Across the globe, the ophthalmic team is seen as critical to improving quality of and access to quality eye care services. The purpose of this chapter is to highlight the varying types of allied ophthalmic personnel (AOP), a
a In 2015 the World Health Organization in its Cambridge Declaration stated “The definition of allied ophthalmic personnel may be characterized by different educational requirements, legislation and practice regulations, skills and scope of practice between countries and even within a given country. Typically, allied ophthalmic personnel comprise opticians, ophthalmic nurses, orthoptists, ophthalmic and optometric assistants, ophthalmic and optometric technicians, vision therapists, ocularists, ophthalmic photographer/imagers, and ophthalmic administrators.”an inclusive term defined by the World Health Organization (WHO) to encompass the many varied titles and responsibilities of AOP in different countries. As countries develop their own AOP, they increasingly are looking at the North American experience, particularly with regard to planning and organization. Therefore this short historical review of the United States experience is provided.
The 1960s was a turbulent decade for the United States politically. At the same time, positive achievements were made in the area of civil rights and socioeconomic benefits. Specifically, the introduction of Medicare and Medicaid made it possible for patients to access health care including eye care and particularly cataract surgery because it would now be covered by insurance.
In anticipation of significant increases in the number of patients seeking care, government and academic health planners met early to discuss challenges and explore solutions. Funds were made available by the government to drastically enlarge medical school classes and in ophthalmology, new residency positions were created. At that time, eye patients had to wait 3 to 5 months for an appointment and the ophthalmologist’s time with each patient became shorter and shorter. It was clear that increasing the number of eye care providers and creating efficiencies was critical, but how to do it in a short period of time? The idea of AOP was identified, but they needed to be reliable and well trained.
In 1963 after 2 years of preparation and under the direction of Dr. Peter Evans, the first full-time 2-year training program for ophthalmic medical personnel (OMP) in the United States was established at the Georgetown University Medical Center in Washington, DC. Soon similar programs followed in university departments across the United States and in Canada. It became clear that not only could more patients see their ophthalmologist in a timely fashion, but that a greater number of important but often time-consuming diagnostic tests could be provided for which the ophthalmologist simply did not have the time to perform. The original time-saving motive had actually resulted in a significant improvement to the quality of ophthalmic patient care.
Many ophthalmologists, especially those establishing training programs, felt there was an urgent need for standardization of training, comparable or uniform examinations, and clear definitions of different levels of expertise: in short, for quality control. In 1969 the Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO) was established and has since enjoyed the support of all North American ophthalmologic and allied health organizations (see also Chapter 52 ).
JCAHPO established an organization to accredit ophthalmic assistant (OA) and technician training programs and to certify personnel at these levels. In the early 1980s, an additional category of OMP was added to the OA and Ophthal-mic Technician levels which was the Ophthalmic Medical Technologist which had increased levels of training and examinations. In 2017 JCAHPO became the International Joint Commission on Allied Health Personnel (IJCAHPO). The Commission on Accreditation of Ophthalmic Medical Programs (CoA-OMP) was under the U.S. Commission on Accreditation of Allied Health Education Programs (CAAHEP). CoA-OMP became independent of CAAHEP in the mid-2000s. In 2018 CoA-OMP became the International Council of Accreditation (ICA) and accredits ophthalmic training programs in Canada, the United States and globally.
At the last census in 2010, the American Medical Asso-ciation stated there were approximately 23,861 ophthalmologists in the United States (pop. 309.4 million) reflecting a ratio of one ophthalmologist per 12,967 people, an entirely adequate ratio, not considering some regional maldistributions. It is estimated that U.S. ophthalmologists are supported by well over 45,000 AOP, not including administrative and other staff. More than 27,200 AOP are certified and recertified every 3 years. Typically, certified AOP earn good salaries with very good job satisfaction. In addition, more than 818 AOP (2020) are now certified in Canada and in other countries where the IJCAHPO certification examination is administered.
