“Hospital optometry is heading in new directions”

Could you describe working as a hospital optometrist in one sentence?

The exceptional opportunities to develop advanced clinical skills whilst working as part of a multi-disciplinary team are second to none when working in a supportive hospital environment.

How long have you worked as a hospital optometrist?

33 years. I completed my pre-registration optometrist training at the Royal East Sussex Hospital (now The Conquest Hospital) in Hastings, East Sussex, from 1988–1989. After a couple of years working as a clinical research assistant at City, University of London and the Institute of Ophthalmology, I applied for and was appointed as head of optometry at Eastbourne District General Hospital between 1991 and 1994. I then moved to Sunderland Eye Infirmary (SEI) to establish an entirely new optometry department.

When and why did you decide to become a hospital optometrist?

It was during my final year at City, University of London, having spent the summer after second year working as an optical assistant in a busy private practice in the City of London.

During this time there were several patients who were referred to Moorfields Eye Hospital, and I found myself being fascinated about what had happened following referral and what treatment had been given for various conditions.

I soon realised that commercial optics at the time was not for me and that I was more attracted to working in a clinical environment in a hospital setting, participating in the medical management of patients.

I was excited by all the opportunities and potential there was to demonstrate what optometrists could offer in a hospital setting. And that’s what I have endeavoured to do throughout my hospital optometry career – develop and promote new advanced clinical roles that can be undertaken by optometrists.

Do you do any other work or volunteering alongside hospital optometry?

I worked regularly in private independent practice as a locum for multiples and independent practices throughout my career until the COVID-19 pandemic, when I decided to step back from this as my main hospital consultant optometrist job became more demanding.

I have also worked with Specsavers in an educational role for many years and produced numerous CET articles and webinars that have been published, previously in the Profile journal and most recently on the Specsavers iLearning web-based platform. I have now authored over 100 peer reviewed publications including two books re: management of diabetes and the eye.

Back in the early 1990s, I spent three months working in Africa. Firstly, I led a two-month trip to Kenya, delivering eye care in rural areas under the auspices of Sight by Wings. A couple of years later, I returned as part of a Vision Aid Overseas team. Both were incredible experiences.

In the more recent past, I qualified as a Duke of Edinburgh expedition leader for secondary school kids undertaking these awards in Northumberland.

Can you name one moment that has made your job feel valuable?

It is a moment that occurs usually several times each day in clinic – the feeling you get when you know you have helped someone achieve and maintain the best sight and eye health they can.

What is the biggest challenge facing hospital optometry currently and why? How can this be resolved?

An ageing population has significantly increased demands in ophthalmology in recent years, especially with the ever-growing number of new treatments available that often require the frequent follow-up of patients in outpatient clinics. The pressures on outpatient services to see more patients has therefore increased enormously.

Also, as people are living longer, they are increasingly living with a number of co-morbidities, for example heart disease, diabetes and dementia. Consequently, many of our patients are much more complex to manage, so it often takes clinicians longer to see each patient in clinic than ever before.

According to the Royal College of Ophthalmologists workforce census, published in March 2023, the vast majority of NHS ophthalmology services are facing significant capacity pressures, with over three quarters (76%) of units not having enough consultants to meet current patient demand and over half (52%) finding it more difficult to recruit consultants over the last 12 months.

Because of this, there is a pressing need to re-evaluate the current scope of practice of hospital optometrists working within multidisciplinary teams in secondary care in the UK. Hospital optometrists are well placed to further expand their roles, along with other multidisciplinary healthcare professionals. There has been a big increase in the use of independent prescribing and the number of optometrists engaged in delivery of laser procedures, including selective laser trabeculoplasty (SLT) and YAG laser. We currently have individual optometrists at SEI trained to deliver both these procedures, and the majority of the optometry team are now independent prescribers.

Up-skilling enough optometrists to fill many of the current gaps in ophthalmology service provision and to facilitate recovery and transformation of these services is an enormous challenge. This requires real-term investment and much greater commitment by NHS Trusts to training and accreditation of these clinicians. The introduction of, for example, advanced care practitioners and extended care practitioners has been a very welcome development, which needs to be rapidly expanded to meet the needs of the ophthalmology services in all the key domains: cataract, glaucoma, medical retina and the emergency department.

Just as important is the work of the integrated care boards, who are overseeing wider optometry changes directly affecting the interface between primary and secondary ophthalmological care. There are still so many patients being managed in secondary care that could be better managed by community-based optometrists with the right infrastructure, governance and funding streams in place. These developments would almost certainly be more cost effective than the current reliance on costly locum cover in NHS ophthalmology units.

Hospital optometrists are well placed to further expand their roles, along with other multidisciplinary healthcare professionals

 

What is hospital optometry’s biggest success in the past three years and why?

In the past 10 years I have been directly involved in the instigation and development of The College of Optometrists higher qualifications, particularly medical retina, and the establishment of the Optometry and Ophthalmology Advanced Clinical Practice (ACP) MSc, offered by University College London and Moorfields.

