India is home to about 20.5% of the world’s blind, 22.2% of the world’s low-vision population, and 21.9% of those with vision impairment.1 Vision impairment of 88.2% of these Indians is avoidable.2 In addition to the role of other cadres of eye care personnel, it is critical to understand the role of optometrists in alleviating such levels of vision impairment through early detection, correction and treatment, appropriate referral, and counseling.3 An estimated 9000 optometrists have graduated with a minimum 4 years of training from more than 86 optometry institutes and are currently practicing in India.4 Information about the services offered by these optometrists and their contribution to the Indian eye care system is largely missing. This is not surprising for several reasons. One, the level of optometric education and the scope of optometric practice in India have varied significantly in the past. Two, there is an absence of a central registry that records information of optometrists and documents their professional services. Three, the profession has largely lacked regulation, raising suspicion about the use of standard operating procedures, instruments, and necessary tests by practicing optometrists. Although significant progress has been made over the last few years to establish a unified, standardized, and regulated profession,5 the lack of information on the current practice patterns of Indian optometrists remains a deficiency. This study therefore investigated the role of Indian optometrists in addressing vision impairment and reviewed the practice pattern of optometrists in the context of current and emerging eye health challenges in the country.
A cross-sectional Internet-based study was conducted in accordance with the Declaration of Helsinki6 to evaluate the range of clinical services offered by optometrists in various modes of optometric practices in India. Although informed consent was obtained from all survey participants, institutional review board approval was not sought as this study was only intended to collect optometrist’s knowledge on the pattern of optometry practice and range of services. This investigation needed no patient information and clinical or experimental intervention. Optometrists who completed a 4-year bachelor of science in optometry (BSopt or B Optom) program were included in the study. The first 3 years of such a program typically includes in-house academic and preclinical teaching whereas the fourth year is for clinical internship wherein the students are posted at various clinical settings to acquire “real-life” patient experience. Optometrists with a diploma qualification (i.e., with less than 4 years of training) were not included in the study because of the variability in nomenclature, subjects taught, and scope of practice among this cadre of subjects. The course curriculum and the scope of practice of the 4-year trained optometrists, on the other hand, are more organized and clearly documented.
Because of lack of a central registry of optometrists in India, a purposive sampling method was used to select participants for this study. A total of 1674 optometrists were requested to participate through a database compiled by voluntary regional research coordinators by sending an introductory e-mail informing them about the study and providing instructions for completing the survey. Participation requests were also made on social networking sites such as Facebook. Information on the study aim and objectives, participant’s anonymity, and rights to refuse to participate were informed to the participants via e-mail correspondence. The survey was conducted using a commercially available online survey portal (SurveyMonkey), which was open for responses for a period of 2 months. Reminder e-mails to complete the survey were sent to participants every fortnight.
The study questionnaire was developed after a focus group discussion with a team of eight optometrists, of whom four were male and four were female with 4 to 12 years of clinical experience and who provided a range of optometric services. The focus group discussion included overall information and scope of optometric practice and the range and details of clinical services offered by optometrists. It was moderated by the principal investigator, and voice recordings of the discussions were made after obtaining informed consent from the participants. Participatory exercises were conducted with the participants to develop a choice set for questions included in the questionnaire. Ranking and pairwise ranking methods were used to determine the most important themes and response choice set to be included in the closed-ended questions. The information recorded was transcribed into textual data, coded using both deductive and inductive approach, and thematically analyzed to generate themes and categories that were included in the questionnaire. The information shared by the participants such as the tests or instruments currently used in general, types of ophthalmic lenses dispensed, and types of low-vision devices offered were discussed by the authors and those considered relevant were framed as questions. Five key opinion leaders of the optometry profession validated the proposed questionnaire and amendments were made accordingly to arrive at the final questionnaire (see Appendix 1, available online at http://links.lww.com/OPX/A207).
