COMMENTARY: OPTICIAN’S REGULATION
Our commentary on the optician’s regulation will include suggestions related not only to
the new text being introduced but also to some of the existing wording.
3.1 Definitions:
In this section several definitions cause us some concern. The term “eyeglasses” as
currently framed does not including contact lenses or low vision aids. “Contact lenses”
are integrated into the regulation under the definition of “contact lens fitter” whereas low
vision aids do not appear anywhere else under definitions. This may be oversight
however the dispensing of low vision aids is gradually becoming an extremely necessary
component of vision care rehabilitation due to the aging of the population and the
increase in incidence of low vision problems associated with degenerative ocular disease.
Typically ophthalmology and optometry are focused on detection and treatment of
disease and ocular conditions whereas opticians are specialists in the selection and use of
rehabilitative products.
The definition of ‘eyeglasses’ is very specific in outlining that it does not include contact
lenses and low vision aids. Taken together with the fact that contact lenses are then
managed via another definition one could conclude that opticians are not entitled to
dispense low vision aids within their regulation. Alternatively this might be interpreted
to mean that any person regardless of training may dispense low vision aids. We look for
15
Reasons for Judgment of the Honourable Mr. Justice Oppal- College of Opticians of British Columbia
and Robert Moss, Jr., John Melvin Moss and Clearbrook Optical Ltd. Doing Business as United Optical
9
guidance on this issue and suggest that the definition be changed by adding low vision
aids to the list of products dispensed by opticians.
The OAC questions the text within the definition section of the word “prescribe” (b). The
wording suggests that in noting the power of lenses required to bring the individual to an
acceptable visual acuity, the prescriber can also specify what type of appliance should be
dispensed. “…authorize a person to dispense the appliance or device for use by a named
individual.” When prescribing a therapeutic drug the optometrist would naturally name
the drug and specify the dosage. With respect to writing a prescription for an optical
product the responsibility of the optometrist is to note the power of lenses at the
refracting distance that will provide best vision for the individual. It is up to that
individual and the optician to decide what modality of product will be used to provide
that correction.
The OAC recommends a change in wording to read:
“…authorize a person to produce an appliance or device based on the stipulated numbers
for use by the named individual.”
The definition of “prescription” (b) includes a category for contraindications. We believe
this should not be part of the definition. It has been well documented that many
optometrists use printed designations on their prescription forms that indicate the
prescription is ‘not for contact lenses’.16 This is interpreted by the public to be a
contraindication to contact lens wear but amounts in fact to no more than a restrictive
trade practice. The current text of the definition provides regulatory authority for this
practice where none, we believe, was intended. We recommend removal of the word
‘contraindication’ from the definition.
The definition of “supervision” b (ii) is somewhat confusing. The text in b (ii) removes
the ability of a certified contact lens fitter to participate in the training of student contact
lens fitters since “only a prescriber can supervise the fitting or dispensing of contact
lenses by a person other than a prescriber or contact lens fitter…”. The practical
application of the clause works against the current system of intern education. We
recommend that the clause be modified to include both prescriber and contact lens fitter
as qualified supervisors.
3.2 Reserved Titles
The OAC agrees with the Minister’s assessment that public education is the major key to
safe sight testing practice by opticians. Opticians have undertaken a variety of public
awareness measures including educational brochures and in-store signage describing the
difference between a sight test and an eye health examination and the differences
between services offered by opticians, optometrists and ophthalmologists. Media
advertising and public access websites are also methods of educational outreach.
16
Prescription from The Optometric Centre
10
We believe sight-testing opticians should also have a title identifying their designation as
separate and apart from a contact lens fitter or an optician since only those who have met
the College of Opticians of British Columbia requirements will be allowed practice. We
would suggest a reasonable reference to be ‘Refracting Optician’ and that a definition of
such should be included in the Definitions section of the regulation.
3.3 Reserved Acts
4(4) indicates that a contact lens fitter may not use the results of an auto refraction to fit
or dispense contact lenses.
The OAC believes that this presents an unnecessary handicap for consumers who wear
contact lenses. Currently contact lens fitters are trained, qualified and regulated to
provide care for contact lens wearers. People who wear contact lenses are carefully
monitored and properly advised of the necessity for routine eye health examinations.
