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Optometrists with Ocular Therapeutics

profpaul(ALSO READ: Optometrist with Ocular Therapeutics: The inside story of how it came about by Prof Paul Ramkissoon.)

The role of the optometrist as an essential primary health care practitioner is entrenched in the scope of optometry. In pursuit of the delivery of this mandate, it is incumbent upon optometry to be challenged by the editorial of September 2018 edition of Lancet, titled, “Putting quality and people at the centre of health systems”. This editorial stresses that expansion of universal health coverage (UHC) remains essential, but without quality, UHC will be an abstract and meaningless myth. To this end, the role of the optometrist as a primary health care practitioner becomes essential in the detection, diagnosis and treatment of the patient. It also emphasises, “People need to be central to all measures of quality.” By adhering to these important tenets, optometry will continue to enhance the quality of accessible eye care and the overall health of the population.

The avenue for Optometrist with Ocular therapeutics has been available for some time. A number of optometrists have pursued this option in spite of the challenges it presents in terms of time and financial burden. This new cadre of optometrists has made a positive impact on the services at public hospitals. Dr Noor, ophthalmic medical practitioner at Madadeni Hospital (supervisor of Ntuthuko Mthimkhulu) and Husna Paruk, was very impressed with their knowledge and their ability to work as part of the eye care team at Madadeni Hospital. Dr Ritesh Nandkoomar, head of ophthalmology at Madadeni Hospital states that optometrists with therapeutics are a huge help and cites the example of Ntuthuko Mthimkhulu, who now manages all the cases that require treatment of external ocular conditions and glaucoma at Utrecht Hospital, immensely easing the burden on the hospital. He further adds; “ Optometrists are a huge help during the cataract camp where they assist with follow-up cases as well as manage all the common cases like VKC, conjunctivitis and chronic glaucoma, while the surgeons are busy operating. They have relieved a huge strain.”

As a profession, we should salute these trailblazers and their achievements are there to inspire all of us. For better insight into their journey I decided to engage with some of them directly.




PR: Tell us briefly about yourself
NM: Ntuthuko Mthimkhulu is a young, humble and goal-driven optometrist born in 1989 in the township of Madadeni. Schools attended before higher education were Cathulani JP School, Sithobelumthetho SP School and Phendukani high school, all of which are in Madadeni from year 1996 to 2007. In 2008, I enrolled at UKZN-Westville campus School of Optometry and graduated in 201. In 2015, I enrolled for the post-graduate programme in Ocular Therapeutics presented by a partnership of SUNY (USA) and UKZN. After passing the theory portion of the program, I did the 600 clinical hours as stipulated by the HPCSA and completed in year 2016.

PR: Where did you do your 600 clinical hours and what was your contribution to the clinical site you chose?
NM: I completed the 600 clinical hours at Madadeni Provincial hospital (MPH). I am employed as an optometrist working at Utrecht Hospital, which is about 40km from Madadeni Hospital. The experience I gained from Madadeni Hospital I implement at Utrecht Hospital and I only refer patients to the regional hospital for surgical care.

PR: What was the experience like for you?
NM: The experience was a great one as I visited MPH three times every week from February to September 2016. I worked with the ophthalmic medical officers and ophthalmologists, applying what I learnt. I came to understand the potential of the relationship between optometry and ophthalmology. I was assisting the visually impaired to regain one of the most important senses in the body, which is sight and that was a most fulfilling experience.

PR: What were some of the things you learnt that you could not get from a textbook?
NM: I wouldn’t say I pinpointed certain conditions which I wouldn’t find in the book, but team work in the eye clinic, a multi-disciplinary approach and management of patients, still is and always will be the most important thing in helping patients.

PR: What advice would you give your colleagues to advance the profession of optometry?
NM: I would like to advise my colleagues to expand their knowledge and skills, especially in diagnostics and ocular therapeutics, since we are the primary providers of eye care. We must understand that the sky is the limit and we can still achieve a lot together in uplifting the profession of optometry.




