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With a career spanning over 40 years in optometry, Jim Kokkinakis is one of the many voices advocating for the inclusion of oral therapeutics in Australian optometric scope of practice.

His practice, The Eye Practice located in Sydney’s CBD, primarily deals with complex contact lens fittings and dry eyes. Ocular therapeutics, he states, is part and parcel of his everyday activity.

Like many of his peers, Jim expresses frustration over the current restrictions Australian optometrists face in prescribing oral medications, despite the fact that it fits comfortably within their scope of practice.

‘Not only does this create inconvenience and financial burden on the government, but it also subjects the patient to a convoluted and ridiculous journey from their initial consultation,’ he said.

In an interview with Optometry Australia, Jim discusses his views on oral therapeutics, sharing why he believes it will benefit the patient, the optometrist and the government.

Q: Can you tell us a bit about yourself?

Jim: I started clinical practice in 1983 after graduating with an optometry degree from UNSW, so this is my 40th year as an optometrist.

I’m a bit of a technology geek (some will say much more than a bit). Around 1987, I nearly enrolled in Computer Science as I found myself stumbling away from optometry to pursue a different pathway. But, at that stage, I decided to purchase an autorefractor which blew me away and ended up becoming a unique marketing difference in my practice. From then on, it was a constant journey of chasing new technology.

In 1991, I completed the first ocular therapeutics course, and this started my passion for ocular disease diagnosis and treatment. Unfortunately, NSW took a while to approve ocular therapeutics and, over 10 years later, I had to retake the course, as the original course was considered unsatisfactory.

Q: In your opinion, do you think optometrists should have access to oral therapeutics?

Jim: Optometrists should be allowed to practice to the highest level of their training. Oral medication prescribing should be an obvious part of this.

I recommend oral medications in my practice numerous times per day. But, because I can’t prescribe them, it becomes a massive inconvenience and expense in both time and money to the patient. Being able to offer patients oral prescriptions – it will save everyone time and money. The patient, the optometrist and the government.

The fact that Australian optometrists do not have oral medication privileges is ludicrous, and any roadblock that we come across is purely political.

Q: Which medications would be helpful?

Jim: For example, augmentin or keflex for infective styes, doxycycline and azithromycin for ocular rosacea and meibomian gland dysfunction, acyclovir and famvir for herpetic eye infections and pulse prednisolone for significant lid allergies.

Q: Can you describe an instance where this restriction impacted you or your patient?

Jim: A few times a day I’ll see recalcitrant cases of dry eyes. Most of these have moderate rosacea, which in turn causes meibomian gland dysfunction. These cases mostly need either oral doxycycline or oral azithromycin combined with topical cyclosporine. The topical cyclosporine I can prescribe, but the oral medication I can’t.

In these cases, I have a templated letter that I’ve drafted, addressed ‘Dear Doctor’, to refer to a GP for the doxycycline or azithromycin. The template includes a study which supports the use of doxycycline or azithromycin. The letter explains the condition, the medication needed, the dosage, the frequency and the duration.

I also have to explain to the patient that in some circumstances the GP may issue the script, but in others the GP may question the treatment and try an alternative or refer them on to see a local general ophthalmologist to confirm the medication and diagnosis. This means now the patient has now seen me, the GP and the ophthalmologist. This is a massive inconvenience and expense in both time and money to the patient.

Sometimes the patient will end up with less appropriate treatment as well, as the second practitioner believes that the standard treatment algorithm is the way to go even though it has failed for the patient in the past.

The truth is all this can be short circuited at the first step if optometrists were allowed to confidently prescribe oral medications.

Q: If optometrists had access to oral therapeutics, how do you think this would affect the public healthcare system?

Jim: I think it will help in lessening the burden on the average GP and ophthalmologist. I also think that both don’t actually understand our training, qualifications, scope of practice and experience – but please note that this is on average. I also have a number of ophthalmologists that clearly see value in me treating these conditions and will refer their patients straight to me. Unfortunately, this is the exception rather than the rule.

Q: What benefits do you see in optometrists having the authority to prescribe oral medications?   

Jim: I believe there will be significant cost savings to the patient and the government, and significant time saving for the optometrist.

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