However, contact lens wearers require changes to lens power between eye health
examinations. 4(4) will legislate the necessity for that contact lens wearing consumer to
pay for a complete oculo-visual examination each time a change is required.
The proposed regulation will provide the ability for opticians to make adjustments to
existing prescriptions, an act that is common practice for contact lens fitters seeking to
fine tune visual acuity. Initial selection of the contact lens is based on the original
prescription however due to eccentricities in contact lens material, shape, design and
thickness visual acuity results may not be optimally achieved. When this happens the
contact lens fitter uses over-refraction techniques to arrive at a final lens specification.
B.C. contact lens fitters are trained in slit lamp biomiscroscopy. This enables them to
view the corneal surface under extreme magnification. Corneal anomalies are
highlighted by a variably positioned light source. Contact lens fitters routinely refer to
ophthalmologists and optometrists contact lens wearers with corneas that appear other
than normal.
B.C. contact lens fitters are also trained in keratometry. A keratometer measures the
curvature of the central area of the cornea. When proceeding with a contact lens fitting
the contact lens fitter takes base measurements to use as a benchmark. At each interface
with the contact lens wearer, new keratometer readings are recorded. In this way the
fitter is able to note extreme changes that may indicate a suspicious steepening of the
cornea, which in turn may be a precursor of occult eye disease. As with anomalous
corneal appearance, contact lens fitters are trained to refer appropriately when such
conditions occur.
Of all the consumers wearing ophthalmic appliances, contact lens wearers come under
the most scrutiny from vision care professionals. They are normally seen every 6 months
for regular check-ups and even more frequently if they order replacement lenses. At each
encounter the contact lens fitter performs the same routine assessment: observation of the
cornea with the biomiscroscope and notation of the current keratometer readings.
11
The OAC’s survey of B.C. optometric offices in 2003 revealed that 64.3% of the 305
offices polled charged an additional fee for a prescription when the customer indicated
he/she wanted to take the prescription to another provider to purchase contact lenses.17
Contact lens wearers, like all other consumers who require vision correction, will require
refinements to their lens powers over time. If they do not have access to opticianperformed sight tests they will be compelled to have an optometric eye examination for
which, as the study shows, they are likely to be charged an extra fee for their prescription.
This places a legislated financial hardship of this group of people.
Contact lens wearers as a group are not more at risk for degenerative eye disease than any
other group of consumers. Under the care of a regulated contact lens fitter the contact
lens wearing consumer is regularly monitored for adverse signs of contact lens wear such
as insult to the cornea or surrounding ocular structures. Opticians routinely refer wearers
who are at risk as a result of contact lens wear to optometrists and ophthalmologists.
The OAC believes that there is no reason to limit the use of the auto-refraction results to
the manufacture of eyeglasses and recommends the removal of 4(4) from the regulation.
3.4 Limitations on Practice
Nowhere does the regulation define an automated sight test or describe the ability of an
optician to perform this activity. That is reasonable since sight testing is not a restricted
activity and as such may be performed by any person. Clearly the intention of the
Ministry based on the announcement made by the Minister on March 30th, 2004 was that
opticians would be able to offer this service. Section 4 (1.1) eliminates the requirement
of oversight by a physician in order to use the results of auto-refraction to manufacture
eyeglasses. The Minister’s statement coupled with 4 (1.1) provides the necessary
legislative authority for opticians to perform sight tests and to produce eyeglasses based
on data derived from those tests.
However, section 6 (3) introduces confusion into this regulation. It says that no registrant
may alter a prescription without the express prior authorization of the prescriber. In
reality, if a consumer wishes to have an eyeglass prescription updated, and the sighttesting optician has to observe the conditions of 6(3), prior authorization will never be
given. Due to the dwindling supply of ophthalmology specialists (estimated at
approximately 800 in Canada), most eye examinations in today’s vision care
environment, are performed by optometrists. The negative commentary, misdirection
and highly engineered backlash streaming from optometric groups since the Minister’s
announcement should give clear warning that there would be no cooperation forthcoming
from optometrists in giving force to the regulation’s intent.
