Blindness and vision impairment continue to be significant public health issues in India. The National Programme for Control of Blindness has emphasized the need for cataract surgical services and refraction services to be augmented, both in quantity and quality, in order to achieve the goal of eliminating avoidable blindness by 2020. Cataract continues to be the leading cause of blindness in India with three out of every four people, above the age of 50 years, blind due to cataract. However, uncorrected refractive error remains a major cause of avoidable vision impairment and the second most common cause of blindness in India. The World Health Organization (WHO) estimates that approximately 39.3 million, including 1.6 million children in India, are blind or visually impaired due to uncorrected refractive error. A recent report states a yet higher prevalence of uncorrected refractive error around 133 million people blind or vision impaired including 11 million children due to lack of an eye examination and provision of an appropriate pair of spectacles. In addition to this, in 2010, the number of people with glaucoma in India (most of whom are undiagnosed) was almost 12 million. Almost 96.4% of vision impairment in the population aged 50 years and over is treatable or avoidable. To eliminate vision impairment and avoidable blindness, adequate standardized and regulated training of eye care personnel is essential.
Disorders of the eye and vision have broad health cost implications in addition to the potential for causing disability, suffering, and loss of productivity. Global economic productivity loss in international dollars (I$) associated with refractive error is in the range of I$191.1–427.7 billion without adjustment for country-specific labour force participation and employment rates, with I$23 billion in India alone. Hence, provision of quality optical correction would benefit the Indian economy significantly.
Access to a comprehensive eye examination and spectacles in India is limited by insufficient trained human resources and inequitable distribution of professionals. At present ophthalmologists bear much of the burden of providing comprehensive eye care in India. The ophthalmologist to population ratio in urban India is 1:25,000. However, in the rural areas of India, the ratio is close to 1:219,000 population. Seventy percent of the ophthalmologists are located in urban areas where approximately 23% of the population of India reside. This discrepancy indicates the pressing need for rural eye care professionals.
In 1998, researchers at the LV Prasad Eye Institute highlighted the escalating burden of blindness and vision impairment in India, discussing the need for increased numbers of eyecare professionals to address these issues of avoidable vision impairment and blindness. In particular, they called for the development and utilization of an Indian profession of optometry. This work attempts to identify the roles and challenges of optometrists in India and discusses the strategies undertaken to develop optometry as a regulated and independent profession.
The education and training of optometrists in India ranges from two-year trained ophthalmic assistants/optometrists or refractionists to four-year trained optometrists [Table 1]. Some institutions provide a one-year vision technician course; however, this does not comply with the minimum optometrist training duration set by the Indian Optometry Federation. India has approximately 9000 four-year trained optometrists and 40,000 two-year trained eye care personnel. To provide comprehensive vision care to all the people of the country, 115,000 four-year trained optometrists are required. It is imperative that regulation and standardization of training and care define this emerging profession in India.
Currently, ophthalmic assistants work as independent associates of ophthalmologists in many hospitals testing vision and prescribing spectacles; performing orthoptic examination, tonometry and visual fields; managing minor operation theatre procedures along with school eye screening and training peripheral staff (Accredited Social and Health Activist [ASHA] workers and Anganwadi workers, multipurpose health workers); and performing preoperative testing (syringing, A-scan, preparation of eye and local anaesthesia before surgery and postoperative care).
According to the Delhi Declaration on Optometry and Blindness Prevention in India, optometry should encompass all those who refract, detect adverse eye conditions and eye signs of general adverse health conditions and prescribe visual aids as part of comprehensive primary eye care. While two-year trained optometrists provide refraction, dispense spectacles and contact lenses and provide basic diagnostic services, four-year professionally trained optometrists provide comprehensive vision care. In order for increased equity in vision care and eye health, there must be widespread implementation of four-year education programs and regulation, which is just beginning to be realized. Through development and implementation of four-year education programs and the push toward regulation, the profession of optometry in India is beginning to position itself to provide a widespread private and public role in vision care as a vital component of the eye health partnership with ophthalmology.
The Role and Challenges of Optometry in India
According to the definition of World Council of Optometry (WCO), an organization which represents over 250,000 optometrists worldwide, “Optometry is a healthcare profession that is autonomous, educated, and regulated (licensed/registered), and optometrists are the primary healthcare practitioners of the eye and visual system who provide comprehensive eye and vision care, which includes refraction and dispensing, detection/diagnosis and management of disease in the eye, and the rehabilitation of conditions of the visual system”.
Refractive error services provide a practical entry point into the eye health system for those needing correction. With 88.2% of blindness avoidable in India, it is important to provide a comprehensive ocular health examination alongside the refractive error services.