These figures are dramatically different in other areas of the world, especially low to middle-income countries (LMICs). In sub-Saharan Africa, the average is just one ophthalmologist per one million population. With most ophthalmologists being located in urban areas and most of the population living in rural areas, this ratio is smaller in urban areas and wider in rural settings when considering access to care. Blinding diseases, such as trachoma and onchocerciasis, almost never seen in developed countries, still exist in LMICs. In 2015 the Vision Loss Expert Group (VLEG) estimated the prevalence of visual impairment globally at 253 million including 36 million who are blind. Approximately 89% of these live in LMICs and 55% are women. Another 1.1 billion have near vision impairment simply because of the lack of reading glasses. In the 1950s initiatives were developed by WHO and nongovernmental organizations (NGOs), to address the inequities in these countries, many of which were still under colonial rule. European and American NGOs, often with funding from their own government agencies, were founded for the express purpose of preventing blindness and restoring sight in LMICs. The WHO works specifically with national governments on policy and public health initiatives to combat disease, and also with a number of NGOs including those focusing on eye health. Most of the leading international eye health NGOs along with academic institutions and corporations are members of the International Agency for the Prevention of Blindness (IAPB; www.iapb.org ), a global advocacy organization working in official relations with WHO and supporting global initiatives to reduce vision impairment.
With unoperated cataract being responsible for as much as 47% of the world’s blindness caused by disease, NGOs including IJCAHPO helped develop national eye health services, provide treatment and surgery, and train ophthalmologists and AOP. Today, most LMICs have their own ophthalmic infrastructure with qualified ophthalmologists and AOP, but the numbers are not adequate to meet the needs of their populations.
Many projects supporting eye health in LMICs are implemented by international NGOs in collaboration with local NGOs, government Ministries of Health, and the ophthalmic community. National governments recognize the need for ophthalmologists and AOP in creating ophthalmic teams to provide efficient, quality eye care. IJCAHPO and ICA work collaboratively with governments, NGOs, and local ophthalmologists to implement an international AOP curriculum, and establish certification and accreditation standards for the workforce and ophthalmic training programs respectively.
VISION 2020: The Right to Sight
Launched by IAPB and WHO in 1999, this ambitious global initiative aimed to eliminate avoidable (preventable and treatable) blindness by the year 2020. WHO passed three resolutions on the elimination of avoidable blindness (2003, 2006 and 2009) and in May 2009 at the World Health Assembly, passed WHA66.4 “Towards universal eye health: a global action plan 2014–2019” demonstrating WHO’s commitment to eliminating visual impairment and giving eye health stakeholders a powerful advocacy tool.
This chapter describes regional challenges and training approaches. Much of the information has been provided by NGOs, ophthalmologists, and AOP working in these countries.
The IAPB’s Vision Atlas is an excellent online source for eye global eye disease data, the leading causes of eye disease by region, human resource availability, and other important data around blindness and visual impairment— www.iapb.org/learn/vision-atlas/ . The Vision Atlas is updated annually with data from the Vision Loss Expert Group— www.iapb.org/learn/vision-atlas/about/contributors/vleg/ .
Latin America and the Caribbean
In most regions of the world, the work of AOP is driven by the need to reach more patients needing eye care. IAPB’s Vision Atlas estimates a prevalence of vision impairment (blindness and low vision combined) of between 1.98% and 3.92% in the Latin America region and 2.6% in the Caribbean. Unoperated cataract is responsible for 42.46% to 43.44% in Latin America and 41.62% in the Caribbean.
The Ophthalmology Society of the West Indies (OSWI) has taken a leadership role in training AOP at the OA level by supporting an annual training program conducted during the OSWI annual meeting. OSWI and IJCAHPO collaborate in conducting a 4 to 5 day program with the students who have studied throughout the year, taking IJCAHPO’s certification examination as the capstone event.
The largest country of South America representing 50% of the entire continent, Brazil also has the region’s largest population of 212.6 million. With 21,063 ophthalmologists, the ratio of ophthalmologist per population is 1:10,000. The ophthalmology residency training is similar to that of the United States. However, the urban versus rural maldistribution of ophthalmologists is even more pronounced than in most other countries in the region. More than 95% of all eye care services are located in urban areas with large swaths of Brazil and its Amazon regions isolated from modern health and eye care.