The OAC strongly urges the Minister to remove 6 (3) from the regulation, as it will have
the potential to neutralize the regulation and prevent the service from being made
available to British Columbians.
17
Opticians Association of Canada Study of Prices Charged for Prescriptions in B.C. Optometric Offices
2003
12
In section 6(5) the regulation states that a registrant must offer to the client, without
charge, a copy of a prescription. Coupled with the definition of a prescription and the
reference to the results of an auto-refraction in 4(1.1) as an assessment, the OAC
concludes that 6(5) does not refer to the data produced by the sight test. We conclude
from our reading of the regulation in its entirety that the Ministry does not intend the
same definition of an assessment as it has given to a prescription. We seek guidance on
this issue.
3.5 Auto-refraction or Automated Sight Test
Reference is made throughout the regulation to an auto-refraction. Sight testing as it is
currently being performed by British Columbia opticians would more properly be termed
an automated sight test. The auto-refraction is only one component of the testing that is
done. Although an auto-refraction will result in a set of numbers that may be turned into
an optical product, the other pieces of technology offer support for safety considerations.
In addition, the autolensometer takes a measurement of the current eyewear and transmits
it to the system computer. The autophoropter holds the test lenses that are displayed to
the client in sequence with the results sent to the computer for comparison with the
current prescription. The suite of machinery that is currently in use also performs a
red/green assessment the results of which can also trigger referral. A computer software
program collects and collates the results of the other automated tests and produces
recommended lens values.
Reference to the procedure as an auto-refraction without a requirement within the
Standards and Guidelines for the other assessments to be performed may not be what the
Ministry has in mind.
3.6 Schedule – Limitations on the Use of ‘Auto-Refractors’
The College of Opticians of British Columbia has reached out to stakeholders for input
into the development of their Standards and Guidelines. The OAC has submitted its
recommendations to the College and has had the opportunity to review the resulting draft
document.
.
• Age restrictions – The OAC supports the Minister’s recommendation of 19
through 65 as suitable to exclude a significant portion of those individuals who
are not suitable for automated sight testing.
o Age is the greatest risk factor for the diseases described by the Canadian
National Institute for the Blind as the leading causes of visual impairmentAge Related Macular Degeneration, Cataract and Glaucoma and Diabetic
Retinopathy18. Studies have shown that the incidence of these diseases is
greater after age 65. Consequently the regulation will eliminate those
individuals as candidates for optician-performed sight testing. The COBC
has provided other screening categories (commented on elsewhere in this
18
Canadian National Institute for the Blind Submission to the Commission on the Future of Health Care in
Canada
13
document) that have sensitivity to eliminate the small number of
consumers between 50 and 64 who may require specialized screening.
19
The Estimated Specific Prevalence Rates for AMD as published
by Prevent Blindness America (PBA), indicates
• AMD affects .5% of the population over age 50. Between
the ages of 50 and 75 the incidence of AMD is fairly stable
running between 1-2 percent of that age group. The figures
take a dramatic leap after age 75. The CNIB estimates that
one in three Canadians will have clinical signs of AMD by
age 75 and that figures leaps to one in two by age 90.20
• Cataract affects 6% of the general population. Starting at
age 50 the incidence of cataract sits at about 2 per cent of
that age group, and rises at age 60 to 10% of the age group.
By age 80 between 60 and 75 percent of the age group will
suffer from cataract. Cataract causes a thickening and
clouding of the crystalline lens therefore negatively
impacting visual acuity, which is a trigger for referral.
• Diabetic Retinopathy occurs in 1.6% of the general
population. It strikes approximately 1% of those people
ages 40 – 49, and at age 50 begins to climb until it spikes at
age 70 at slightly less than 6 per cent for whites and blacks,
and 10% for Hispanics. This eye disease is best diagnosed
by a physician 3-5 years after onset of diabetes
• Glaucoma occurs in .6% of the general population. It
strikes those between ages 50 – 64 at a rate of
approximately 2%-4% of that age group and escalates
dramatically after age 70.
The population demographics and environmental circumstances
are similar enough between the United States and Canada that we
can safely extrapolate data that is equally applicable in this
country.