Fully qualified optometrists with a minimum of four years of training are qualified to:
- Prescribe the latest advances in spectacle lenses including progressive, aspheric, and safety/protective spectacles based on the visual needs of the patient,
- prescribe rigid and soft contact lenses including orthokeratology, frequent replacement, and extended wear contact lenses,
- conduct complex contact lens fitting for paediatric eye conditions, keratoconus, postsurgical complications, eye trauma, and corneal ectasia,
- prescribe vision therapy, vision training or orthoptic treatment for children with learning problems or common binocular vision disorders, including strabismus and ambylopia,
- provide low vision and rehabilitative services-vision aids assisting visually impaired people to use their functional vision more effectively,
- detector diagnose ocular conditions and associated systemic health conditions, and refer them to appropriate health care professionals, and
- offer counselling services on preventive vision care.
The services offered by an optometrist vary from country to country. The scope of practice of optometry in India is still poorly defined. The public do not have a clear understanding of the role and responsibility of optometrists in the healthcare system. There are multiple cadres of optometrists providing eye care services with varying levels of skill and training.
Comprehensive vision care comprises evaluation, assessment, management, and coordination of a wide range of health care needs with appropriate referral to ophthalmologists or general practitioners when required. In addition to early detection and preventative care, optometrists educate patients regarding the status of their vision and eye health, advise when to seek assistance to ensure early intervention, promote lifestyle choices to ensure good vision and health, provide information regarding visual ergonomics, identify environmental hazards to the eyes and vision, and educate the community to prevent problems and maintain ocular health.
Ongoing communication and common referral systems between optometrists, ophthalmologists, and other medical and rehabilitation professionals provide improved patient management and benefit public wellbeing. Four-year trained optometrists are able to take an active role in the co-management of vision and eye care problems of their patients along with general practitioners and other health professionals. At present, co-managed care between ophthalmologists and optometrists is relatively uncommon in India. With more four-year trained optometrists and the regulation of practice and education, it is expected that highly trained optometrists will play a vital role in inter-professional communication.
Indian two-year diploma optometrists are trained in refraction, and some also have training in contact lenses, ocular disease detection, diagnosis as well as binocular vision and low vision. Eye care personnel with fewer than four years training are less expensive to train; however, they lack the theoretical underpinning, critical thinking skills and ability to contribute to clinical decision-making and vision research. Ophthalmologists require much more expensive training to be able to provide these services.
Four-year trained optometrists offer a reasonable human resource approach as they acquire sufficient basic training and experience to provide comprehensive vision care. Four-year trained optometrists are able to perform comprehensive examination of both the internal and external structures of the eye, carry out subjective and objective tests to evaluate patients’ vision, analyse the test findings, and establish a diagnosis and initiate appropriate management. It is thus more efficient to use four-year trained optometrists, freeing up ophthalmologists for surgery and for treatment of complex cases.
It is not cost effective for the eye health system to provide refractive and ocular disease detection only in tertiary eye health services. Regulated and standardized 4 year trained optometrists can make a major contribution to eye care in a more convenient and cost effective way at a community level.
In countries such as Australia, the United States and United Kingdom, optometry is practiced in accordance with strict regulatory guidelines. An independent regulatory body ensures all people who seek the services of an optometrist receive a consistent and high standard of comprehensive eye care. Registered optometrists are required to adhere to a code of practice, standards and guidelines that define the practice of optometrists. The registration boards are also responsible for approving accreditation standards and accredited courses of study to ensure graduating practitioners have the skills and competency to practice optometry to a high standard.
Optometry in India is making progress toward regulation. The Optometry Council of India, which is due to commence in late 2012, will serve as a peer reviewed independent statutory body to promote high standards of professional practice and conduct and assure quality control in education and in the practice of optometry. The council will deal with complaints against registered optometrists regarding matters of professional misconduct, and implement disciplinary action against those who do not adhere to the code of practice. Therefore, the scope of practice needs to be clearly defined.
The Future of Optometry in India
Regulating optometry and defining the scope of practice for an optometrist
While optometry is not recognized by the Government of India as an independent healthcare profession, the Optometry Council of India will be a self regulating body to accredit practitioners and optometry schools against a set of guidelines. Initially, the Optometry Council of India will register those with less than a four-year degree, providing mechanisms for any such candidate to reach the requisite level of skills and knowledge of a four-year trained professional. This will be achieved through the development and implementation of bridging courses and lateral entry into optometry training programs by schools and colleges of optometry. By 2020, it is envisaged that the Optometry Council will only accept new registrations from four-year qualified optometrists.
With input from the Association of Schools and Colleges of Optometry and Indian Optometry Federation, the Optometry Council of India will develop a national system for the accreditation of optometry schools, colleges and training institutions through the implementation of a Common Minimum Optometry Curriculum and have competency skill level evaluations and assessments for each level of optometry. Registered practicing optometrists will be required to participate in continuing education courses to encounter the new challenges of changes in technology and practice spectrum.
The unification of optometry: The Indian Optometry Federation
India has at least 13 major state and national optometry and ophthalmic assistant associations. To achieve regulation and recognition of optometry, the profession must be represented by a single peak body to provide a common platform and united voice for optometry in India.
