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On page 8 of the College of Opticians submission, it is stated: "Recognition of pathology is a mandatory requiremen
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VISION INSTITUTE OF CANADA 16 YORK MILLS ROAD, SUITE 110 NORTH YORK, ONTARIO M2P 2E5 Phone: 416-224-2273
June 13th, 2005. Ms. Barbara Sullivan, Health Professions Regulatory Advisory Council, 55 St. Clair Avenue West, Suite 806, Box 18 Toronto, Ontario M4V 2Y7 Dear Ms. Sullivan, The Vision Institute of Canada wishes to take this opportunity to comment on the submissions to HPRAC sponsored by the College of Opticians of Ontario and the Ontario Opticians Association, in regards to the issue: Whether there is a risk of harm in dispensing eye wear and what aspects, if any, of this activity need to be controlled under the RHPA, whether refractometry is within the scope of practice of opticianry, and how standards should be set and measured for both of these activities. The Vision Institute of Canada is a charitable organization dedicated to the preservation, promotion and advancement of good vision and eye care services for the public through the provision of optometric clinical services, research and education. The Vision Institute has operated in Toronto for over twenty-three years and is Canada's only optometric clinical charity. It is a public clinic accepting referrals for specialized low-vision assessment and therapy, and for electro-diagnostic testing of patients with neurological impairments or physical disabilities. It provides specialized pediatric assessments for infants and schoolaged children with visual impairments or learning disabilities. It also provides continuing education programs for optometrists across Canada, a successful ongoing three month clinical externship programs for Canadian optometry students in the final year of their university doctorate program, and an outreach program to over twenty nursing homes. With this in mind, we would like to address the issue of "refractometry" first. "Refractometry" It has been clearly stated by a previous HPRAC review that "refractometry" is not within the scope of practice of Opticianry. The College of Opticians of Ontario and the Ontario Opticians Association are not contesting this. Instead they ask
whether it should be part of their scope of practice. We would like to answer that question. In January of 2004, a conference was held in Toronto called The Cost of Blindness: What it Means to Canadians. The Canadian National Institute for the Blind and its partners brought together representatives from leading visionhealth organizations in Canada and around the world to discuss the cost to Canadian society, both financial and psychological, of sight loss. To quote from the Executive Summary published and sent to health-care providers:
"The general public and public policies must support the messages to stop smoking, eat plenty of dark green vegetables, lose weight, wear sunglasses, and get their eyes tested. Health care professionals must be shown how much eye disease is going undiagnosed." A complete and comprehensive eye examination involves several components that cannot be separated and delivered individually in a meaningful way. If the refractive part of an eye exam is performed as a stand-alone procedure ("refractometry") without the necessary eye health assessment, the risk of undiagnosed eye disease increases. The Cost of Blindness symposium identified that too much eye disease is already going undetected. The financial, physical, and psychological cost of blindness is enormous. To permit opticians to perform refractions and to prescribe based on their refractive findings without an assessment and diagnosis of ocular health, is not in the public interest. On page 38 of the submission to HPRAC by the College of Opticians of Ontario, it is stated: "Patients who visit an optician because they want to update their eyewear or replace lost or damaged glasses may wish to have their refractive error measured to ensure that their current prescription is still valid. There is no valid reason why they must be subjected to a complete eye examination in order to do so." There is a valid reason. The reason is that it is good clinical and medical practice and in the public interest. An assessment to determine if there is a change in refractive error provides an opportunity to assess for eye disease which otherwise would go undiagnosed. References are made in the submissions of both the College of Opticians and the Opticians Association to an opticianry model in British Columbia, a model that has in fact been rejected by the B.C. government. There were, and are, many opponents of this economically motivated model, not least of which is the College of Physicians and Surgeons of British Columbia. That College issued a policy statement in March, 2003 saying:
"The College considers that a physician, in signing a prescription for correction of a visual refractive error which may be a prescription resulting from automated refraction performs a medical act which endorses that the patient has had the entirety of his/her ocular health professionally scrutinized and that ocular pathology has been excluded or appropriately addressed. A patient who seeks a prescription for visual correction is presenting with the implicit complaint that their vision is suboptimal for whatever reason.Therefore, prescribing based on the results of an autorefraction alone, without having taken a history from the patient and without having conducted an examination based on that history compromises the medical method of diagnosis and places the patient at significant risk with the potential of missing significant ocular, and possibly systemic, pathology." www.cpsbc.ca - Policy Manual Revision - March 2003 The College of Physicians and Surgeons of Ontario has issued a similar policy statement: "Examples of prescription practices that are not acceptable because they lack the basic elements of assessment and diagnosis include: 1) Prescribing for a patient solely on the basis of mailed or faxed information, or an electronic questionnaire 2) Co-signing (also called counter-signing) a prescription issued by another physician without direct patient contact 3) Signing a prescription issued by an optician without proper assessment and diagnosis." www.cpso.on.ca/Policies/drug_prac.htm There is no argument that "refraction" is a public domain activity, but when the results of a refraction are used to dispense eyewear, it constitutes the controlled act of prescribing which carries a risk of harm. Prescribing, by its very nature, includes a proper health assessment and diagnosis. On page 13 of the submission made by the Ontario Opticians Association, it is stated: "...it is reduced visual acuity that normally triggers a visit to the refractionist, ..." Reduced visual acuity is often a sign of eye disease. Simply correcting the refractive error and prescribing based on the refraction without a proper eye health assessment and diagnosis is not in the public interest, nor is it good clinical or medical practice. Any act of prescribing, whether it is for drugs, corrective lenses, orthotics, or a hearing aid requires an assessment and
diagnosis. Simply prescribing based on a data-gathering procedure without the requisite knowledge, skill, judgement and accountability in regards to treatment, exposes the public to a significant risk of harm. The submission of the Ontario Opticians Association is full of both contradictory statements and falsehoods. For example, on page 13 , it is stated: "A search of the literature has revealed that in fact there is no correlation between the need for visual correction and the presence of eye disease. In other words, persons with Myopia, Hyperopia, Hypermetropia, and Presbyopia are not more prone to eye disease than the portion of the population not requiring visual correction." This is then contradicted on subsequent pages, where it is stated: "People who are farsighted (called hyperopia) are at an increased risk of glaucoma because the anterior chambers of their eyes are shallow, reducing the ability of the eye to drain away tears." - page 31 [note There is no correlation between tear drainage and glaucoma. One assumes they meant intra-ocular fluid. This error is repeated on page 32.] "Individuals whose lens powers are considered 'high' are more likely to develop glaucoma." - page 31 "Individuals with high myopia are at risk for conditions such as retinal detachment..." - page 32 Patients with refractive errors are more prone to eye disease. For example, hyperopic (far-sighted) patients are more prone to macular degeneration, the leading cause of age-related blindness in the western world. Hyperopes are also more prone to closed-angle glaucoma. People who are myopic (near-sighted) are more prone to open-angle glaucoma. Myopes are also more prone to retinal detachments. The Opticians Association submission states on page 18: "According to the AAO [American Academy of Ophthalmology] schedule, whether they wear eye glasses/contact lenses or not, adults between the ages 20-29 need a comprehensive eye exam once throughout those years while those between 30-30 [sic] should have two eye health examinations and those between 40-64 need be examined every two to four years." This schedule is in fact for people with healthy eyes and vision who do not wear glasses or contact lenses. According to the prestigious Mayo Clinic:
"If you don't wear glasses or contact lenses, have no symptoms of eye trouble, don't have a family history of eye disease and you don't have a chronic disease, such as diabetes that puts you at risk of eye disease, have an eye exam at the following intervals: 1) Once between ages 20 - 29 2) Twice between ages 30 - 39 3) Every two to four years between ages 40 - 65 4) Every one to two years after 65. If you do wear glasses or contact lenses, you'll need to have your eyes checked yearly. And if you notice any problems with your vision, schedule an appointment with your eye doctor as soon as possible." www.mayoclinic.com (Getting an Eye Exam: What To Expect - Mayo Foundation for Medical Education and Research) It is also stated on page 14 that a condition called 'papilledema' can be "diagnosed with stereoscopic indirect fundoscopy" and that such sophisticated diagnostic equipment "is not standard in an optometric practice." In fact, the use of such a procedure and its attendant instruments are a standard of practice in optometric offices and a standard of care of the profession. On page 20 of the Optician Association's submission, it is stated: "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. Through their primary education Ontario opticians are trained to recognize ocular anomalies and to refer when they observe symptoms other than normal." Within their professional role, to "refer when they observe symptoms other than normal" requires the knowledge, skill, judgement and accountability that is part of assessment and diagnosis. The profession of Opticianry is one of the five regulated health professions that are specifically excluded from having "assessment" within their scope of practice statement. (The five professions excluded are Dental Technology, Medical Laboratory Technology, Medical Radiation Technology, Opticianry, and Pharmacy.) To allow opticians to determine who needs an eye exam and who does not is beyond the scope of their education and their scope of practice. To be properly trained and educated for such authority and accountability would require the educational curriculum presently required of optometrists and physicians. Recognizing "ocular anomalies" requires assessment and diagnosis, neither of which is part of the profession of opticianry or its scope of practice.
