Healthcare services improved significantly over the last decade in Saudi Arabia. This improvement is visible at the level of major and specialised hospitals in the capital and major cities respectively. Nevertheless, in addition to the challenges faced at the level of primary care centres in peripheral regions and rural areas, the healthcare system in Saudi Arabia continues to be associated with drawbacks, such as the high cost of healthcare services provided at major hospitals, rapid increase in population, limited and unequal accessibility to specific healthcare services, absence of speciality clinics at primary care centres, and the long waiting lists in major hospitals.^1,2,3 Furthermore, the quality and safety of healthcare services offered by primary care centres do not always align with the quality standards in Saudi Arabia.⁴ Consequently, patients tend not to seek treatment at primary care centres. A previous study revealed that patients who sought treatment at primary care centres in Saudi Arabia were not satisfied with the quality of care and availability of specialised medical staff.⁵ Primary care centres function as the first level of health services for the citizens of Saudi Arabia. Therefore, a strategy plan for 2010–2020 was initiated by the Ministry of Health (MoH) to address these challenges and enable primary care centres to provide adequate and safe healthcare services to the community.⁶

Primary eye care (PEC) is an essential medical service provided by primary care centres. Primary eye care comprises available, accessible, and affordable comprehensive eye care. Furthermore, it may include the complete assessment of the adnexa, visual examinations, such as ophthalmic refraction, and subsequent prescription of spectacles and contact lenses for adults and children; detection and diagnosis of common ocular diseases; implementation of ocular therapeutic and treatment strategies for common ocular diseases; and referral to other specialists for further treatment.^7,8 Primary eye care providers are the first-line medical staff that can perform a comprehensive eye examination of patients as well as continuing eye care through lifetime.^7,8 All community individuals from all age groups must have an easy access to a continuous, available, and affordable PEC. The lack or reduction in proper PEC services may lead to avoidable visual impairment and blindness. Despite emphasising the importance of the availability of PEC services, they are not offered by primary care centres in Saudi Arabia.

According to the current model of eye care in Saudi Arabia, patients are initially evaluated by general practitioners at the level of primary care centres and subsequently referred to hospitals if ophthalmic treatment is necessary. The patients are directed to an ophthalmologist in hospital settings and may be further referred to an optometrist. Optometrists perform refraction examinations and prescribe spectacles or contact lenses as needed. The number of ophthalmologists in certain hospitals is not sufficient to meet the requirements of all patients, especially in peripheral areas. This results in an increase in waiting time before a patient can access adequate ophthalmic treatment in central hospitals. Furthermore, this model is costly and impractical as ophthalmologists are overwhelmed by the requirement for assessing non-surgical and minor eye conditions, such as blepharitis, conjunctivitis, dry eye, refractive errors, early cataract, and screening for patients with diabetic retinopathy. These assessments can be performed by an optometrist.⁹ The number of optometrists in Saudi Arabia may not be sufficient to meet the healthcare requirements. The World Health Organization (WHO) recommends maintaining a ratio of at least 1 PEC specialist per 50 000 individuals by 2020.¹⁰ However, Al Motowa et al. estimated that the ratio was 1 optometrist per 95 000 individuals in Saudi Arabia,¹¹ indicating the urgent requirement for increasing the number of optometry graduates and facilitating proper ocular care in primary care centres following international health standards.

