By Dr Michael Hope, UK Doctor of Optometry – working with the Ophthalmic Practitioners Group – Patients before profits – July 2020
The educational differences in Optometrists between these two developed western nations shares both common themes and stark differences. First and foremost is the title that these practitioners are recognised by within their respective countries. USA Optometrists are recognised as Dr, and qualify as a “Doctor of Optometry”1whereas UK Optometrists currently graduate and qualify with no such distinction.2Responsibilitiesin the two professions are broadly similar, however licensed USA practitioners have further responsibilities and wider access to prescription only medicines3, which are currently only available to UK practitioners following further Independent Prescribing examination and certification.4In addition to USA Optometrists holding the title Doctor,Canadian Optometrists also hold this privilege.5To understand the core differences underlying educational status of Optometrists between these two nations, it would be useful to briefly examine their respective history and professional regulations.This demonstrates an almost100-yeargulf between the formal award of “Doctor of Optometry” status between the USA and UK.Historical context and timelines United States. It was in 1923 that Pennsylvania College of Optometry awarded the first Doctor of Optometry (O.D.) degree.By 1940 the Association of Schools & Colleges of Optometry (ASCO) was created; Albert Fitch was the first President. In 1961 Pennsylvania Optometrists introduce a bill to authorise the use of ophthalmic diagnostic pharmaceutical agents, but it was defeated.It wasn’t until 1973,that a bill was introduced in North Carolina to authorize Optometrists to use and prescribe pharmaceutical agents for diagnostic and therapeutic purposes.In 1976 the first therapeutics law passed in West Virginia, permitting the use of therapeutic drugs by Optometrists. By 1998 all states and D.C. had therapeutic laws formalized in state legislature.6United Kingdom It was within the 1930’s that diagnostic ophthalmic drugs became a consideration to those in the UK practicing “optics”. The first examination in drugs for Fellows of the “worshipful company of spectacle makers” was held at Liverpool in March 1938. In 1946 D.W.A. Mitchell, of the London Refraction Hospital, published a textbook on the use of drugs by Optometrists and courses were arranged at training institutions.7By1948, an examination in ophthalmic drugs was instituted by the British Optical Association (BOA)and was open to all Optometrists. There were four examination sections: General & ocular anatomy; Drugs used in refractive ophthalmic practice; Clinical use in refraction; and contraindications. The first BOA examination was held in July 1949. When the length of Fellowship training for all new Optometrists increased to three years all candidates were examined automatically in ophthalmic drugs as part of their training. 7LegalaspectsofoptometricuseofophthalmicdrugsintheUKThe use of drugs by Optometrists (and all medical professionals) in the UK is governed by the Medicines Act 1968. A provision in this act allows Optometrists to use and supply drugs during the course of their professional practise. In 2007UK Optometrists became able to undertake additional postgraduate training and qualifications that allow them to prescribe medications to treat and manage eye conditions.8There are three registerable specialties: •Additional supply specialty -to write orders for, and supply in an emergency, a range of drugs in addition to those ordered or supplied by a normal Optometrist.•Supplementary prescribing speciality -to manage a patient’s clinical condition and prescribe medicines according to a clinical management plan set up in conjunction with an independent prescriber, such as a GP or ophthalmologist or a qualified IP Optometrist.•Independent prescribing specialty(IP)-to take responsibility for the clinical assessment of a patient, establish a diagnosis and determine the clinical management required, including prescribing where necessary.8UK Regulatory bodies and “Doctor of Optometry”titleIt was not until after the introduction of the National Health Service (NHS) in 1948 7that the then Health Minister and the Secretary of State for Scotland set up a Committee to determine whether a regulatory body should be created.Before the1958Opticians Act and the formation of the GOC in parliament,UK Optometry was not a regulated profession.The GOC’s core functions were:•To maintain registers of Optometrists (and dispensing opticians)who have the relevant qualifications;•Tomanage the inspection of training institutions and examining bodies which grant qualifications;•To monitor the practise of optics and use of protected titles(such as Optometrist) by those who are unregistered by statutory prohibition•To exercise disciplinary powers over registered Optometrists, and in stil and enforce appropriate ethical standards.In 1989there were further Opticians Act amendments. In 2005 