PR: Tell us briefly about yourself?
ZA: I have been practicing optometry for the past 20 years. My experience in optometry includes academic, private and public practice. I am currently heading the Department of Optometry at Voortrekker district hospital. My field of expertise is diabetic retinopathy. I am working on my PhD with the aim of developing and implementing a referral protocol in the district health system for patients with diabetes mellitus to prevent blindness caused by diabetic retinopathy.

PR: Where did you do your 600 clinical hours and what was your contribution to the clinical site you chose?
ZA: My clinical hours were done at Voortrekker District Hospital and FH Odendaal Hospital. FH Odendaal is one of the referral hospitals for patients requiring ocular and surgical treatment.
I contributed by reducing the waiting periods of patients requiring treatment from the ophthalmologists. This was done by providing ocular treatment for anterior segment ocular pathology; conditions such as conjunctivitis, blepharitis and styes. The inconvenience and transport costs for patients travelling to the referral hospitals for glaucoma review on a monthly basis was reduced as I monitored IOP and provided glaucoma treatment as per the ophthalmologist instruction. Patients on chronic glaucoma treatment are now being reviewed by the ophthalmologist on a 6 monthly basis or sooner if required. This arrangement has assisted in reducing ophthalmologists’ workload, given the shortage of ophthalmologists in the public sector in Limpopo province. By reducing their workload, ophthalmologists have more time to train the medical officer/registrars in ophthalmology and are able to concentrate on more serious ocular complications which require surgical intervention. The knowledge that I gained from my mentors has been imparted to my two subordinates. Optometry has become more interesting in the department; a diversion from the traditional ”better 1, better 2” practice!

PR: What was the experience like for you?
ZA: Inspiring and a bit challenging. It was challenging to juggle my workload and to travel 3 hours per day to get to the referral hospital for training. However, I was inspired by the work ethic and dedication of my hard working mentors who manage to do so much for patients given limited resources such as the shortage of staff, equipment, working space and also medication at times.

PR: What were some of the things you learnt that you could not get from a textbook?
ZA: Procedures observed in practice always made more sense than following a textbook.

  • Incision and drainage of hordeolums and the need to conduct blood tests and pus swabs to determine the underlying cause of the condition was interesting.
  • The need to conduct a tissue biopsy to verify a cancerous growth like squamosal cell carcinoma (SCC), often misdiagnosed as pterygium, was crucial.
  • A multidisciplinary team approach is necessary to manage patients with systemic complications. General practitioners, dieticians and optometrists need to co-manage patients with hypertension and diabetes to prevent vision complications which could lead to irreversible blindness.

PR: What advice would you give your colleagues to advance the profession of optometry?
ZA: Optometry is not just about “Better 1, better 2 and dispensing spectacles! We optometrists are capable of doing so much more to make the profession interesting and more meaningful. ‘The eye is the window to the soul’, and by monitoring vitals, conducting a comprehensive eye examination and advancing our therapeutic skills we will be taking optometry to another level!




PR: Tell us briefly about yourself?
LN: I have been qualified for seventeen years, from the University of the North now called University of Limpopo. I am a past president of the South African Optometrist Association and also served on the board of Medshield medical aid scheme as Clinical Risk Chairperson for a 5 year period. I am currently in private practice in Pretoria and serving as executive director on the board of Iso Leso Optics. I am a mother of 4 and enjoy spending time with my family.   

PR: Where did you do your 600 clinical hours and what was your contribution to the clinical site you chose?
LN: I completed my 600 therapeutic hours at Tshwane District Hospital in Pretoria.  I took time off from my private practice and concentrated on learning and training at the hospital. Over and above the training hours I contributed screening patients and booking them for further investigation. Together, with HOD Mr Lam Khai and Ntombi Zitha, we established a Contact Lens and Low Vision Clinic at the hospital. I examined low vision patients, fitted prosthetic eyes, RGP, hybrid and scleral contact lenses.

PR: What was the experience like for you?
LN: We were faced with a challenge as the Gauteng Province denied us permission to train at their hospitals, even if the hospital had capacity.  We then wrote a letter of complaint to the Department of Health and we were reassured that we can continue at the hospital and they will engage with the Province and various stakeholders.  We are grateful that the Tshwane District Hospital accepted us and the doctors were willing to supervise us.  I personally learned a lot from the entire eye care team. The doctors were friendly and willing to train and supervise us. We would see a minimum of fifty patients per day. The experience I gained, I will never trade for anything and that is why I have decided to continue to volunteer and assist with specialised optometric care (scleral contact lenses and low vision) even though I have acquired my 600 clinical hours for registration.

