Will new rules put vision at risk? - Macleans.ca

Will new rules put vision at risk?

Medical groups rail against deregulated eye care in B.C.


Photograph by Simon Hayter

British Columbia’s Health Services Minister Kevin Falcon is clearly willing to incur the medical establishment’s wrath.

Since his surprise March 18 announcement that B.C. would deregulate eye care exams on May 1, Falcon has shown steely resolve in ignoring the condemnation of international ophthalmological societies, optometrists, the Canadian National Institute for the Blind, and the College of Physicians and Surgeons, all of whom accuse his government of putting the vision of the province—and potentially the nation—at risk.

Under the precedent-setting change, B.C. is now the only North American jurisdiction to allow adults between 19 and 64 to replace eyeglasses or contact lenses without an eye health exam by an ophthalmologist (a medical doctor who is an eye specialist) or an optometrist (an eye specialist who has completed a four-year optometry program). The new rules increase the diagnostic authority of opticians who fit eyeglasses and make lenses to correct vision problems. Once only allowed to fill prescriptions, now they can write them based on computerized eyesight testing, no longer needing an ophthalmologist’s approval. And B.C.-based Internet eyewear providers can now dispense eyeglasses and contact lenses based only on customer information; a hard copy of a prescription, sight-test assessment or contact-lens specifications isn’t required.

Critics of the new rules fear a dangerous precedent has been set. Like other provinces, B.C. no longer covers optometrists’ eye exams for residents 19 to 64. Still, an eye doctor was required to update or verify prescriptions if they were more than two years old. And eye care exams didn’t just check vision; they looked for conditions like glaucoma and macular degeneration that sight tests don’t pick up.

Falcon says the changes were necessary to “modernize” the health system. In an interview with Maclean’s, he points out B.C. opticians have been using computers for sight testing since 1998. Ophthalmologists’ sign-off was just a rubber stamp, he says: “Often they were in other provinces.” The new rules were fast-tracked in response to an October 2009 B.C. Court of Appeal decision involving Vancouver-based Internet eyewear provider Coastal Contacts Inc. The fast-growing company, which has 120 employees and annual revenues of more than $100 million, was ordered to start verifying hard copies of customers’ prescriptions by May 1, 2010, or stop selling prescription eyewear online.

Updating the law was necessary given the online retail landscape, Falcon says: “It was time to bring outdated regulations into the 21st century.”

Sara Moshurchak, president of Opticians of British Columbia, praises the government for expanding opticians’ scope of practice and making it more “convenient” to replace eyewear. The medical community, however, is less sanguine, angry that they weren’t even consulted before the revised legislation.

The B.C. government has been deluged with letters, many posted online. One from ophthalmologist Thomas Freddo, director of the University of Waterloo’s optometry school, blasts the “rush to judgment that puts 120 jobs above the health and safety of four million citizens.” He compares an opticians’ sight test “to checking the dipstick in your car and using the oil level as assurance that the transmission, the brakes, the suspension, the steering, the tires, the wipers, the headlights and emissions are all fine.” The American Optometric Association also weighed in, calling the measures “a marked and unwarranted regressive step backward in any First World or developed nation.”

A repeated refrain is that the new rules put no emphasis on prevention. Antoinette Dumalo, president of the B.C. Association of Optometrists, a group whose members’ livelihoods stand to be adversely affected by the changes, cites a Canadian Journal of Optometry study that found one in seven who go for an eye care exam are diagnosed with an asymptomatic eye disease. The Canadian Diabetes Association issued a statement stressing the need for regular eye care exams to identify serious conditions like diabetic retinopathy, the most common cause of legal blindness in people aged 19 to 65. Seventy-five per cent of blindness is preventable with early detection and treatment, says John Mulka, executive director of the CNIB’s British Columbia and Yukon division, who notes blindness costs the Canadian economy $15.8 billion a year.

Falcon believes such fears are overstated. He spoke recently with an out-of-work 22-year-old who was angry she had to pay an optometrist $180 to renew her contact lens prescription. “There’s no medical evidence that she should be having an eye health exam,” he says. Undiagnosed illness is a risk, he allows: “But I am not going to have every male over 15 tested for prostate cancer. I could do that but it would not be a logical use of scarce medical resources.”
There’s also fear the B.C. model will spread. “Eyes offer a unique snapshot of health,” says Toronto optometrist Andrew Leung, who notes routine eye exams can reveal intracranial tumours and vascular problems. He sends at least one patient a day on to a specialist, he says. One, a seemingly healthy 43-year-old woman, presented an ocular melanoma on a retinal scan.

