Wednesday 23 October 2013

Role of Optometrists in Singapore

Team-based model boosts eye-care delivery

DR JERRY Tan may not have fully comprehended the set-up of our Stable Eye Condition Clinic ("A step backwards for eye care?"; last Saturday).

Many people with eye conditions seek treatment from eye surgeons or ophthalmologists.

The increasing number of appointment requests at our clinics attests to the growing demand for specialist eye treatment with an effective primary care surveillance system in place.

However, without an effective follow-up system for patients with mild and stable eye conditions, highly trained eye surgeons will not be able to commit time and attention to more serious diseases, perform surgery or develop better therapies.

This situation is untenable even as, paradoxically, more ophthalmologists are trained to provide accessible quality eye care to all sectors of our population.

In recent decades, there have been transformations in models of care worldwide.

Health-care professionals like nurses and allied health professionals are constantly contributing their expertise towards comprehensive care for patients, alongside doctors.

These team-based models improve the delivery of health care, and allow doctors to lead in complex care, research, education and innovation.

Tan Tock Seng Hospital's Stable Eye Condition Clinic (SECC) leverages on the shared expertise of a care team to bring about effective and timely care for patients requiring long-term follow-up and who are not ready for discharge to the general practitioner.

By including specially trained optometrists in our system, patients with critical eye conditions can be given appropriate attention by ophthalmologists, while those with stable eye conditions on long-term follow-up can be cared for by optometrists, supervised by ophthalmologists.

Patient safety and clinical rigour are of paramount importance in the SECC.

Our optometrists are degree-qualified and must pass an extensive training programme conducted by the National Healthcare Group (NHG) Eye Institute.

They see stable patients on long-term follow-up, such as those with dry eyes or early cataract not requiring surgery; they do not assess new patients.

Consultations are supervised by on-site ophthalmologists. Care pathways ensure clinical consistency, and patients are reviewed cyclically by ophthalmologists.

Renowned hospitals like Britain's Moorfields Eye Hospital and Bristol Eye Hospital have embarked on these models for many years and they show excellent results and patient satisfaction.

TTSH is fully accountable for the system of care described under its clinical governance framework.

The roles and responsibilities of the various health-care professionals participating in this project are fully compliant with the privileges and obligations accorded to them by their professional bodies and profession Acts.

It is timely that we adopt proven models of care to provide better access for our population.

Thomas Lew (Associate Professor)
Chairman, Medical Board
Tan Tock Seng Hospital
ST Forum, 22 Oct 2013

Front-line soldiers in war against blindness

IN LAST Saturday's letter ("A step backwards for eye care?"), Dr Jerry Tan said that "First World medical care does not involve optometrists running clinics to treat eye disease" and suggested increasing the number of ophthalmologists in Singapore.

The World Health Organisation defines optometry as a health-care profession that is autonomous, educated and regulated. It adds that optometrists are the primary health-care practitioners of the eye and visual system who provide comprehensive eye and vision care.

This includes refraction and dispensing, detection/diagnosis and management of disease in the eye, and the rehabilitation of conditions of the visual system.

Optometrists in Singapore receive a minimum of three years of tertiary optometric education that is dedicated to the ocular system. Some even do an additional two years of an optometry degree course.

With such intense training in all aspects of the ocular system, optometrists can perform primary eye care effectively and at a lower cost.

Optometrists act as front-line soldiers in the war against blindness and in ensuring that our patients have good-quality vision.

We can diagnose eye diseases and, if necessary, refer the patients to ophthalmologists. For example, we can help monitor the progression of cataract and refer the patient for surgery when necessary.

We can also co-manage stable patients after they have been treated by ophthalmologists, for example, by monitoring eye pressure and visual fields and examining the optic nerve of stable glaucoma patients.

This way, we help to free up time for the ophthalmologists to treat more serious and urgent eye diseases and cut waiting time in the eye departments of hospitals.

The Ministry of Health has recognised the important roles of optometrists and in 2007, regulated the profession to ensure that optometrists are properly trained and equipped to fulfil the role of providing primary eye care.

Just like in other First World countries such as the United States, Canada, Britain, Australia and New Zealand, it is only right that optometry is integrated into the health-care system. It is progress for our nation.

Koh Liang Hwee (Dr)
ST Forum, 22 Oct 2013

Optometrists can provide primary eye care

AS A PhD student and practising optometrist in Australia, I disagree with Dr Jerry Tan's view that optometrists should not be involved in the treatment of eye disease ("A step backwards for eye care?"; Oct 19).

His sentiment that "allowing" optometrists to treat eye diseases is "a step backwards" and "not representative of first-world medical care" is both flawed and unsubstantiated.

Optometrists have been routinely treating eye diseases in first-world countries such as the United States, Britain and Australia for many years.

In my practice, I routinely prescribe eye drops for the treatment of common eye conditions such as conjunctivitis, iritis and glaucoma.

Having undergone training for such intervention and prescribing, I know my limitations and duly refer patients for surgical intervention should the need arise.

Dr Tan's argument that eye surgeons (ophthalmologists) train for 13 years is valid but misleading.

Where I study, medicine and optometry require the same length of study. Doctors wishing to become ophthalmologists undertake further training to become eye surgeons.

The distinction between the two is that optometrists do not perform surgery and therefore do not require the extensive further training needed by an ophthalmologist. Instead, we practise at a primary-care level, similar to a dentist and, like dentistry or general medical practice, undertake a similar level of training.