a number offurther changes were made to the legislation. These included the introduction of mandatory continuing education and training for full registrants, and the introduction of registration for student optometrists and dispensing opticians.It wasn’t until 2008that the UK moved forward to offer the post-graduate Doctor of Optometry qualification at the Institute of Optometry, London and then Aston University, Birmingham.As can be noted from the above, the USA gained “Doctor of Optometry” qualification in 1923, nearly 100 years before it became available as a postgraduate qualification in the UK. Currently, the Doctor of Optometry qualification remains unavailable as an entry point to the profession in the UK. In respect of the prescribing of pharmaceuticals, historically UK optometry was aheadof the USA, with laws and examinations governing their use being in place in the UKfrom1938 onwards and formalised into examinationin1949,administered by the British Optical Association (the forerunner to the UK College of Optometrists).7This was reinforcedby the Medicines Act 1968whichallowedOptometrists to use and supply drugs during the course of their professional practise. During the 1960’s –mid 70’s USA Optometrist counterparts were being refused access to ophthalmic diagnostic and therapeutic agents and it wasn’t until 1973 that a bill wasintroduced in North Carolina to authorise Optometrists to use and prescribe pharmaceutical agents for diagnostic and therapeutic purposes.Then in 1976 the first TherapeuticsLaw passed in West Virginia permittingthe use of therapeutic drugs by Optometrists.5This then set the stage for USA Optometrists to overtake their UK colleagues by gaining access to more ophthalmic drugs and increasingly managing ocular disease through the 1980’sand 1990’s. It wasn’t until 2007that UK Optometrists were permitted to use a fuller range of ophthalmic drugs9and this was only after undertaking further postgraduate lectures, clinical placement with an Ophthalmologist and then the common final assessment examination administered by the College of Optometrists. The integration of this IP qualification into the UK Optometry degree has not yet been formalised but with an ageing population and a lack of capacity withinNHSOphthalmology10,it is possible this integration may only be a matter of time.Current UK and USA Optometry syllabi, common themes and differences Of note between the training background of these two nations, USA provide their4 year Doctor of Optometry degree at a postgraduate level following an undergraduate science based degree and accompanied by a high OAT (Optometry Admission Test) score, though this may not precludeentry by qualified opticians with experience (but also requiring a high OAT score). UK Optometry is currently studied at undergraduate level, typically as a 3-yearBSc (Hons)following science based A Levels such as Biology, Chemistry and Physics,common UCAS offers are AAB11. Again,there is an option for optician entry to the degree and for those opticians that excelan option for direct entry to the second year of the traditional optometry degree.The subsequent UK pre-registration year is then completed in either corporate/independent or hospital-basedpractice and is ofapproximate12-16-monthduration, dependent on practitioner performance.In the UKonce qualified with 2 years’ experience,there is an option to upgrade to Doctorof Optometry(including academic modules for IP) with a 6 year part-timepostgraduate course(whilst remaining in practice)12.In this preliminary review of the two courses in Optometry, large established mainstream Optometry courses from their respective countries have been selected –for the United Kingdom –the University of Bradford, and for the United States –The University of California, Berkeley. Comparison of the two degrees can only be made to some extent, since the pre-registration year accounts for a significant component of a UK Optometrists training, and the learning outcomes from the UK College of Optometrists and objective structured clinical exams would be additionally relevantto consider, when comparing to a 4 year USA Optometry degree. Nevertheless,in the authors view, there is still merit in comparing the core academic components of the two degrees.Examining the syllabi (see appendix) shows common themes, particularly in year 1, where general anatomy and physiology, ocular anatomy and physiology and pure/visual optics dominate both
