Orthoptist (ORT)

Key Points at a Glance

Key Points of This Disease

• An orthoptist (ORT) is a nationally licensed medical professional who performs orthoptic training and ophthalmic examinations under the direction of a physician.
• In Japan, it is a title-protected profession under the Orthoptist Act, requiring passage of the national examination and a license from the Minister of Health, Labour and Welfare.
• The main duties are broadly divided into four areas: orthoptic training, visual function testing, three-year-old child health checkups and adult screenings, and low vision care.
• Some procedures, such as the use of dilating drops and fundus photography, require specific instructions from a physician.
• In the United States, orthoptists are positioned as mid-level providers in pediatric ophthalmology and neuro-ophthalmology.
• With the reform of physicians’ work styles, orthoptists are expected to expand their role as task shifters and task sharers.

1. What is an Orthoptist?

An orthoptist (ORT) is defined in Article 2 of the Orthoptist Act as “a person who, licensed by the Minister of Health, Labour and Welfare, uses the title of orthoptist and, under the direction of a physician, performs corrective training for the recovery of binocular visual function in persons with binocular visual impairment and the examinations necessary for such training.” It is a national qualification with exclusive use of the title, and orthoptists are not independent healthcare providers.

More than 50 years have passed since the enactment of the Orthoptist Law, and the scope of practice has changed significantly. Initially specialized in orthoptics, the field now encompasses a wide range of examination tasks.

Status in Japan and the United States

In Japan, orthoptists are medical professionals who perform ophthalmic examinations and orthoptics under the direction of a physician. In the United States, they function as mid-level providers (advanced healthcare practitioners positioned between physicians and nurses) primarily in pediatric ophthalmology and neuro-ophthalmology. Recognized by the American Medical Association (AMA), they work alongside ophthalmologists in a manner similar to nurse practitioners (NPs) and physician assistants (PAs).

Unlike optometrists, orthoptists are not independent practitioners. They also differ from ophthalmic technicians in terms of educational background and the duration and complexity of formal training.

Q What is the difference between an orthoptist and an optometrist?

A

Orthoptists are medical professionals who perform binocular vision training and ophthalmic examinations under the direction of a physician and are not independent practitioners. In contrast, optometrists can independently provide eye care, which is a major difference.

2. Main Duties

The duties of orthoptists in Japan are broadly classified into four areas.

Orthoptic Training

Strabismus correction training: Includes suppression removal training, abnormal correspondence correction, glare stimulation, and afterimage methods.

Amblyopia orthoptic training: Manages treatment using occlusion and penalization methods¹.

Visual Function Testing

Wide range of tests: Conducts various tests such as visual acuity, intraocular pressure, visual field, OCT, and corneal endothelial tests.

Eye position and eye movement tests: Performs eye position tests, convergence tests, AC/A ratio measurement, and fixation tests.

Health Checkups and Screenings

3-year-old health checkup: Conducts visual function screening for early detection of amblyopia and strabismus²³.

Adult screenings: Engages in public screening services such as glaucoma screening.

Low Vision Care

Selection of assistive devices: Select assistive devices such as magnifiers and tinted glasses, and provide instructions on how to use them.

Daily living support: Provide support to maximize the use of remaining visual function.

Details of Examination Work

Examinations performed by orthoptists are classified into input, integration, and output systems.

• Input system examinations: Visual acuity test, static quantitative perimetry, axial length measurement, corneal endothelial examination, anterior chamber and angle examination, color vision test, eyelid examination, optical coherence tomography (anterior segment OCT, posterior segment OCT, OCTA), intraocular pressure measurement, contact lens examination and fitting instruction, electrophysiological examination, corneal topography, light perception test, exophthalmometry, fundus examination
• Integration system examinations: Binocular vision function test, retinal correspondence test
• Output tests: Ocular alignment test, convergence test, fixation test, AC/A ratio measurement, eye movement test

Other Duties

In addition to examinations and training, the following duties are also performed.