Originally, only orthoptists were trained in formal courses. In 1988 Professor Newton Kara-José at the University of Campinas in Sao Paulo started a training program for OAs which has continued without interruption. Four times a year, a full-time 2-month course is offered to 10 high school graduates, 90% of them women. There also are a number of short, 1 to 3 day courses offered by professional societies, the University of Campinas, and during ophthalmic meetings (20–30 per year). Therefore, very few of the estimated 6000 to 7000 AOP in Brazil have had any formal training. The upper income limit for AOP is equivalent to approximately U.S. $8000 annually.
The leading causes of blindness in Brazil are similar to most countries: cataract, uncorrected refractive error (URE), glaucoma, and diabetic retinopathy. Most important in children are infantile cataract, uncorrected refractive error (URE), toxoplasmic retinitis, and retinopathy of prematurity. Since 1999, as a result of collaborative efforts between the Ministry of Health and the Brazilian Council of Ophthalmology, cataract surgery has dramatically increased from under 70,000 per year to more than 300,000 per year.
Despite a few notable exceptions, most ophthalmologists in Brazil still need to be convinced of the advantages to them and to the public of formal training of AOP. The situation is similar in other countries in the region. Kara-José notes that ophthalmic societies are strongly opposed to training of allied eye health personnel because of a perceived threat of these people working independently without ophthalmic supervision.
Located in Central America, Guatemala has a population of 17,915,568 and 96 ophthalmologists for a ratio of 1:186,621 with most ophthalmologists located in urban areas. There are no formal training programs in Guatemala except for ophthalmologists. AOP are trained within eye units and hospitals for specific skills. Visualiza located in Guatemala City with its satellite Vincent Pescatore Eye Hospital in the Peten reached only by air, uses ophthalmic nurses, OAs, operating room (OR) nurses, optical shop dispensers, and equipment technicians (angiograms, optical coherence tomography), as well as patient counselors and outreach coordinators. Visualiza has developed courses to improve skills of existing ophthalmic technicians, OR nurses, and counselors for their own facilities as well as others in the country.
Haiti, the poorest country in the Western Hemisphere, has a population of 11.4 million with 1.23 million living in the capital Port-au-Prince. Haiti is mountainous and has very poor electrical service, mostly from aging generators. Although improved, the estimated prevalence of blindness is 1.2%. Cataract is responsible for approximately 50% with glaucoma responsible for approximately 30% of blindness. Blinding malnutrition from vitamin A deficiency can still be found, and diabetic retinopathy is common.
There are 65 ophthalmologists in Haiti, nearly all in urban areas. In the 1980s NGOs began supporting sporadic training of OAs for 1 year who were deployed throughout the country. With new eye clinics and hospitals being established outside the capital, access to eye care has improved but is still limited with some parts of the country having no eye care services at all.
The estimated number of AOP in Haiti is 100 with an average monthly salary of less than U.S. $200. Most AOP work in eye centers outside the capital where they receive on-the-job training. Political unrest is still a challenge and the devastating earthquake of 2010 destroyed infrastructure including at the university’s Department of Ophthalmology. The Haitian National Committee for the Prevention of Blindness (CNPC) coordinates with international and national NGOs and donors to strengthen eye health services in the country.
Peru counts 222 ophthalmologists for its population of almost 33 million (2020) for a ratio of 1:149,000 and again, they are located in urban areas. A large geographic part of Peru is in the Amazon. The government hospital in Peru’s Amazonian capital Iquitos has an eye unit and a new eye hospital has been built by the Peruvian NGO Clinica Divino Nino Jesus with support from international NGOs These. are the only eye care services accessible to Peru’s Amazonian population who cannot reach the rest of Peru except by rivers or by air. Although the National Eye Institute in the capital Lima conducted ophthalmic training courses for nurses and auxiliary personnel from 1979 to 1995, there are at this time no similar programs in Peru. Challenges are a lack of direct supervision after the trained personnel returned to their original sites, little continuing education or evaluation of their activities, and often AOP were reassigned to duties outside of eye care for which they had been trained.
