Editorial: Hospital optometry, an evolving specialty

26 November 2019
Volume 20, Issue 4

Professor Jonathan Jackson MCOptom and Professor Martin Rubinstein introduce this special bumper issue of Optometry in Practice.


This special edition of Optometry in Practice (volume 20, issue 4) has been prepared to highlight the diversity of optometric work undertaken by many of those employed within, or actively supporting the work of, the Hospital Optometry Service in the UK. It has been released to correspond with the 45th Association of Optometrists (AOP) Hospital Optometrists Annual Conference, which takes place for the first time in Northern Ireland.

All of the authors invited to contribute to the special edition are presenters at the conference and the papers published not only reflect an aspect of the clinical activity to which optometrists contribute, but highlight the content of their lectures or workshops as presented at the conference. Importantly, the diversity of the clinical activity presented demonstrates very clearly how hospital optometry has evolved from a service primarily associated with the provision of refraction, low vision, contact lens and visual function assessment services, expanding into new and exciting areas sometimes referred to in the USA as medical optometry.1 The concept of widespread evolving optometric secondary care roles in the UK is however not new to Optometry in Practice, having been addressed 10 years ago by Chris Steele and referred to in many subspeciality papers in the intervening period.2

The topics covered provide further evidence in support of the results of research published by Harper et al. (2016)3 in the College of Optometrists’ research journal, Ophthalmic and Physiological Optics. Robert Harper, supported by five other senior leaders in the field of hospital optometry and the College’s Research Lead, has highlighted the expanding scope of hospital-based optometric practice in the National Survey, which it is hoped will be rerun in the near future.

As optometrists, two of our most fundamental clinical contributions are to quantify accurately all aspects of visual function and to manage refractive error. In the first paper in this special edition, Roger Anderson, who in addition to holding academic professorial positions at the University of Ulster Coleraine and the UCL Institute of Ophthalmology in London has long established clinical affiliations with Moorfields Eye Hospital, London, and the Royal Victoria Hospital, Belfast, with his coauthors takes us on a journey of visual acuity. Figure 1 in this paper is a beautifully illustrated timeline taking us from Arabian stars to electronic test charts. Whilst acknowledging how far we have travelled down this road, the authors remind us that there is further to go: this may involve the routine adoption of new-generation ‘vanishing optotype’ charts, one of which is the Moorfields acuity chart.4 The potential added value this type of chart brings to disease detection and monitoring is discussed and we should all follow developments as they occur.

In the second paper, Flanagan and Saunders eloquently draw our attention back to the first of the most fundamental optometric clinical skills mentioned above, namely refraction. They remind us that, whereas we have a primary role in correcting refractive deficit in myopia, our responsibility is changing in light of public health concern about exponentially expanding global rates of childhood myopia. Reference to the College of Optometrists’ recently published guidelines on myopia management is made early in the paper, as is reference to other important global discussion papers on the subject. Commencing with a review of the factors known to be associated with the risk of developing myopia, the paper then looks at optometric management strategies used to restrict progression. These include a range of spectacle and contact lens prescribing options coupled with advice on lifestyle. As with the paper by Anderson et al., the authors take a look into the future and draw our attention to the results of exciting longitudinal randomised control trials designed to control progression through the use of very-low-dose atropine. A term referred to in the paper, and one not necessarily in our vocabulary yet but worth looking out for, is ‘pre-myopia’.

Moyra McClure and Jenny Lindsay present a paper on one of the more traditional aspects of hospital optometry, namely low vision. They have however chosen an interesting style, highlighting in some detail the content of four clinical case studies of older vision-impaired patients attending a multidisciplinary hospital-based low-vision service. The combination of sensory, physical and neurological challenges facing these four patients, and the approach taken to address a range of daily living challenges using both
optical and non-optical aids together with complementary support from sensory support teams, has been explained. Importantly, messages learned from the interventions have been clearly outlined in the main body of the text whereas clinical findings have been presented in tabular form. Those wishing to delve deeper have also been provided with a comprehensive reference section.

Two areas where hospital optometry has seen considerable movement recently – movement which is matched by developments in primary care optometry – concern the role optometrists play in the detection and management of glaucoma and acute-onset eye disease. Katie Graham, assisted by senior optometric and consultant ophthalmologist coauthors, introduces us to the LiGHT trial and speculates as to the importance this trial may have in developing future roles for optometrists in the management of glaucoma.
The challenges are outlined against a background of changing epidemiological trends, which are largely population age-related. The review succinctly raises some challenging questions regarding how optometric training needs to adapt to ensure that experienced optometrists can contribute not only to disease detection and monitoring but to treatment management using both topical medications and selective laser trabeculoplasty (SLT).