On page 8 of the College of Opticians submission, it is stated: "Recognition of pathology is a mandatory requirement of the profession as opticians must be able to identify problems, determine their significance, and refer patients to the appropriate health care professional in the proper time frame." This statement implies that opticians perform diagnostic assessments. They have neither assessment nor communicating a diagnosis as part of their scope of practice and so have no liability or accountability, other than when it comes to the controlled act of dispensing. On page 39 of the College of Opticians submission, it reads: "It is important to emphasize that the College is not seeking to give Opticians the power to prescribe. Opticians will be augmenting existing lens powers to fine tune visual acuity within a specified age group and power, and in accordance with appropriate Standards of Practice." On page 7 of the Opticians Association submission, it states: "Ontario opticians wish to provide refractometry services for Ontario consumers independent of physician/optometric oversight. As well, they wish to use the results derived from the refractometry service to make eye wear." The College of Opticians and the Association of Opticians want their members (in order to "make" and therefore sell "eye wear") to be able to prescribe without calling it prescribing. However, using the results derived from a refraction to provide corrective lenses is the controlled act prescribing. HPRAC, in its letter to Health Minister Elizabeth Witmer, dated September 27, 2000, stated: "HPRAC considers the act of changing a prescription to be, for all intents and purposes, the same as the controlled act of prescribing." page 4, Letter to Health Minister Elizabeth Witmer, September 27, 2000. Prescribing that is in the public interest and reduces the risk of harm associated with it requires an examination of the eye for pathology. The "prescribing" that opticians want to perform with "refractometry" would be substandard care in both Medicine and Optometry. Optometrists and Physicians would be open to allegations of professional misconduct by failing to maintain the standards of practice if they prescribed without a proper and thorough assessment for eye disease.
In conclusion, "refractometry" is not within the scope of practice of opticianry, nor should it be within their scope of practice, unless it is under direct in-office supervision by the prescribing optometrist or physician. Regulation of Dispensing To address the question of whether there is a risk of harm in dispensing eye wear, we would like to state that there are varying degrees of risk associated with the numerous types of eye wear that are available. To deregulate dispensing would not be in the public interest. The present use of the controlled act scheme to protect the public from the inappropriate fabrication and delivery of eye wear by untrained and unregulated personnel is effective, enforceable and necessary in maintaining quality care. Dispensing involves the knowledge, skill, and judgement to interpret and fill a prescription. A prescription for corrective lenses is derived from a complete diagnostic assessment of the eye and contains information that cannot be converted to an optical appliance without proper training and accountability. Dispensing contact lenses carries a significant risk of harm to the corneal surface of the eye. Improper dispensing can lead to physical damage to the eye, including blindness. Dispensing prescription safety glasses can also lead to significant physical injury if improperly fabricated and delivered to a worker. Dispensing to children and seniors carries a more significant risk of harm than dispensing to the average adult. Effective and enforceable standards of practice need to be in place to protect the public from the inherent risk of harm in filling a prescription, whether it is for a drug, an optical appliance, a dental prosthesis, or any medical device. For corrective lenses, this can be done effectively through the RHPA and the College process of regulating its members and the dispensaries in which they work. It is also worth stating that "refractometry," as described and defined in both opticianry submissions, would permit opticians to "dispense without a prescription" (page 38 of the College of Opticians submission.) This is not in the public interest and carries a significant risk of harm. At present, an optician can only dispense upon the prescription of an optometrist or physician. This regulation and standard of practice must be maintained and be enforced. The Vision Institute is in favour of maintaining the current regulatory framework concerning dispensing as a controlled act and the present mechanisms in place to enforce the regulations. We would however, like to see greater regulation of retail optical dispensaries to ensure that they are operated in the public interest.
Yours truly,
Dr. A. Paul Chris, Optometrist, Executive Director