What’s your vision worth?

As the last patient departs her busy eye clinic in Montreal’s Maisonneuve-Rosemont Hospital, Dr. Marie Carole Boucher takes a much-needed break, her first of the day. “The number of patients I see each day is scandalous,” she says with a laugh that doesn’t quite disguise the exasperation behind it. “I’m going crazy. We all are.”

The “we” she refers to are the 1,000 Canadian ophthalmologists, the professionally trained medical physicians who handle the refractive, medical and surgical disorders of our eyes. Ophthalmologists should not be confused with optometrists or opticians. There’s a good supply of these.

But Boucher, whose practice might be mistaken for a busy emergency room (she can see up to 50 patients each morning), says it’s not only the workload that’s forcing her colleagues to question their collective sanity. What galls her is that despite their best efforts, they can’t keep up with the demands of their patients. And they can’t see any light at the end of this dark tunnel.

Canada’s vision care system is gridlocked – too many people are waiting unreasonably long to receive screening, diagnoses and medical or surgical treatmentor numerous eye diseases. “It takes at least eight months for a new patient to book an appointment,” says Boucher. “And I’m turning many more away.”

It’s the same all over Canada. If your optometrist or family physician suspects eye disease and refers you to an ophthalmologist, it may take a year to receive treatment.

This isn’t good news for an aging population:

  • most experience some vision change nearing the age of 50
  • by age 65, one in nine will experience severe vision loss
  • by 85, this increases to one in four.

If the system is barely able to cope now, what will happen to waiting times over the next few decades when the aging boomers begin developing cataracts, diabetic retinopathy, macular degeneration, glaucoma or any other typical age-related vision ailment? 

Next page: Why is there a crisis?

Studies show that if we catch vision problems in their early stages, we can often treat them before they cause severe vision loss. Obviously, averting possible blindness is a desirable health outcome, and it also makes financial sense. In its report to the Commission on the Future of Health Care in Canada, the Canadian National Institute for the Blind came to the same conclusion that a number of important American studies also put forth: early detection of vision problems in seniors could result in very substantial savings for the health care system. It’s estimated that blindness costs the federal government up to $1 billion a year in support payments and lost tax revenues.

But far more important than the financial burden is the human cost of blindness. Only those with severe vision loss can understand the tremendous emotional suffering and loss of independence it causes. Pointing to long wait times, ophthalmologists feel not enough is being done to avert what some are calling a crisis in vision care.

Why is there a crisis?
The number one reason: there aren’t enough ophthalmologists. “We used to certify about 40 [ophthalmology] residents each year in Canada,” says Dr. Duncan Anderson, president of the Canadian Ophthalmological Society (COS). “Now, because of cutbacks to the number of medical school positions allowed, we’re only certifying 20.”

“We have a decline in ophthalmologists at the same time as an increase in the number of patients who need ophthalmic services,” he says.

  • by 2016 Canada will need at least 1,400 ophthalmologists to handle the load.
  • if current projections hold, we’ll have 853 eye doctors in 2016

In fact, a 2001 Fraser Institute study called Hospital Waiting Lists in Canada shows that the wait to receive treatment from an ophthalmologist has doubled in the last decade and is now longer than the wait for treatment from any other medical specialist.

Granted, without immediate radiation or heart surgery, patients could die. But what’s happening to those waiting to receive eye treatment? “They can’t work, can’t drive, can’t read – none of the things we need our eyes for,” says Anderson. “And if they have serious eye disease that isn’t detected and treated in a timely fashion, they’ll suffer permanent damage.” 

Despite this evidence, the provinces aren’t admitting there’s a vision care crisis. With a median of 44.6 weeks, Saskatchewan was pegged as having the longest wait time to receive treatment from an ophthalmologist. Yet health officials there say they have no plans to hire any more ophthalmologists.

As long as provinces struggle to control health costs, quality and timely eye care seems destined to remain a second-tier priority on the health care agendas. Sensing this, those on the eye care frontlines have developed solutions that may not cure the problem but could certainly address the symptoms.

Next page: High-tech screening

High-tech screening
Boucher feels that tele-ophthalmology – a high-tech way of screening for eye disease – is a potential solution to alleviate some of the burden on ophthalmologists’ services. She recently piloted a project in Varennes, Que., where a special camera took detailed pictures of the eyes of diabetic patients, most of whom were at high risk for developing retinopathy. The pictures were then electronically transmitted over a secure network to a centre in Montreal. Here, a specialist was able to examine the pictures and identify the patients who needed to have follow-up treatment.

A tele-ophthalmology program would address two huge problems: by increasing our access to screening, it will catch more early-stage eye disease; and, by acting in the place of an ophthalmologist, the cameras will free up the specialists’ time, which they can then devote to treating patients. “The technology is here and it’s simple,” Boucher says, noting tele-ophthalmology is already being used in Scotland. “Now that the tools are available to economically prevent severe visual loss from diabetes, it’s up to the government to develop a program that takes advantage of them.”

A new model of eye care
If all the players in an eye care system have clearly defined roles, we’ll have an effective and efficient system and our waiting times will be shorter, says Dr. Raymond LeBlanc, professor and head of ophthalmology at Dalhousie University in Halifax. LeBlanc also serves as chair of the National Coalition for Vision Health, a group of 17 organizations that seeks to change public policy on eye care and to increase the profile of vision care needs in Canada.

The coalition’s immediate goal is to increase Canadians’ accessibility to vision care. LeBlanc has already made great strides toward this goal in his own province, despite the shortage of ophthalmologists and the scant health care resources.

“Before doing anything, we consulted widely with patients, family doctors and other health care professionals and asked them to help us develop a model that would best suit their eye care needs,” says LeBlanc. This brought about the Eye Care Working Group, a concept that involves family doctors, optometrists and ophthalmologists and other vision care professionals working together as a team to deliver quality and timely vision care.

Developing an expanded role for optometrists and then integrating that with the roles of family physicians and ophthalmologists, the system now provides greater access to eye care, and shorter wait times. LeBlanc feels the Nova Scotia model might be adapted on a national level in both rural and urban communities.

Next page: Is privatization the answer?

Is privatization the answer?
Private clinics offer yet another, though controversial, solution. We already pay for a great deal of eye care – glasses, contact lenses and refractive laser surgery – out of our own pockets.

Privatization takes many forms, two of which are:

  • people receive treatment sooner by paying a facility fee
  • patients access private clinics that specialize in specific treatments

Critics claim that expanding private alternatives will only lure ophthalmologists out of the public system, increasing the workload on those who stay. However, as private clinics continue to creep into Canada, they may one day become a possible way of obtaining immediate eye care.

Ultimately though, no solution is possible until Canada’s health policy planners stop turning a blind eye to this rapidly approaching crisis in vision care. The hope that those policy-makers will finally see the light is all that keeps ophthalmologists sane. “We live in hope that governments’ vision will sharpen, that they’ll untangle health and political issues and that they’ll finally focus on overall health results,” says Boucher. “Because if they wait too long, we won’t be able to cope.”