• Interview: Taking patient symptoms and medical history
• Surgery-related: Indirect operating room duties, duties as a scrub nurse or first assistant
• Education/Research: Supervision of clinical trainees, research duties, education of medical students and residents
• Patient education: Explanation of intraocular lenses, instruction on contact lens insertion
• Administrative work: Drafting official application documents, preparing referral letters
• Other: Clinical trial-related tasks, examinations related to orthokeratology, tasks related to LASIK, hospital committee work

Q What kind of examinations does an orthoptist perform?

A

Orthoptists are responsible for most examinations performed in ophthalmology, including visual acuity tests, intraocular pressure tests, OCT, visual field tests, eye position tests, and binocular vision function tests. They perform a wide range of examination tasks across input, integration, and output systems.

3. Legal status and scope of practice

The duties of orthoptists are defined by the Orthoptist Act.

Main Provisions of the Orthoptist Act

• Article 2 (Definition): Under the direction of a physician, perform orthoptic training for the recovery of binocular vision and necessary examinations.
• Article 17 (Duties): May also perform ophthalmic examinations (excluding those with a high degree of influence on the human body).
• Article 17, Paragraph 2: Notwithstanding the provisions of the Public Health Nurse, Midwife, and Nurse Act, orthoptic training, examinations, and ophthalmic examinations may be performed as “assistance in medical practice.”
• Article 18 (Restriction of Specific Acts): Some acts require specific instructions from a physician.

Classification of tasks by physician instruction level

Tasks are classified according to the level of physician instruction.

Instruction level	Orthoptic training	Examination
Specific instruction required	Occlusion therapy, abnormal retinal correspondence treatment, dazzling stimulation, afterimage method	Use of mydriatics, fundus photography, electroretinography, electrooculography, electronystagmography, visual evoked potential
Can be performed under a doctor’s order	Orthoptic training other than the above	Ophthalmic examinations other than the above

What is a specific order?

This refers to an order given with as much detail as possible so that the person receiving the order does not need to exercise discretion regarding various judgments (such as appropriateness and method of implementation) when performing relative medical acts.

Note that lacrimal duct irrigation and dye tests (excluding those using eye drops) are prohibited by Ministry of Health, Labour and Welfare ordinance.

Licensing System

According to Article 3 of the Orthoptist Act, it is necessary to pass the national orthoptist examination and receive a license from the Minister of Health, Labour and Welfare. Successful candidates are registered in the orthoptist registry and issued a license certificate.

Q Are there any tests that an orthoptist cannot perform independently?

A

The use of mydriatic drugs, fundus photography, electroretinography, electrooculography, electronystagmography, and visual evoked potential testing require specific instructions from a physician. Additionally, lacrimal irrigation and dye tests (excluding those involving instillation of dye) are prohibited.

4. Education and Qualification

Japan

To become an orthoptist, one must pass the National Examination for Orthoptists. To be eligible to take the exam, it is necessary to complete the prescribed curriculum at a designated training institution (university or vocational school).

United States

In the United States, the American Orthoptic Council (AOC) oversees the development of educational requirements, accreditation of programs, examination and certification, and recertification.

The educational and certification requirements are as follows:

Item	Details
Admission requirements	Baccalaureate degree
Training period	24 months in an AOC-accredited program
Affiliated institutions	Mostly ACGME-accredited medical schools
Certification examination	Written examination and oral/practical examination
Recertification	Every 3 years (proof of continuing education required)

The AOC is composed of representatives from the American Academy of Ophthalmology (AAO), the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), the American Association of Certified Orthoptists (AACO), the American Ophthalmological Society (AOS), the Canadian Orthoptic Society, and the Canadian Orthoptic Council.

Ethical standards

Certified orthoptists are bound by the AOC Code of Ethics. This code requires that orthoptic services be provided only under the overall supervision of an ophthalmologist.