The paper by Maura Bailie, Deirdre Burns and colleagues looks at the challenges faced by hard-pressed eye casualty medical and nursing staff, in a similar light. The authors clearly highlight how valuable an asset optometrists – those with independent prescribing qualifications – can make to this service when fully integrated into the team and empowered to use clinical decision-making skills to the full. The authors provide some background as to how this type of service has evolved in a number of UK hospitals, and more recently in Northern Ireland, creating an ideal platform from which to launch 11 very informative case reviews. These beautifully illustrated cases will no doubt make invaluable reading for those wishing to follow Maura, Deirdre and colleagues through the eye casualty door.

One of the optometric services in which the team at Moorfields has most recently led the way concerns the management of patients with keratoconus. Traditionally those of us who worked within hospital-based corneal and contact lens services have become very experienced at dealing with the refractive challenges posed by the ectatic cornea, and indeed the often astigmatic post-keratoplasty cornea. The release of NICE guidelines in 2009 and more recent upgrades has however introduced us all to corneal cross-linking. Vijay Anand and Marcello Leucci have provided us with a very useful review of the history and relevance of corneal cross-linking and in addition have shown
us the direction in which this treatment modality is travelling – one more very well-referenced article that should be carefully assimilated and put to use.

The last of the seven papers, although not including an optometric coauthor, deals with a topic that should be of growing interest to both hospital and primary care optometrists. Cushley and Peto highlight apparently contrasting messages, namely the increasing global prevalence of diabetes and the reduction in UK sight-impaired and severely sight-impaired certification/registration related to diabetic eye disease, as a leading cause of significant sight loss. This they attribute to the sustained efforts of those responsible for coordinating diabetic healthcare services, including the four-regions diabetic eye screening programmes. The authors acknowledge the important role optometrists have to play in this area and encourage us, whether employed in secondary care or primary care, both to support and promote this service. So this is the first hospital optometry special edition of Optometry in Practice and we trust that it will fulfil two functions. Firstly, that it will act as a resource for optometrists hoping to contribute to the development of evolving hospital optometry services, which we believe need to be utilised in light of developing population trends and the current optometric education review exercise. And secondly, that the papers help inform those working in primary care as to how hospital optometry is developing and how we wish to utilise lessons learned to assist our primary
care colleagues who will need to take up more and more of the workload challenge. Further information regarding the breadth of activity undertaken by this enthusiastic and highly committed family of UK optometrists can be gleaned from reviewing a selection of conference poster abstracts, published as an appendix to this special edition. Our grateful thanks are extended to the AOP for their support in sponsoring the Hospital Optometry Conference.


Adjunct Professor A Jonathan Jackson PhD MCOptom FBCLA FAAO

Jonathan is a hospital optometrist who for over 30 years has pursued a career in secondary care. His experience has been gleaned through working in teaching hospitals, universities and professional colleges in Ireland (Royal Victoria Hospital, Queen’s University, Ulster University and Dublin Technological University), England (Moorfields Eye Hospital), the USA (University College Berkeley) and Australia (Australian College of Optometry, Royal Victoria Eye and Ear Hospital and University of Melbourne). He has worked with many of the world’s foremost ophthalmic surgeons, clinical and research optometrists and vision scientists. He has co-authored over 100 peer-reviewed papers, many of which have focused on visual disability, low vision and contact lens and corneal topics. He has been responsible for establishing both adult and paediatric low-vision and contact lens services at a number of hospitals, services built on an evidence base and validated against clinical standards. He qualified as an independent optometric prescriber in 2016 and in 2017 was awarded an American Academy of Optometry Low Vision Research Diploma.

Martin P Rubinstein PhD FCOptom FAAO


1. American Board of Certification in Medical Optometry. www.abcmo.org

2. Steele C. Extended roles in hospital optometry and liaison with community optometrists. Optom Pract 2008;9:v–ix.

3. Harper R, Creer R, Jackson J et al. Scope of practice of optometrists working in the UK Hospital Eye Service: a national survey. Ophthalmic Physiol Opt 2016;36:197–206.

4. Shah N, Dakin SC, Whitaker HL et al. Effect of scoring and termination rules on test–retest variability of a novel high-pass letter acuity chart. Invest Ophthalmol Vis Sci 2014;55:1386–1392.