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Issue: May 25, 2019
May 20, 2019
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Optometric integration and scope of practice still disputed

Issue: May 25, 2019
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As optometrists gain more scope of practice rights throughout the country and are employed by ophthalmic practices to comanage patient care, ophthalmologists and optometrists have varied opinions on what roles optometrists should play in patients’ lives and exactly what services they should be allowed to perform.

In four states — Louisiana, Kentucky, Oklahoma and Arkansas — optometrists have broadened their scope to include some surgical procedures, which in other states would be performed only by MDs and DOs.

Since June 2014 when HB1065 took effect, ODs in Louisiana can perform several laser procedures, including YAG capsulotomy, peripheral iridotomy and selective laser trabeculoplasty. Kentucky ODs can perform “lumps and bumps” procedures around the eyelid and eye as well as conduct therapeutic laser techniques, excluding PRK, LASIK and retinal procedures.

Kenneth P. Cheng, MD
Physicians need to develop relationships with their legislators, both state and federal, to make them aware of patient safety issues, according to Kenneth P. Cheng, MD, chair of the AAO Surgical Scope Fund.

Source: Kenneth P. Cheng, MD

State board-certified optometrists in Oklahoma may also practice “the science and art of examining the human eye and measurement of the powers of vision by the employment of any means, including ... laser surgery procedures, excluding retina, laser in-situ keratomileusis (LASIK), and cosmetic lid surgery,” according to the optometry laws of Oklahoma.

Arkansas became the fourth state in the country to grant optometrists laser privileges and certain surgical procedures after Gov. Asa Hutchinson signed HB1251 into law on March 27, effectively amending optometrists’ scope of practice.

According to Belinda R. Starkey, OD, Arkansas Optometric Association president, in an interview with OSN sister publication Primary Care Optometry News, the bill will allow optometrists to perform selective laser trabeculoplasty and Nd:YAG laser procedures, injections (excluding intravenous and intraocular) and removal of lid lesions, and chalazion incision and curettage.

Alaska is also in the process of developing regulations for laser use. Tennessee and New Mexico allow scalpel lid procedures with injectable anesthetics, and Iowa allows scalpel procedures with topical anesthetics only. None of these states allow optometrists to use lasers.

The remaining states do not provide optometrists with any surgical authority. However, lawmakers in several states have introduced legislation or regulatory proposals as of Feb. 1, 2019, to increase the optometric scope of practice to include some types of surgery. Wyoming recently proposed legislation to allow some surgical procedures as well as the ability to prescribe, dispense and administer approved pharmaceutical agents.

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According to an Associated Press report, lawmakers introduced the bill because of perceptions that optometrists in Wyoming can be more accessible in remote areas than ophthalmologists. In the state, there are 166 licensed optometrists and 54 licensed ophthalmologists. Under the legislation, optometrists would have been able to perform surgical procedures defined as “any optometric procedure that does not penetrate beyond the cornea or sclera.”

The bill, Wyoming Senate File 55, “Optometrists’ practice act amendments,” was passed by the Senate in January and would allow therapeutic lasers or surgery for use in optometric procedures. The bill was postponed indefinitely by the House in February when Wyoming ophthalmologists demonstrated to the legislature that access to optometrists was no better than access to ophthalmologists and that the procedures in question were still very much eye surgery, according to Kenneth P. Cheng, MD.

A question of safety

As optometrists look to gain a greater surgical scope of practice, the American Academy of Ophthalmology is working with state ophthalmological and medical societies to oppose state-level efforts to grant medical and surgical privileges.

Cheng, who is an OSN Pediatrics/Strabismus Board Member and chair of the AAO Surgical Scope Fund, said the issue simply boils down to patient safety and ensuring patients receive proper care from trained medical physicians.

“Without appropriate education and training, which includes the full route of medical school, internship and ophthalmology residency, it’s inappropriate and not in the interest of patient safety to expand the scope of practice of optometrists for any form of surgical procedure. No procedure is a minor procedure. The reportedly smallest of surgical procedures that optometrists want to expand their scope into could still have very significant potential complications for patients, and patients simply deserve better,” he said.