The government regulation eliminates individuals over 65 as candidates for a
standalone sight test and the College of Opticians of British Columbia intends
to educate the public to the AAO guidelines for frequency of eye examination.
That document recommends an eye health examination every two to four
years for people between the ages of 40 and 65.
o There has been fair evidence that for healthy adults a vision chart was the
best monitor of onset of eye disease. The OAC believes that the COBC
protocols surrounding optician-performed sight tests will provide a more
highly refined referral mechanism than that recommendation. This in turn
should result in better eye health outcomes for British Columbians.
19
20
Prevent Blindness America – Prevalence of Vision Impairment and Age-Related Eye Disease in America
Toronto Globe and Mail 2003-Health Supplement/Learning to Live With Vision Loss
14
o The lower age threshold in the regulation is reasonable. The major
changes in physiology affecting vision take place from birth to 19.
21
Infants at birth are all farsighted (approximately 2 dioptres). This
farsightedness ordinarily decreases in most by age 2 and levels off to zero
by age 6. There is a greater prevalence of myopia after age 8 leveling off
at puberty. Myopia typically worsens throughout the teen years and levels
off in adulthood.
The Department of Ophthalmology, Odense University Hospital,
Denmark did a 2-year study on myopia progression in children 9 –
12 years of age. They revisited the same cohort of children 8 years
subsequent to the study when the children were 17-20 years of age.
They found the mean increase to be approximately 2.37 dioptres.22
Refraction has been found to be stable for adults between the ages
of 20 and 40 at which point most people require vision correction
for reading.23
•
Illnesses and Conditions- Individuals should be excluded from an automated sight
test who suffer from diabetes, high blood pressure, heart disease, glaucoma or
who have a personal family history of eye disease unless a physician is treating
their health condition. Once an individual suffering from any of these diseases is
under care there is no valid reason why the supervision physician should not refer
to an optician for an ophthalmic lens update.
o An eye health examination is not an effective tool for diagnosing diabetes,
high blood pressure or heart disease but it is an effective tool for
monitoring those conditions once having been diagnosed.
It is important for people with diabetes to have regular retinal
examinations. Approximately 3% of the population suffers from
diabetes. Half of those or 320,000 Canadians are at risk for sight
threatening diabetic retinopathy.
Uncontrolled diabetes can lead to glaucoma, cataracts, heart
disease and diabetic retinopathy.
People who require vision correction and who suffer from
diabetes, glaucoma, cataracts, and heart disease may have need for
changes in their lenses to improve visual acuity separate and apart
from their regular visits to a physician or optometrist. Once under
the supervision of a physician or optometrist these individuals
should be able to access sight testing services from opticians.
The COBC Standards and Guidelines will eliminate as candidates
for optician-performed sight tests those individuals with diagnosed
diabetes who are not under the care of a physician or optometrist.
21
Development of Refractive Error in Typically Developing Children and In Children With Down’s
Syndrome
22
Myopia in teenagers- An eight-year follow-up study on myopia progression and risk factors. H. Jensen
23
Gross & Erickson 1987
15
•
Symptoms – The Canadian Ophthalmological Society (COS) Policy Statement on
‘Appropriate Referral’24 provides guidance, which the OAC endorses as to
symptoms that should trigger the optician to advise referral. With the exception
of three, the listed symptoms are easily observable or notable without special
equipment. The COS Policy states:
o A nonmedical practitioner providing services to any person should refer
that person to a licensed physician and surgeon for definitive diagnosis
and treatment at any time the patient requests, when an eye disease or
central nervous system disorder is suspected or when the nonmedical
practitioner notes:
Failure to achieve corrected 20/40 visual acuity in either eye,
unless the cause of the impairment has previously been medically
confirmed and appropriately treated (The COBC guidelines err on
the side of caution by requiring 20/30 visual acuity to be achieved)
Complaints of flashing lights, recent onset of floaters, haloes,
transient dimming or distortion of vision, obscured vision, loss of
vision or pain in the eyes, lids or orbits, double vision or excessive
tearing (included in the COBC Standards and Guidelines).