nations courses.However,the USA year1 syllabus demonstrates increased neuro anatomy content and this is critical in gaining a good understanding of the cranial nerves and systemic disease.The second year of the UK course appears to have more dispensing content than its USA counterpart. Ocular and general pharmacology, contact lenses and binocular vision are shared central modules in year 2 of both UK and USA courses.The third year of both courses shows some divergence in training. The USA course has a module “Optometry 435. Advanced Procedures in Ocular Disease Diagnosis”which does not appear to be included in the UK course. Furthermore, the USA course consolidates its ocular pharmacology content from year 2, with the modules “Optometry 246. Diagnosis and Treatment of Anterior Segment Ocular Disease pathophysiology, pharmacotherapy, and clinical management of systemic and ocular disease” and “Optometry 256. Diagnosis and Treatment of Posterior Segment Ocular Disease pathophysiology, pharmacotherapy, and clinical management of systemic and ocular diseases”The UK course has the module“Management of Ocular Disease Core 40 1&2 OPT6019-D” but this may not be as extensive as the 2-modulecontent of the USA course. The fourth year of the USA course is largely clinical practise based with a heavy clinical workload time table of approximately 50 hours with the addition of “grand round” clinical case presentations. The UK has a pre-registration system, where the graduate undertakes approximately 37 hours of clinical contact time in practice, combined with approximately 10-14 hours of study each week. Within the UK pre-registration year, there is a significant Ophthalmology input via a clinical placement with a Consultant Ophthalmologist,of approximately 10-12 days (up to 24 clinical sessions). This will typically involve a rotation between different ophthalmology sub specialties, such as vitreo-retinal, glaucoma, cornea and ophthalmic casualty. The USA degree appears to keep much of this “in-house” via the fourth year of its programme.A full comparison of the degree content is outside the scope of this preliminaryreview, however, could be a useful masters/doctoral thesis undertaking for a UK or USA post-graduate student.Preliminary recommended revisions for UK Optometry BSc degree to achieve Doctor of Optometry standard as entry to the UK profession•Increased general and ocular pharmacology within year3 content,building on year 2•Incorporate IP prescribing into UK Optometry degree•A Level Chemistry minimum grade B for all entrants to the course (including Disp Optician entry)•Increased neuro-anatomyin year1,including structure and function of all cranial nerves in the human body.•Separation of ocular abnormalities(year3) into anterior and posterior segment and to include ocular pharmacology/pharmacodynamicstreatmentsfor both•Clinical theory and application of advanced ophthalmic techniquesincluding but not limited to: OCT interpretation, Gonioscopy, PCO Yag laser, Foreign body removal/algerbrush, Culture of specimen removal, interpretation of blood test results –Full Blood Count, Urea &Electrolytes, CT, X-Rayand MRI scan interpretation focussing on orbits (including labs/clinical experience in all)•Lengthening of UK degree to fouryears to allow for above to be incorporated into syllabus•Grand Round Modulein year 4to include case presentations and linksto current research•Larger dissertation to include successful VivaVocedefence•Pre-reg year to remain, possibly lengthened to 16-18 months to allow for IP incorporation•Reduction in dispensing content on UK course to give way to increased medical and pharmaceutical content•Successful candidates to take Optometry oath on qualification•Doctor of Optometry to be awarded on successful passing pre-registration year and OSCE’sFace to face meetings between UK and USA students who have completed Year 1, Year 2 etc of each course would assist in identifying elements of the UK course which require reinforcing/revision. Face to face meetings of UK and USA Optometry Lecturers to assist in identifying differences in course content. A Masters or doctoral thesis identifying historical and current differences in both curricula may also be of value.Current UK Government plansfor graduate accelerated medics and the EUopticstraining model The UK Government have this year, indicated a new pathway for registered pharmacists (and possibly even paramedics) to undertake a three-yeardegree which will allow them to qualify as a foundation year Doctor13. Enhancing UK optometry training to doctoral status aligns well with such Government aspirations and provides a swift range of primary eye care doctors at a reasonable cost investment, with an ability to manage a wider range of eye disease in primary care with significant potential economic savings for the NHS.Within the optical press there has been recent discussion about a possible UK Optometry entry level apprenticeship course,training Optometrists within a predominantly corporate optical environment and removal of much of the University training, similar to the way European “optical practitioners/technicians”train. However, this approach will not be compatible with a UK Doctor of Optometry training, where enhanced academic and clinical skills are required.With the UK exiting the EU-where levels of optometry standards are either unknown or potentially inadequate-the argument for apprenticeship sas entry level practitioners in medicine, optometry or dentistry needs a muchstrongerevidence base before meriting further consideration.Of note –there are no other English-speaking western nations offering such courses.
