Who provides ophthalmic care?
Sight is precious, especially so for those at risk of losing their vision, and careers in ophthalmology are not just interesting and very rewarding. At first glance it can seem surprising that so many different professionals are involved in ophthalmic practice, but the visual system is complex and the treatment of eye disease is very much a team effort. Here your will find information about the different professions and the work that they do.
There have been many advances in surgeries, laser treatments and new drugs to treat eye diseases, but some of the most remarkable developments have been in the technologies that allow us to visualize, measure and assess the function of the living eye in extraordinary detail. This technology increases our ability to make the right decisions about the diagnosis and management of eye diseases, but the education and training of staff who perform the diagnostic tests has not kept pace with demand. AHPO has, therefore, prioritised the development of education programmes in assessment and diagnostic testing and we can now offer a distance learning Diploma in Ophthalmic and Vision Science that will enable someone new to healthcare to develop their knowledge and skills to associate practitioner level. Many other ophthalmic staff – nurses, orthoptists, optometrists, dispensing opticians and others – have extended their professional roles, and if needed they can also access modules in the Diploma programme that are relevant for their area of practice.
Ophthalmology is the study of normal and abnormal functioning of the visual system – the eye and its supporting structures, the neural pathways from the eye to the brain, and the visual cortex and other parts of the brain responsible for the perception of vision and control of eye movement. The professionals with the major responsibility for the diagnosis and medical and surgical treatment of ophthalmic diseases are ophthalmologists – medical doctors who have specialised in all aspects of eye care including diagnosis and management of ocular diseases and disorders. This includes surgery for cataract, squint, glaucoma, retinal detachment and other conditions, and laser treatment for a number of conditions including glaucoma and diabetic retinopathy. Some ophthalmologists also perform surgery and/or laser treatments to correct errors of refraction such as myopia (short sightedness). The eyes and visual system are frequently involved in disease processes affecting other parts of the body. An ophthalmologist who taught medical students offered a bottle of whisky to any student who could find a disease that never affected the eye, and claimed he had never lost his whisky.
Ophthalmic and Vision Scientists and Practitioners
Ophthamic and vision healthcare scientists (vision scientists) are involved in the provision of diagnostic evaluations, primarily in the fields of electrophysiology and psychophysics of vision, ultrasonography of the eye and ocular adnexae, and in the development of new and improved methods of testing. Ophthalmic practitioners and associate practitioners undertake ophthalmic patient assessments, measurements and imaging that aid the ophthalmologist and other ophthalmic professionals in the assessment, diagnosis and treatment of ophthalmic diseases. Ophthalmic assistants undertake a smaller range of tests and investigations, generally under supervision.
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Patients who develop eye diseases need treatment and care, and this is provided by nurses who have specialised in ophthalmic nursing. Ophthalmic-trained nurses may become further specialised as ophthalmic nurse practitioners, ophthalmic surgical care practitioners and ophthalmic nurse specialists. Nurses utilise a range of specialist ophthalmic skills in addition to general nursing skills to provide care for patients with ocular and systemic conditions, and have a key role in educating patients and carers about the promotion of ocular health. Skills used by ophthalmic nurses range from the highly technical such as diagnostic measurements and procedures to counselling and rehabilitation and include a whole spectrum of examination, diagnosis and management skills. Advanced practice in ophthalmic nursing is widespread, including nurse led emergency care, the management of pre assessment for surgery and post operative management, nurse led clinics in areas such as glaucoma and dry eye and in a range of other specialist areas such as nurse led minor surgery. Ophthalmic theatre nurses have for many years acted as the surgeons first assistant and ophthalmic nurses continue to expand the boundaries of traditional nursing practice. The introduction of supplementary prescribing by nurses has increased their scope of practice to initiate and manage medical treatment of ophthalmic conditions.