Reports of suspected or real permanent or temporary loss of any
part of the visual field (included in the COBC Standards and
Guidelines);
Presence of a tumour (as reported by the client – OAC comment),
swelling of the eyelids or orbit or protrusion of one or both eyes;
Presence of detected opacities or abnormalities in the normally
transparent media of the eye, the ocular fundus or the optic nerve
(not observable by optician – OAC comment);
Presence of inflammation of the lids, conjunctiva or globe
(included in the COBC Standards and Guidelines);
Strabismus or maligned eyes, whether permanent or transient
(included in the COBC Standards and Guidelines);
Rapid or unexpected changes in optical measurements, even
though the vision may be fully correctable (included in the COBC
Standards and Guidelines);
Intraocular pressure suspected to be above normal (currently
opticians are not able to measure intraocular pressure within their
scope of practice. Automated tonometry (pressure reading) is
available and could be provided by opticians in much the same
way as blood pressure testing is provided in drug stores);
Anisocoria (un-equal pupil size) (included in the COBC Standards
and Guidelines)
Any case that does not respond normally to routine testing
(included in the COBC Standards and guidelines).
24
COS Policy Statements and Guidelines-Appropriate Referral
16
•
Previous Eye Health Examination – The OAC endorses, as does the Canadian
Ophthalmological Society, guidelines for frequency of eye examination as set out
by The American Academy of Ophthalmology (AAO).
o The AOA recommends that adults between the ages of 20-29 should have
an eye health examination once during that period.
o Between 30-39 individuals should have two eye health examinations.
o Between the ages of 40 and 64 an eye health examination is recommended
every 2 to 4 years. The COBC has incorporated this recommendation into
their Standards and Guidelines.
•
Rapid change of lens strength required – If the required lens power changes by
1.00 dioptres of strength or more over a 6-month time frame or if there is a
change of 2.00 dioptres since the last prescription, the opticians should refer that
client to a physician. This applies to spherical as well as cylindrical components.
The natural refractive power of the eye is dependant on the curvature of the
cornea, the power of the crystalline lens of the eye, the length of the eyeball from
front to back and the radius of the eyeball. Any physiological changes in one or
all of those components will result in changes in vision. Conditions that create
pressure within the anatomy of the eye will have the affect of altering the physical
optics and this will be reflected in the requirement for a change in vision
correction.
In the age group under consideration vision is normally stable with the major
change taking place around age 40 when correction for reading is typically
required. Between ages 40 and 45 most people will start requiring vision
assistance for reading. The reading power will increase gradually over a period of
10 years and then level off at around +2.50 dioptres. This establishes a norm for
reading power in the age group 40-50.
o A study of refractive changes of individuals between the ages of 20 and 40
years revealed refraction changes very little during that period. Although it
is normal for children to experience an increase of –0.50 to –1.00 dioptre
of power per year, for an adult, an increase of –1.00 dioptre of power over
a 6-month period would indicate a dramatic steepening of the cornea and
raise concern about the possibility of kerataconus.25
Because the presence of Diabetes, Glaucoma, Age Related Macular Degeneration
and Cataract have an influence on either the radial or axial length of the eyeball,
the curvature of the cornea or the thickness of the crystalline lens, dramatic
changes in required lens powers can signal concern and should trigger referral.
25
Primary Care Optometry-Grosvenor, 1977c
17
For example:
o If the cornea becomes steeper, the physical optics of the eye will no longer
bring light to a point of focus and the individual’s visual acuity will
decrease.
Refraction will reveal the necessity for a change in
eyeglass/contact lens power.
Increased intraocular pressure is a symptom of glaucoma and
sudden onset can cause a progression of up to 1.50 D of myopia.
Such occurrence would trigger referral for an eye health
examination.
People who are farsighted (called hyperopia) are at an increased
risk for glaucoma because the anterior chambers of their eyes are
shallow, reducing the ability of the eye to drain away tears. Should
this become a problem the ocular pressure pushing outward would
cause a change in the physics of the visual system resulting in
compromised visual acuity and a change in refraction.
