Optometry is a noble profession providing eye and vision care services to the general population all over the world. The integral role of optometrists in providing these services to reduce avoidable blindness cannot be overemphasized. Optometrists have varied levels of training and provide eye care from primary to sub-specialty level in different countries all over the world including Nepal. Nepal has been producing optometrists since 2001 but their recognition and inclusion in the mainstream eye health care system remains elusive.
The scope of optometry practice differs across countries throughout the world depending on the level of education and practice legislation provided to them. Practice settings and higher education opportunities also vary. North American countries like the United States (US) and Canada have optometry programs at the doctoral level that usually require a bachelor’s or pre-optometry degree for enrollment. Optometrists in these countries perform comprehensive eye exams, provide vision correction and assistive devices like spectacles, contact lenses and low vision devices, administer vision therapy to treat binocular vision problems, prescribe medications to treat eye diseases and even perform laser eye surgeries in some states. They practice in a variety of settings like private clinics, hospitals, non-governmental organizations (NGOs), state and federal health care agencies, army and higher education institutions. They can also obtain master’s and PhD degrees at a number of higher education institutions. European, Asian and African countries where optometry has a longer history, have programs at the bachelor level with some countries offering a six-year doctor of optometry program after high school. The practice scope in these countries is usually similar to that provided by the American optometrists with limitations in surgeries. They work in similar settings as their American counterparts. Countries that did not allow optometrists to prescribe drugs for diagnosis and treatment of eye diseases previously have started to permit such privileges. There are also some countries with no legislation for licensing or defining the scope of practice. Some institutions in the UK, Norway, Portugal, Australia, New Zealand and India offer higher education in optometry and vision science awarding master’s and PhD degrees.
In Nepal, optometry is currently taught as a 4-year bachelor’s degree at the Institute of Medicine, Maharajgunj Medical Campus (IOM, MMC) of Tribhuvan University. The legislative body controlling the licensing and practice of optometry in Nepal is Nepal Health Professional Council (NHPC). According to the code of ethics for optometry practice approved by NHPC, optometrists can examine eyes, prescribe vision corrective devices, vision therapy, use drugs to help in diagnosis of ocular disease and prescribe drugs to treat those diseases. Optometrists mostly practice in eye hospitals/institutions run by NGOs or by private companies. A few have gone to private practices. Although optometrists have been produced for the last 18 years, they have not been provided suitable positions in the eye care sector by the government of Nepal. Those that want to get higher education have no institutions to go to in Nepal.
Ophthalmologists are the other independent eye care practitioners in Nepal who have a doctor of medicine degree and can prescribe vision corrective devices, drugs to treat diseases and perform surgeries. There is a third large group working in the eye care field in Nepal who are known as Ophthalmic Assistants (OAs). As the name says, they are assistants to ophthalmologists and have a certificate/diploma in ophthalmic science. They assist in eye hospitals and clinics and have also been placed in primary eye care centers in the rural areas. Since the enforcement of health care laws are weak in Nepal and the general population does not understand the differences between these eye care providers and quacks, optical outlets with the sole purpose of selling glasses and making profit run by quacks are rampant. Even ophthalmic assistants have been found to call themselves optometrists and practice in such clinics. There is no clear demarcation and law enforcement on who can practice in an independent eye care setting or establish an optical shop. This has led to profiteering by optical business owners with little regard to the eye health of the patients. The public is also unaware of the differences between various eye care practitioners and are duped into unnecessary optical correction and treatment advised by the unscrupulous practitioners.
Eighty-two optometrists have graduated from IOM in Nepal till date, of which almost half (38) of them have left the country. Attainment of higher education has been the major motive for moving out of the country although a few have emigrated for better paying jobs and recognition of the profession. Lack of opportunities in career growth and, higher education in the country in addition to the lack of respect for the profession from the ophthalmic fraternity have contributed to the emigration.
A new bachelor of optometry and vision science program was announced by National Academy for Medical Science (NAMS) about a month ago citing lack of qualified eye technicians in the country. It is a welcome news that a new optometry program is starting but derogating independent professionals as mere technicians is not acceptable and will certainly not improve the mutual respect between different eye health professionals in Nepal. The new program itself seems questionable as to whether it is going to produce well-qualified optometrists. The entrance exam consists of 40% of ophthalmic science knowledge that seems to be biased toward the ophthalmic assistants. Although I am not against providing higher education opportunities to OAs, a heavy emphasis on ophthalmic science in the entrance exam will result in only OAs getting into the program. Is the purpose of the program to produce technicians that have a bachelor’s degree? A separate entrance exam for 10+2 graduates and OAs focusing on their background knowledge would be much better.
Furthermore, the course only has six months of basic science instruction, which is very short. Even a one-year basic science course in the currently available optometry program at IOM, MMC has been deemed short by graduated optometrists. A fellowship opportunity in optometry has also been announced by Nepal Netra Jyoti Sangh, Biratnagar Eye Hospital, which is also a welcome step, but no specifications have been provided on what the specialties are for the fellowship. This creates suspicion on what the motives are behind the program and how the program will be run. Fellowships usually are higher education programs and need optometrists/ophthalmologists with higher education credentials in that specific sub-specialty. Many questions have arisen about the start of these two programs. Do the hospitals have enough optometry faculties to provide instruction? Is it fair to recruit students without recruiting required optometry faculties? Have the hospitals fulfilled all other requirements to open a new optometry/fellowship program and have they been cleared by the regulatory authority, NHPC to run the program? Will the fate of these programs be like the private medical colleges that are mushrooming in the country? Will there be a need for another Dr Govinda KC to sit for fast-unto-death in optometry too? The most astonishing part is that optometrists in Nepal, even those who have Master’s and PhDs and their professional association, the Nepalese Association of Optometrists (NAO) are not included in any of these decision-making processes like starting a new optometry program. When professionals with experience of over 17 years in the country itself are not given opportunities in decision making processes for their own profession, there is obviously going to be resentment, which will ultimately lead to bigger emigration of optometrists to foreign countries. That is not what stakeholders in eye care will appreciate very much.
To sum up, an environment of mutual respect between various levels of eye care practitioners and opportunities of involvement in decision making processes for the optometrists along with a career progression ladder are the major needs of optometry in Nepal. Doctors of Optometry practicing as primary eye care providers and recognition among health care fraternity and the public along with optometric experts in various subspecialties should be the main goal of any optometry program to be started in Nepal, if the core objective of eliminating avoidable blindness from the country is to be fulfilled.
(Dr Panthi ( B.Optom. PhD) is a post-doctoral fellow at the University of Alabama at Birmingham, USA)