The AAO Surgical Scope Fund provides grants to state ophthalmological societies to educate legislators and the public to ensure appropriate laws are passed. Physicians need to develop relationships with their legislators, both state and federal, to make them aware of the patient safety issues that are at stake, Cheng said.

However, optometrists can be a valuable resource for ophthalmologists and patients. More ophthalmic clinics are employing optometrists to provide patients with screening and refractive services, eyeglasses and contact lens fitting, Cheng said. Optometrists can also act as an entry point into a practice for all types of eye care.

Ophthalmologist-led eye care

The demand for eye care is growing. OSN Chief Medical Editor Richard L. Lindstrom, MD, noted in a presentation at the Cataract Surgery: Telling It Like It Is meeting that the 65-and-older U.S. population will grow by 15% in the next 15 years. Seniors older than age 65 consume up to 10 times the eye care services of younger patients, he said, and ophthalmologists will be faced with a 5% year-on-year rise in demand for services coupled with no measurable annual gain in eye surgeons.

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Currently, about 500 ophthalmologists retire each year and only 450 new ophthalmologists are trained each year, which will lead to a static, at best, ophthalmology workforce while the patient pool continues to age and grow, increasing the demand for eye care. Optometric providers may help fill this gap, he said.

Richard L. Lindstrom, MD
Richard L. Lindstrom

“Right now, two out of every three ophthalmologists in the country employ at least one optometrist,” Lindstrom said in a follow-up interview.

In fact, the trend of ophthalmologist-led integrated eye care delivery is growing in clinics throughout the country, he said.

Lindstrom said that the practice where he works employs 18 ophthalmologists and 12 optometrists who work side by side every day. The “megatrend” of ophthalmologists, optometrists, physicians assistants, ophthalmic technicians and opticians, all working together under one roof, is a convenient way for clinics to increase patient volume and also improve the patient experience.

“In our practice, our optometrists practice independently. Today, we allow them to undertake the full scope of optometric practice as established by our Minnesota state licensing board,” he said.

This does not include invasive incisional surgery, intraocular injections or laser therapy, he said, but it does include preoperative and postoperative care for surgical patients. Optometrists at his practice also treat many medical problems including dry eye disease, which involves external lid treatment with devices such as BlephEx (BlephEx LLC), LipiFlow (Johnson & Johnson Vision) and iLux (Tear Film Innovations).

“They don’t do glaucoma surgery. They don’t do cataract surgery, corneal transplants, YAG or SLT lasers. No LASIK or PRK. They can remove a corneal foreign body from the eye because that is inside the Minnesota state scope of practice,” Lindstrom said.

Even if the Minnesota state legislature or another governing board one day voted to allow optometrists to expand their scope of practice into invasive surgery, Lindstrom said they would not do so in their practice.

“The only optometrists in the state of Minnesota that I am quite confident will never do cataract surgery are the ones that work with us,” he said.

“It just would not make sense for us or our patients to have an optometrist conduct a complex surgical procedure like cataract surgery when our practice already employs experienced residency- and fellowship-trained ophthalmic surgeons to provide surgical care,” he said.

After graduation from medical school, completion of a 1-year internship and receipt of his license to practice medicine, Lindstrom said that his “legal scope of practice” arguably included any number of complicated surgical procedures, including cataract surgery and even organ transplantations or joint replacements.

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“All I needed was my MD and a year of general internship, and I could arguably do all of that. Would it have been in the best interest of society to have me do that? Would it have been in the best interest of citizens of Minnesota to have me do that? I don’t believe it would have been, so I went on and did 5 additional years of training after my internship — 3 years of ophthalmology residency and 2 additional years of fellowship — to become an anterior surgery microsurgeon and specialize in that area. That’s what it takes to be good,” he said.