Falcon insists the new system contains safeguards. Anyone getting eyeglasses or contacts for the first time must still be fitted by an optometrist or ophthalmologist. Only “healthy” people are eligible to take an opticians’ sight test; a list of questions screens out those with diabetes, macular degeneration and other high-risk conditions. And opticians must explain that a sight test does not constitute a full eye health exam.

The B.C. legislation blazes another new and potentially thorny path: it’s the first province to challenge Health Canada’s position that contact lenses (a “Class II medical device”) not be purchased online. Now people outside B.C. can use B.C.-based Internet providers to refill an eyewear prescription indefinitely or even tweak it themselves. (Coastal Contacts even offers over-the-phone instruction on how to determine the distance between pupils, a key measure in fitting eyeglasses.)

This fact concerns contact lens giant Johnson & Johnson Vision Care. It wrote the B.C. government noting that if online vendors don’t verify prescriptions, patients can keep ordering “based on what they think is needed, without getting their eyes re-examined on a regular basis.” Nor is there anything stopping someone who has never been prescribed contact lenses from placing an order based on what they think they require.

Falcon, an eyeglass wearer himself, has faith in the public: “An informed public will make the right decisions on their own health,” he says. Dumalo is less confident, noting most people don’t know the difference between an ophthalmologist, an optometrist and an optician. “The job of the government is to protect citizens, not to put them at risk,” she says.

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Will new rules put vision at risk?

  1. Mr. Falcon has zero expertise in the subject of eye health (He is a BA and has never had any background in health or science) and obviously his advisors do not either. When you have groups like the CNIB, the Canadian and American Optometric and Ophthalmological Societies denouncing the changes maybe he should listen. How can Mr. Falcon's policy advisors know more about the subject of eye health than the professionals? Contact lenses are medical devices (Health Canada, FDA) they are pieces of plastic that sit on the surface of the eye and interact with the the cornea, conjunctiva and tear film. The contact lens requires a specific curve, diameter etc in order to fit an eye properly.

  2. As an optometrist, one of my biggest issues with these changes is that people who wear contact lenses often say they're eyes feel fine even when subtle changes are occurring due to physiological changes to the cornea that can lead to scarring, infection and blindness. Contact lens wearers are often less sensitive to corneal irritation than the average person, that is why we need to check the eyes on an annual to semi-annual basis in contact lens wearers. Poorly fitting lenses often "feel good" but can lead to new blood vessel growth on the usually clear cornea. These changes can't be reversed, and if they grow big enough can lead to permanent vision loss.

  3. Mr. Falcon states that his changes are based on modernization, convenience and choice. He is pulling the wool over the publics eyes. Consumers have always had a choice as to where they take their prescriptions… they just needed a valid prescription for it. It's like saying, "it's inconvenient for people to go to their family physician to for a physical on a yearly basis, so if that individual feels ok, he can just renew his blood pressure meds and change the dosage as he sees fit" .This is corruption and I am shocked by how blatantly Mr. Falcon is working in the interest of a corporation rather than the health of the citizens. Since when has it been the Health Ministers role to make changes based on commerce versus public health? I really can't believe that such legislation could be changed so easily by someone who knows absolutely nothing about eye health except what his advisors and an internet company has told him and he ignores the professionals who have trained for years in this very specialized field and the medical evidence that they have provided to him.

  4. Shame on Minister Falcon for putting the health of British Colombians at risk. As the Minister of Health, He should be the first person to advocate on behalf of citizens who may not be informed enough to know the difference. Instead, his irresponsible, rash legislation may cause thousands of people with treatable eye disease to go undiagnosed until it is too late. Does he realize the expense the BC health care system will be faced with to treat these patients? My sister falls into the age category of people that qualify for a 'sight test'. If she had had one of these computerized tests done, she would have not been diagnosed with glaucoma- a serious ASYMPTOMATIC eye disease which causes blindness if left untreated. Once vision is lost to glaucoma, it is gone for good. Minister Falcon's 'wait and see' approach to health care is not only dangerous, but a glaring disregard of the health of the citizens he has sworn to protect.