Previous studies have focused on the impact of the reduction in PEC on ocular health in Saudi Arabia and worldwide. Pascolini and Mariotti¹² reported that uncorrected refractive errors (43%), followed by cataracts (33%), are the cause of visual impairment in approximately 285 million individuals worldwide encompassing all age groups. Thirty-nine million of these patients are blind, whereas the remaining 246m have partial vision. Visual impairments could have been avoided in 80% of these cases if treatment had commenced during the early stages of the disease.¹² Approximately 1.5% of the total population in Saudi Arabia is affected by blindness, and its prevalence among individuals aged > 60 years has reached 20%.¹³ A study conducted in the Al-Jouf province of Saudi Arabia revealed that the prevalence of blindness and visual impairment among patients who sought treatment at primary care centres was 0.8% and 13.9%, respectively. Refractive errors (36.0%), followed by cataracts (29.1%) and diabetic retinopathy (20.9%) were the most common causes, whereas glaucoma (5.8%) was the least common cause.¹⁴ Aldebasi reported that < 5% of school children with refractive errors in Qassim, Saudi Arabia, used corrective spectacles. Moreover, 94% of the children who were not using corrective spectacles had amblyopia.¹⁵ According to the National Prevention of Blindness Committee (NPBC), MoH, Saudi Arabia, patients with diabetes aged > 50 years have a 1.1% risk of developing diabetic retinopathy.¹⁶ Approximately 36.8% of patients with diabetic retinopathy in Saudi Arabia are blind.¹⁶ Easy access to proper treatment during the early stages of the disease may have helped prevent the incidence or reduced the severity of different ocular morbidities. The World Council of Optometry (WCO) defines optometry and optometrists as follows:

In addition to prescribing pharmaceutical agents, as needed, optometrists in Australia, Canada, the United States, the United Kingdom (UK), and other countries have been licensed to diagnose and treat common ocular diseases, since the 1970s.¹⁸ Measures have been taken to ensure that the field of optometry education in Saudi Arabia adheres to international standards. Two universities provide a 6-year programme accredited by national and international accreditation institutes, with students graduating as optometrists each year. Optometry graduates in Saudi Arabia provide comprehensive PEC services. Moreover, these graduates work along with ophthalmologists to determine optimal treatment choices and refer patients to other specialities, if necessary. However, the current scope of practice for optometrists in Saudi Arabia is limited to performing refraction and prescribing spectacles and contact lenses.⁹

The scope of optometry ranges from visual assessment and optical correction in a few countries to the complete assessment of eye health in developed countries.¹⁹ Several guidelines have been developed to define the role of optometry in PEC to consolidate the variations in the scope of optometry practice across different countries. The WCO has developed a framework describing the role of optometrists as PEC providers in providing diagnostic and therapeutic services in addition to optical dispensary services.²⁰ The College of Optometrists of Ontario, Canada has developed standards for optometric practice. These standards define the role of optometrists in PEC, which is similar to the description provided by WCO.²¹ The Royal College of Ophthalmologists, UK, has developed an ophthalmic service guideline that emphasises the role of optometrists as PEC providers, including their role in the management and co-management of common ocular diseases in community centres.²² The Eye Care Competency Framework (ECCF), proposed by the WHO in 2022, is considered the most recent and most comprehensive guideline describing the role of optometrists and other PEC providers at different levels ranging from primary to tertiary eye care centres.⁸

Eye Care Competency Framework comprises six domains: practice (P), professionalism (PM), learning and development (LD), management and leadership (ML), community and advocacy (CA), and evidence (E). Each domain focuses on a specific role and skill that must be acquired by PEC providers. Practice (P) refers to the interaction of the PEC provider with patients. Professionalism (PM) refers to best practice care that is ethical, safe, efficient, and effective, in addition to being of high quality. Learning and Development refers to the professional development of PEC providers and other personnel; it encompasses teaching, learning, and reflective practice. Management and Leadership relate to service development, resource management, team leadership, and organisation. Community and Advocacy relates to advocating for the needs of the community, empowering the members to access available resources, and contributing to long-term beneficial changes. Evidence (E) relates to the use, generation of, contribution to, and dissemination of evidence for eye care interventions, services, and systems.⁸

Each domain has a list of competencies and activities that describe the roles and performance of PEC providers. Competencies reflect knowledge and skills related to the behaviour of the PEC provider towards patients and staff. Activities reflect knowledge and skills that are related to the clinical practice and performance of the PEC providers. Eye Care Competency Framework classifies PEC providers into four categories: introductory, intermediate, advanced, and expert levels. The framework classifies optometrists into the advanced level for most competencies and activities or the expert level for other competencies and activities. The advanced level comprises PEC providers with a high level of knowledge and practical skills who exhibit competency and accurately complete the activity. The expert level comprises PEC providers with an expert level of knowledge and practical skills that enable them to exhibit competency, complete activities, create opportunities, lead a team, and impart learning.⁸

The quality, safety, and patient experience of PEC service in Saudi Arabia require improvement. Policymakers must improve these domains by developing a new eye care system or adopting an existing model that adheres to international standards and is recognised by authorities such as ECCF.