Humans have eyes at the front of their heads that can move in any direction to view the world around them. Because the images from the two eyes overlap, the brain can fuse the two images and give a perception of depth – that is binocular (stereoscopic, or "3D") vision. The study of the complex processes that keep the eyes in exact alignment is called orthoptics. Orthoptists are allied health professionals who specialise in the investigation, diagnosis, management and treatment of disorders of binocular vision, visual development and the brains’ control of eye movements. These include disorders of the alignment of the eyes (called squint or strabismus), disorders of binocular vision, and conditions where there are restrictions or other abnormalities of the movement of the eyes. In children with squint and other disorders vision may fail to develop properly in one or both eyes, a condition termed amblyopia or lazy eye. This can be fully or partially reversed with early diagnosis and treatment, usually with glasses to correct refractive error (long-sightedness, shortsightedness and astigmatism) and patching of the better-seeing eye to encourage development of vision in the amblyopic eye.
Optometrists and Dispensing Opticians
The eye is an optical device that, like a camera, bends (refracts) light to form an image on a light-sensitive film (the retina). As an optical device the eye is a wonderful instrument, but not always a perfect one, and errors of refraction such as myopia (shortsightedness), hypermetropia (longsightedness) and astigmatism can be corrected by spectacles or contact lenses. The study of the optics of the eye is called optometry, and the professions with the major responsibility for the correction of optical errors are optometrists (commonly called opticians) and dispensing opticians.
Optometrists examine eyes and prescribe and dispense visual aids (such as contact lenses and spectacles) to maintain or restore maximum visual function. They also examine the eyes and the associated visual system to detect the presence of any abnormality or disease that might require referral to a medical (or other) practitioner. Optometrists may share the care of patients who have chronic ophthalmic conditions with general medical practitioners or ophthalmologists. Optometrists with additional training can have prescribing rights to treat eye diseases.
Dispensing opticians advise on, fit and supply the most appropriate spectacles and other optical appliances including low vision aids after taking into account each patient's lifestyle and vocational needs. They are also able to fit contact lenses after undergoing further specialist training. Dispensing opticians do not undertake sight tests or issue optical prescriptions.
Some people with vision impairment may need to learn different skills to enable them to live independent lives such as learning to maximize the use of their remaining vision. They may also need emotional support to come to terms with their sight loss. Specialist rehabilitation workers can help offer this practical and emotional support.
The rehabilitation officer is responsible for assisting visually impaired people to lead independent lives, and is trained to advise and equip people who have serious sight problems to cope with most aspects of their daily lives. This includes the provision of support to overcome the emotional and practical consequences associated with sight loss. The core of their role is to help people learn new ways of carrying out everyday tasks, such as cooking, making a cup of tea, cleaning and washing, and getting about (mobility). This may involve people having independent living skill training, mobility training, as well general advice and support in the use of special equipment (which may include low vision aids). They may also help individuals acquire new skills by teaching them Braille and Moon and can arrange further training, such as typing or computer lessons. They will also refer people to services where they can get advice about entitlements (such as particular benefits).
Some rehabilitation officers work with visually impaired children. This puts a different emphasis upon their work – one of ‘teaching’ rather than ‘rehabilitating’. Again the work will often include developing mobility skills and independent living skills. Part of their role in working with children will be to help the child’s family to understand and use these strategies and aids.
Orbital prosthetists provide a service for patients who have lost one or both of their natural eyes or have a blind, shrunken, or disfigured natural eye. Services include the provision of an artificial eye or cosmetic shell to match as near as possible the patient’s natural eye in all its characteristics. Other services include the assessment of the socket, polishing of the prosthesis or replacement where necessary, and referral if appropriate to the patient’s ophthalmologist or general practitioner in the case of socket deterioration or infection. Most eye removal today is accompanied by the inclusion of an implant in the socket. An artificial eye is fitted over the implant and the orbital prosthetist needs to work as a team member with the consultant ophthalmologist in the management of the various types of implant in existence. They also need to empathize with their client group some of whom may be recovering from severe trauma or the psychological consequences of cancer.
Orbital prosthetists concentrate solely on the fitting of a prosthesis. Those who both manufacture and fit the prosthesis are usually referred to as ocularists. Ocular technicians make the artificial eyes from prescriptions and patterns.
All these different staff specialise in some aspect of ophthalmic practice, but it should be remembered that to a greater or lesser extent they will share knowledge and skills. Patients attending eye clinics in different parts of the country, or even in one hospital, may have the same test performed or treatment given by different professionals. It is important that all the professionals work together as a team, using their specialist skills and expertise as needed to deliver the best possible care to patients.