  5. I know several people that work at OPTICALS (places that only sell glasses). I don't think they have a optician's license, but I could be wrong. They may seem to know a lot about glasses, but they don't seem to know much about eye health. Whenever someone asks them a question about the eyes, they always say there's nothing wrong. They hardly EVER tell a customer to get their eyes checked by an optometrist (except maybe their relatives). I'm not trying to say OPTICIANS can't be trusted, but when it's in their best interest to their BOTTOM LINE that they DON'T go see an optometrist, I question their motives. Now with the ability to check your prescription and keep you in the store, OPTICIANS now have a TOOL to manipulate you to avoid seeing your optometrist.

    • Ontario has not had this for years. BC is the first one

      • People between 19 and 64 in Ontario has to pay for their eye tests…unless they have certain diseases that put their eyes at rick.

    • Ontario has certainly not "had this for years". However, there have been a hand full of opticians performing sight tests and prescribing from them in recent years, even though it is illegal.

      • Well in my part of Ontario it has been for years.

  6. modernization? Then why is this the same system in place in third world countries where you have a 'sight test' for glasses and see an ophthalmologist later in life to mop up the mess of eye disease that could have been prevented earlier if they had had an eye exam. There will be a lot more eye disease in later stages (because regular eye exams pick it up early, often before a patient is even aware they have it.) and sadly more people will lose vision.

    Let's face it, we all have busy lives…how many innocent people are going to put off an eye exam, get new glasses and maybe miss picking up something important early on? Too many. Falcon says it is not statistically significant…is one patient a day from every optometrist accros North America insignificant? And would you think it was insignificant if it was your or a loved one or dear friend whose vision or life was saved by a routine eye exam?

  7. So Mr.Falcon's modernization approach seems to be all about making our own choices about our health care. Eat properly,
    exercise, don't smoke, get a good night's sleep and don't run on the railway tracks (okay so far I'm two for five if you count the railway thing). So while this may be good in theory and politically correct … the numbers don't bear out too good a track record on our decision making. Face it we make some bad choices and not that infrequently. So about my health…hmmm… should
    I decided when I need medication, what kind and how many (this definitely doesn't work). Those who should need meds may
    not take them and those that shouldn't well they tend to sometimes. How about surgery…how's my ticker's plumbing working? I'm old enough to know I'm not bullit proof despite the exterior not showing too much rust. Yet when did I last get a physical, a pap, a mammogram (okay so the known medical community can't make their minds up on that one). I have a darn sore tailbone (it's only been that way for over two years) but I still am too busy to get it checked. Care to take a guess
    what my eye pressure is (like a grape or more like a cherry?) Gee , I'm healthy (or so my insurance says) so it can't be too high can it? I think my grandmother had glaucoma (or was that another kind of coma)? What does it feel like…? I had a
    headache the other day and I think one eye went blurry for a minute (but I can't remember which one). Oh good grief now
    what should I do. I know I'll go to the internet. Good decision.

  8. Kevin Falcon has no clue what he is talking about and only has the interests of Clearly contacts in mind. Clearly contacts donated 18,000 dollars to the liberal party recently. Hey Kev – how good is your safegaurd ensuring that initial contact lens fits and glasses are done by an optometrist/ophthalmologist? Anyone can go online and purchase contacts without a valid prescription. Who is checking to ensure that they have had contact lenses fitted on their eye by an eye care professional "the first time"? Whats next? Can i start updating my blood pressure medications without a prescription from my family doctor? You sir are whats wrong in politics and in the world in general. Corruption and greed.

  9. Kevin Falcon is a grade A douche bag

  10. As an optometrist, it's sad to say that I have already had two patients since the new regulations started that ordered contact lenses online without being fitted. Mr. Falcon eliminated the verification of prescription, which is the only safeguard for making sure people are fit properly with contact lenses. One patient (young student) decided to order without a fit due to financial constraints. Another patient (older professional) did not have financial constraints but seemingly just didn't have the time to get a fitting. Common sense? I think not… One of those patients developed sterile infiltrates on both corneas and for now, has to stay out of lenses.

    It's completely obvious that the government (Minister Falcon, Premier Campbell and the Liberals) has other motivations here but they are unwilling to budge and they want to "sell" this to their voters as way to "save money" when in the end, taxpayers (whether you wear corrective glasses/CLs or not) will end up paying more taxes on our burdened health care system taking care of people with vision loss from eye diseases that have gone undetected.