The Delphi method is a repeated measures methodology that collects opinions from a group of experts with expertise in a certain field until consensus is reached. This method uses a series of newly developed statements or existing statements developed using previous literature. The responses are modified based on feedback.²³ This method has been used widely in different areas of research, including healthcare studies.²⁴ The responses obtained using this method are considered robust as the participants can freely express their opinions owing to the anonymity of the participants, repetition of measurements, feedback control, and the final decision being made based on the consensus results of the majority of participants.²³ The Delphi method is cost-effective, and it has the ability to reach to consensus judgement by contacting a limited number of expert participants.

The quality, safety, and patient experience of PEC service in Saudi Arabia need improvement and this study aimed to adopt the ECCF proposed by the WHO by considering the opinions of experts in the field of optometry and ophthalmology regarding the role of optometrists as PEC providers in primary health care centres in Saudi Arabia. To the best of our knowledge, a similar study has not been conducted in Saudi Arabia before.

The ECCF comprises 119 statements encompassing all competencies and activities from the six domains. Among these 119 statements, 97 (82%) statements achieved at least 80% consensus during the first round. Among these 97 statements, 33 (34%) statements achieved 100% consensus. These statements have been delineated using bold font in Table 2. Twenty (18%) of the 119 statements did not achieve 80% consensus. These statements have been delineated using bold font, italic font, and underlined cells in Table 2. However, 13 of these 22 statements reached > 75% of the consensus level.

The majority of statements that did not achieve consensus were related to domain P, which relates to the ability of optometrists to perform vision and eye examinations accurately in clinical settings (11 statements). A few participants suggested that optometrists in Saudi Arabia must receive additional practical training in hospitals under the supervision of an expert, such as an ophthalmologist or an optometrist with additional training (for instance, a residency certificate) in PEC or the management of ocular diseases from international institutes before being considered qualified to conduct eye examinations, diagnose ocular diseases, and prescribe proper treatment. The second most common statements that did not reach consensus were related to domain E, which relates to planning, strengthening, and implementing research (6 statements). These statements and the remaining statements that did not reach consensus were modified according to the comments and suggestions of the experts and included in the second round. Additional statements were not provided by the participants in this round.

Table 3 shows only the modified statements from the first round. All 22 statements included in the second round achieved 80% consensus. Moreover, 5 statements (23%) achieved 100% consensus (bold cells in Table 3). Additional suggestions, comments, or new statements were not provided by the participants during this round. Thus, the second-round questionnaire was adopted as the final model for the PEC system to be adopted by the healthcare system in Saudi Arabia in this study (Online Appendix 2).

The World Report of Vision released by WHO in 2019 proposes a few strategies to improve the quality of PEC services being offered to the community. The first recommendation is to increase the level of consciousness among citizens and communities about the importance of undergoing routine eye examinations. This could increase the probability of detecting and treating ocular diseases at an early stage. The second recommendation is to enhance the quality of PEC services by increasing the number of qualified and trained PEC providers capable of detecting, diagnosing, and managing common ocular diseases and referring complicated cases to specialists during the early stages of the disease. The third recommendation is to increase collaboration between eye healthcare services and other programmes, such as diabetes awareness, child health programmes, and public health programmes.²⁹

Traditionally, the role of optometrists is restricted to the detection and correction of refractive errors in Saudi Arabia. Optometry programmes in Saudi Arabia adhere to the international standards and scope of optometry practice. Thus, optometrists in Saudi Arabia can provide PEC services safely and effectively. Optometrists play an active role in the eye healthcare system across different countries around the world. Thus, ocular health professions must be surveyed to identify domains that require improvement and further steps must be taken to improve the quality of PEC services in Saudi Arabia. This can be achieved by enabling optometrists to participate in PEC services in primary care community centres.