The following edits were made to the data before its analysis using Stata version 11.1 (StataCorp LP, College Station, TX): (1) validation edits to check that every field of a record contained a valid value, (2) missing data to check if relevant fields for a respondent were completed (e.g., an answer to a preceding question may determine that the subsequent questions are to be answered or not answered), (3) logical edits to correct contradictions between fields (e.g., everyone who completed postgraduate studies as well as completed undergraduate studies or work experience should not be more than the years after qualification), and (4) consistency or reconciliation edits to ensure that arithmetic relationships were upheld.7,8 Because majority of the data did not follow the normality assumption (checked using the Shapiro-Wilk test), all statistics were performed using nonparametric statistics (e.g., Mann-Whitney test to check if two independent samples are from the same population distribution and χ 2 test to check if there was a relationship between two categorical variables). Continuous variables were considered to be variables, which can take any value in a defined interval, such as time spent in the field. Other discrete variables such as number of subjects taught were considered for analysis as continuous. Closed-ended questions or questions with options were considered to be categorical, such as the type of discipline or the provision of services (Yes/No). Fisher exact test was used when at least one cell had a count less than 5.
Reliability of responses between survey data and actual data was measured for one section and then extrapolated to the entire data set. For instance, actual contact lens data on the number of fits, materials, design, and modality were collected from 16 randomly selected optometrists, over a 3-month period, and were averaged. These were then compared with the data received from responses to the survey using canonical correlation and intraclass correlation coefficient. There was good correlation between the linear combination of actual measurements and the survey measurements (both r = 0.84; p < 0.01).
Of the 1674 surveys distributed, 641 (38.3%) participants responded to the survey. However, data from only 563 (33.6%) participants were complete with valid responses and therefore included in the study analysis. Invalid responses were received from alumni practicing abroad and from those still in the final year of their optometry training. The valid surveys were from graduate optometrists of 41 optometry institutions working across 23 states and 2 union territories of India. Two hundred twenty-five (40.0%) participants were female. The median year of graduation was 2009 (25th to 75th interquartile range [IQR], 2006 to 2010). The years of experience were distributed across a wide range of up to 33 years, with the median years of experience being 2 years (IQR, 0.8 to 3.6 years). More than half of the participants (51.2%) had completed a postgraduate program after their graduation (Table 1).
Modes of Practice
Almost all respondents (n = 556) indicated that they were involved in at least one mode of practice. Of the total respondents (n = 563), the modes of practice were as follows: hospital-based practice, 44.8% (n = 252); academia, 42.8% (n = 241); working in optical retail, 33.0% (n = 186); research, 23.6% (n = 133); administration, 22.6% (n = 127); owning an optical practice, 22.2% (n = 125); and corporate, 21.3% (n = 120). Out of their total professional time, optometrists reported spending maximum time working in hospital-based practice (24.9%) followed by working in optical retail (22.3%). The average time (percentage) spent in different modes of practice, out of the total professional time, is shown in Fig. 1.
Three hundred forty respondents (60.5%) were involved in more than one mode of practice. Participants who undertook postgraduate studies (248 of 563; 56.0%) had a significantly higher average of the number of modes of practice compared with those who did not (315 of 563; 44.0%) (p < 0.01).
Modes of Practice versus Sex
Relative to female subjects, more male subjects worked as optometrists in optical retail outlets (124 of 338 male subjects; 36.7%; p = 0.02), owned optometry practices (98 of 338 male subjects; 29.0%; p < 0.01), and offered corporate professional services (85 of 338 male subjects; 25.1%; p < 0.01). Female subjects (114 of 225; 50.7%) were mostly involved in hospital-based practices or worked in association with ophthalmologists compared with male subjects (138 of 338 male subjects; 40.8%) (p = 0.02). This trend could be attributed to fixed timings and in office duties while working at hospitals in India. A significant number of female subjects (6 of 225; 2.6%) were not working compared with only 1 of 338 male subjects (0.3%) (p = 0.01).
