Editor's Note: This article regarding Dutch Optometry was forwarded to us by Dutch member Feike Grit. As president of the Dutch Optometric Association for 14 years and involved with the long struggle to make Optometry a licensed independent profession he deserves the title, "Father of Dutch Optometry".
Eyes and legislation have been closely related since Hamurabi, who was king of Babylon from 1792 to 1750 BC. The probably most quoted and best known legal phrase is derived from Hamurabi’s Codex: “An eye for an eye, a tooth for a tooth” which shows that even in those times eyes were considered important enough to be included in legislation. (1)
However, although full optometry has been practised as a recognised branch of health care in Anglo-Saxon countries for many years, to this day optometry in most countries is still inadequately and incompletely legislated. Minnesota (USA) has legislation regulating optometry since 1901, the United Kingdom since 1948, and in The Netherlands legislation became effective only on November 15th, 2000. The new Dutch legislation allows optometrists full scope of practice including, in addition to the traditional dispensing- and sight testing activities, also the use of diagnostic pharmaceutical agents for examination of patients for refractive error and eye disease. (2, 3, 4, 5, 6, 7)
The Dutch optometrist has been described in the bill by the Minister of Health Care as an autonomous primary health care practitioner,(8,9) who is the specialist of the healthy eye and who specializes in the care of the health eye.(8) Monitoring the health of the eyes of his clients constitutes an important part of his work.(9) Dutch optometry is now at the forefront of international optometry but it has taken a very long and difficult time to get there.
Until January 1st, 1998, both medicine and optometry in The Netherlands were regulated in the Medical Practice Act, which was enacted in the year 1865. Precisely in the period that the great Dutch physiologist and ophthalmologist Franciscus Cornelis Donders created order in the field of refraction and accommodation with the publication in 1864 of his classic work “On the anomalies of accommodation and refraction of the eye”.(10)
The book was a primer on the practice of optometry and heralded the invasion of opticianry by medical doctors that was then just beginning.(11) Duke Elder considers the ophthalmologists William Bowman in England and Albrecht von Graefe in Germany and the physiologist and ophthalmologist Franciscus Cornelis Donders in The Netherlands the founders of modern ophthalmology.(12)
Donders (1818 – 1889) was one of the greatest ophthalmologists of all time and was without a doubt the first to analyse the various types of refractive error and to point out their great clinical significance.10 In his own right Donders may therefore be called one of the founding fathers of optometry, since his publications altered the whole concept of ocular refraction and constituted the scientific foundation for the development of optometry.
Many of his pupils contributed also to the development of optometry. Snellen, acting on the suggestion of Donders (13), introduced in 1862 the Snellen Optotypes and the Snellen Fraction.(14) The early optometrist-optician could not operate without the hanging wall-chart devised by Snellen.(15) Today these optometric tools are still in use all over the world.
Verschoor, another of Donders’ numerous disciples, wrote in 1865 a doctoral dissertation on refraction and related problems and named it “Optometers and Optometry”.(16) Verschoor defined optometry as the methods to measure the refraction and accommodation of the eye. The instruments used were called optometers. (17) Verschoor distinguished practical optometry for use by the ophthalmologist and scientific optometry, which required a much higher degree of accuracy.(17)
Verschoor (1865) was (one of) the first to define modern optometry and in that period optometry in The Netherlands was practiced principally by ophthalmologists. In the USA, the beacon of international optometry, most of the early practitioners practiced optometry as a sideline to some other business, often jewellery, but soon some were specializing in optometric services. They did not call themselves optometrists but used the word optician or refracting optician. In 1898 the American Optometric Association came into being as the American Association of Opticians. (18) To distinguish themselves from manufacturing opticians and dispensing opticians the American Association of Opticians adopted the term optometrist in 1903 officially as the recommended designation for refracting opticians. (19) The association itself did not change its name to American Optometric Association until 1919. (19, 20)
While the word optometrist appears to have been newly coined in the USA the concept of optometry had already been known in Europe for a long time. After all, it was Porterfield, who in 1759 introduced the optometer as an instrument based upon Scheiner’s principle to examine refractive conditions.(21)
In 1928, Great Britain, The United States, Germany, France, Switzerland ànd The Netherlands were the founding countries of the International Optical League, now the World Council of Optometry. Before the Second World War, a number of Dutch opticians received their training in Germany in Jena and until the 1970s German Augenoptik, with its strong physical basis and its emphasis on the optical aspects of refraction, heavily influenced Dutch optometry.
