Vision Health
(Globe & Mail insert)
A new view in sight
Access to eye care is critical if Canada is to avoid a crisis in vision loss
Canada is on the verge of a crisis in vision loss that's related to a crisis of access to eye care. To begin with, the 105,167 Canadians currently registered with the Canadian National Institute for the Blind (CNIB) will nearly double to 187,000 people by 2015.
The National Coalition for Vision Health recently reported to the Commission on the Future of Health Care in Canada, "it is conservatively estimated that the [CNIB] registry captures only 50 per cent of Canadians with severe vision loss."
An obvious trend line here is simple demographics, with the four leading causes of vision impairment - macular degeneration, glaucoma, diabetic retinopathy and cataract - all age-related and only cataracts being curable. No less obvious to Canadians already requiring eye care, however, is the crunch in access to specialized medical attention. As reported by the Fraser Institute for the year 2001, of all medical specialties, ophthalmology has the second longest wait period for referral from a family doctor to actual surgery by the ophthalmologist, a staggering 26 weeks. From specialist visit to actual surgical treatment, the wait time is also one of the longest at 15.8 weeks.
"Over the past decade, the number of ophthalmologists in training has been reduced by 50 per cent across Canada because medical school and specialty training enrolment was cut," reports Dr. Duncan Anderson, President of the Canadian Ophthalmological Society.
The United States has twice as many ophthalmologists per capita as Canada. "Canada has about half the medical school seats per capita of any country in the Western world," Dr. Anderson says.
In the past decade alone, Canadian residency programs in ophthalmology have shrunk from 40 graduates to about 20. Meanwhile, more than 35 per cent of present ophthalmologists are over the age of 55.
"As governments were dropping medical-school class numbers, we were getting the baby-boomer generation aging," says Dr. Anderson, based at the University of British Columbia in Vancouver. "The problem is that it takes four years of undergraduate studies, four years of medical school and four years of specialty training to produce an ophthalmologist."
Ophthalmology is hardly the only medical specialty that has faced cuts and is dealing with stringent shortages today, but the situation ranks among the most severe in the health system. And despite vision loss ranking as the most feared potential consequence of aging after cancer, public and political awareness of the issue is low.
"Canadians, and the provincial and federal governments that represent them," Dr. Raymond LeBlanc, Chair of the National Coalition for Vision Health told the Romanow Commission, "do not seem well informed regarding vision health and the consequences of vision loss. There is a perception and acceptance that vision loss is an inevitable part of natural aging. Furthermore, many if not most Canadians are not aware of the vision care and rehabilitation services available to them or how to access them."
The National Coalition for Vision Health has recommendations:
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Launching a national-awareness campaign to highlight vision-health
issues -
Doubling enrolment in post-graduate ophthalmology programs
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Creating guidelines to address waiting times for vision care
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Standardizing pre-school eye health screening programs
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Task forces in all provinces to develop and implement a team-based
eye-care approach such as the Comprehensive Vision Care Program being piloted in Nova Scotia.
This latter suggestion is key, drawing as it does on the extensive professional resources for diagnosing, monitoring and referral available to Canadians through optometrists and family doctors.
"We already provide 70 to 90 per cent of primary eye care, depending on the province," says Dr. Scott Mundle, president of the Canadian Association of Optometrists in Winnipeg. "Optometry is the profession that is most represented in all non-urban settings. We work along with family physicians."
While ophthalmologists have been concerned about relinquishing primary-care responsibility (outside of refraction to test visual acuity), overwhelming patient demand has in practice compelled an increasingly team-oriented approach.
"There are probably eight or 10 [types of] specialists who are involved in eye care," notes Dr. Anderson, alluding to ophthalmological technical assistants, opticians, low-vision specialists and others.
Dr. Mundle reports that his association has been working hard to change drug legislation so optometrists can administer certain eye medications (five provinces now allow this) and to create national standards for training and exams.
The Canadian Ophthalmological Society in Ottawa has also recommended that new eye-care-delivery models be explored in each province, along with increasing the number of ophthalmologists in training. It additionally urges that access to equipment and technology for medical, surgical and diagnostic eye care be adequately supported.
"If you speak to ophthalmologists in Ontario," Dr. LeBlanc says, "they'll say they have 25-per-cent less capacity for surgery than they did five years ago."
That's the wrong direction for a trend line, with seniors predicted to comprise 20 per cent of the Canadian population in the next two decades. "Our bottom line," Dr. Anderson says, "is that unless we dramatically change the present system of eye care, we're going to have a very serious squeeze."
