Optometry is turning a century old as a profession in India. The profession has risen from its humble beginnings in the early 20th century to become a force to reckon with in the eye care ecosystem. This editorial aims to capture the origins and growth of the profession in the country, take a critical look at its present status, and explore ways for its continued success in the future. In doing so, this editorial also hopes to serve as a general guide for steering the profession in areas of the world where optometry is at its budding stage.

ORIGINS, EARLY GROWTH, AND FOUNDATIONS FOR MODERN OPTOMETRY

The origin of Indian optometry may be traced back to its colonial past when a British-trained optologist, K.D. Dutta, started a 10-month long training program in refraction and dispensing optics at the Indian College of Optics in Bengal, Eastern India.1 This was closely followed by a 2-year diploma program in optometry, once again initiated in Bengal, in the early 1930s. The next wave of professional training happened nearly three decades later, with the establishment of 2-year diploma programs in optometry across the country through the Regional Institutes of Ophthalmology. During these early years, Indian optometrists were largely confined to performing ocular refraction, dispensing spectacles, and assisting ophthalmologists in select diagnostic or management procedures (e.g., pterygium extraction). A significant push toward expanding the profession of optometry happened in 1976, with the All India Institute of Medical Sciences establishing a 3.5-year BSc (Hons) degree in ophthalmic techniques. The curriculum expanded to include training in basic ocular diseases and in specialty areas like contact lenses, orthoptics, and low vision. The foundation for “modern optometry” in India was laid in 1985 with the 4-year baccalaureate level training at the Elite School of Optometry, Sankara Nethralaya, Chennai, Tamil Nadu.1 This program was modeled after the curriculum offered then at the UC Berkeley School of Optometry and became affiliated with one of India's foremost technological universities (Birla Institute of Technology and Science, Pilani, Rajasthan). The program intended to create an optometry workforce with sound knowledge and skill in comprehensive eye examination, speciality areas of optometry, ocular diseases, ophthalmic instrumentation, and vision science research. It envisioned that optometrists would work symbiotically with ophthalmologists and other cadres of eye care personnel to bridge the huge unmet eye care needs of the then 750-million-strong population of India. In 1989, the L V Prasad Eye Institute, Hyderabad, Andhra Pradesh (now, Telangana), initiated the first fellowship program in clinical optometry for recent graduates to upgrade their clinical acumen. Post-graduate training programs focused on research in optometry subsequently began at the Elite School of Optometry in 1996 (MPhil in Optometry) and 2002 (PhD in Optometry and Vision Science). In 2003, the Association of Schools and Colleges of Optometry (ASCO)-India, modeled on the lines of ASCO-USA, was formed under the aegis of the World Council of Optometry (WCO). ASCO-India worked collaboratively with the Elite School of Optometry to frame the Common Minimum Optometry Curriculum2 and worked with the Optometry Council of India, an independent self-regulatory body, to develop the Indian Entry Level Optometry Competency Skill standard.3 Today, these documents have been adopted by the Ministry of Health and Family Welfare, Government of India, as national level training frameworks to standardize the professional education of optometry in the country. The growth of the profession from the early 2000s was also supported by contributions from several national and international nongovernmental organizations such as the Brien Holden Vision Institute, Orbis International, Sightsavers International, and Optometry Giving Sight. These organizations have ably supported the profession by either directly getting involved in public eye health endeavors in underserved communities of India or supporting public health initiatives through grants for equipment and human resource or through financial support for training programs in several key areas of clinical optometry.

Until the turn of the 21st century, there were only three schools/colleges that offered bachelor's level training in optometry, with each school graduating no more than 20 students per year. Two of these schools stemmed from ophthalmological institutes, while the third operated from within a university framework. A large portion of its student pool were those who could not enroll in medical school but sought an alternate career in health care. Upon graduation, they primarily worked for eye hospitals or optical chains. As opportunities for post-graduate education were limited in India, several graduates looked abroad for higher education, contributing to the brain drain of an already limited pool of optometrists. Adding to all this, with professional regulation far from sight, several fly-by-night operators ran questionable short-term courses in the name of optometry.