After the war, several Dutch opticians went to Great Britain to receive formal training in ophthalmic optics. Since the 1970s, Dutch optometry has been orientated more towards British optometry and has now fully incorporated the clinical aspects of optometry in its scope of practice.
Since the 1970s, British optometry has been Dutch optometry’s benchmark, with important but silent influences from American optometry; silent, because American developments often do not carry a positive load in The Netherlands, especially not among medical professionals and government officials.
Optometrists in the UK have had the right to use diagnostic drugs for longer than any other country in the world; Dutch optometrists now watch the British efforts to extend that right to treatment very closely.
Despite the important Dutch contributions to the development of optometry in the nineteenth century legislation recognising and regulating optometry was implemented only in 2000. Several Dutch optometrists have suggested (22, 23) that in the 1860’s Donders and his colleagues did their utmost best to influence the legislators in order to restrict the scope of practice of opticians as much as possible, but so far no proof of this theory has yet been found. However, it is a fact that after 1865 the prescription of glasses became the almost exclusive domain of medical doctors.
Dutch opticians in the 19th century were mainly technicians and dispensers who did not measure refraction. The profession developed into a technical direction under the influence of German optics, contrary to Anglo-Saxon opticians who became more and more clinically orientated. In the Medical Practice Act of 1865 the testing of sight was not mentioned but it was considered the domain of medical doctors.
Opticians became especially interested in refracting when in the 1930’s colleagues, educated in Germany at the Jena school, started to promote refractions openly. After several lawsuits the law was revised in 1937, defining subjective refraction as a non-medical act whereas all other activities in the field of eye care were considered strictly medical acts to be performed by medical doctors only.
Examination of the eyes with instruments was not permitted to opticians and any suggestion of an examination by opticians had to be avoided at all costs. (24) The consequence of the revision of the law in 1937 was that the use of objective instruments such as the refractometer, ophthalmoscope, retinoscope, slitlamp, etc. was not permitted. Until November 2000 the use of these instruments by optometrists was officially forbidden, but the government turned a blind eye to infringements of the law and since 1945 no optometrist has been sentenced for using them.
The controversy between opticians and ophthalmologists originated in the 1930’s, although some incidents of controversy between doctors and opticians in the nineteenth century have been reported. (25) For the next 60 years innumerable attempts were made to change the law or to introduce an Optician’s Act, but as a result of reluctance of the government and opposition and often plain sabotage by ophthalmologists these efforts were always fruitless. Until the year 2000, because in that year new legislation regulating the practice of medicine worked to the advantage of optometry at last.
New medical legislation
New medical legislation, the Individual Health Care Professions Act, was implemented on January 1, 1998, and focuses on individual health care, i.e. care that is aimed directly at the individual patient. The Act is a regulatory vehicle and defines broad outlines only. Details are regulated by Order in Council. This legislation framework offers great opportunities to optometry - opportunities that were not possible before 1998 under the old legislation.
The purpose of the Act is to foster and monitor high standards of professional practice and to protect the patient against professional carelessness and incompetence. It replaces all twelve existing statutory regulations governing the health care professions, the oldest of which was the Medical Practice Act of 1865. The antique Medical Practice Act prohibited the unauthorised practice of medicine, allowing only doctors, dentists, midwives and paramedical personnel such as physiotherapists to perform certain legally specified procedures. Other professionals could do so only if they were acting on a doctor’s instructions, otherwise they were in theory breaking the law.
The Individual Health Care Professions Act takes a fresh approach to the provision of care by professional practitioners. It basically opens up the practice of medicine instead of restricting it, thus lifting the ban on the unauthorised practice of medicine and giving patients the freedom to choose the care provider they want. Patients can now consult the care provider they feel can do them the most good, no matter whether the care provider practices conventional or alternative medicine.