From a public health perspective, optometrists detect and diagnose more eye diseases than do eye surgeons.

A recent article published in journal Ophthalmology by the UK Glaucoma Treatment Study group concluded that community optometrists in Britain competently detect glaucoma with "remarkable sensitivity", diagnosing cases which might have otherwise gone undetected.

Optometry is a safe, cost-effective, accessible profession capable of providing primary eye care.

Patients who see eye surgeons for simple conditions not requiring surgery inadvertently put unnecessary strain on the public health budget and add to waiting lists.

Having worked in Australia and experienced first-world eye care, I am of the opinion that our country deserves better avenues for training optometrists.

One possibility worth considering is the establishment of an optometry degree programme in one of our local universities.

With extra training, our profession will be well placed to fill the current gap in eye care as primary-care providers.

Jeremiah Lim
ST Forum, 25 Oct 2013

A step backwards for eye care?

AS A senior doctor and eye surgeon (ophthalmologist), I am perturbed and dismayed by Tan Tock Seng Hospital's move to open a clinic manned by optometrists, to cut the workload of eye doctors ("TTSH to open clinic for less serious eye cases"; last Saturday).

First-World medical care does not involve optometrists running clinics to treat eye diseases.

The lack of eye doctors is self-inflicted because there are only a few positions available for doctors wanting to train in ophthalmology in government hospitals.

It takes 13 years of study and training to become a doctor and an eye specialist.

In contrast, it takes only three years to get a diploma in optometry, and an additional two years for a university degree, or four years if one is directly admitted to university.

Obviously, there will be a great disparity in expertise.

Is there any recourse for negligence claims? Will the supervising ophthalmologist or the hospital be liable?

A common case of blurring of vision in the elderly can be due to something as simple as cataracts, or as complex as a brain tumour. If there is a delay in the diagnosis of a brain tumour, it can be fatal for the patient.

This downgrading of medical services is driven largely by costs and a sudden surge in the number of elderly people with eye problems.

Doctors in government hospitals work a five-day week, compared with 51/2 days in the past. Also, the Health Ministry has made the conditions for the employment of foreign eye specialists onerous, convoluted and unnecessarily difficult.

To maintain our First-World medical care, I suggest:
- Increasing the number of doctors training to become ophthalmologists;
- Going back to a 51/2-day work week for doctors in government hospitals; and
- Streamlining the registration for foreign-trained ophthalmologists to work in Singapore.
These are simple measures that can be undertaken without compromising the high standard of care we have strived to achieve.

We should not take a step backwards and allow our citizens to be treated for medical conditions by non-doctors.

Jerry Tan (Dr)
ST Forum, 19 Oct 2013

TTSH to open clinic for less serious eye cases
Manned by optometrists, it will cut growing workload of eye doctors
By Poon Chian Hui, The Straits Times, 12 Oct 2013

TO LIGHTEN the increasing load on its eye doctors, Tan Tock Seng Hospital (TTSH) is opening a new clinic in January to serve those seeking treatment for less serious conditions.

The Stable Eye Condition Clinic, which will be housed in the hospital’s National Healthcare Group (NHG) Eye Institute in Novena, will be staffed by two optometrists who hold degrees in optometry. This initiative was revealed by the Health Ministry’s Permanent Secretary, Mrs Tan Ching Yee, during an eye congress at Singapore Expo yesterday.

Currently, many patients believe that only ophthalmologists have the skill to treat eye conditions, be they mild or serious, said Mrs Tan. “This state of affairs is neither desirable, nor clinically sound, and is certainly unsustainable.” Of the 120,000 patient visits to TTSH for eyesight issues, up to 30 per cent are considered to be “stable cases”, said Dr Wong Hon Tym, medical director of the NHG Eye Institute.

Less serious conditions such as dry eyes, earlystage cataract and spots often do not require prescription medicine. Still, doctors often devote significant chunks of time to attending to patients with such complaints.

“Some may eventually need surgery, but a large number just have to be monitored,” he said. This group can instead be managed by optometrists. Unlike ophthalmologists, they are not licensed to perform surgery, but can conduct eye exams and identify potential diseases.

Up to 1,000 patients are expected to be treated at the new clinic, where the optometrists will be supervised by an eye specialist, next year.

Said Dr Wong: “We are not throwing them out. If their condition turns serious, they can easily link back to the ophthalmologist.” Costs are being worked out, but patients are expected to pay less to see an optometrist instead of an eye specialist, he added. The institute plans to eventually offer the service nearer patients’ homes, such as at polyclinics. Meanwhile, two research laboratories have been set up to develop innovative technology for treating eye problems.

One lab is located at TTSH, and the other at the Institute of Infocomm Research, under the Agency for Science, Technology and Research (A*Star).

One project involves creating a computer system that can generate text in different languages and sizes for eye screening tests. Currently, patients are usually asked to read alphabet or number charts.

But this can be a problem for some, such as those who are unfamiliar with English, said Dr Jimmy Liu, programme manager of ocular imaging at the Institute for Infocomm Research. Yet, a lot of treatment and monitoring processes are based on the test, said Associate Professor Lim Tock Han, NHG’s deputy group chief executive of education and research.

He added: “I think we have not really understood visual acuity measurement in a multicultural environment.”

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