PR: What were some of the things that you learnt that you could not get from a textbook?
LN: Visual impairment is significant in the public health sector. I have learned that every patient is unique, a different approach may be required and often not necessarily following the text book guidelines exactly. Multiple co-morbidities are common and greatly increase the complexity of managing disease in patients. Cataract, glaucoma, VKC and refractive error are the most common cases that we managed.  A rise of HIV infection, diabetes increased the risk and contributes to post operation complications.  Patients present late and thus add to the difficulty in management. Availability of essential drugs and co-morbidity pose serious challenges in management. Experience is the best teacher, the more you do something the better you become. Learning never stops.

PR: What advice would you give your colleagues to advance the profession of optometry?
LN: Collaboration of all professionals in the eye care team is crucial to tackle the burden of ocular disease that Public Health Care faces. We as optometrists need to upskill ourselves and volunteer to assist these multiple challenges and we will see some inroads in prevention of avoidable blindness and visual impairment. The lack of funding for low vision aids, RGP and scleral contact lenses is a huge challenge. Consequently, many low vision and keratoconic patients are unable to receive assistance. We need to advocate our role as primary health care providers, the gate keepers of eye care. As much as we face opposition we should soldier on and we will eventually conquer the resistance.




PR: Tell us briefly about yourself?
PM: I am an optometrist, qualified in 2004. In 2005, I started working in the private sector. In 2008, I worked at the University of KwaZulu-Natal, Westville campus. Then I joined an NPO (Brien Holden in 2009). In 2012, I was absorbed by the Department of Health and currently working as an optometrist at McCord Provincial Eye Hospital.

PR: Where did you do your 600 clinical hours and what was your contribution to the clinical site you chose?
PM: I did my clinical hours at McCord Provincial Eye Hospital.  McCord hospital covers all the areas from KZN. So we get huge numbers everyday because it is a very busy hospital. In doing my hours in that hospital department, I was helping the medical officers because they had one more person in the department. 

PR: What was the experience like for you?
PM: It was a great experience working there because there is a lot of pathology presenting that you do not get to see in the private sector. Patients appreciate your intervention and when they come back feeling better, it is so fulfilling. 

PR: What were some of the things that you learnt that you could not get from a textbook?
You learn a lot of things because even though you read the text book, you tend to appreciate it more when you see the actual condition in a patient rather than in the picture of a book. Conditions seen regularly are corneal diseases, pan uveitis, etc.

PR: What advice would you give your colleagues to advance the profession of optometry?
PM: I would advise them to visit hospitals more often so that they can get to see more pathology.




PR: Tell us briefly about yourself?
RK: I completed my optometry degree at the University of Johannesburg in 2008. Thereafter, I returned to my hometown Vryburg and worked as a full time optometrist and locum for private practices in the area. I would see patients almost daily present with various ocular conditions, ranging from allergies to glaucoma and cataracts. Vryburg is a small town in the North West Province and the closest ophthalmologist to refer to was almost 200 km away. An ophthalmologist would visit the private hospital once a month, which did help quite a bit with referrals. My love for making quality eye care accessible to many, prompted me to register for the Ocular Therapeutics Course. Having completed the course, I then went on to establish my own private practice – R Kana OPTIX in Vryburg. I am grateful to have the opportunity to serve my community with this added skill.

PR: Where did you do your 600 clinical hours and what was your contribution to the clinical site you chose?
RK: I completed my 600 hours at Joe Morolong Memorial Hospital in Vryburg under the supervision of Dr Sonia Fernandez Perez, a Cuban ophthalmologist. Having done the theory it was now time to put it into practice; I was able to quickly classify patients as per their conditions.

PR: What was the experience for you?
RK: I had an amazing experience, the ophthalmologist and I would examine each patient and discuss the cases. The follow ups were truly coming full circle as I could monitor the treatment and its effectiveness.

PR: What were some of the things that you learnt that you could not get from a textbook?