Any restrictions on this freedom must be limited to those, which are necessary in the interest of the patient. Everybody may practice medicine, but, in order to prevent unacceptable health risks to the patient as the result of a lack of professional competence, certain procedures are specifically excluded and may only be performed by those professional practitioners who are by law authorised to do so. Currently, there are eleven such exclusive procedures, e.g. surgical procedures, punctures and injections, anaesthesia, etc. In addition, the act limits medical freedom of action by including a provision, which makes it an offence to act in a way that is injurious to the patient’s health.
The Act also contains provisions relating to the protection of title, registration, exclusive procedures and medical discipline. If necessary Orders in Council and other implementation decrees can be issued to regulate additional aspects of quality in the area of professional practice, e.g. continuous education, ethical code, peer review, locum arrangements and consulting room equipment. Persons practising a profession, which is regulated by law, may use a professional title, protected under public law. They must meet a number of statutory requirements, the most important of which are of an educational nature. By using a title, professional practitioners make it clear to the public and to the insurance companies in what field they are experts. Protection of title has replaced protection of profession.
Optometric education and legislation
1982 was a turning point in the history of Dutch optometry. In that year, after yet another almost successful attempt to obtain optometric legislation, the professional bodies decided to change course and start a new school of optometry, thus drastically raising the level of education. In 1988, they initiated a new, full-time, 4-year, optometry course at the Hogeschool van Utrecht, based on the curriculum of the Department of Optometry and Visual Science of City University, London, U.K. Later lecturers from the Pennsylvania College of Optometry, Philadelphia, US, contributed to the completion of the curriculum. In 1992, the course was officially recognised by the Minister of Education. The new course was initially financed by the school together with the professional bodies. In 1993, funding was taken over by the government.
In 1996, after publication of reports by the University of Maastricht (26) and the Individual Health Care Professions Council (27), the Minister of Health Care decided to legislate and regulate the profession of optometry. The Minister considered the profession of the (new-style) optometrist a new profession; the profession of optician would not be recognised or regulated, and no general pardon or grandfather clause would be permitted to old-style optometrists educated at secondary level. Old-style optometrists, practitioners with lower qualifications, were given an opportunity to attend a transition course of 920 hours to obtain a certificate granting the same title and the same privileges as the diploma of the 4-year, full-time, bachelor’s degree course of the Hogeschool van Utrecht.
However, after the Minister’s decision in 1996 to legislate and regulate optometry, it took another 4 years before the Optometry Bill had finally passed all stages of legislation and became law in 2000. In that period, a lot of people had the opportunity to give their opinion about the proposed legislation. This public enquiry procedure is an example of what is now known as the Dutch Poldermodel. The Netherlands have the dubious honour of having developed the concept of Poldermodel, which means that eternal discussions take place before consensus is reached. The Poldermodel dates from the 16th century when the Dutch population had to work together in order to fight water. During the 15th and 16th century The Netherlands were regularly struck by massive floods. The population had to cooperate and reach a consensus during the repair of the damage, construction of dikes and impoldering. This seems to be the origin of the present-day Dutch attitude to reach a consensus before deciding on important issues, and the phenomenon is thought to be the basis of the recent economic miracle in The Netherlands.
However, to reach consensus between ophthalmologists and optometrists is a completely different matter and an utterly impossible task. In such a case only intervention by the government can force consensus! Until the very last millisecond, ophthalmologists (together with orthoptists) tried to block the proposed Optometry Act, in particular because of the use of diagnostic drugs by optometrists, using the same old arguments ophthalmologists all over the world have always used – “Patients die when optometrists use diagnostic drugs!” Ophthalmology was especially disturbed about the use of phenylephrine but amazingly not about the use of atropine!
By now, Dutch optometrists should have developed the hide of a rhinoceros as a result of the persistent and innumerable attacks by ophthalmologists on the professions of opticians and optometrists. Every new generation of optometrists has to become accustomed again to statements in public as: “Many eye patients victim of incorrect practice of opticians”, “Optometrists are bad for your health” and “Optometrists are worse than firework”. (28) These statements continue to hurt, despite the thickened hide!