Cataracts may start to develop around age 40-45. While it isn’t
unusual for a myope to require small increments of negative
power, it would be unusual for a hyperope to swing in the direction
of less positive power. When cataracts start to form the crystalline
lens will begin to thicken providing the eye’s natural vision system
with more positive power than it previously had. The hyperope
will begin to be more comfortable with less positive power.
•
High Minus or Plus Powers – Individuals whose lens powers are considered
‘high’ are more likely to develop glaucoma. A referral for an eye health
examination should be triggered if the client requires lens powers exceeding
–8.0026 dioptres or +8.00 dioptres.
o Individuals with high myopia are at greater risk for conditions such as
retinal detachment than those with lower lens powers due to the increased
length of the eyeball as compared with average, and the resultant
stretching and thinness of the retinal layer covering the back of the
eyeball.
o Individuals with high hyperopia are at greater risk for conditions such as
certain types of glaucoma due to the shorter than average length of the
eyeball and the resulting pressure placed on the ducts that drain tears.
•
History of Eye Surgery – Automated sight tests should not be performed on
individuals who have had surgery for a detached retina, refractive laser surgery,
corneal transplant, Inter-ocular lens implant.
Visual Acuity-The measurement of visual acuity has been indicated by several
authoritative bodies to be a sensitive bell-weather of eye disease. A Visual Acuity
is the first measurement recommended for each of the eye diseases listed in the
•
26
Ophthalmology-Journal of the American Academy of Ophthalmology – May 2001
18
AAO Summary Benchmarks For Preferred Practise Patterns.27 The COS Policy
Statement on Referral recommends as its standard, failure to achieve a Visual
Acuity of 20/40 in each eye. The OAC supports this standard.
4.0 OVERVIEW OF KEY PUBLIC ISSUES
The purpose of all health regulations and legislation is to protect the public from risk of
harm. Many provincial health acts have, in recent years, been restructured and refocused
on several additional over-arching principles. These core principles include:
• A scope of practice should not be exclusive to any group or groups of health care
professionals. Instead, health commissions have recommended and governments
have acted to legislate in favour of listing restricted or reserved ACTS.
• As a corollary to this fundamental construct is the position that these restricted or
reserved acts may be performed by ANY health professional who
o Has the training to do so AND
o Can demonstrate the ability to do so.
Additionally, reports and recommendations of health commissions including the
Schwartz commission Report, the Mazenkowski Report, and The Manitoba Law Reform
Commission Report, in detailing ways to more effectively make use of health systems
have uniformly recommended that it is in the public interest to:
o Have a menu of choices for consumers seeking a health professional to
perform a service
o Make the most effective use of the existing array of health care providers
o Make provision for the natural and desirable career progression of
professionals.
These concepts are clear and should be applied with an even hand to the regulation
announced by British Columbia.
The act of sight testing is not a restricted or reserved activity under B.C. legislation. This
is not – or should not – be at issue. B.C. opticians are not asking for authority to perform
a reserved activity. Sight testing as proposed in the regulation would allow opticians to
fine tune existing lens powers under rigidly controlled standards and guidelines. The
only matter under consideration is whether B.C. opticians have met the burden of
responsibility required by the legislation.
4.1 The Basic Training of an Optician Provides the Appropriate Underpinning
o The training programmes used by opticians in British Columbia are
well respected both nationally and internationally and continue to be
accepted by eight Canadian provincial regulatory bodies as appropriate
pathways to licensing and certification. The integrity of the COBC
27
American Academy of Ophthalmology, October 2003-Summary Benchmarks for Preferred Practice
Patterns™
19
registration examination has been affirmed as meeting a standard
equivalent to that used by the 8 other regulatory bodes.28
4.2 Sight Testing Opticians Must Be Required to Have Specialty Training to
Perform This Service
o The College of Opticians of British Columbia has adopted a subset of
the National Competency Matrix upon which the Automated Sight
Testing training programme will be based. Every sight-testing
optician will have to successfully challenge an advanced practice
examination including those opticians who have previously performed
sight-testing services prior to regulation.
4.3 Opticians Have Demonstrated the Reliability of the Results of the Sight Testing
They Perform
o Eyelogic Systems (the vendor of the automated sight testing suite
currently in use by B.C. opticians) conducted a survey of its B.C.
clients and found that with half of its operators reporting, it is
estimated that since 1997 opticians have performed over 80,000 free
sight tests for British Columbians.