When any medical professional attempts procedures beyond their scope of training and education, safety becomes an issue. Optometrists should not have a role in the surgical realm because they do not have adequate training and experience to safely perform surgical procedures in place of an ophthalmologist, Cheng said.

“The roles of the different providers very much need to remain within the qualifications of their education and training so that patients have not just access to care, but access to qualified care. That’s what’s in their best interest,” he said.

Patients often do not know the difference between an optometrist and an ophthalmologist, which can add to the confusion. An optometrist receives a doctor of optometry degree and is licensed to practice only optometry, not medicine. The practice of optometry deals with examining the eye to prescribe and dispense corrective lenses and screening patients to detect eye abnormalities. Patients who see their “eye doctor” on a regular basis may not recognize the threat to safety and warning bells when presented the idea of undergoing surgery by an optometrist, Cheng said.

“As ophthalmologists and physicians, it’s part of our responsibility to make sure that we take care of not just individual patients, but also live up to our societal responsibility to take care of and advocate for patients who aren’t aware of issues that may jeopardize their safety,” he said.

Trending to collaborative care

When ophthalmologists and optometrists work together in the same practice, with each professional sticking to his or her specialized area of care, the results can be beneficial. This type of collaborative care, said Sondra Black, OD, FAAO, head of Professional Strategy, Surgical Commercial Americas, at Johnson & Johnson, can benefit both practitioners professionally while improving patient care.

Black worked in private practice for years with Jeffery J. Machat, MD, after her own experience with LASIK surgery in his clinic. Thrilled with her surgical outcomes, she began referring patients to his ophthalmology practice and became one of his top referring doctors.

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Sondra Black, OD, FAAO
Sondra Black

“I began working on building my refractive practice and began accompanying the patient into the surgery center so they would feel more comfortable and have a familiar face. After about 18 months of this, he asked me if I was interested in working with him on a clinical trial on a part-time basis. After 1 month, he asked me to give up private practice and come onboard full time. I ended up leaving my own private practice and went to work with him. It has been an interesting journey,” she said.

Black’s duties included all preoperative and postoperative patient care, programing the laser for each specific procedure and providing notes to Machat before each surgery. This allowed Machat to focus mainly on performing surgery.

It was an ideal and rewarding collaborative care agreement, she said.

“Everyone has different skill sets. Ophthalmologists go into medical school and ophthalmology because they want to do surgery. That’s their goal. They don’t want to sit with patients, especially for cataract surgery or glaucoma surgery, and go over all the various options and technologies used in the procedure. They want to perform surgery,” Black said.

A heavily booked ophthalmology clinic can have upward of three to four rooms of patients waiting to be seen. If an optometrist is employed in the clinic, he or she can perform all initial patient workups, perform all preoperative and postoperative care, and allow the ophthalmologist to focus only on surgery if that is what the surgeon wants, Black said.

“In order for this to be successful, it has to be collaborative care. It’s important that the ophthalmologist takes the optometrist under their wing and trains them. To throw an optometrist into that setting with no training and no way to understand what the ophthalmologist is thinking, there is no way it will work. It must be a true partnership,” she said.

A different expertise

Optometrists provide unique expertise and experience to ophthalmology clinics, OSN Technology Section Editor William B. Trattler, MD, said.

His private practice employs three optometrists; two are focused primarily on postoperative care, and a third practices general optometry with a focus on contact lens evaluations including scleral lens fitting services, an important aspect for patients who undergo corneal cross-linking.

“Scleral lenses have made such a tremendous impact on the vision and ocular health of patients with keratoconus. While cross-linking is effective in helping to stabilize patients with keratoconus, it’s really the optometrist and scleral lens experts who change the day for the patients by providing unbelievable levels of vision. Our practice works closely with optometrists who are scleral lens experts outside of our practice, including some of the leaders in this field, as their expertise is critical to improving vision in patients with keratoconus,” he said.

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OSN Cataract Surgery Board Member Cynthia A. Matossian, MD, FACS, founder and medical director of Matossian Eye Associates, currently employs five optometrists in her practice, to include a part-time optometrist who specializes exclusively in fitting patients with scleral contacts lenses, complex hybrid and rigid gas permeable lenses.