PRESENT STATUS

The professional scene for optometry changed between the early 2000s and the present day. Today, optometry and its role in eye care are more recognized among the general public, health care personnel, and the government. The profession's dream of a standardized definition, scope of practice, and education was also recently realized through the National Commission for Allied and Healthcare Professions (NCAHP) Act, 2021.4 Several self-regulatory bodies of optometry in India (e.g., Optometry Council of India, Indian Optometric Association, Indian Optometry Federation) worked together with the Ministry of Health and Family Welfare, Government of India, to achieve this important milestone. The Ophthalmic Science Professional category within this act duly recognizes only those with a 4-year bachelor's degree in optometry as “optometrists” (ISCO code 2267) with independent practice rights, while those graduating from a shorter and more skill-oriented training programs are identified as “ophthalmic assistants” or “vision technicians” (ISCO code 3256).4 One can now identify four distinct cadres of individuals in eye care — the ophthalmologist, the optometrist, the ophthalmic assistant/vision technician, and the optician — who can work symbiotically to offer quality eye care to the Indian public.

There are now over 300 schools/colleges of optometry across India that produce optometrists in accordance with the definition of the NCAHP act. The majority of these institutions are either directly run by universities or are run by hospitals with affiliation to universities. With each institution graduating approximately 25 students per year, the annual graduate pool of optometrists has now increased to about 7500, a good two log-units more than in the 1980s. While these schools/colleges broadly adhere to the guidelines set forth by the regulatory bodies, a systematic audit on the level of compliance is yet to be undertaken. Today's optometry graduate has a plethora of career paths — clinical optometry in eye hospitals or retail optical chains, independent or comanaged private practice, community-level eye care in government or nongovernmental organizations, teaching in schools/colleges of optometry, and as business associates in multinational eye care corporates. All these career options are appropriately supported through higher education opportunities in the forms of clinical fellowships, master's degree in optometry or public health, or hospital/business administration.5 The growth of vision science research in India in the past two decades deserves a special mention. Optometrist-led laboratories that focus on cutting-edge basic and translational vision science and public eye health research are now available in India. Several of these individuals are world leaders in their respective areas of research and prominently feature in the recently collated list of globally accomplished optometrists.6 This research ecosystem, although presently restricted to a handful of institutions, has also enabled a new cadre of research optometrists who form the primary workforce for these laboratories and pursue doctoral studies in vision science. This ecosystem is also resulting in a brain gain, with several alumni of Indian optometry considering a career back in India following their training abroad. Indian optometry now also engages in collaborative ventures with several professional bodies and universities globally that involve student/faculty exchanges, conducting continuing education programs, research conferences, and public eye health service delivery programs. These activities indirectly reflect the growth in standards of the profession in India, vis-à-vis, the global benchmarks.

Given all this progress, it is worthwhile comparing today's Indian optometry with the more established enterprises in North America, United Kingdom, and Australia. Three major differences emerge. First, the profession is far more standardized and regulated, leading to more uniform practice patterns and specialized roles for optometrists in these locations, relative to India. While independent private or group practices may be the norm for optometrists in these locations, the average Indian optometrist continues to pursue their career in a hospital setting or in optical shops where they perform only basic eye examination and refraction procedures. This trend severely impacts the latter's ability to independently diagnose, manage, and provide continued care for the patients despite examining a greater number and heterogeneity of patients than their western counterparts. Second, as a follow-up point, optometrists are considered as an independent service provider in the western public health system, with their services being recognized by governmental and private financial reimbursement schemes (e.g., insurance coverage for eye examinations). In India, optometrists continue to be seen largely as a support service, thus undermining their full utilization in the eye care ecosystem. Third, optometry is a preferred career choice by the majority of students joining the program in the west, while for a sizeable number of Indian students, it remains an accident or a compromised choice, at best. Expectedly, the competition for enrolment into an optometry program is far higher in the west than in India, leading to students with overall higher competencies joining the programs in the former than latter locations. Both factors collectively determine the self-confidence and motivation level of the student, which, in turn, impacts their career choices and the overall health of the profession.7 Taken together, it is apparent that, while Indian optometry has certainly come of age in the past 100 years, certain key aspects of the profession has remained unchanged from its early years (compare this paragraph with the second paragraph in section Origins, early growth, and foundations for modern optometry). How might these and other associated issues be tackled need to be deliberated seriously as the profession lays its foundation for the next century of contribution to eye care.