  11. Another point — optometrists (not opticians) were asked to volunteer for the Vancouver Olympics at the Athlete's Village to perform eye exams and dispense glasses for athletes (majority of whom were 19-64 age range, health individuals that would be "okay" for sight tests). Supposedly, the province wanted to showcase the best health care available — obviously they felt a full eye exam by an optometrist was the best standard but they are now being hypocritical and saying British Columbians do not deserve the same standards as the rest of the world. They would have been able to process a lot more patients with sight testing at the villages as appointments were booked solid but obviously it's not something they wanted to promote to the rest of the world visiting.

  12. Hmmm… I always thought of an optician as a specialized salesperson. Similar to a person working behind the cosmetics counter at Shoppers Drug Mart.

    Is this what "modernizing" health care means? Will the next thing be for the cosmetics counter salesperson to start assessing skin conditions and ruling out skin cancers, too? It's a slippery slope.

    • Opticians spend 2 years in school before they can dispense. They are by no means a doctor however, they are trained well above a salesperson.

  13. This legislation is akin to getting a birth control Rx online without getting a Pap. I'm glad I don't live in BC, but scared about what may happen in my province because of these new (irresponsible) laws.

  14. I think its remarkable that a single politician could make such sweeping change, without any oversight whatsoever. An uneducated, biased (isn't his sister an optician?), likely corrupt (bought and paid for by coastal contacts), politician?!? Give me a break already. It's obvious this guy made this change for the wrong reasons, and then tried to "spin it" as favorable to the public. How many cases of blindness will it take for this to be reversed? What a jerk

  15. This has bribe / behind-the-scene handshake written all over it.

    This comes right after the BC Court of Appeals decision to force Coastal Contacts to verify prescriptions. – Just terrible, Mr. Falcon must have been given a nice present at Christmas.
    Astonishing that one minister can make such a "significant" change without any consultation.

  16. Optometrists are shameless greedy pigs. They rip off the taxpayers to fund their own privileged lifestyle. They needlessly extract billions of dollars every year from consumers forced to attend unnecessary eye exams.

    So spare us the crocodile tears about patient care. This is about your Hummer and your house at the lake.

    • How many optometrists do you know who own a hummer and a lake???? Do you know how much it costs to go to optometry school?? Do you know how many years of my life I have given up to help the public with visual concerns???? You have been blinded by one man who knows nothing about eye disease or vision. You are sad and pathetic!! I just graduated from optometry school and I bet I diagnose a patient with Glaucoma every other day. The youngest of which was 33 years old!!! How will this affect her? Will she go blind? Do you even know??? Do you think she even knew she had glaucoma?? Can you answer any of these questions?? If every optometrist in BC were to diagnose a patient with glaucoma every other day how many patients would that be?? You are speaking out of line and clearly don't care about patient care. You should go join Falcon and his paid off group

    • Needlessly? Unnecessary? If you are lucky, you may be able to continue to think so. Preventative medicine, in all its forms, is tremendously important for the bottom line of the taxpayer. Optometrists attend eight years of school to be able to do what they do, and it takes a long time to pay off that kind of student debt! If medicare still covered regular eye exams, you probably wouldn't be complaining any more than you do about going to see your GP (if you are fortunate enough to have one) in order to get a prescription refilled. However, since the government doesn't cover regular optometric costs anymore, yes, that money gets passed on to you directly. Unfortunate, maybe, but not a ripoff. And, for the record, I am not an optometrist. I am an optician who took two years of training to become a license, and I firmly believe that regular eye health checks are as important as seeing your GP. We don't all support this new legislation.

  17. Sam, you are a perfect example of the uneducated public and why this legislation is so dangerous. In the calendar year 2009, there were 226, 675 medical services associated with Optometrist to Ophthalmologist referrals, representing 60, 687 total referrals for eye disease. I certainly do not own a Hummer, nor do I have a house at the lake. I take my work very seriously and find your comments very offensive.

  18. I just had a 36 yr old patient today with vague symptoms of eyestrain/headache/squinting for 6 months come in for an exam today. He believed he was healthy. He thought he needed glasses. His vision corrected to 20/40 R eye and 20/20 L eye with glasses. Unfortunately when you look in the retina, he has severe macular exudates, hemes and cotton wool spots from hypertension. I sent him to see a walk in physician emergently today to check his blood pressure and get treatment. He would be a perfect candidate for sight testing and I know for a fact, there are opticals that are NOT telling people that they are getting a sight test (not an eye exam) until after they sell them a pair of glasses. In fact, I had a patient that didn't find out until they told him they couldn't sign the Motor Vehicles form to renew his Class 1 license.

