Should paramedical staff be entitled to perform surgical procedures such as YAG laser capsulotomy?

Yes, if properly trained

Declan W. Flanagan

In the U.K., trained nurses and other health care practitioners have been performing clinical procedures as members of managed clinical teams for many years.

In 2009, Moorfields Eye Hospital in London trained a group of ophthalmic nurses and optometrists to perform YAG capsulotomies, and they now perform this procedure regularly.

The decision that a capsulotomy is indicated and will benefit the patient is always made by an ophthalmic surgeon. The nurse or optometrist then performs the procedure, adhering strictly to agreed clinical protocols. Outcomes are audited to ensure that the procedure is clinically indicated and that the clinical outcomes are satisfactory.

Patients find the combination of clinical examination and explanation by an eye surgeon with the procedure then performed by a trained, competent nurse or optometrist very reassuring.

YAG laser capsulotomies are only performed in hospitals funded by the United Kingdom National Health Service. The nurse practitioners and optometrists are all employees of NHS hospitals. The hospital, as the employer of the ophthalmic nurse practitioners and optometrists, takes full responsibility for the safe performance of YAG laser capsulotomies and all other procedures performed by clinical staff.

Delegation of this clinical procedure is designed to ensure that the skills of all the professional groups in the clinical team are used appropriately and safely to optimize patient care.

This allows YAG laser capsulotomies to be offered to patients in a timely and cost-effective fashion without long waiting lists.

Declan W. Flanagan, FRCOphth, is the medical director and consultant ophthalmic surgeon at Moorfields Eye Hospital, London.

No, only ophthalmologists can provide maximum quality, safety

Matteo Piovella

YAG capsulotomy is a medical act and should consequently be performed only by ophthalmologists. In my opinion, this indication is nonnegotiable, as it guarantees the quality of the service we offer to the patient.

Education and training have always been considered key elements in developing professional skills and competencies to provide the best standards of care. European ophthalmologists are qualified through a long and intense curriculum of 10 to 11 years. They are trained as specialists but have a 360° knowledge of all aspects of medicine. This enables them to take care of patients and to take responsibility for their health.

Paramedical qualifications entail a 3-year curriculum, in which knowledge and experience are reduced by 80% compared with the education of a specialized medical doctor.

There are no reasons to have paramedics perform procedures that were previously reserved to doctors. A shortage of qualified medical workforce may leave no other choice in countries such as the United Kingdom. However, these reasons should be clearly stated in the U.K. If political and economic considerations have to prevail, governments should take full responsibilities for the implications of such choices, in terms of decreased quality and safety of health services.

Patients should have a right to choose whether they want to be treated by an expert ophthalmologist or by non-medical staff with a shorter, nonspecific training and no ability to deal with possible complications. They should, in the first place, be made aware of the difference between the two options.

Matteo Piovella, MD, is an OSN Europe Edition Associate Editor and president of the Italian Society of Ophthalmology.