Recognition of ocular therapeutics in optometry

profpaul — Paul Ramkissoon was born in Inanda, Duban. He chose optometry as a career after receiving his first pair of spectacles from a hospital clinic while in foster care in standard 7. Paul obtained a Bachelor of Optometry degree from the University of Durban-Westville in 1987. He is a perpetual student and is an alumnus of RAU and Newenco. He has the unique distinction of successfully completing all academic qualifications offered in optometry and holding two doctorates. Eleven optometry qualifications in total! He is actively engaged in the optometric management of children with learning difficulties and perceptual problems and is a pioneer in overnight Orthokeratology. Paul describes himself as a “person who eats, drinks and sleeps optometry” and is grateful for the lifestyle that optometry provides his family.

Introduction

SOUTH AFRICAN OPTOMETRISTS with the necessary qualifications can now use pharmaceutical agents to treat ocular diseases. Both the HPCSA and the Medicines Control Council have approved the use of medicines for diagnostic and therapeutic purposes by optometrists.

This article looks at the legislation governing optometry and the steps required for an optometrist to practise the enhanced scope: Ocular Therapeutics in Optometry.

Legislation governing the scope of optometry

The scope of optometry as published by the Government Gazette No.29748, 5 APRIL 2007 reads as follows:

Acts pertaining to the profession of optometry

(1) The following acts are hereby specififed as acts which, for the purposes of the Act, are deemed to be acts pertaining to the profession of optometry:

(a) The performance of eye examinations on patients with the purpose of detecting visual errors in order to provide clear, comfortable and effective vision; and

(b) the correction of errors of refraction and related factors by the provision of spectacles, spectacle lenses, spectacle frames and contact lenses, and the maintenance thereof, and the use of scheduled substances as approved by the board and the Medicines Control Council or by any means other than surgical procedures.

Although the legislation governing the scope of optometry allowed South African Optometrists to treat ocular disease as far back as 2007, approval was still required from the HPCSA and Medicines Control Council. These bodies as well as other relevant organisations were engaged to enable the legislative framework and appropriate education and clinical training to get optometrists to use therapeutics.

Legislation permitting optometrists to treat ocular diseases

Appearing in the Government Gazette, dated 3 June 2016, “The Minister of Health has, in terms of section 22A(2) of the Medicines and Related Substances Act, 1965 (Act 101 of 1965), on recommendation of The Medicines Control Council, made and updated the Schedules in the Schedule” to include optometrist with therapeutic privileges. Below are the relevant extracts from the Gazette:

Optometrist (Bachelor’s degree in Optometry-BOptom) registered with the Health Professions Council of South Africa in terms of the Health Professions Act, 1974 (Act 56 of 1974) and in possession of a Section 22A (15) permit as provided for by the Medicines and Related Substances Act, 1965 (Act 101 of 1965).

Schedule 1

In terms of section 22A(4)(a)(v) of the Act, a practitioner, nurse or a person registered under the Health Professions Act, 1974 (Act No. 56 of 1974) other than a medical practitioner or dentist may prescribe and supply, only within his/her scope of practice and subject to the indication for use of such substances and medicines and to the conditions determined by the Medicines Control Council, to patients under his/her care, the Schedule 1 substances and medicines provided for in the Annexures to this Schedule published in the Gazette in terms of the Act.

Schedule 2

In terms of section 22A(5)(f ) of the Act, a practitioner, nurse or a person registered under the Health Professions Act, 1974 (Act No. 56 of 1974) other than a medical practitioner or dentist may prescribe and supply, only within their scope of practice and subject to the indication for use of such substances and medicines and to the conditions determined by the Medicines Control Council, to patients under his/her care, the Schedule 2 substances and medicines provided for in the Annexures to this Schedule published in the Gazette in terms of the Act.

Schedule 3

Schedule 4

Professional board for optometry and dispensing optitians (PBODO) regulations governing therapeutics

Paul-therapeuticspdf — **Figure 1.** Optometrist, Ntuthuko Mthimkhulu
(one of the first batch of optometrists to complete 600 clinical hours) at his farewell function organised by the Madadeni Hospital Eye Clinic staff on his last day of clinical rotation. *Courtesy, Sister L. Lawrence.*

Currently, the only post-graduate course approved by the HPCSA that meets the statutory requirements is the Post Graduate Certificate in Ocular Therapeutics (PGCOT) run by UKZN. The pre-requisite for the PGCOT is the HPCSA approved-diagnostic course. UKZN in partnership with the State University of New York (SUNY) has fi nished training 2 groups of optometrists from across South Africa in the recognised therapeutics curriculum. The PGCOT course has 3 modules. Module 1 and 2 covers many ocular conditions and the management thereof. Also, these two modules deal with pharmacology and systemic conditions as well. Module 3 encompasses ethics, epidemiology and important public health concepts. After successful completion of all three modules, UKZN off ers a letter that the optometrist uses to gain access to public ophthalmology departments to complete a minimum of 600 hours of practical training utilising the skills taught and prescribing therapeutics under clinical supervision of an ophthalmologist or medical officer. The Optometrist notifies UKZN of the public institution he/she will commence the clinical rotation. Log sheets have to be completed indicating the treatment followed for each patient which has to be signed by the ophthalmologist/medical officer. The log sheets must also bear the hospital stamp. The log sheets must be forwarded to UKZN every 3 months. A portfolio of evidence containing 10 interesting cases is also submitted. The HPCSA may visit the optometrist at the clinical site at any time. After completion of the clinical training, UKZN issues the successful optometrist a certificate which the optometrist submits together with form 19 ODO in order to get official recognition of Ocular Therapeutics in Optometry. This qualification will appear on the optometrist’s HPCSA registration card thereafter. Practitioners who hold the new PGCOT qualification must still apply for a permit that authorises them to acquire, use and supply medicines in terms of Section 22A(15). The annual renewal requires optometrists to complete a designated form and attach their current HPCSA registration, expired permit, and copy of ID. The completed application is forwarded to the following email address: permits@health.gov.za