In the meantime, the Minister instructed the optometrists to participate in a National Eye Care Platform, where scope of practice, definition of responsibility, agreements and relations were to be discussed with representatives of all other professions involved in eye care.29 Another example of Poldermodel, but inevitable and correct for a new profession that wishes to play a role in primary health care. After four more years of many patiently borne frustrations, we now have an Act, that is exactly what we wanted. And indeed, it does include the franchise to use diagnostic drugs such as phenylephrine 2.5%. Dutch optometrists are grateful to the Minister of Health Care and her civil servants for their foresight and their perseverance. Optometry is now regulated by section 34 of the Individual Health Care Professions Act and by a number of Orders of Council.(2, 3, 4, 5, 6, 7)
Section 5 of Order in Council 297 of July 4th 2000 reads as follows:
1.Scope of practice of the optometrist:
The screening of the patient for eye disease using the appropriate instruments or by administering as part of the examination the appropriate pharmaceutical agents, as indicated by the Minister, and in case of eye disease referral to a general practitioner or ophthalmologist The conducting of supplementary examinations relating to eye disease of eligible patients with chronic diseases on referral of a general practitioner or ophthalmologist using the appropriate instruments or by administering the above mentioned pharmaceutical agents
2.The aforementioned referral by the general practitioner or ophthalmologist is in writing, dated and signed by the referring doctor and includes at least the relevant diagnostic data that are, in his opinion, necessary for the optometric examination of his patient (3)
The observant reader will have noticed that the above scope of practice does not include traditional optometric procedures such as refraction and the prescription and dispensing of optical aids. These procedures, and also some of the procedures mentioned in the Optometry Act, are not exclusive to optometrists and under the Individual Health Care Professions Act they can be carried out by any other (unqualified) practitioner. Practitioners, who have not graduated in optometry, may nevertheless work in the field of optometry, but are not allowed to use the title of optometrist.
It is the patient’s own responsibility to consult either a professional, who graduated from a recognised school with an official diploma and who is entitled to an official title, or somebody who may not use that title and still claims to be an expert. Opticians will continue with refraction, prescription, fitting and dispensing of optical aids including contact lenses, but so may other (unqualified) practitioners. In The Netherlands, contrary to the title of optometrist, the title of optician is no longer a protected title; to open an optical establishment (or any other shop or business) only a retailer’s certificate used to be required, but since January 1st, 2001, even the retailer’s certificate is no longer necessary. Anybody may screen for disease, but the public has not a single guarantee that the screening by such a person is performed in a proper way.
On the other hand, optometrists will also continue with refraction, prescribing and dispensing, since these activities have always subsidized the clinical part of optometry, but only the activities in the field of individual healthcare fall under the Optometry Act. However, from the beginning the Minister was worried about this combination of commercialism and health care.(2, 3, 29) On the instruction of the Minister an ethical code was therefore developed.(30, 31) This code provides a strict boundary between the health care function of the optometrist and his commercial activities such as the sale of spectacles. For example: an optometrist must hand over a prescription immediately after the examination so that the patient is free to go where he wants to buy new spectacles. Also, the optometrist may not sell spectacles to a patient who has been referred to him by an optician or by another optometrist.
On October 22, 2001, the National Eye Care Platform presented the final report (32) to the Minister of Health Care with recommendations how to increase efficiency and transparency in eye care in The Netherlands. Agreements among professionals were made on a national level about all aspects of eye care, such as definition of domain, definition of responsibility, relationship and agreements with other professionals involved in eye care, etc. These agreements will now be implemented at a regional level, several experimental projects have already been started (Maastricht, Rotterdam).
No agreement could be made on the age of patients visiting the optometrist. Sordid discussions took place between ophthalmologists and orthoptists on the one side and optometrists on the other side. Ophthalmologists and orthoptists claim that children under 11 years of age should be seen first by them and not by the optometrist, since the visual system of children under 11 years of age is still in the stage of development. Optometrists argue that optometry knows no age limit, that the new legislation regulating optometry does not include an age limit and that optometrists are adequately trained to examine patients of all ages. It is intriguing that the protocol for general medical practitioners advises them to refer children of 0 up to and including 5 years of age to the ophthalmologist. On a national level no agreement about the age limit could be reached and therefore both points of view of the opposing parties were included in the final report. (32) It demonstrates that the relationship of optometrists with ophthalmologists and orthoptists continues to be troublesome.