Today in Peru, AOP are trained in the eye hospitals where they work. The government requires that those being hired and trained as AOP must be either 5-year university trained nurses (equivalent to Registered Nurse) with a sixth year of training in rural/public health, or a 3-year trained Technical Nurse (equivalent to Practical Nurse). They are trained at their hospitals to perform specific skills, such as measurement of visual acuity, visual fields, and autorefraction, and university-trained nurses usually have supervisory positions in clinics and ORs.
Although Puerto Rico is part of the United States, it had very few U.S.-graduated ophthalmologists in the 1950s. The first ophthalmology residency program was established in 1954 at the University of Puerto Rico by Professor Guillermo Picó. In 1961 the International Eye Foundation (IEF) helped establish the first Basic Science Course in Spanish for ophthalmologists and is attended annually by ophthalmologists from throughout the Latin America region.
In 1972 there was one ophthalmologist per 42,000 population. Because a more ideal ratio was felt to be unattainable, planning began for an ophthalmic technician training program at the university’s Department of Ophthalmology. This became a 2-year undergraduate degree program with the first year in general education and the second in ophthalmic technology. It was officially accredited at the ophthalmic technician level by ICA and students take the IJCAHPO certification examination. Today, the program is rated highly with students coming from throughout Latin America.
The population of Puerto Rico in 2018 was 3.2 million reflecting a significant decline after Hurricanes Maria and Irma. With 120 ophthalmologists, also a decline after the hurricanes, the ratio of 1:26,600 is much improved but would be better had it not been for the destructive hurricanes and their aftermath. There are approximately 300 ophthalmic technician graduates, mostly women, working under the direct supervision of ophthalmologists, usually in urban areas. The value of AOP has resulted in more patients being seen by an ophthalmologist at a lower cost. Uniformly, the community benefits are an increase in the number and quality of ophthalmic services. The remuneration of AOP in Puerto Rico is comparable to that of other mid-level health workers and nurses in the country.
Until the end of World War II, only four countries in this second largest continent of the world were independent nations: Egypt, Ethiopia, Liberia, and South Africa. During the following turbulent decades, almost 40 former African colonies gained independence from their European rulers (Great Britain, France, Belgium, Germany, and Portugal). The continent is divided geographically between Arab North Africa and sub-Saharan Africa with their own cultural, social, economic, and language differences.
Many sub-Saharan African countries experience civil strife, terrorism, and epidemic health problems, such as malnutrition, malaria, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), and outbreaks of diseases, such as Ebola. National governments, WHO and international donor budgets focus, rightly, on diseases causing mortality leaving per capita spending on eye health insufficient compared to the need. The training and utilization of AOP in Africa has been critical with AOP often serving as the backbone of public eye health services.
Notation: Egypt and Cameroon
The Magrabi Foundation based in Egypt has taken a leadership role in expanding AOP in the Eastern Mediterranean and African regions where the need is significant. The Magrabi Foundation is funding two important programs to train OAs and technicians; one in Cairo, Egypt and the second in Yaoundé, Cameroon. The programs follow the International Core Curriculum for Ophthalmic Assisting and have embraced the ICA accreditation standards to ensure quality measures. Both programs implement IJCAHPO’s certification program by using the certification as a graduation examination. Most AOP are employed by NGO managed eye hospitals and paid according to each hospital’s wage structure.
On the East African coast of the Indian Ocean astride the equator, Kenya’s population is 53.8 million and two-thirds of the population live in rural areas.
Kenya’s Ministry of Health reports 115 ophthalmologists in the country of which 60 are located in the capital Nairobi reflecting an ophthalmologist per population ratio of 1:468,000, far below the WHO’s recommended 1:250,000.
The leading causes of blindness in Kenya are cataract, corneal blindness caused by trachoma, and glaucoma. The first group of ophthalmology residents graduated from the University of Nairobi School of Medicine in 1981 after 3 years of training. To supplement the need for more qualified medical personnel, Kenya’s government began training medical assistants in the Kenya Medical Training College. The program recruited high school students and trained them for 3 years in clinical medicine to become clinical officers (COs). A CO could then specialize for another year to attain a diploma as CO in pediatrics, orthopedics, and so on.