5. Employment Patterns and Economic Impact

Employment Patterns

The employment patterns of orthoptists are diverse. In Japan, they work in hospitals, clinics, private practices, and academic medical institutions. In the United States, the following patterns have been reported.

• In-house type: Patients are examined in the same facility or satellite office as the supervising ophthalmologist. They see patients referred for management of non-surgical conditions such as sensory-motor function evaluation, amblyopia, convergence insufficiency, and accommodative esotropia.
• Rotating type: Multiple physicians who do not require a full-time orthoptist share the services of one orthoptist, who rotates through each office throughout the week.
• Multispecialty clinic type: Referred by multiple ophthalmologists within the same clinic for sensorimotor function evaluation and treatment.
• Technical support type: Performs preliminary examinations for ophthalmologists (may include cycloplegic retinoscopy). May also serve as a scrub nurse or first assistant in the operating room.

Economic Impact

Employing orthoptists has a positive economic effect on clinics. Adding one full-time orthoptist to a clinic can increase patient volume by 40% and lead to an increase in surgical procedures. It is possible to improve care quality and increase revenue simultaneously.

Salary structures are set based on education level and experience. In the absence of an established salary system, it may follow the salary scale of nurse practitioners (NPs) in equivalent positions.

Q What are the benefits of employing an orthoptist for a clinic?

A

フルタイム1人の追加で患者数が約40%増加し、手術件数の増加にもつながる。ケアの質を向上させながら、医師が診察できる患者数を増やすことで収益にも貢献する。

7. 今後の展望

医師の働き方改革の実現に伴い、各医療職種の専門性を活かしたタスクシフト（業務の移管）のみならず、医療職種間のタスクシェア（業務の共同実施）が推進されている。スペインで実施された全国調査では、約90%の小児眼科・斜視専門医が視能訓練士の部門への組み込みは「ケアの質を改善し待機時間を短縮する」と回答しており⁴、英国・アイルランドの調査でも視能訓練士はチーム医療の中核として遠隔診療を含む多様な業務を担っている⁵。

地域包括ケアシステムの構築に伴い、訪問診療や介護施設などにおいて医師とともに、あるいは医師の包括的指示の下で高齢者の視機能管理を行うことが望まれている。今後は眼科診療での役割を核として、保健・介護・福祉の領域での業務を拡大し、国民の眼の健康維持に貢献することが期待されている。

参考文献

Footnotes

1. Tan JHY, Thompson JR, Gottlob I. Differences in the management of amblyopia between European countries. Br J Ophthalmol. 2003;87(3):291-296. PMID: 12598440. PMCID: PMC1771562. doi:10.1136/bjo.87.3.291 ↩

2. Tamura S, Yoshitake S, Okano M, Uchikawa Y, Onitsuka S, Kawano R. Benefits of consulting a certified orthoptist in a pediatric vision screening program. J AAPOS. 2020;24(6):371.e1-371.e4. PMID: 33246111. doi:10.1016/j.jaapos.2020.07.013 ↩

3. Lequeux L, Thouvenin D, Couret C, Audren F, Costet C, Dureau P, et al. Vision screening for children: Recommended practices from AFSOP. J Fr Ophtalmol. 2021;44(2):244-251. PMID: 33388188. doi:10.1016/j.jfo.2020.07.005 ↩

4. Cruz Lasso AM. Enhancing Paediatric and Strabismus Ophthalmology Departments in Spain Through the Inclusion of Orthoptists: Insights from a Nationwide Survey. Br Ir Orthopt J. 2024;20(1):241-257. PMID: 39650624. PMCID: PMC11623091. doi:10.22599/bioj.359 ↩

5. Rowe FJ, Hepworth LR, Howard C, Lane S. Orthoptic Services in the UK and Ireland During the COVID-19 Pandemic. Br Ir Orthopt J. 2020;16(1):29-37. PMID: 32999991. PMCID: PMC7510392. doi:10.22599/bioj.153 ↩