Range of Services
Respondents indicated that they were involved in providing the following optometry services: academics and research (37.8%; 213 of 563), corporate optometry and administration (40.3%; 227 of 563), community services (53.1%; 299 of 563), and clinical services (78.3%; 441 of 563).
The provision of community services, such as vision screening and awareness programs, was reported by 53.1% (299 of 563) of optometrists, with those involved in these programs showing a significantly higher number of average [SD] years of experience (3.1 [3.8] years vs. 2.5 [2.8] years) (p = 0.02) than those who did not (264 of 563; 46.9%). The median of average days spent on providing community services every year was reported as 15 days (IQR, 10 to 45).
Continuing education programs were attended by 60.9% (343 of 563) of optometrists with a median of 3 programs (IQR, 2 to 5.5) and 24 hours (IQR, 12 to 40) of continuing education undertaken every year. Participants who are currently continuing with their education (343 of 563; 60.9%) had a significantly higher number of average (SD) years of experience of 3.1 (3.7) years compared with 2.3 (2.7) years for participants who are not (220 of 563; 39.1%) (p < 0.01).
Of the 563 participants, 441 (78.3%) reported that they provide clinical services. The top three clinical services provided were refraction and routine eye examinations (434 of 441; 98.4%), contact lenses (310 of 441; 70.3%), and optical dispensing (295 of 441; 66.9%). The average (SD) time spent in providing the top three clinical services was as follows: refraction and routine eye examinations, 40.4% (19.7%); contact lenses, 19.4% (14.0%); and optical dispensing, 15.3% (15.3%) (Fig. 2).
Routine Eye Examination
Routine eye examinations were conducted by 98.4% (434 of 441) of clinicians. A median of 160 (IQR, 80 to 380) refractions was performed every month. The Snellen chart was used for testing vision by 91.7% (398 of 434), whereas the logMAR (logarithm of the minimum angle of resolution) chart was used by 52.1% (226 of 434) of optometrists. Trial frames and trial sets were still the most commonly (85.3%; 370 of 434) used instruments for vision testing. The autorefractometer (47.9%; 208 of 434) was almost equally preferred to retinoscope (51.6%; 224 of 434) for performing objective refraction. Most clinicians performed slit lamp examinations (68.7%; 298 of 434) and tonometry (57.2%; 174 of 434) on every patient. Fundus examination, using a direct ophthalmoscope, was performed routinely by 20.7% (90 of 434) of optometrists, whereas 50.0% (217 of 434) performed it only when indicated. Indirect ophthalmoscopy was performed by 29.8% (129 of 434) of optometrists when needed, whereas only 2.8% (12 of 434) made it a routine practice.
A significant difference was found for the pattern of routine eye examination performed and the level of education. Significantly more optometrists who completed postgraduate studies (excluding master of business administration [MBA]) performed higher number of average [SD] refractions per month (316.9 [328.7]) than graduates (251.8 [276.8]) (p = 0.02), used the logMAR chart (96 of 152; 63.2% of postgraduates vs. 130 of 282; 46.1% of graduates) (p < 0.01) and retinoscope (99 of 151; 65.6% of postgraduates vs. 125 of 281; 44.5% of graduates) (p < 0.01), used the slit lamp biomicroscope at least when indicated (147 of 152; 96.7% of postgraduates vs. 257 of 282; 91.1% of graduates) (p = 0.04), used the Schiotz tonometer (16 of 152; 10.5% of postgraduates vs. 20 of 282; 7.1% of graduates) and applanation tonometer (90 of 152; 59.2% of postgraduates vs. 88 of 282; 31.2% of graduates) (p < 0.01), performed cycloplegic refraction (129 of 151; 85.4% of postgraduates vs. 160 of 278; 57.6% of graduates) (p < 0.01), and conducted a color vision test when indicated (148 of 152; 97.4% of postgraduates vs. 260 of 282; 92.2% of graduates) (p < 0.01).
