By Dr. Shannon Hughes
I have grown up incredibly lucky. I have always had access to the healthcare that I needed. I lived in a big city, both of my parents drove their own cars, and we had the means to pay for healthcare services. While I was aware that there were areas of the world that struggled, I was fortunate enough not to even be exposed to them, while I was growing up. That all changed during my time in optometry school. Two pivotal experiences during my optometry training—in rural British Columbia and Malawi, Africa—opened my eyes to the immense challenges faced by underserved communities in accessing eye care. These moments not only reshaped my perspective but ignited a lifelong passion to work toward closing these gaps.
My most recent experience was during my last placement of my fourth year. I was working at FYiDoctors Smithers in rural BC. My favourite days working at the clinic were our outreach days, two days spent in smaller townships about an hour’s drive from Smithers providing full scope eye exams in elementary schools. We were well equipped to do full refractions and fundus exams. But my first experience with optometry outside the clinic did not have as many tools. In the summer after my second year of optometry school, I had the opportunity to go on a VOSH trip to Malawi. I learned a lot about doing screenings and providing eye care in unconventional settings. And my retinoscopy improved so much! How could it not, when I was doing ret up to a hundred times a day? And while that in and of itself was hard, there were many challenges to be overcome when performing those screenings and exams. Although my time in Malawi and rural British Columbia occurred in vastly different parts of the world, the challenges felt strikingly similar—language barriers, limited resources, and the immense need for basic eye care.
Language
On a day to day basis we all deal with the language barrier that is healthcare lingo. We have to be able to explain terms like “astigmatism” and “diabetic retinopathy” to patients using layman’s terms that they can understand. But when you don’t speak the same basic language to begin with, it’s hard enough just to ask the patient to look in one direction while you do a quick cover test. In Malawi, we used a tumbling E chart to evaluate visual acuity. Although our alphabets were similar, our sounds and words were not, so patients identified the orientation of the letter E at different sizes. We also learned basic phrases in their language, though I’m sure our pronunciation left something to be desired. In the case of outreach days in BC, the level of education of some of the children was not where one might expect it to be, so it was difficult to even get basic information such as visual acuities. Luckily I was able to apply my knowledge from Malawi to use simpler visual acuity charts and my greatly improved retinoscopy skills to get a better idea of the children’s visual needs. In both cases, objective testing becomes extremely important, which is especially difficult when you have only been doing it for a year and a half and you don’t quite trust yourself yet.
Resources
Another barrier is the actual access to necessary services and products. It’s all well and good to determine that a patient needs glasses. But the next step – what frames and lenses are in their price range? Where will the glasses come from? How will the glasses get to the patient? These are important steps that are not discussed in school. We learn to prescribe the best possible care for our patients, which works well in a more affluent setting. But what do you do when your patient doesn’t have a way to get to the optical dispensary to choose a frame or even to have their measurements taken for glasses? In BC, we brought a few simple frames with us for the kids to try on, and were able to take measurements in person. The spectacles were then ordered from the lab and shipped to the school, which made them more accessible for the students. On the other hand, donated glasses were a huge blessing in Malawi. As a project in optometry school, we used our new skills with a lensometer to determine the prescription in donated lenses. We packed a suitcase with those glasses and tons of low add over the counter readers, which allowed us to easily prescribe low plus for children and reading glasses for adults, as well as a few more specific prescriptions.
Continued care
More than just spectacles, there are certain conditions that we identify that need care from a family doctor or a specialist. Diabetic retinopathy should be monitored by a general practitioner. Strabismus might require vision therapy or even surgery. And cataracts need to be removed by an ophthalmologist. In Canada, it is becoming increasingly difficult to find a family doctor. And in Malawi, it was even more rare. When we encountered children with VKC, we wrote steroid prescriptions on scrap paper and hoped that our translators explained clearly that they should take them to a pharmacy. It is that follow up to care which becomes difficult in these situations. In Smithers, the closest ophthalmologist was several hours away. With further barriers such as transportation, these cases become more difficult to manage. This is where the importance of being able to prescribe medications and do minor procedures becomes really evident. Rural optometry practice expanded my knowledge of ocular disease management simply because there was no other option for these patients.
Conclusion
I don’t have the answers to all the questions that come up when practicing optometry outside of the clinic. I don’t think that anyone can completely satisfy all of these problems. But there are people out there working on them. My supervisor in BC was very excited about a new opportunity FYidoctors was going to provide him with, which was a travelling optometry clinic created from a bus. It was built with a full exam lane, virtual visual field system, and storage for a small dispensary, and would be able to travel to rural areas to provide eye care. This is just one example of providers who are working to help the people in their particular community. And that inspires me to continue to try to find solutions, too. While these challenges persist, I remain committed to finding solutions and advocating for greater access to eye care, both in Canada and abroad. Every patient deserves the opportunity to see clearly, and I am determined to play my part in making that a reality.
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