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OD PERSPECTIVE

Changes to the Prescription Laws 
in British Columbia - Is the U.S. Next?

As of May 1st, the Health Professions Act passed by the British Columbia Ministry of Health Services went into effect. These new regulations now allow internet contact lens companies to provide assessment records and prescriptions without possession or verification of a current refraction and allow “sight testing” opticians to independently conduct automated refractions. If this “trend” is developing in British Columbia, will it follow in the United States?

Under the new regulations, only the initial fitting and dispensing of contact lenses will have to be performed by an optician, an optometrist, or an ophthalmologist using information contained in the prescription or sight test assessment. The new regulations will permit anyone, including internet suppliers to sell eyeglasses or replacement contact lenses. In order to ensure that patients can easily order their eyeglasses or contact lenses through any source, the regulations require optometrists and opticians to provide their patients with a copy of the patient record, including all the fitting and lens specifications, regardless of whether the patient requests it.

A copy must also be given to a third party eyewear seller or other person if requested by the patient. The measurement of the distance between the pupils (PD), which is required for the proper fitting of eyeglasses, must be included in a prescription or sight test assessment. Patients will now be able to order eyeglasses or contact lenses online without having to give the seller a copy of their prescription, sight test assessment, or contact lens specifications.

Optometrists and ophthalmologists will no longer be the only professionals entitled to perform refractions. The scope of practice of opticianry has been expanded to include refraction or “sight testing”. Previously, opticians in British Columbia could perform sight tests but were required to have the results approved by a physician. The amended regulation will permit opticians who have completed a certification program, to perform sight tests using an automated refraction suite on healthy individuals between the ages of 19 and 65 and dispense eyewear based on the results of the sight test. A screening process will be put in place to ensure a patient is healthy enough to be eligible for the sight test and is fully informed about the difference between a sight test and an eye health exam. 

“The British Columbia Association of Optometrists (BCAO) mounted a campaign against the proposed changes in March. Allowing people to buy contacts online without having to prove that they have a prescription is like allowing patients to keep ordering medicine from an old prescription without ever having to go back to their doctor to have a check-up on their condition or to make sure the treatment is still appropriate,” said Dr. Antoinette Dumalo, President of the BCAO.

“Going forward, we trust the public to be able to make decisions on their own behalf,” the Ministry of Health said in a prepared statement. “If the public wishes to have an eye health exam by an optometrist every year or more, they have the right to do that. But the public should also have the right to determine whether or not they wish to take advantage of the services of an optician and now they can make those decisions if they meet certain health requirements.”

There are those who believe the British Columbia law fails on many levels. The following list is a brief representation as to why this British Columbian law and laws in the United States are different, including some questions that the citizens and politicians of British Columbia may wish to ponder. Are British Columbian (B.C.) patients going to know the difference between daily use lenses where they receive one pair for a year vs. disposable lenses that should be used daily, weekly, or monthly? Will B.C. patients suffer corneal infections by sleeping in lenses that were meant for daily use? What happens when contact lens companies discontinue contact lenses as is now occurring with the Ciba Focus monthly lens, the Ciba Freshlook lens, the Ciba Hydrocurve lens, the Ciba Standard Visitint lens, and the Ciba Polycon sphere lens? What lens would be substituted and by whom? When an eyeglass prescription is determined, how will the contact lens prescription then be determined? Many patients assume incorrectly that an eyeglass prescription and a contact lens prescription are the same.

Anyone who has ever fit a contact lens knows that there can be a subtle fitting difference of a contact lens with a base curve of 8.7 and a diameter of 14.4 mm compared to a base curve of 8.6 and a diameter of 14.2 mm. There may be a problem with a tighter fitting lens that can cause corneal edema, limbal hypoxia, corneal dryness, corneal infections, and keratitis among other issues. There may be general eye discomfort or blurriness that is sometimes viewed as solution sensitivities or patient allergies when most often, it is a fitting problem. The fit of any contact lens must be exact. There does not seem to be any rational explanation that would allow anyone to be provided with any contact lens before a proper fitting was completed, the patient had an adequate time to try a pair of trial lenses, and to be thoroughly educated as to the handling, wearing time, solution use, and risks of wearing contact lenses.

Most importantly, patients need to know that saline solution is not an eye drop nor is it a solution that should be used for cleaning or storage of contact lenses. This discussion centers primarily on soft contact lenses. What are patients and the public going to do when they need gas permeable contact lenses? This type of contact lens always requires more time and attention by the doctor to fit and to prescribe.

Are the internet companies who sell contact lenses going to advise their “customers” to wash their hands with unscented soap and to rinse thoroughly, not to re-use or top-off the disinfecting solution, to replace their contact lens cases regularly, never to use tap water to rinse the lenses, to not use saline solution for storage, to follow the recommended wearing schedule, never wear contact lenses while swimming, or in a hot tub or spa, or not sleep in lenses unless thoroughly evaluated by a doctor first? Who will educate and protect these consumers? Who will assume the liability in the event of harm to the consumer?

The American Optometric Association warns that “consumers” who purchase lenses without a prescription from an eye doctor put themselves at risk of serious bacterial infection, or even significant damage to the eye’s ability to function, with the potential for irreversible sight loss. Preventive care is critical when prescribing a contact lens regimen. While the ECP must consider many factors, the most important goal is to provide good vision and maintain the health of the patient’s eyes. Poor patient compliance and lens hygiene are often associated with contact lens-related infections. Even patients who do demonstrate proper lens care and hygiene practices are not completely immune to the risk of infection. Bottom line - we instill preventive care by education of our patients and providing them with the products we believe will be best for them.

In an article published in Review of Cornea and Contact Lenses, Dr. Mile Brujic and Dr. Jason Miller stated the following: “As many as 35% of patients don’t even wash their hands before handling their contact lenses. Significant research has been done in the area of understanding the care habits of contact lens wearers. Up to 90% of contact lens wearers are non-compliant with their lens wear and care, and only 16% of contact lens wearers perform the rub, rinse, and soak steps of lens disinfection. Additionally, the Contact Lens Council found that 44% of contact lens wearers always or occasionally top off (re-use) their contact lens solution.” Naturally, these statistics are derived from a public that is under much more restrictive access to contact lenses than the B.C. law in question. If the restricted access is removed, what may happen to these statistics as we go forward?

Sight assessments are not eye examinations. How will a patient know if there is some corneal abnormality without the proper use and medical evaluation using a biomicroscope, a keratometer, a pachymeter, or a topographer? How will it be determined if a patients suffers from keratoconus, corneal irregularities, corneal dystrophies, irregular astigmatism, or corneal scarring? How will medical eye problems be diagnosed such as glaucoma, diabetic retinopathy, hypertensive retinopathy, or optic nerve disorders without a dilated fundus examination?

Health and government agencies are primarily empowered to protect the consumer and the health of its citizens. Contact lenses can have serious vision consequences when used under the best of circumstances. To remove the standard safeguards from the professional practice of eye care is tantamount to committing malpractice on a huge scale. Unfortunately, the consequences will be seen by the unsuspecting public in the coming months and years unless this law is revoked or repealed. Oh Canada, I thought that I knew you better. Hopefully, the U.S. does not follow the British Columbian lead.

(References available upon request)

Jason Smith
OD, MS

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