An association was evident between the availability and type of instruments used to level of education. More graduates reported the unavailability of direct ophthalmoscope (66 of 282; 23.4% of graduates vs. 16 of 152; 10.5% of postgraduates) and indirect ophthalmoscope (169 of 282; 59.9% of graduates vs. 43 of 152; 28.3% of postgraduates) (p < 0.01). More graduates reported the use of a noncontact tonometer (24.6%; 69 of 282) or that a tonometer was not available (37.0%; 104 of 282).
Optical Dispensing and Contact Lenses
Two hundred ninety-five optometrists (66.9%) of 441 reported that they practiced optical dispensing whereas contact lenses were reportedly dispensed by 70.3% (310 of 441) of respondents. About half of the contact lenses dispensed were reported to be new fits. Slit lamp biomicroscope (70%; IQR, 50 to 100%) and keratometer (40%; IQR, 20 to 80%) were frequently used as investigative instruments for contact lens fitting. For details, see Appendix 2 (available at http://links.lww.com/OPX/A208).
The use of corneal topographers for contact lens fitting was significantly high among postgraduate optometrists (108 of 310; 34.8%) compared with graduate optometrists (202 of 310; 66.2%) (p < 0.01). Postgraduate optometrists (108 of 310; 34.8%) also fit significantly higher number of RGP lenses (p < 0.01), lenses for keratoconus (p < 0.01), lenses for orthokeratology (p = 0.02), and scleral lenses (p < 0.01) when compared with graduate optometrists (202 of 310; 66.2%).
Binocular Vision and Orthoptics
Binocular vision and orthoptics was reportedly practiced by 45.1% (199 of 441) of respondents. The median of various cases seen per month in an orthoptic clinic was as follows: convergence and accommodation anomalies, 13.5 (IQR, 5 to 30); strabismus, 7 (IQR, 4 to 20); and amblyopia, 7 (IQR, 5 to 20). Occlusion therapy was the most commonly used modality of treatment for binocular vision anomalies (see Appendix 2, available at http://links.lww.com/OPX/A208).
Postgraduate optometrists (72 of 199, 36.2%) used prism bar, synoptophore, and Maddox rod/wing significantly more (p < 0.01) to perform orthoptic examination and investigations. They also demonstrated significantly higher use of prism bar techniques/exercises, synoptophore technique/exercises, stereogram technique/exercises (p < 0.01), and occlusion therapy (p = 0.02) while treating orthoptic conditions in comparison to optometrists who did not undertake postgraduate studies (127 of 199; 63.8%).
Respondents engaged in assessment and correction of low vision (133 of 441; 30.2%) reported that they examined a median of 9 (IQR, 3 to 20) patients per month with a median evaluation time of 30 minutes (IQR, 30 to 60) per case of low vision (see Appendix 2, available at http://links.lww.com/OPX/A208).
Postgraduate optometrists (60 of 120; 50%) took longer evaluation time per case than graduate optometrists (60 of 120; 50.0%) (p < 0.01). Postgraduate optometrists (63 of 133; 47.4%) also reported to dispense a higher number of optical devices (p < 0.01), including telescopes (p = 0.02) and prismospheres (p < 0.01), compared with graduates (70 of 133; 52.6%).
Clinical investigations were performed by 44.0% (194 of 441) of the clinicians. A median of 60 (IQR, 20 to 200) patients received various clinical investigative procedures every month. Slit lamp biomicroscopy, keratometry, perimetry, ophthalmoscopy, and A-scan were the most frequently performed procedures. Advanced instruments like optical coherence tomography (OCT), topography, Orbscan, Pentacam, glaucoma diagnostic test (GDx), Heidelberg retinal tomography (HRT), and specular microscopy had limited use.