At a time when the NHSis under huge strain, now and for the foreseeable future, the question should not be whether the UK upgrades its optometryBScqualification to Doctor of Optometry, but rather,why has it taken so long to get to this point.The prospect of a UK Doctor of Optometry practitioner is not a revolutionary premise–it is finally aligning UK optometry with other culturally similar,western advanced nations. For the ageing UK population and a struggling NHS, this re-alignmentin UK optometry cannot come soon enough. Acknowledgements: I wish to acknowledge the Universityof Bradford, UK for supplying the curriculum, and Professor Flanagan from the University of California, Berkeleyfor the same. As far as the author is aware, this represents the first review of the subject matter by a UK Doctor of OptometryReferences 1)https://www.aoa.org/about-the-aoa/what-is-a-doctor-of-optometry, cited 5-7-202)https://www.college-optometrists.org/qualifying/a-career-in-optometry/what-is-an-optometrist.html, cited 5-7-203)Pharmacy and the U.S. Health Care System, Third EditionCRC Press, 22 Jul 2005, p63-64 Michael Smith4)https://www.college-optometrists.org/guidance/guidance-for-therapeutics.html, cited 6-7-205)https://opto.ca/becoming-a-doctor-of-optometry, cited 10-7-206)http://fs.aoa.org/optometry-archives/optometry-timeline.html, cited 6-7-207)http://www.barnardlevit.co.uk/assets/Lectures/Use-of-diagnostic-drugs-by-optometrists-Stockholm-2008.pdf, cited 6-7-208)https://www.college-optometrists.org/cpd-and-cet/training-and-qualifications/qualifying-as-an-independent-prescriber.html, cited 7-7-209)https://www.optical.org/en/news_publications/news_item.cfm/GOC-welcomes-new-prescribing-rights-for-optometrists,cited 7-7-2010)https://www.rcophth.ac.uk/2019/01/new-rcophth-workforce-census-illustrates-the-severe-shortage-of-eye-doctors-in-the-uk/, cited 8-7-2011)https://www.manchester.ac.uk/study/undergraduate/courses/2020/03571/bsc-optometry/entry-requirements/, cited 8-7-2012)https://www.aston.ac.uk/study/courses/doctor-of-optometry-doctor-of-ophthalmic-science-doptom-dophsc, cited 15-7-2013)https://www.chemistanddruggist.co.uk/news/pharmacists-could-be-fast-tracked-doctors-under-new-government-plan, cited 8-7-20
Appendix Current UK syllabus–University of Bradford, UKFHEQ Level Module Title Type (Core/ Option/ Elective) Credits Semester (s) Yr 1 Semester 1 and 2•Refraction & Refractive Error Core 20 1&2 OPT4002-B •Pure & Visual Optics Core 20 1&2 OPT4003-B •Physiology of Vision & Perception Core 20 1&2 OPT4004-B •Evidence-based Practice and Professionalism Core 20 1&2 OPT4007-B •Ocular Health Assessment 1 Core 40 1&2 OPT4012-D•General and Ocular anatomy/physiologyYear 2 Semester 1 and 2Module Code •Ophthalmic Lenses & Dispensing •Clinical Optometry & Communication Skills •General and Ocular Pharmacology •The Assessment and Management of Binocular Vision •Ocular Health Assessment 2 Core 20 1&2 OPT5014-B •Contact Lens Practice Core 20 1&2 OPT5011-B Year 3 Semester 1 and 2 Module Code •Clinical Competence Core 0 1&2 OPT6012-Z •Evidence-based Optometry 2 Core 20 1&2 OPT6013-•Management of Ocular Disease Core 40 1&2 OPT6019-D •Clinical Practice and Professional Studies Core 40 1&2 OPT6017-D •Clinical Case Studies Core 20 1&2 OPT6014-BUSA 4 yr Doctor of Optometry program, TheCaliforniaUniversity,Berkeley,USAFirst Year 38.5 units Fall Semester Optometry 200A: •Clinical Examination of the Visual System Two hours of lecture per week. (2 units) (and lab) •Optometry 499: Optometry Career Development Course •Vision Science 203A: Geometrical Optics (+laboratory), and one 1-hour discussion per week. Geometrical methods applied to the optics of lenses, mirrors, and prisms. Thin lens eye models, magnification, astigmatism, prism properties of lenses, thick lenses. •Vision Science 205: Visual Perception and Sensitivity Three (and labs) Psychophysical basis for clinical tests in acuity, perimetry, and colour vision. •Vision Science 206A: Anatomy and Physiology of the Eye Four hours of lecture for seven and one-half weeks. •Vision Science 206D. Neuroanatomy/Neurophysiology of the Eye & Visual system•206A (must be taken concurrently). Formerly half of 206A. Structure and function of the neurosensory retina, photoreceptors, RPE including blood supply. Current concepts of aetiologyand management of major retinal conditions. Overview of diagnostic techniques in retinal imaging, electrophysiologic testing and new genetic approaches. •Optometry 200B. Clinical Examination of the Visual System (and labs): Classification and epidemiology of refractive errors, evaluation of accommodative and binocular status. Tonometry, advanced techniques of examining the posterior pole, evaluation of visual pathway function. •Optometry 200BL. Clinical Examination of the Visual System Six hours of laboratory per week. Prerequisites: 200A. Classification and epidemiology of refractive