The applicability of the ECCF proposed by the WHO to Saudi Arabia and the statements that achieved consensus according to the experts in the field of eye healthcare in Saudi Arabia were assessed in this study. All 119 statements included in the ECCF achieved at least 80% consensus after two rounds, with certain statements being modified according to comments and suggestions provided by the experts. This study demonstrated that ECCF is highly applicable to the eye healthcare system in Saudi Arabia and can be used to improve the quality of service provided by optometrists as PEC providers. To the best of our knowledge, this is the first study to adopt the ECCF proposed by the WHO to assess the quality and availability of the eye healthcare system in Saudi Arabia.

Most statements (82%) achieved consensus during the first round but statements that did not reach consensus were clustered in two domains, namely: domains P and E. Nevertheless, the majority of experts stated that optometrists are not sufficiently qualified to perform specific roles related to clinical practice. The majority of statements (78.9%) achieved high levels of consensus, with 15 of the 19 participants being ‘confident’ or ‘strongly confident’ that the specific role can be fulfilled by an optometrist. Analysis of the comments and suggestions provided by the experts who were not confident revealed concerns regarding weaknesses observed in certain skills of optometrists and the requirement for additional training and participation in additional courses to acquire the skills to examine the eye and visual system and accurately prescribe therapeutic agents. Copies of the Optometry Doctor programme’s curriculum and Programme Learning Outcomes (PLOs) that received full accreditations from national and international authorities were sent to the participants. The participants recommended that undergoing 3 months of extensive training under the supervision of an expert (for instance, a consultant ophthalmologist) is still necessary to perform certain roles that are concerned with the diagnosis and treatment of ocular diseases affecting the posterior segment. The remaining statements that did not achieve consensus belonged to domain E, which concerns research skills. All suggestions provided by the experts were used to modify the statements for the second round. The modified statements and the previous statements that achieved 80% consensus were included in the second-round questionnaire.

The findings of this study emphasise the urgent requirement for improving the quality of the eye healthcare system in Saudi Arabia by enabling optometrists to provide PEC services. The prevalence rate is high in both males (14.8%) and females (11.7%) in Saudi Arabia, and this prevalence rate has increased to almost double among patients with obesity. These patients are at a high risk of developing retinal disease that necessitates continuous monitoring for the maintenance of ocular health.³⁰ Aldebasi et al. reported that the majority of patients who visited ophthalmology departments of public hospitals in Saudi Arabia can be managed by optometrists. Moreover, they reported that approximately 68% of cases can be managed by prescribing spectacles, contact lenses, or low-vision devices for other minor conditions. However, the remaining 32% of cases required advanced treatments, surgeries, or referrals for further medical care.⁹

This study is novel in that, firstly data were collected from 19 experts. A sample size of 19 is considered sufficient for a Delphi study. Secondly, the expert panel comprised experts from various subspecialities, such as ophthalmologists, optometrists, ocular pharmacists, and authorities in the field of eye care. Thirdly, the participants represent different organisations, such as academic departments and hospitals, public hospital departments, private sectors, and decision-making authorities. Limitations identified in this study include that only a few experts from different geographical regions of the country, including Jeddah, Qassim, and Aljouf participated in the study, and most of the participants were concentrated in Riyadh.

The ECCF proposed by the WHO can be used as a model to reinforce the role of optometrists as PEC providers globally. The model facilitated achieving consensus levels for all statements applicable to the healthcare system in Saudi Arabia using a Delphi method. Thus, this model can be utilised to improve the PEC services by other countries facing similar challenges.