No significant difference was found between the average number of clinical investigations performed per month for those who undertook (66 of 165; 40.0%) and who did not undertake postgraduate studies (99 of 165; 60.0%) (p = 0.13). However, when analyzed by the mode of employment, optometrists working in hospitals (114 of 165; 69.1%) performed higher average number of clinical investigations per month when compared with optometrists working in other modes (51 of 165; 30.9%) (p < 0.01).
Use of most of the advanced investigative procedures (e.g., GDx, HRT, and OCT) did not show any significant difference based on level of education. However, as represented in Table 2, optometrists who were employed in hospital-based practices performed higher number of advanced investigative procedures as compared with those who worked in other modes of practice. The use of routine investigative procedures like slit lamp biomicroscopy and direct ophthalmoscopy did not show a statistically significant difference based on modes of practice.
Academia and Research
Engagement in academia and research was reported by 37.8% (213 of 563) of optometrists. Postgraduates, excluding MBA (46 of 100; 46%), were more inclined to academia or research than graduates (23 of 100; 23%) (p < 0.01). A large number of educators (130 of 213; 61.0%) were involved in teaching more than two subjects. The subject-wise distribution of respondents involved in teaching is given in Table 3.
Furthermore, 32.3% (69 of 213) of optometrists involved in academia and research were also engaged in conducting Continuing Education Programs on the following subjects: contact lenses (37 of 69; 53.6%), dispensing optics (18 of 69; 26.1%), low vision (17 of 69; 24.6%), disease and investigations (14 of 69; 20.2%), and binocular vision (11 of 69; 15.9%). A statistically significant difference was found with regard to the number of national presentations (p < 0.01), international presentations (p < 0.01), and publications (p < 0.01) for those who undertook postgraduate studies (118 of 213; 55.4%) and those who did not (95 of 213; 44.6%).
Corporate Optometry and Administration
An association was found in the study between sex and being involved in corporate optometry. Significantly more male subjects (85 of 338; 25.2%) were involved in corporate optometry than female subjects (35 of 225; 15.6%) (p < 0.01). More than half the optometrists (17 of 30; 56.7%) who completed MBA (without other postgraduate qualifications) were involved in corporate optometry.
This is the first systematic survey conducted on the practice patterns and range of services provided by optometrists in India. The strength of this survey lies in the number of respondents and the impact these results will have toward documenting the current state of affairs of the profession and in revamping the future scope of optometry practice in India.
In developed countries like the United States, where optometry is now a standardized, regulated, and legislated profession, the development of optometry underwent logical progressive change. The reforms that occurred were mainly based on two factors: adequate education and public interest at large.9 Increasing patient demand for surgery increased the surgical burden placed on ophthalmologists and thus there was a need felt to expand the role of optometrists, to address the nonsurgical aspects of ocular conditions. This led to major changes in the scope of practice of optometry in the past 30 years.10
Similarly, understanding the current pattern of optometric practice in India will help make appropriate reforms to the scope of optometric practice to effectively address the mammoth demand for vision care. It may also necessitate revamping of core optometry education in the country to produce skilled and competent optometrists.
Modes of Practice
The study found that optometrists in general are involved in multiple modes of practice. This can be attributed to a combination of factors:
- Dearth of optometrists in India. It is estimated that India requires 115,000 optometrists to cater to the vision care needs of the Indian population.4
- Additional source of income/revenue generation.
- Job satisfaction or interest in multiple fields.
- Disciplines complementing each other (e.g., clinical experience can enable educators to explain situations and demonstrate skills better).
It was further noted that although a similar number of respondents was involved in hospital-based practice (44.8%) and academia (42.8%), the average time spent on these two modes is 24.9% and 15.8%, respectively. This is indicative of a “part-time” nature of the academic role.
There is substantial need to develop, test, and implement evidence-based interventions that translate research into enhanced clinical and community practice to effectively deliver eye health interventions. However, the study found that 133 optometrists spent limited time in research, which could be attributed to a number of factors such as lack of infrastructure, guidance, and interest in research. Further probing is required to understand the factors preventing optometrists from conducting research.