Another aspect of Dutch health legislation is the absence of regulation in the field of contact lenses, which appears to be in concert with the liberal and (possibly) progressive spirit of the Individual Health Care Professions Act. In July 2001 the Health Council of The Netherlands advised the Minister to reserve the fitting and after care of contact lenses to optometrists and ophthalmologists only; in addition it concluded that permanent wear contact lenses should be discouraged. (33)
During the presentation of the final report of the National Eye Care Platform on October 22, 2001, the Minister indicated that she will not follow Health Council’s advice. She agreed with the optical and optometric associations that opticians with post graduate training in contact lens fitting are sufficiently qualified to undertake the fitting and after care of contact lenses.(34) The optical and optometric associations will now probably opt for a private law regulation with a register of qualified contact lens specialists; yearly renewal of the registration will require continuing education and compliance with an ethical code.(35)
Recent medical legislation offers great opportunities to Dutch optometry. The Individual Health Care Professions Act has opened up the practice of medicine instead of restricting it, thus lifting the ban on the unauthorized practice of medicine and giving patients the freedom to choose the care provider they feel can do them the most good. Dutch optometry is now regulated under article 34 of the Individual Health Care Professions Act and by a number of Orders of Council, which puts The Netherlands at the forefront of international optometry. The optometrist has been described as the specialist of the healthy eye, the monitoring of the health of the eyes of his patients constitutes an important part of his work. In The Netherlands the profession of optometry is a new profession that still has to establish that it deserves a position in primary health care. Experiments are under way in Maastricht (University of Maastricht and University Hospital) and in Rotterdam (Eye Hospital Rotterdam) to give optometry that place in primary care.
Efforts to regulate the fitting and after care of contact lenses have so far been to no avail. New times have come but much work is required to establish the optometrist as the primary eye care provider!
1 Taylor S.P., Austen D.P. Law and Management in Optometric Practice. London: Butterworths, 1986:vii
2 Ontwerp-Besluit opleidingseisen en deskundigheidsgebied optometrist. Nederlandse Staatscourant 1999, nr. 51:7 (Bill regulating education and scope of practice optometrist)
3 Besluit opleidingseisen en deskundigheidsgebied optometrist. Staatsblad van het Koninkrijk der Nederlanden 2000, 297 (Act regulating education and scope of practice optometrist)
4 Regeling aanwijzing certificaat Overgangsopleiding HBO-optometrie. Nederlandse Staatscourant 16 november 2000, nr. 223:23
5 Wijziging Regeling U.R.-geneesmiddelen. Nederlandse Staatscourant 16 november 2000, nr. 223: 23
6 Regeling nadere uitwerking deskundigheidsgebied optometrist. Nederlandse Staatscourant 16 november 2000, nr. 223:24
7 Besluit van 1 november 2000, houdende vaststelling van het tijdstip van inwerkingtreding van het Besluit opleidingseisen en deskundigheidsgebied optometrist. Staatsblad van het Koninkrijk der Nederlanden 2000, 477 (Act date of implementation)
8 Ontwerp-Besluit opleidingseisen en deskundigheidsgebied optometrist. Nederlandse Staatscourant 1999, nr. 51:7; in the explanatory memorandum of article 5 of the bill regulating education and scope of practice optometrist
9 Besluit opleidingseisen en deskundigheidsgebied optometrist. Staatsblad van het Koninkrijk der Nederlanden 2000, 297; in the explanatory memorandum of article 5 of the act regulating education and scope of practice optometrist
10 Donders F.C. On the Anomalies of Accommodation and Refraction of the Eye. London: The New Sydenham Society, 1864. Translated from the author’s manuscript by William Daniel Moore, Dublin.