The growing number of hospital-based optometrists now undertaking or planning to undertake advanced clinical training is a testament to the success of the introduction of these highly structured training programmes, which are aimed at enhancing the role optometrists will play in future ophthalmology care delivery.

What is your biggest success in the past three years and why?

During the COVID-19 pandemic, many of our medical and nursing staff at SEI were redeployed across Sunderland and South Tyneside Foundation Trust hospitals to help in a variety of other clinical areas.

Meanwhile, at SEI, the medical retina service and emergency department continued to operate as normally as possible. This was only possible because a team of senior and experienced optometrists at SEI stepped up to the challenges of helping to deliver these services to patients. We now have an optometrist ACP working in the emergency department, and optometrists now independently see a significant proportion of medical retina patients in outpatient clinics, with an often complex caseload.

We have two optometrists who are trained to deliver intravitreal injections. One has recently been appointed as a specialist ophthalmic healthcare practitioner, which combines a clinical role integrated with a nursing role within the retinal service.

Personally, I now work almost exclusively within the medical retina service, managing a predominantly vascular caseload (diabetic retinopathy and retinal occlusions), in addition to macular degeneration, with the remainder of my clinical time spent in a new cataract patient and glaucoma review outreach clinic.

We now also have an optometrist performing SLT laser treatments, as mentioned earlier, and the same individual has been also specially trained to undertake general paediatric ophthalmology clinics, where the caseload is equally shared between the paediatric consultant ophthalmologist and the optometrist.

These are all quite significant developments in the advancement of extended clinic roles undertaken by hospital optometrists, showcasing what can be achieved.

What is the most surprising case you have seen in the hospital setting?

Many years ago, whilst reviewing a patient referred for diabetic screening, an interesting feature was noted within the vessel wall boundaries of a patient’s left eye supero-temporal branch retinal artery.

There was a small fine black line apparent that resembled a dust fragment that had contaminated the camera lens. However, on checking all the other images from this patient, this fine black line was only present in the one fundus image. So, whatever it was, it had to be something lodged within the artery and not an artefact.

On taking a full history it transpired that this patient had undergone open heart surgery a few weeks prior to this. Having discussed this finding with my consultant colleague, he suspected it was a suture remnant that had travelled up from the heart during surgery to the eye and lodged itself in the branch retinal artery.

At this stage there was no evidence of retinal arterial occlusion. My consultant colleague was a close friend since medical school with one of the cardiothoracic surgeons at the Freeman Hospital in Newcastle, where this open-heart surgery had taken place, and he contacted his colleague.

It was agreed that this was indeed the most likely explanation for this finding and the surgeon asked the manufacturer of the suture material for some further details that would aid a forensic analysis to prove this causality.

This had unforeseen consequences as the manufacturer responded to this request as it would a reported clinical incident, that resulted in a temporary suspension of the use of this particular suture material on a European-wide basis. The suture remnant did ultimately lead to a small retinal artery occlusion, but thankfully the patient remained completely asymptomatic.

What would you say to optometrists working on the High Street about working in a hospital environment?

There are so many opportunities to further develop and maximise the use of your optometric skills within hospital optometry. Apart from enjoying the camaraderie of working alongside a supportive multidisciplinary team of staff, there are so many exciting things happening right now, be it in research or clinical practice.

Many optometrists working in community practice may feel put off by some aspects of the hospital work, as it can be very different to High Street practice and there may be a perception that the type of work is overly challenging.

However, with the right training and support optometrists are now able to practice in areas unheard of even just a few years ago, when only an ophthalmologist was considered worthy of such clinical undertakings. Times really are changing, and hospital optometry is heading in new directions.

Although it is not always necessary to do so, if you are willing to move around different hospitals, there are some very significant career progression opportunities available as you gain more experience and gain higher qualifications.

At SEI, research and development will keep discovering new and better treatments, as is the case in many other hospitals across the UK. As one of the few specialist eye hospitals in the country, research and using developing technology is a key part of our work. We encourage innovation and research in everything we do, which in essence is what hospital optometry is also all about too. There is always something to get involved in.

With the right training and support optometrists are now able to practice in areas unheard of even just a few years ago

Is there anything else to add on the subject of working as a hospital optometrist?

If you share this vision for ‘excellence in all that we do,’ why don’t you come and join the ever-growing number of hospital optometrists and apply for one of the many available posts there are currently around the UK? You may wish to consider a full-time post, or maybe a part-time role to see if it suits you, whilst maintaining your community practice role.

You may not initially wish to pursue any advanced clinical roles described here, which is absolutely fine. There are also still many opportunities to specialise in the more traditional core roles of hospital optometry, where you can develop clinical expertise, for example, in managing specialist medical contact lenses or low vision rehabilitation. These roles are as important as ever for the benefit of patients.