errors, evaluation of accommodative and binocular status. Tonometry, advanced techniques of examining the posterior pole, evaluation of visual pathway function. •Optometry 222A. Optics of Ophthalmic Lenses (and labs) •Vision Science 203B. Optical System and Physical Optics (and labs)•Vision Science 206B. Anatomy and Physiology of the Eye and Visual System (and labs) Structure and function of the tissues of the eye, ocular appendages, and the central visual pathways •Vision Science 217. Oculomotor Functions and Neurology One (and labs)•Vision Science 219. Binocular Vision and Space Perception One (and labs)Second Year Fall Semester 34 units •Optometry 200C. Clinical Examination of the Visual System(and labs)•Optometry 213. Evidence-Based Optometry Basic concepts in evidence-based optometry including various clinical study designs, potential sources of bias in each design, study analysis etc•Optometry 222B. Ophthalmic Optics and Environmental Vision•Optometry 226A. Systemic Pharmacology•Optometry 236A. Systemic Disease and Its Ocular Manifestations•Optometry 270B. Eyecare Business and Professional Management•Vision Science 215. Infant VisionSpring Semester •Optometry 200D. Clinical Examination of the Visual System(tear film, cataract affecting VA etc) (and labs)•Optometry 226B. Ocular Pharmacology Two hours of lecture and one hour of discussion per week. Basic pharmacology as applied to the eye and ophthalmic drugs, clinical prescribing issues including formulation, dosing and prescribing•Optometry 236B. Systemic Disease and Its Ocular Manifestations: The pathophysiology, pharmacotherapy, and clinical management of systemic and ocular diseases •Optometry 240. Diagnosis and Treatment of Sensory/Motor Abnormalities (+labs)Diagnosis and treatment of heterophoria, accommodative,BV etc•Optometry 260A. Contact Lenses: Examination of the Contact Lens Patient (+labs)The physiological basis for fitting contact lenses. Effects of a contact lens on the tears, lids, cornea. Examination procedures and instrumentation in CL, Contact lens inspection,care, and handling. •Vision Science 206C. PBL Anatomy and Physiology of the Eye and Visual SystemThird Year 45.5 units Summer Semester •Optometry 430A. Optometry Clinics Minimum of 32 hours of clinic combined with 1 hour of lecture and •Optometry 432. Introduction to Clinical Topics for the New ClinicianFall Semester •Optometry 241. Advanced Management & Rehabilitation of Sensory/Motor Anomalies (+labs) •Optometry 246. Diagnosis and Treatment of Anterior Segment Ocular Disease pathophysiology, pharmacotherapy, and clinical management of systemic and ocular disease•Optometry 251. Low Vision •Optometry 430B. Optometry Clinic practise Two hours of seminar per week and a minimum of 18 hours of clinic per week. •Optometry 435. Advanced Procedures in Ocular Disease Diagnosis (+labs) Spring Semester •Optometry 256. Diagnosis and Treatment of Posterior Segment Ocular Disease pathophysiology, pharmacotherapy, and clinical management of systemic and ocular diseases •Optometry 270C. Eyecare Business and Professional Management •Optometry 430C. Optometry Clinic Two hours of seminar per week and a minimum of 18 hours of clinic per week. Fourth Year 46units Summer Semester •Optometry 440A. Advanced Optometry Clinic Two hours of seminar and a minimum of 20 hours of clinic per week. Optometric examination of patients in the primary care clinic performed independently by student clinicians under supervision of the clinic staff. •Optometry 441A. Specialty Clinics Two hours of seminar and a minimum of 16 hours of clinic per week. Examination, diagnosis, prognosis, treatment, and management of patients in the specialty clinics. •Optometry 440B. Advanced Optometry Clinic Two hours of seminar per week and a minimum of 22 hours of clinic per week. Diagnosis, prognosis, treatment, patient management and follow-up. •Optometry 441B. Specialty Clinics Minimum of 15 to 20 hours of clinic per week. Examination, diagnosis, prognosis, treatment, and/or management of patients in specialty clinics; oculardisease, contact lenses, binocular vision etc•Optometry 450A. Grand Rounds and Seminar Two hours of discussion per week. Must be taken on a passed/not passed basis. Presentation of clinical cases demonstrating basic and advanced optometric care, includingdiagnosis, treatment, and patient management. (2 units
Spring Semester •Optometry 440C. Advanced Optometry Clinic -Examination of patients in a primary care setting. Diagnosis, prognosis, treatment, patient management and follow-up. •Optometry 441C. Specialty Clinics Minimum of 15 to 20 hours of clinic per week. Examination, diagnosis, prognosis, treatment, and/or management of patients in specialty clinics, ocular disease, contact lenses, binocular vision etc•Optometry 450B. Grand Rounds and Seminar.Presentation of clinical cases demonstrating basic and advanced optometric care