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MDs react to OD PRK
SIDEBAR: What ophthalmologists are saying
--- Daniel L. Tiller, OD
BOISE, Idaho—According to Daniel L. Tiller, OD, it shouldn't come as a shock to the ophthalmic community that he and four of his fellow optometrists have been performing photorefractive keratectomy (PRK) at the Idaho Refractive Laser Center here since February. After all, during the past two decades, the line between MDs and ODs has become increasingly blurred.
As reported in the June 1996 issue of Primary Care Optometry News, the American Academy of Ophthalmology, along with the Idaho Medical Association and the Idaho Society of Ophthalmology, have filed a complaint in State District Court, Ada County, to stop optometrists from performing PRK.
"Some ophthalmologists aren't aware of the capabilities of optometrists," Tiller said. "In the past 10 years, we have advanced light-years in the use of pharmaceutical and therapeutic agents."
Tiller, who has a private practice in nearby Nampa, Idaho, has been comanaging PRK patients for the past 18 months. "I don't really think it matters whether you are an MD or OD. It's whether you are willing to go through all the certification classes and necessary education. It shouldn't matter what your degree is."
Surgery or procedure?
In fact, Tiller intends to train other ODs, as well as MDs, to use the excimer laser for PRK. But isn't PRK considered surgery by many? Unquestionably, but to Tiller and his colleagues, it isn't.
"Technically, it is more of a procedure," he explained. "There are no blades involved. From my standpoint, it's a procedure simply to help correct near-sightedness and astigmatism. And that's been the basic goal of optometrists through the years, whether through contact lenses or glasses. This is only another step further down the same line."
The American Academy of Ophthalmology begs to differ. "Any time that tissue is removed from the human body—either by knife, laser or any other device—it is surgery," stated Robert R. Dougherty, vice president of advocacy and ophthalmic relations.
"We consider it inappropriate for ODs to perform PRK. Our concern is for the public interest. In fact, Summit's training policy, which was required by the Food and Drug Administration, states, 'Only practitioners who are experienced in the medical management and surgical treatment of the cornea ... may use this device. We feel that PRK is the domain of providers who have had extensive training in corneal surgery and medical treatment of the cornea."
"I really think that the controversy is overrated," said Charles W. Stewart, OD. "The objective is to help provide good patient care in a cost-effective manner, whether it's ophthalmology or optometry."
Stewart, who has developed PRK services in Asia, and is one of the four ODs in Idaho performing PRK, is intent on forging a partnership between the two medical specialties. "The best vehicle for PRK is a comanagement environment," he said, noting that "in reality, there are very few optometrists—even where legal—who are probably going to be using the excimer laser."
Maintaining skills
The reason for only a few ODs pursuing PRK, Stewart believes, is because, like cataract surgery, the procedure requires that it be performed frequently and routinely in order to acquire and maintain skills, something most ODs and some MDs will not opt for in their practices. Moreover, economies of scale improve with highly utilized surgical skills being leveraged by a broad base of perioperative providers.
"An appropriate balance between providers will create a setting for clinical excellence in a cost effective manner: a yield of success," said Stewart.
Dougherty, of the American Academy of Ophthalmology, has no problem with MDs and ODs working together. As with cataract surgery, however, "The ODs should refer their patients to qualified surgeons. Optometrists are qualified to refer to surgeons when they see fit, but they are not surgeons."
Last October, the Idaho board of optometry issued a statement declaring that refractive and therapeutic laser procedures are within the scope of practice for optometrists. The state's board of medicine sent a letter to the optometric board asking that the statement be withdrawn. The optometric board refused.
Larry E. Benton, executive director of the Idaho Optometric Association, may be contacted at 9077 Maple Hill Dr., Boise, ID 83709, or at 208-378-7700. The American Academy of Ophthalmology can be contacted at 655 Beach Street, P.O. Box 7424, San Francisco, CA 94120-7424, or at 415-561-8500.