In 1956 during British colonial times, it was recognized that the severe undersupply of ophthalmologists could not be changed in the foreseeable future. Kenya’s government with administrative support from the Kenya Society for the Blind established the Kenya Ophthalmic Programme (KOP). The first cadre of Clinical Officers trained in ophthalmology (OCOs) were trained for 1 year and recognized as a separate cadre within the Ministry of Health and paid by the government at a higher rate than general COs thanks to advocacy to make sure OCOs would not leave service for better pay elsewhere. They were deployed to a network of over 70 government and NGO static and outreach service delivery points throughout the country, often working independently. They provide comprehensive eye care, referrals for surgery, outreach services, and participate in community education for prevention of blindness. In 1993 OCOs could train for an additional year as OCO Cataract Surgeons (OCO/CS) performing intracapsular cataract extraction (ICCE) and then extracapsular cataract extraction (ECCE)/intraocular lens (IOL) under supervision of an ophthalmologist.
The official acceptance of primary eye care (PEC) as an element of primary health care (PHC) in 1996 led to a work overload for OCOs. In the 1990s the need for formal training of other cadres of AOP became evident, such as community eye care workers, OAs, ophthalmic nurses, ophthalmic scrub nurses, and nursing assistants. With the advent of the IAPB/WHO “VISION 2020: The Right to Sight” targets, childhood blindness became a priority and special training for low-vision therapists was accepted by the government.
Nurses have been the backbone of healthcare services in East Africa. The Kenya Nursing Council (KNC) has evolved in its recognition of nursing and Nurse Assistant (NA) training.
In 2003 a 1-year university diploma course was established specifically for ophthalmic nurses with financial support from international NGOs. Their training and job description aimed to avoid duplicating the responsibilities of OCOs and concentrate on health promotion, management of eye units and eye camps, and the operating room.
Training of OAs began at the Kikuyu Eye Unit near Nairobi with support from the German-based NGO Christoffel Blindenmission (CBM). The aim was to give the necessary skills to the OA to screen, diagnose, prescribe for common eye infections, and to know when and where to refer patients with serious eye problems. OAs could be deployed to primary or secondary government or mission hospitals.
The 3-month course covers basic ophthalmology with an emphasis on eye conditions, such as trachoma, practical procedures related to administering medications, and preoperative patient preparation, as well as postoperative care after surgery, especially for patients in rural areas who are operated by a visiting surgical team. OAs working in areas with endemic trachoma are taught how to perform bilamellar eyelid surgery for trichiasis. An OA training program was established by Dr. Kiage in Kisii, western Kenya, which implements IJCAHPO’s certification program.
Malawi is a small, landlocked country in southern Africa, one of 16 member states of the Southern African Development Community (SADC). Malawi has a population of 17 million people, 87% of whom live in rural areas. There 12 ophthalmologists in the country equate to 1.4 ophthalmologists per million people. Fortunately, Malawi is a very small country and patients can usually reach ophthalmic services in Blantyre in the south, Lilongwe in the center of the country, and Mzuzu in the north by public transport.
The major causes of blindness are cataract, trachoma, and glaucoma. Blinding malnutrition from vitamin A deficiency can still be found, especially in the arid south. In 1980 the International Eye Foundation (IEF) established the first OA Training Program in Malawi which ended in 1997 as trainees preferred the OCO training described later. In 1983 the SADC Ophthalmic Training Center was established at the Malawi College of Health Sciences in Lilongwe, with financial and human resources support from the British-based SightSavers International (SSI). It is run by the Ministry of Health and Population and its specific objective is to create trained mid-level eye health personnel equipped with the knowledge, attitudes, and skills to prevent and cure eye diseases.
Training in Malawi has evolved. There is a 3-year OCO training program awarding a diploma in clinical medicine and training approximately 30 OCOs per year. There is an 18-month “Cat. Surgeon” (nonphysician) training program for OCOs to perform cataract surgery and external ocular surgery awarding an advanced diploma and training approximately 10 per year. These “Cat. Surgeons” work in SADC countries and Kenya. Malawi’s ophthalmic nurses were actually general nurses who took an OMA course receiving a certificate but were not trained formally as ophthalmic nurses. Botswana and South Africa have postgraduate ophthalmic nurse courses with Botswana basing its course on Malawi’s OCO curriculum.