RK: Due to the limited resources available at the district hospital in terms of medication and equipment, one has to rely on clinical expertise and the available medication to make an informed decision with regards to treatment of patients. Dealing with patient compliance to treatment regimens and prognosis of disease due to the many impoverished patients was also another challenge.

 PR: What advice would you give your colleagues to advance the profession of optometry?

RK: We have been gifted the opportunity to make a difference in the lives of many and with the advancement of ocular therapeutics we can surely make quality eye care accessible. My advice is to constantly empower ourselves with knowledge and training, aiming to offer the best care to our patients.




PR: Tell us briefly about yourself?
NT: I am a very optimistic person. I graduated from UKZN in 2011 and commenced my duties at St Elizabeth Regional Hospital in the Eastern Cape where I acquired extensive practical experience in my field. When ocular therapeutics became an option in South Africa in 2015, I decided to grab the opportunity and enrolled. I believed that it would expand my knowledge spectrum and improve efficiency, thus benefiting the communities I served and our province’s health fraternity at large.

PR: Where did you do your 600 clinical hours and what was your contribution to the clinical site you chose?
NT: I executed my 600 clinical hours at St Elizabeth Regional Hospital and the benefits were far more than meets the eye as our facility no longer referred patients with minor ocular conditions to ophthalmologists. Previously, patients had to embark on a 3 hour trip for a procedure that would take merely 5 to 10 minutes to complete; i.e. foreign body removal, which I can now perform with ease. It saved costs in terms of travelling expenses which the hospital incurred transporting patients to another institution and back. Patients also enjoyed relief in terms of travelling expenses because treatment was available locally. Furthermore, patients enjoy the benefit of receiving eye care from the practitioner with whom they had developed a professional relationship of trust, a relationship developed over many years of service to them.

PR: What was the experience like for you?
NT: It was an enriching experience as it afforded me the opportunity to manage a wide range of ocular conditions and acquire experience in the appropriate use of ocular and systemic drugs, and to better co-manage other conditions.

PR: What were some of the things you learnt that you could not get from the textbook?
NT: I learnt that attitude towards work is paramount. It is not something given in books or taught in class. It comes from within. For example, following up patients you have seen and referred to ophthalmologists, discussing these cases yields more information and improves overall management. Theory alone is not sufficient. Also, patients do not present according to the book and there are some things that you can only learn through doing and experiencing. 

PR: What advice would you give your colleagues to advance the profession of optometry?
NT: I would strongly advise other optometrists to consider ocular therapeutics as it will greatly improve service to patients. Ocular therapeutics is not only recommended to optometrists in public sector but those in private sector too as it would differentiate their practices from the corporate model practices. To the optometrists out there who have not done ocular therapeutics yet, do yourself a favour and seize this opportunity as it would enable our profession to increase the scope.

The Regulation

Optometry is a regulated profession and governed by the Health Professions Council of South Africa (HPCSA). Clause 2 (1) of the Regulation 280 (No. 2978; April 2007) of the Health Profession Act 1974 (Act 56 of 1974) states “The following acts are hereby specified as acts which, for the purposes of the Act, are deemed to be acts pertaining to the profession of optometry:

  1. The performance of eye examinations on patients with the purpose of detecting visual errors in order to provide clear, comfortable and effective vision; and
  2. 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 Medicine Control Council or by any means other than surgical procedures.

As the majority of optometrists in the country had Ocular Diagnostic level competencies, additional training had to be introduced to enable optometrists to acquire a permit for prescribing these scheduled medicines. In defining the outcome competencies required and noting previous levels of didactic and clinical training of optometrists in ocular diseases, the HPCSA determined that optometrists should complete 600 clinical hours under the supervision of a medical practitioner or ophthalmologist within a public health institution.The Medicines Control Council, now known as the South African Health Products Regulatory Authority (SAHPRA) approved a list of medicines that are prescribed by registered optometrists who are in possession of a permit to prescribe such medicines. SAHPRA is reviewing the list after submission by the PBODO and SAOA to expand the list of medicines for optometrists.Some hospitals have created opportunities for the optometrists to undertake their clinical hours within their respective eye departments.