The remaining optometrists are full-time employees of Matossian Eye Associates and enable the practice to offer weekend and night hours, an impossibility before their employment, Matossian said.

“They have expanded our hours and consequently helped grow our volume. Our optometrists help us with our postoperative patients. They see them on the day 1 and 1-month follow-up visits so we, as surgeons, can continue to see patients who truly need our surgical skills,” she said.

Cynthia A. Matossian, MD, FACS
Cynthia A. Matossian

Increased volume means increased surgical cases, as a certain percentage of patients will always need to undergo surgery, she said.

Optometrists help channel appropriate levels of disease care to the different subspecialties within the practice. Ophthalmologists are free to focus on and treat more complicated eye conditions, while optometrists provide regular eye checkups for patients complaining of blurred vision or dry eye disease or who are pseudophakic, Matossian said.

The optometrists focus on the ocular surface health of the patients they examine, Matossian said. A patient with an optimized ocular surface can be evaluated more accurately for cataract surgery compared with a patient with an unstable tear film.

“By having these expanded hours, with increased availability of eye care practitioners to see patients, it’s created a gateway for more patients to enter our practice. If they only need contact lenses and are 20/20, they stay with our optometrists. But if that patient also has wet AMD or very high eye pressure, they get appropriately channeled to the proper subspecialties in our practice,” she said.

Policing eye care

As this collaborative trend with optometry colleagues grows and integrated eye care practices become more popular, the ophthalmology community has a duty to their patients to monitor carefully who is allowed to perform eye surgery to ensure quality outcomes and patient safety, Lindstrom said.

When new legislation is being considered, it is up to individual practicing ophthalmologists and the institutions where they work to provide input regarding the training required for any invasive surgical procedure.

Just because a governing body passes legislation that allows an optometrist or even a comprehensive ophthalmologist to perform a complex invasive ocular surgery, that does not mean it is a good idea, he said.

“We don’t let our fellow ophthalmologists do every type of surgical procedure. I don’t do retinal detachment surgery. I don’t do epiretinal membrane peeling. I no longer do very complex pediatric ophthalmology cases. Even though I’m an MD, even though I’ve completed 4 years of medical school, an internship, 3 years of ophthalmology residency and another 2 years of ophthalmology fellowship, there are a lot of surgical eye procedures I don’t do and shouldn’t do. If I walked into my own ASC, where I’m the practice founder and a partner, and wanted to do a retinal detachment surgery, it wouldn’t be allowed. We police ourselves,” he said.

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There is no substitute for proper education, training and experience to be able to execute a complex, invasive eye surgery. It is in every patient’s best interest regardless of the field, be it eye care, orthopedics or cardiac care, to have someone who has the training and experience to complete surgery in an outstanding fashion perform it, Lindstrom said. – by Robert Linnehan

  • For more information:
  • Sondra Black, OD, FAAO, can be reached at email: drsblack@yahoo.ca.
  • Kenneth P. Cheng, MD, can be reached at 100 Bradford Road, Suite 320, Wexford, PA 15090; email: kpchengmd@me.com.
  • Richard L. Lindstrom, MD, can be reached at Minnesota Eye Consultants, 9801 Dupont Ave. S., Suite 200, Bloomington, MN 55431-3200; email: rllindstrom@mneye.com.
  • Cynthia A. Matossian, MD, FACS, can be reached at Matossian Eye Associates; email: cmatossian@matossianeye.com.
  • William B. Trattler, MD, can be reached at Baptist Medical Arts Building, 8940 N. Kendall Drive, Suite 400-E, Miami, FL 33176; email: wtrattler@gmail.com.

Disclosures: The sources in this article report no relevant financial disclosures.

Editor’s note: This article has been updated to include DOs with MDs as being within their scope of practice to perform some surgical procedures. Healio regrets the error.

Click here to read the Point/Counter, “Should an ophthalmology practice employ optometrists?”

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