4.4 There Is a Consumer Need for Optician Performed Sight Tests
o The use of automated sight testing suites has not been widely
broadcast in British Columbia due to the pushback their use received
from other stakeholders who initiated litigation against the opticians
operating the equipment. The College of Opticians of British
Columbia as well was compelled due to official complaints from the
Board of Examiners in Optometry to pursue this practise through the
courts. In spite of that consumers indicated their approval for the
service as noted above in the numbers that availed themselves of the
service.
4.5 There Has Been No Injury to Consumers as a Consequence of Optician
Performed Sight Tests
o The OAC cannot speak to any official complaints that may have been
generated by consumers unhappy with the service or who have had
cause to seek medical attention as a consequence of their optician
performed sight test. Investigation and disciplinary matters are the
responsibility of the regulatory body and the College of Opticians of
British Columbia is able to address that issue.
In 2000, the OAC contacted the opticians’ and ophthalmologists’
regulatory bodies in the three provinces in which sight tests have been
performed by opticians. At that time the only complaints that had
been lodged were at the instigation of or by competing stakeholders.
28
Professor Ernest Skakun
20
5.0 CONCLUSION
Since the Ministry of Health Services’ announcement in March 2004, there have been a
few public statements of concern, suggesting that there is an inherent risk of harm in the
announcement.
The OAC has been attempting to address these statements of opinion with clear
statements of fact.
Some optometrists have suggested the risk of harm derives from the inability of an
optician to detect eye disease. Optometrists maintain they are in a better position to
perform sight tests because they combine sight tests with a complete oculo-visual
examination and that through this oculo-visual examination they are better able to
identify incipient disease. In other words, even if you are simply requesting an up-grade
in your prescription you must have an accompanying physiological eye examination.
The public has been told by various optometric groups that optometrists are able to detect
diabetes, AIDS, high blood pressure and even cancer through a complete oculo-visual
examination.
Unfortunately, there is no evidence to support these claims. Worse, the OAC is concerned
that these statements will lead to increased confusion and harm to the public.
We believe that an eye health examination is an effective method of monitoring
progressive vision deterioration brought on by related diseases but it is not an effective
method for detecting and diagnosing those same diseases.
The OAC is committed to public education, and will continue our efforts to ensure the
public receives appropriate information that will help them make good choices regarding
the care of their eyes.
In our initial submission on the B.C. opticians regulation, the OAC submitted
documentation pointing to the fact that individuals who are at risk for eye disease are
easily identifiable and in any case are not captured within the age-restricted group that are
eligible for an optician performed sight test.
A philosophy that dictates that a sight test and an eye health examination must be
performed in tandem presumes that the eyeglass wearing public is at greater risk for eye
disease than the non-eyeglass wearing public since it is normally a reduction in visual
acuity that triggers a request for a sight test. There is no evidence to suggest that eye
disease occurs more frequently in eyeglass wearers.
It does not seem reasonable to force the eyeglass wearing population to undergo the
bundled services of sight test and oculo-visual examination in order to screen for the
small number of people who are likely to have eye disease. Together, the province and
opticians, optometrists and ophthalmologists must find a more effective screening device
and a Family Practitioner-centred model.
21
If we are to discover eye disease in the at risk population, we need to find methods of
reaching out to all 30 million Canadians and not just those Canadians who wear
eyeglasses. With approximately 4000 optometrists across the country available to
perform eye health exams, it would seem clear that in the best of all possible worlds, the
work of attending to the sight testing requirements of the eyeglass wearing consumer who
is not at risk can safely be placed in the hands of opticians.
The OAC suggests that British Columbia opticians have met the burden of responsibility
set out in the Health Act and they have performed due diligence. They have mandated
appropriate training and they have demonstrated they are able to safely perform the act.
The OAC believes that you have an opportunity before you to reaffirm a decision that
will benefit consumers, AND that will add dimension to, and an enrichment of, the vision
care system for British Columbians.
We urge you to allow British Columbia opticians to implement the regulation.
22