Will new rules put vision at risk?

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.