11 Classé J.G. Legal Aspects of Optometry. Boston: Butterworth-Heinemann, 1989:3
12 Duke-Elder S. Ophthalmic Optics and Refraction. In: Duke-Elder S, ed. System of Ophthalmology, Vol. 8. London: Henry Kimpton, 1970:255
13 Emsley H.H. Optics of Vision. In: Visual Optics, Vol. 1. London: Hatton Press, 1963: 63
14 Snellen H. Scala tipografica per mesurare il visus. Utrecht, 1862
Snellen H. Probebuchstaben, zur Bestimmung der Sehschärfe. Utrecht, 1862
Snellen H. Test types for the determination of the acuteness of vision. Utrecht, 1868
In: Duke-Elder S, ed. System of Ophthalmology, vol. 7. London: Henry Kimpton, 1962:380
15 Pettey W.A. Optometry in Texas, 1900 – 1984. Austin, Texas: Nortex, 1985:9
16 Verschoor J.W. Optometers en Optometrie. PhD dissertation. In: 6e Jaarlijksch Verslag van het Nederlandsch Gasthuis voor Ooglijders, Utrecht, 1865:97-160
17 Verschoor J.W. Optometers en Optometrie. PhD dissertation. In: 6e Jaarlijksch Verslag van het Nederlandsch Gasthuis voor Ooglijders, Utrecht, 1865:102-103
18 Koetting R.A. AOA’s First Century. St. Louis: American Optometric Association, 1997:9
19 Hofstetter H.W. Optometry; Professional, Economic and Legal Aspects. St. Louis: The C.V. Mosby Company, 1948:90
20 Koetting R.A. AOA’s First Century. St. Louis: American Optometric Association, 1997:18
21 Emsley H.H. Optics of Vision. In: Visual Optics, Vol. 1. London: Hatton Press, 1963: 100
22 Kortland K. The development of eye care in The Netherlands. Thesis for fellowship of the American Academy of Optometry. Rotterdam: Kees Kortland, April 17, 1994:14
23 Merkx J.Th.M. Van Marskramer tot optometrist. Thesis for Bachelor of optometry degree, Hogeschool van Utrecht. Culemborg: Jan Merkx, May 1996:8
24 Vries de J. Uitoefening der geneeskunst. In: Nederlandse Staatswetten. Zwolle: W.E.J. Tjeenk Willink, 1975:4-6
25 Doijer D. De Brillenkwestie. Leiden, February 1888. In: Feestbundel aan Franciscus Cornelis Donders, Nederlands Tijdschrift voor Geneeskunde. Amsterdam: F. van Rossen, 1888:70-71 (The matter of spectacles in Donders’ Liber Amicorum)
26 Horst van der F.G.E.M., c.s. Onderlinge Afstemming Oogzorg in Nederland. Maastricht University, 1996
27 Advies regeling van het beroep van optometrist krachtens artikel 34 van de Wet BIG. Raad BIG. Publication B5/’96. Zoetermeer: May 1996 (Advice regulation optometry)
28 Utrechts Nieuwsblad: June 29, 1979; NRC: June 29, 1979; De Volkskrant, June 30, 1979; Gooi- en Eemlander, July 2, 1979 (articles in national newspapers)
29 Borst-Eilers E, Minister of Health Care. Letter CSZ/BO nr. 9613753 to Raad BIG, November 22, 1996:3
30 Borst-Eilers E, Minister of Health Care. Letter CSZ/BO nr. 9613755 to Dutch Optometric Association ANVO, November 22, 1996:4
31 Dute J.C.J., c.s. Gedragscode voor Optometristen. Maastricht, ANVO, 1999. Reviewed September 2001, third version (Ethical code for optometrists)
32 Kwartel van der A.J.J. Samenwerking in de oogzorg. Utrecht: Prismant, nr. 201.35, September 2001 (Final report National Eye Care Platform)
33 Gezondheidsrisico’s van contactlenzen. Gezondheidsraadadvies aan de Minister van Volksgezondheid, Welzijn en Sport, nr. 2001/20. The Hague: July 25, 2001. (Health hazards of contact lenses, advice of the Health Council of The Netherlands to the Minister of Health Care)
34 Borst-Eilers E, Minister of Health Care. Speech at the presentation of the final report of the National Eye Care Platform. The Hague, Ministry of Health Care: October 22, 2001
35 ANVC Nieuwsbrief, Oktober 2001. Haarlem, Algemene Nederlandse Vereniging van Contactlensspecialisten (October Newsletter Dutch Contact Lens Association)
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