THE FUTURE: CHALLENGES, OPPORTUNITIES, AND SOLUTIONS

The onus is on the current leadership of Indian optometry to build a larger vision for profession and place it on a continuous growth trajectory in the 21st century. Their biggest responsibility is to operationalize the NCAHP act to regulate and streamline the quality of Indian optometrists, their scope of practice and the training programs that produce these optometrists. Given the availability of the four distinct cadres of eye care work force, optometry's role may shift from one performing routine eye examinations to offering services in optical technology, visual functions assessment, ocular diagnostics (with appropriate pharmacological usage), and comanaging the patient for optical/rehabilitative care, as described in the scope of practice model developed by the WCO.8,9 The bulk of therapeutic/surgical care of the patient will be managed by the ophthalmologist, and the optician will dispense the appropriate pair of refractive correction to the patient. Optometric education may be built into this model by having trainees perform part of these procedures under the guidance of experienced eye care personnel. A clear plan entailing the following activities is to be in place to align with the future expectations out of the profession: (1) homogenize the presently variable quality of optometrists graduating from the enormous number of schools/colleges of optometry in the country through licensure examinations and those in practice through periodic renewal of licensure, (2) critically reassess the number of training programs needed to meet the altered optometrist-to-population ratio, (3) strengthen optometry schools/colleges through curriculum upgrades and investment in good quality infrastructure,10,11 (4) develop a pool of well-trained faculty who have good handle on both clinical and academic aspects of optometry, and (5) expand the pool of vision scientists who can engage with various governmental and nongovernmental bodies and the ophthalmic industry to pursue translational research of national significance. To achieve all this, the leadership group must effectively liaison with all the stakeholders of the profession — the government to frame regulations for the clinical practice of optometry, the clinical practices to ensure implementation/compliance to these regulations, the schools/colleges of optometry to ensure quality training, the governmental and nongovernmental organizations for generating resources to implement these activities, and the public for advocacy regarding optometry's role in maintaining quality eye health. A certain reluctance of optometry graduates to engage in community-related activities has also been observed, despite the most recent evidence that uncorrected refractive errors and cataract remain the leading cause of avoidable vision impairment in India.12 This reluctance should thus be actively overcome by creating a clear career path for optometrists in public eye health services and making the activity financially and emotionally enticing for the graduates.

LESSONS FOR REGIONS WITH AN EVOLVING OPTOMETRIC PROFESSION

The century-long story of Indian optometry offers three broad lessons for regions where the profession is still at an evolving stage. First, the growth of the profession is a top-down process, enabled through a coherent leadership with unified vision. The leadership needs to effectively work with the government, on one hand, to frame policy regulations (e.g., scope of practice, licensure), and with the individual practitioners/schools, on the other hand, for implementing these policies (e.g., through regular audits of training infrastructure, faculty pool, and curriculum). The leadership should ensure that evidence-based optometry is at the heart of the profession, the seeds for which are sown by integrating basic and translational research with clinical teaching at an undergraduate level.13 Second, the eye care needs vary tremendously across regions and keep evolving with time14,15 — the optometry profession should also keep dynamically evolving to stay relevant in the local region. Controlled expansion and evolution of the profession, while maintaining quality, should be the overarching mantra for optometry in these areas. Having said this, optometry will continue to play a key role in managing public eye health in most of these regions, up until the foreseeable future. Optometry graduates should therefore be mandated to offer such services as part of their professional and social responsibility. Third, undergraduate and post-graduate training curricula should be periodically upgraded to ensure that the graduates have the desired skill sets to become immediately employable and contribute meaningfully to eye care in the respective regions. Ideally, the professional course should be within the ambit of university education that can provide clinical teaching within their own health care system or through collaboration with established clinical partners.

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