  19. The regulatory changes fall into two categories: removal of restrictions for selling contacts and glasses, and additional requirements for optometrists and opticians.

    Optical stores (whether online, or retail) are no longer required to have trained medical professionals on their staff to dispense glasses and contacts. Nor are they required to have prescription. There is a third change that allows prescriptions from professionals outside B.C. to be filled, but this seems absurd if no prescription is required at all.

    Optometrists are now required to provide a prescription to ALL patients, whether they need one or not (previous regulation required the prescription be given upon request). Optometrists will be required to incorporate eyeglass fitting into their exams. Optometrists will be required to facilitate sales transactions with third parties at no charge.

    Online retailers are able to undersell traditional Optical stores for three reasons: they do not have space to meet their customers, they do no have the staff to fit contacts or glasses for their customers and they sell much higher volume. While a fully booked optometrist may see around 3,000 patients, Coastal Contacts boasts of more than 300,000 customers. Currently, the traditional retail outlets underwrite online sales by providing fittings and customer support for minimal (if any charges) in the interest of developing ‘loyal customers' who purchase from them. These regulatory changes seem clearly crafted to secure this benefit for online retailers like Coastal Contacts as the traditional outlets see their share of the market decrease. As this happens, traditional retailers will be forced to charge for these services and consumers will see their costs increase.

    While I can see great advantages for online retailers like Coastal Contacts, I don't really see any health benefits or gains for consumers.

  20. I am an optometrist. In my working lifetime I have detected 8 people who were asymptomatic patients , but were confirmed to have a malignant melanoma in one eye. I have detected and referred patients with leukemia based on the pathological picture presented in the back of the eye. I have detected and referred several with signs/symptoms that were confirmed as brain tumors – also, countless patients who showed pathological complications due to high blood pressure, diabetis, cholesterol, age related macular degeneration ……….. the list goes on.

    I am always surprised that very seldom does the individual have symptoms, and these conditions are detected because of the individual wanting to upgrade their glasses, want a new pair of glasses, or present due to recall for a routine annual eye health and vision exam, which I stress should be an annual examination. They are dumfounded that they could have anything at risk, when they felt their vision and health was acceptable.

    Mr. Falcon should be allowed to "fly the coup" courtesy of the BC electorate in the next election – his actions are putting the public at risk.
    Some vision problems can be signs of a life threatening event.

  21. I'm 36. My prescription hasn't changed in 20 years.
    I require single visions glasses, I don't have diabetes or any health problems.
    In Canada, the law requires me to go back to an optician/opthamologist to get my eyes checked every two years before I can fill a presciption at a dispensing optician.

    The last time I had an eye exam, the doctor added something to it that ended up distoring my vision when I had the prescitpion filled.
    So I had to make another trip back to get him to change to back to the WAY IT WAS on my last prescription.

    Here in Winnipeg, the average cost of an eye exam is $65 – 80.
    Glasses, off the shelf, for single vision, no coatings, thick plastic lenses, start at above $200. One of the last full pair of prescirption glasses I purchased cost me over $400 – and that's without transitions, progressives, etc.

    I just got a quote for $155+ taxes to simply replace the lenses in an old pair of glasses. My presciption is 3 years old – BUT IT HASN'T CHANGED.

  22. Now I'm going to get dinged for both an exam AND overpriced lenses just to replace the lenses in a pair of glasses – which is more than I paid for these glasses originally.
    I might as well just throw them in the garbage.

    I want to buy glasses online, because I really can't afford to go hungry because of the cost of eyeglass examinations and dispensing in this city/province/country.
    The doctor who does eye exams doesn't measure pupilary distance, and/or doesn't write it on the prescirption.
    The dispensary won't measure it unless I pay them about as much as a full eye exam.
    And even if they had to take the 5 minutes to measure my PD during a lense replacement, they would CHARGE me for the pleasure of having me sign a release form to obtain that information.

  23. I presonally know people who have purchased eyeglasses online.
    They have had ZERO issues with vision or quality of their lenses.
    I've also used contact lenses I purchased online, again, with ZERO issue.

    The current laws, rules and practices aren't about "patient safety"; they were influenced heavily by powerful optometrist/optician organizational lobbies and designed to guarantee income for the local doctors and dispensaries, and protect their business.

    Knowing Manitoba, it will take another 10 years for these changes to make it here. I hope they do.