Only 45.1% of optometrists performed binocular vision and orthoptics examinations, 30.2% provided low-vision services, and 44.0% performed other clinical investigations. It was dissatisfying to find optometrists investing little time in providing these core optometry services. Although these services may be regarded as time consuming and less rewarding financially, there is a strong need to sensitize optometrists about the importance of providing these services to successfully manage the visually impaired population in India. It is also important to encourage ophthalmologists to refer patients with vision impairment for low-vision services.
Mode of Practice and Range of Services
Usage of advanced investigative procedures was not found to be influenced by higher education but rather by the mode of practice. Advice from ophthalmologists for detailed investigations and the availability of such instrumentation at tertiary eye care centers could be the reasons why optometrists who are based in hospitals are seen to perform advanced investigations. The equal use of basic investigative procedures like slit lamp biomicroscopy and ophthalmoscopy in hospital- and nonhospital-based practices reflects that comprehensive eye examinations are performed, even by optometrists in optical practice. This is an encouraging sign as patients visiting optical practices for an eye examination will also undergo these important tests.
Impact of Postgraduate Education
The multidisciplinary practice trend is even more strongly reflected in optometrists with postgraduate qualification. In addition to the reasons listed earlier, this could be attributed to an increased demand and more opportunities being offered to them.
Optometrists with a postgraduate degree or even fellowship seem to understand the importance of a comprehensive clinical examination and investigations and also seem to be confident when performing them. This is reflective in the current practice pattern of postgraduate optometrists who perform comprehensive basic examination and are involved in advanced level of contact lens dispensing as well as orthoptic and low-vision evaluation and management.
Limitations of the Study
This study has limitations that should be considered in future studies of this nature. Probable reasons for the limited response rate (563 of 1674) could be related to the following:
- Failure to deliver the survey link to the target population (incorrect e-mail address, inability to access e-mails, etc.)
- Reluctance of the target population to respond.
- Inability to comprehend a particular question resulting in incomplete surveys.
Furthermore, it was not possible to evaluate practice patterns based on an urban and rural geographical divide because of the lack of registry data for optometrists and the investigator’s lack of knowledge on separating the urban and rural areas. Such information could be pivotal to policy-makers and program planners.
This study documented the current-day scope of optometry practice and the range of services that optometrists provide in India. Most optometrists are involved in multiple modes of practice. Optical practice, hospital-based practice, and academia were the leading modes. Routine eye examination, contact lenses, and optical dispensing were the top three clinical services provided. Optometrists need to be more involved in providing the core optometric services of binocular vision and low vision. Higher education was associated with better level of practice and involvement in multiple modes of practice. There are more opportunities available to optometrists who have a higher qualification, especially in the field of academia and research.
We thank the experts, namely, Shehzad Naroo, Sonja Cronje, Judith Morris, Yeshwant Saoji, and Lakshmi Shinde, and all the optometrists for taking time to complete the survey.
We thank KJ Abhishek, Ajay Mishra, Amod Gogate, Arun Kumar, Bausch + Lomb Professional Services Team—India, Gaurav Kumar Bharadwaj, Gazal Amini, John KK, Kiran Challa, Manisha Ghai, MD, Oliullah Abdal, Monica Chaudhry, Moumita Sarkar, Pinaki Patra, Prashant Jaiswal, Prema Chande, Rajesh Kumar, Rajesh Wadhwa, Rushit Patel, Ukti Shah, Vivek Mendonsa, and Yeshwant Saoji for assisting in the compilation of a database of optometrists with their contact details.
Received June 5, 2014; accepted January 27, 2015.
Appendix 1, a summary of the questionnaire, is available at http://links.lww.com/OPX/A207.
Appendix 2, the details of clinical services, is available at http://links.lww.com/OPX/A208.