The Indian Optometry Federation (IOF) was registered as a national body in 2011. The IOF has adopted a single nomenclature “optometrist” for all practitioners with qualifications of two or more years [Table 1]. Optometrists, ophthalmic assistants and ophthalmic officers who have 10 years of school, two years of science training, and two years of clinical placement, or higher qualifications have joined the associations and organizations that have formed the IOF. Currently, IOF has 13 member associations.
The IOF is actively working on creating public awareness about optometry and its contribution to society. In addition, it is actively lobbying the government to obtain independent status for optometry in India. The IOF is also a member of VISION 2020 India and is planning to work actively with them to achieve distribution of human resources throughout the country with respect to eye care so that the goals of VISION 2020 are met.
Through the IOF, the profession of optometry in India is currently making the necessary changes to establish itself as an integral part of the health system. Strategies that are being undertaken to enable this include:
- Defining the scope of practice of an optometrist
- Unification of optometry under one professional organization
- Advocating the regulation of the practice of optometry by the government
- Registration of optometry as an independent profession
- Building of optometric human resources and infrastructure for eye care delivery
- Development of a public health responsibility and rural placement strategy for undergraduate optometrists
- Contribution to clinical and fundamental vision science research
Registering optometry as an independent health care profession
Currently, optometry is considered by some to be an allied health or paramedical profession in India. Considering the primary access by the public, the skills and services provided by optometrists, and the contribution to knowledge by optometric research, optometry must be considered an independent profession and be afforded an independent government controlled council such as pharmacy and dentistry. The optometrist, being the first line of contact in eye care, must be legislated to work independently in order to provide essential eye care service across the country, detect various systemic diseases in the population and work collaboratively with ophthalmologists.
Building human resources and infrastructure
Optometry schools require a large cohort of skilled faculty to meet the enormous education needs. Initially, priority should be given to up-scale existing education resources, infrastructure, and educators. Currently, there are around 70–100 optometric academics in India with postgraduate qualifications, mainly Masters degrees. Increasing the number of educators with postgraduate qualifications will build the capacity of schools to produce high quality research.
For optometry to establish itself in India it is important for the profession to contribute to the field of eye care through research and publication in peer reviewed journals. Publications in peer reviewed journals are a statement of independent science and knowledge. They are the public face of the profession, showcasing the work of optometry not only to other practitioners and scientists, but also to policy makers and the public. Research by optometrists facilitates sharing of new information, allowing clinicians to benefit from clinical observations and scientific discoveries.
To address this, the India Vision Institute (IVI), established in October 2011 by the Brien Holden Vision Institute and LV Prasad Eye Institute, is coordinating a major business strategy to develop the necessary human resources, infrastructure, and research advancement to provide quality vision care for India and also establish a vision industry of global significance and impact. IVI has conducted workshops and forums to assist optometry colleges including the International Centre for Eye Care Education (ICEE) EyeTeach workshops, forums on refractive error, research methodology workshops and low vision awareness programs. IVI is currently providing scholarships for Indian optometrists to undertake postgraduate education in India.
Developing public health responsibility and rural placement undergraduate optometry
With adequate training and regulation, optometrists are able to provide comprehensive eye care in private, hospital and remote environments without supervision. As training four-year optometrists does not ensure they will practice in rural regions, it is important that any strategy for training optometrists also includes methods to recruit and retain them, including providing incentives and career systems to encourage practice in rural communities.
The WHO has issued specific recommendations for the recruitment and retention of rural health professionals. Broadly, these can be grouped into three areas–education and regulatory interventions (e.g., targeting rural students for admission, and early and frequent exposure to rural practice while training), special compensation (e.g., an allowance for working in rural, remote or difficult areas, or providing housing), and management systems (including better education opportunities for those who want to pursue further studies and supportive supervision).
The training and scope of practice of optometry in India has been somewhat fragmented in the past but has, in the last two years, made tremendous progress toward the establishment of a unified, standardized, and regulated profession that will meet its responsibilities for vision care, eye health, and provision of optical services to all those needing vision correction. Progress has included the formation of the IOF, the adoption of the Common Minimum Optometry Curriculum, the development and adoption of the Delhi Declaration, the commitment to a four-year degree program for all optometry registrants from 2020, and the establishment of a peer review Optometry Council of India to oversee education and educational institutions and to register optometrists. This augurs well for the elimination of the blindness and impaired vision due to uncorrected refractive error that affects 133 million Indians at a societal cost of over I$23 billion in lost productivity and for 456 million Indians requiring vision correction to go about their daily lives. Indian optometry awaits approval from the Government of India to grant an independent healthcare professional status to optometrists. This will benefit the people of India, providing eyecare services for all, regardless of their economic status or geographical location.
The authors thank Dr. David Wilson, for having assisted by proofreading the manuscript, and Optometry Giving Sight for their support of the development of optometry in India.