Malawi now has a 4-year degree course for optometrists and an 18-month optometric technician course, each training approximately 20 per year. A key challenge is the lack of continuing education because of lack of funds for trainee costs and for international trainers.
The Institut d’Ophtalmologie Tropical de l’Afrique (IOTA) originates from the former Trachoma Institute transferred from Dakar, Senegal to Bamako, Mali in 1953. In 1960 IOTA joined the Organisation De Coopération Et De Coordination Pour La Lutte Contre Les Grandes Endémies (OCCGE), an intercountry network of research and training institutions. In 2000 at the termination of OCCGE, IOTA was transferred to the Malian authorities and became a specialized national public hospital. In 2006 IOTA became a University-affiliated Teaching Hospital (Centre Hospitalier Universitaire CHU-IOTA).
Being a tertiary level facility, CHU-IOTA has four essential functions: (1) research, (2) specialized eye care, (3) training and education, and (4) provision of technical support and expertise in eye care, training, research, and prevention of blindness to Francophone countries in Africa.
Annual services provided include 100,000 outpatient visits, 6000 ocular surgeries, 7000 specialized eye examinations, and 1000 laser treatments (yttrium aluminum garnet [YAG] and Argon). Academic and clinical staff include 24 senior specialists in ophthalmology, optometry, and anesthesiology including academic subspecialists (professors and lecturers), and consultants. IOTA’s research capacity includes, on average, 10 research studies per year.
CHU-ITOA’s training capacity includes 10 ophthalmology residents per year in a 4-year training program; 10 ophthalmic nurses (Technicien Spécialisé en Ophtalmologie) per year in a 2-year training program; 10 optometrists per year in a 3-year training program; and eight opticians per year in a 6-month training program. In addition, IOTA provides Continuous Professional Development and additional training on an ongoing basis for eye care professionals from Francophone Africa, as well as surgical training supported by fully equipped wet and dry labs.
Since 1991, IOTA has trained 267 ophthalmologists, 487 ophthalmic nurses, 66 optometrists at the bachelor level, 163 optical technicians, and 30 ophthalmic nurses who received specialized training in special ocular examinations.
Nigeria has the largest population in Africa at 206,139,589 and reports 300 ophthalmologists, many being subspecialists. The ophthalmologist to population ratio is 1:687,000. Nigeria’s ophthalmic nurses are trained in the Nigerian Teaching Hospitals, optometrists are university trained, and opticians are trained on the job. Hospitals take high school graduates for 6-week courses for OAs and ophthalmic technicians at the National Eye Centre in Kaduna established by Prof. Adenike Abiose. There is a constant need to train and retrain to retain staff but lack of funding is a challenge.
There are 27 ophthalmologists in Tanzania with a population of 59.7 million people yielding an ophthalmologist per population ratio of 1:2.2 million with most located in urban areas. The leading causes of blindness are cataract and corneal disease from trachoma.
Although known and described for thousands of years, trachoma had been studied particularly in Egypt in the 19th century and became known as the “Egyptian [eye] disease.” The chlamydia infection is endemic, highly contagious, and usually bilateral, affecting especially women and children in arid areas. Trachoma causes conjunctival inflammation under the upper eyelids leading to scarring, entropion, and trichiasis over time. Trichiasis causes corneal opacification and blindness. This preventable cause of blindness is a major focus for community eye workers and OAs who can jointly enact the WHO’s SAFE strategy to prevent trachoma—Surgery, Antibiotics, Facial cleanliness, Environmental hygiene. The trained OCO can perform eyelid surgery to remove the scarring, relieve entropion, and eliminate trichiasis ( Fig. 53.1 ). The critical activities revolve around providing antibiotic ointment to treat early, infectious trachoma and teaching community members about the importance of face washing and environmental hygiene to reduce fly populations that spread the disease. Tanzania has paramedical ophthalmologists, ophthalmic nurses, and OAs similar to Kenya. They are trained by either government or NGO-supported programs and work in government facilities or NGO or mission eye units ( Fig. 53.2 ).