SCHEDULE 1
ANALGESIC
Substance	Paracetamol
Indication	Mild Pain
Route of administration	Oral
ANALGESIC/ANTI-INFLAMMATORY
Substance	Ibuprofen
Indication	Mild to Moderate pain
Route of administration	Oral

SCHEDULE 2
ANTIBACTERIAL
Substance	Mupirocin
Indication	Impetigo(Eyelids),
	External Hordeolum,
	Infected atopic dermatitis
Route of administration	Topical application
ANTIHISTAMINE/VASOCONSTRICTOR/MAST CELL STABILISER
Substance	Antazoline
Indication	Allergic and Atopic Conjunctivitis
Route of administration	Topical application
ANTIHISTAMINE/VASOCONSTRICTOR/MAST CELL STABILISER
Substance	Tetrazoline
Indication	Minor ocular irritation, Red eye
Route of administration	Topical application
ANTIHISTAMINE/VASOCONSTRICTOR/MAST CELL STABILISER
Substance	Oxymetazoline
Indication	Minor ocular irritation, Red eye
Route of administration	Topical application
ANTIHISTAMINE/VASOCONSTRICTOR/MAST CELL STABILISER
Substance	Cetrizine, Loratidine, Levocetirizine
Indication	Atopic dermatitis involving the eyelids
Route of administration	Oral
ANTIHISTAMINE/VASOCONSTRICTOR/MAST CELL STABILISER
Substance	Sodium Cromoglycate
Indication	Vernal Keratoconjunctivitis
Route of administration	Topical application
STEROIDAL ANTI-INFLAMMATORY
Substance	Hydrocortisone
Indication	Dermatitis, Ectopic or Seborrhoeic Eczema
Route of administration	Topical application

SCHEDULE 3
CYCLOPLEGICS
Substance	Atropine
Indication	Cycloplegic refraction, Treatment of Uveitis
Route of administration	Topical application (drops)
MYDRIATICS/CYCLOPLEGICS
Substance	Tropicamide
Indication	Cycloplegic, Mydriatic
Route of administration	Topical application (drops)
MYDRIATICS/CYCLOPLEGICS
Substance	Cyclopentolate
Indication	Cycloplegic,Mydriatic
Route of administration	Topical application (drops)
MYDRIATICS/CYCLOPLEGICS
Substance	Homatropine
Indication	Cycloplegic,Mydriatic
Route of administration	Topical application (drops)
MYDRIATICS/CYCLOPLEGICS
Substance	Homatropine
Indication	Cycloplegic, Mydriatic
Route of administration	Topical application (drops)
ANTI-GLAUCOMA
Substance	Pilocarpine
Indication	Acute Glaucoma
Route of administration	Topical application (drops)
ANTI-GLAUCOMA
Substance	Timolol
Indication	Acute Glaucoma
Route of administration	Topical application (drops)

SCHEDULE 4
ANTIBACTERIAL
Substance	Chloramphenicol
Indication	Bacterial conjunctivitis, Anterior blepharitis, Posterior blepharitis
Route of administration	Topical application
ANTIBACTERIAL
Substance	Tetracycline
Indication	Chlamydial conjunctivitis, Blepharitis
Route of administration	Topical application
ANTIBACTERIAL
Substance	Erythromycin
Indication	Chlamydial conjunctivitis, Blepharitis, Impetigo (Not to be used as 1st line of treatment)
Route of administration	Topical application
ANTIVIRAL
Substance	Acyclovir
Indication	Conjunctivitis, Herpes simplex, Blepharitis, Epithelial keratitis
Route of administration	Topical application
LOCAL ANAESTHETIC
Substance	Tetracaine
Indication	Diagnostic aid
Route of administration	Topical application (drops)
LOCAL ANAESTHETIC
Substance	Oxybuprocaine and other equivalent LAs
Indication	Diagnostic aid
Route of administration	Topical application (drops)

Paul-therapeuticspdf2 — **Figure 4.** SAOA President, Audience Maluleke and Dr Vanessa Moodley facilitating Joe Morolong Memorial Hospital as a clinic site for Optometrists. *Courtesy, A. Maluleke.*

Table 1. Schedule of Pharmaceutical agents for Optometrists published in the Gazette. Please NOTE that the above drugs are part of The Standard Treatment Guidelines and Essential Medicines List for South Africa. The Department of National Health believes that access to affordable essential medicines is a vital component of an efficient public health care system. This list does not exclude optometrists from using other drugs that meet the standard of care. Medicines are placed in different schedules. Optometrists are permitted to use oral and topical medicines from schedules 1 to 4 for both paediatric and adult patients.

The South African optometry undergraduate programme has been extended to 5 years where future graduates will have diagnostic and therapeutic privileges. Optometrists holding foreign qualifications will still have to write local examinations to enable them to obtain diagnostic and therapeutic privileges. As expected, while some optometrists were warmly accepted at public hospitals, there were many who were met with resistance. The Department of National Health is aware of this and supports optometry’s training. In light of
this, the Director General of Health wrote a letter which instructed the public institutions to allow optometrists to complete the 600 clinical hours. This was circulated to Heads of Health in all provinces.

Conclusion

The enhanced scope of optometry promotes public good by improving quality, accessible and efficient eyecare as well as promotes the optometrist as an important primary health care practitioner. I love being an optometrist. Everyday, it is an honour to help patients see and function effectively in their lives. In addition, it is a privilege to bring relief to patients for a variety of problems including removing foreign bodies and treating diseases of the eye and ocular adnexa.