Born and raised in Waterloo, Dr. Sarah MacIver was instrumental in getting her University of Waterloo 2010 Doctor of Optometry graduating class out to local events such as Oktoberfest. But it was her residency in New York State that shaped her current trajectory in ocular disease care and made her an emerging leader for the profession in Canada.
MacIver, now an associate clinical professor and director of continuing professional development at the School of Optometry and Vision Science, became interested in ocular disease during her OD studies. Following graduation, she pursued a residency in that area at the State University of New York College of Optometry.
The experience showed MacIver the impact optometrists can have in patient care when they collaborate with other health-care professionals and practice to the fullest extent of their training and education.
“Residents worked in the hospital and also in the University Eye Center ocular disease clinic,” says MacIver. “It was really rewarding being front-line in the hospital. Patients would go straight from the emergency room to our clinic if they had any eye issues, so we saw a lot of acute problems like red eyes, foreign bodies in the eyes and sudden vision loss.
“We really saw the value of the role optometry can play in treating and managing ocular disease and integrating into a fast-paced interprofessional health care setting. In addition, we managed patients with acute and chronic eye disease and hospital inpatients. We had access to all the patients’ medical history, lab testing and neuroimaging and could order those tests when it was deemed appropriate for the patient case.”
A faculty position at the University of Waterloo opened up towards the end of MacIver’s residency, so she successfully applied.
“What really interested me the most was the opportunity to take what I had learned about practicing in an interprofessional setting and having a role in not only ocular disease management but systemic disease management as well as contributing to the growing role of optometry in this space at Waterloo,” says MacIver.
Seeing rewards in the clinic
Since she’s been back in Waterloo, MacIver has been managing patients with eye diseases such as glaucoma. Some have been seeing her regularly for over a decade.
“For the most part, the patients I’ve seen have not progressed past a stage of moderate glaucoma, which means they haven’t lost a significant amount of vision under our care,” says MacIver. “We intervene early and build relationships with these patients, so we can adjust management options if necessary and keep a clear eye on what’s happening with their disease.”
MacIver and her colleagues maintain good relationships with local ophthalmologists so patients who need more advanced care can be referred to them. However, MacIver does miss being able to collaborate as closely as she did in New York, with optometrists handling early-stage or slow-progressing disease and ophthalmologists seeing patients with more severe cases – all under one roof.
When construction on the new Waterloo Eye Institute is finished – expected to be in late 2026 – the hope is to have a more integrated continuum of care that enables the right care at the right time by the right provider.
“Ultimately, a collaborative approach with other health-care professionals will provide a simpler patient pathway and improved outcomes,” says Dr. Stanley Woo, director of the School.
Advocating for scope expansion
Currently, MacIver is part of the nationwide movement advocating for optometrists to be able to perform laser procedures for anterior segment disease and minor surgical procedures for eyelid lesions. Other items on the agenda include ordering relevant lab tests and imaging.
"We teach these skills in our programs, both in optometry school and through continuing professional development. We want to continuously modernize our scope to extend what we’re already doing in order to provide improved access to patients for more timely eye care," says MacIver. “I have always been very inspired by the work of my mentors in this space, particularly Dr. C. Lisa Prokopich’s timeless work that went into our last national scope expansion."
Optometrists can currently diagnose and manage glaucoma. However, in Canada, they can’t perform selective laser trabeculoplasty (SLT), a procedure to unclog the mesh-like structures that drain fluid from the eye. This helps lower intraocular pressure and therefore lowers the risk of damage to the optic nerve.
“Studies show that SLT is a safe procedure that should be done as first-line treatment, but with the way the health-care system is set up, it’s just not possible for every patient that has a new diagnosis of glaucoma to get SLT,” says MacIver. “If optometrists included the procedure in their practice, then it could be feasible. It would be particularly beneficial for patients in rural and remote communities who could get much-needed care closer to home.”
With regards to eyelid lesions, there is growing evidence that patients are waiting longer and longer to see ophthalmologists so minor lesions can be removed, says MacIver.
“Since we’re already doing the diagnosis, pre-op and post-op care, it’s just a small update to our scope to allow for the injection of a numbing agent so the removal can be done easily in the clinic. It makes sense that if a disease falls under our scope of practice, then treatments that are non-invasive or minimally invasive should be included in the treatment options available to us so our patients have access to them. It would also free up ophthalmologists to do more advanced and complicated surgery that they are uniquely qualified to deliver.”
Optometrists can already perform laser and minor surgical procedures in over a dozen states – in Oklahoma, this has been the case for more than 20 years – and there have been essentially no issues, says MacIver.
Education before legislation
Part of MacIver’s advocacy is rooted in her role leading continuing professional development for the School.
“As an educational institution, the best way we can support advocacy efforts is ensuring that education is accessible,” says MacIver. “We want to de-mystify scope modernization efforts, because optometrists who have taken the Office-Based Laser and Minor Surgical Procedures for Optometrists course have found that what may have seemed like a new set of skills is actually just a lateral translation of skills they already have.”
To optometrists who might be waiting for legislation to change before they undergo training, MacIver has a simple message: just do it.
“We need a critical mass of people to understand what these procedures are, so when optometrists are talking to their patients or MPPs, they can speak to the facts: that diagnosing and managing these diseases is already covered under our scope of practice, and that scope modernization is feasible, would help patients and would help improve the efficiency of the health-care system,” says MacIver.
“The more optometrists who take the course, the more people who can speak to the benefits of scope modernization. That will be an important part of moving the profession forward.”
